FAQ W Ans (Pott 18-FAