Introduction
“Children are on a different plane. They belong to a generation and away of feeling their own”.George Santayan.
It is both the best of time and the worst of times for today’s children. Their world possesses powers and perspectives inconceivable 50 years ago. Despite the medical advances made in the last few decades, pain in children is still a topic of interest.
Thorough observational skills to cover head to toe are necessary when assessing the presence of pain when child is under 5years of age. Behavioral cues are the primary sources of data those include increased irritability, restlessness, lack of appetite, pulling away, rubbing, and guarding specific parts of the body. Vital signs are important indicators the increase in heart rate and respirations often present with pain, should decline after non pharmacologic intervention. Other physiologic responses that may indicate the presence of pain include increased blood pressure, pallor, decreased peripheral circulation, sweating, and dilated pupils.1
A variety of assessment techniques may be used to assist older children in describing location and intensity of pain. The child can put an ‘X’ or color in the area of pain on a body outline drawing crayon colors can be used indicate the severity of pain. Yellow, orange, red and black, may be selected to represent the degree of pain with older children, a graduated color chart may be used. Parker chips are also sometimes used. Chips indicate ‘little’ hurt and four chips ‘most hurt’. A 10-Cm scale has been used by abu-saad and Holzemer to measure the level of a child’s perception of pain. Used as a continuum, one end indicates “no pain” and other “severe” pain.1
The experience of pain is complex, involving, emotional and cognitive components pain is subjective and highly individualized. Carr and Coudas describe pain as the normal,
predicted physiological response to chemical, thermal, mechanical stimulus associated with the surgery, or an acute illness and thus characterize it as a sensory response. There are many scales available to asses pain .Such as The visual analogues Scale (VAS) the verbal rating scale (VRS) pain –o- meter, mcGill pain questionnaire (MPQ), the faces rating scale, and the numerical rating scale (NRS).3
Brief Resume of the Intended Work
6.1 NEED FOR STUDY
Pain is a subjective experience, and infants and children respond to pain with behavioral reactions that depend upon their age and cognitive processes. pain may occur as a result of procedures, surgery, illness, or injury.
The new born baby, the infant, and the toddler are unable to localize and describe the severity of pain. Pediatric nurses are the health team members who spent most of the time with the pediatric patients during their hospitalization. Nurses must be aware of child's response to pain through the assessment of behavioral responses and differentiation of crying. Because the children have difficulty in explaining the type of discomfort or pain, they have or its location in any body part.4
Perception and response to pain varies according to age group. Between 3 and 10 months of age, infants are able to localize pain as they withdraw their limbs, stool, hiccough and cry. Infants react intensively wit physical resistance and uncooperativeness as they refuse to lie still, attempt to push the nurse away, are attempt to escape with whatever motor activity they achieved such has rolling away. The toddler is able to localize pain and reacts by withdrawing the affected part. This age group responds with intense emotion and physical resistance to any actual or perceived painful experience, including clenched teeth, rocking, aggressive behavior, and crying. By the end of the toddler period, the child is usually able to verbalize about the pain although unable to describe or localize it. Preschool children still have limited ability to understand anything beyond the immediate event.
The may see them self as the cause pain and fear mutilation, body invasion, and loss of recently gained control. Children in School age may try to be brave when experiencing pain. Concerns expressed relate to body injury and death, fear, anxiety, missing school, not playing sports, and losing autonomy.1
Standardized pain assessments are vital for recognizing pain, quantifying pain intensity, and evaluating treatments provided to relieve pain. Nurses in clinical settings need valid and reliable tools to quantify pain in all patients. These tools should supplement pediatric nurses' clinical judgment and provide a standardized method to communicate and document pain. These tools should be easy to use and require minimal nursing time in order to encourage consistent utilization. Several pain scales have been developed for research purposes that assess and quantify acute pain experiences from surgery and painful procedures in preverbal children. The feasibility and clinical usefulness of these scales need to be further explored.5
The nurses can use a self report pain scales that is, Faces pain rating scale. The Faces pain rating scale is valid and reliable in helping children to report their level of pain but this scale cane be used for the children who can understand the concepts that is children above 3 years of age. In this scale different kinds of Faces can be used and accordingly child can ask about the description of amount of pain the child feels.1
FLACC scale can be used to identify the nurses own knowledge regarding assessment of pain among children it observed for 5 minutes or longer. Observe the legs and body and covered. Reposition the patient or observe activity. Assess body for tenseness and tone. Initiate consoling interventions if needed. Each of the five categories is scored from 0 to 2, resulting in a total score between 0 and 10.A total score of 0=relaxed and comfortable;1-3=mild disconfort;4-6=moderate pain;7-10=severe discomfort or pain.6
A study was conducted to further test the validity of the faces, legs, activity, cry and consolability (FLACC) behavioral pain assessment scale for use with children. Thirty children aged 3 to 7 years who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20+2 hrs after surgery.
FLACC score were assessed by one of the nurse investigators and a self report of pain using the FACES scale was obtained from the child. There was a significant and positive co relation between the FLACC and FACES scores for the entire thirty samples and for the score of children 5 to 7 years of age but not for children < age 5. These finding provide additional support for the construct validity of the FLACC pain assessment tool. The difficulty in quantifying and qualifying pain in young children may place this population at the risk for inadequate pain control. While self report of pain should be obtained when ever possible, behavioral observation remains the primary methods for pain assessment in children with limited verbal and cognitive skills. The faces, legs activity, cry and consolability behavioral pain assessment tool was developed to provide a simple and consistent methods for nurses to identify, document, evaluate pain in children who have difficulty verbalizing the presence of intensity of pain this study was designed to further validate the FLACC tool by comparing nurses assigned FLACC scores to the child self report of pain.7
It is extremely important to assess the child accurately for pain, because if the nurse administers a medication, a coexisting problem may be missed such as pneumonia,aurinarytractinfection, orapost-operativeinfection. Becauseofabove reasons the investigator has selected this as a part of research study.
6.2 REVIEW OF LITERATURE
A prospective, single blind, controlled trial was under taken in children who presented in the emergency department with pain. Pain was assessed in the waiting room and again at triage before any treatment was administered using the alder hey tri age pain score, and observational tool designed for triage, and a self report tool, either Wong-baker faces pain rating scale for 3 to 7 years old children are a visual analogue scale for age. 75 children (29 aged 3-7years and 46 aged 8-15 years) were enrolled in the study. The AHTPS scores were significantly lower than the scores measured by the WBS/VAS (PLO.001). The level of pain measured by both methods (self – report, observational) was lower in the triage room. Compared with the AHTPS, the WBS and VAS scored significantly lower in the triage room than in the waiting room (p<0.042 and p<0.006 respectively) for 8 to 15 years old children.
Score were compared by instrument and emergency department.Observational pain assessment underestimates children's perception of pain and should not be recommended in children age under 3 years. Triage has a calming effect on children.8
A study conducted to determine the pediatric nurse’s current attitudes and knowledge regarding pain. Pain management knowledge deficiencies were identified, including assessme,pharmacologic management, risk of addiction and the treatments’ of procedural pain and surgical pain. The pediatric nurse’s knowledge attitudes regarding pain survey was completed by a convenience sample of 274 nurses at a large children’s medical center. 66percentage of the questions were answered correctly. Nurses with their master’s degree scored significantly higher (75percentage). Hematology / oncology nurses (76percentage) nurses from the ICU (71percentage) and emergencyroomnurses (70percentage) scored significantly higher than nurses from other patient Care unit. 10
A study was done to describe the nurse’s attitude and knowledge about reliving children’s pain, perceived barriers to optimal pain management. Data were collected from 67 nurses and 132 children in their care. Out comes were measured with the nurses knowledge and attitudes surrey regarding pain, the nurses perceived barriers to optimal management for children survey, calculations of the order analgesia administered by the nurses, and the ocher scale for intensity for children’s pain. Most nurses demonstrated knowledge and positive attitude about relieving children’s pain but lacked knowledge about the incidence of disease and thought that children over report their pain. Inadequate or insufficient physician medication orders for pain were identified by 99 (percentage) of nurses as the greatest barrier to optimal pain management. The children’s mean pain level was 1.63 (scale 0 to 5) of the 117 children who reported pain, 74(percentage) received analgesia. Nurses administered means of 37.9(percentage) of available morphine and 22.8(percentage) of available total analgesia. The study was concluded that in practice nurses need to become more aware of the value of children self report of pain, limitation of relying on children behavioral manifestation and judgment of pain intensity 11
A study conducted on evidence-based review of seventeen pediatric pain measures, spanning pain intensity self report, questionnaires and diaries, and behavioral observations were examined. Measures were classified well established, approaching well established or promising according to established criteria. Information was highlighted to help professionals evaluate instruments for particular purpose. Eleven measures met criteria for well established, six approaching well established and zero were classified as promising. hear are a number of strong measures for assessing children’s pain, which allows professionals options to meet their particular needs. Future directions in pain assessment are identified such as highlighting culture and the impact of pain on functioning. This review examines the research and characteristics of some of the commonly used pain tools in hopes that the reader will be able to use this evidence-based approach and the information in future selection of assessment devices for pediatric pain.12
A study was conducted to validate the FLACC Pain Assessment Tool as a useful clinical tool for assessing pain and evaluating pain management interventions in preverbal patients. Five pediatric nurses from each of the five specialty pediatric units volunteered to collect FLACC data on patients they were assigned to care for as part of their routine clinical practice. Their training for the study included patient identification, discussion of the five categories of the FLACC Pain Assessment Tool, clarification of specific behaviors in each category, scoring, and data collection form completion. Training took less than 10 minutes. Prior to the start of the study, each of the 25 volunteer nurses independently assigned a FLACC score to ten videotaped patients. The scores were then compared among these nurses to determine interrater reliability. Using an average weighted Kappa > 0.60 as a benchmark for providing reliable interrater agreement, the six volunteer nurses with an average weighted Kappa below 0.60 were dropped from the study. Of the remaining 19 nurse volunteers asked to collect patient data, 14 collected data. The average weighted Kappa for these 14 data collectors from the five units was 0.61.
The results of this study provide further evidence of the validity, reliability and clinical utility of the FLACC Pain Assessment Tool for assessing surgical pain intensity in pre-verbal children. This study also indicates that the FLACC scale is an appropriate pain assessment tool for preverbal children experiencing pain from other disease processes.5
Problem Statement
A Comparison of Children Self Report of Pain and Nurses’ Assessment of Pain in Selected Hospitals of Bangalore With a View to Develop Pediatric Pain Assessment Guidelines.
6.3 OBJECTIVES
1. To rate the self report level of pain in children by using Wong-baker faces pain
rating scale.
2. To rate the level of pain in children assessed by nurses usingFLACC pain assessment scale.
3. To compare the pain rating of children’s own self report and nurses assessment.
4. To find out the association between self reporting of children and nurses assessmentof pain with selected demographic variables.
5. To develop pediatric pain assessment guidelines.
6.4 OPERATIONAL DEFINITIONS
1. Comparison: This refers to the comparison of pain between children’s self report of pain and nurses assessment of pain to establish consistency in pain assessment.
2. Self report: given by the individual child to the nurses about their intensity of pain by using Wong baker faces pain rating scale.
3. Pain: It refers to an unpleasant sensory and emotional experience arising from medical or surgical condition in children admitted in different pediatric units.
4. Nurse’s Assessment: It refers to the assessment of pain by the nurses using FLACC scale.
6.5 Assumption:-
1. Children will be able to express their intensity of pain verbally.
2. The nurses will be able to assess the pain in children by using the different pain rating scales.
Variables of Study
- Research variable:– Children’s self report of pain, Nurses assessment of pain.
- Demographic variable:– age, gender, education, socio-economic status, area, cultural background,care givers response, past experiences with pain of child qualification,experiences of nurses
DELIMITATION:
- This study is limited to the children of age group of 3 to 15 years of age.
- This study is also limited to the staff nurses posted only in the pediatric unit.
7. MATERIALS AND METHODS
7.1Source of data: Children who have different kinds of pain and are admitted in the selected hospitals of Bangalore.
RESEARCH APPROACH: The investigator will use Non – experimental exploratory approach to compare the self report of pain and nurse’s assessment of pain.
RESEARCH DESIGN: The research design for the study will beComparative descriptive survey design.
RESEARCH SETTINGS: Study will be done in the pediatric units of selected hospital of Bangalore.
Sampling technique:Investigator will use convenient-sampling technique to draw the sample.
Sample size: The sample size will be 100
Population: - The target population for the study is children who are affected with different kinds of pain and nurses who are taking care of those children.
SAMPLING CRITERIA
INCLUSION CRITERIA:
- Children admitted to general pediatric units and having any kind of medical or surgical pain.
- Children between the age group of 3 to 7 years.
- Children present at the time of data collection.
- Children whose parents are willing to cooperate with the study.
- Nurses who are willing to participate.
EXCLUSION CRITERIA:
- Children who are critically ill.
- Children who are admitted in pediatric intensive care unit.
- Nurses who are caring for critically ill children.
Method of data collection: The investigator will use the interview scheduled to collect demographic data from child and nurses. Scheduled interview will used to asses child’s self report of pain and skilled observation of child’s pain will be done by the nurses.
7.2 DATA COLLECTION TOOL:.
Part I - Will contain demographic data like age, education, socio – economic status, area cultural background, care givers response, past experiences with pain.
Part II - The investigator will use Wong Baker Faces pain rating scale to assess the self report of pain in children.
Part III – FLACC pain assessment scale used by nurses to assess the pain in children
PLAN FOR DATA ANALYSIS:
The data will be analyzed using descriptive and inferential statistics.
Descriptive statistics like mean, mode, median and percentage standard deviation will be used.
Inferential statistics like‘t’ test and Chi – square methods will be used to find the association between different demographic variables.
7.3 DOES THE STUDY REQUIRES, INTERVENTION TO BE CONDUCTED ON PATIENT OR OTHER HUMAN OR ANIMALS?
No, this is a descriptive study,it does not required any investigation to be conducted on patient or other human or animals.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?
1. The ethical clearance will be sought from the research committee of AECSMaarutiCollege of nursing.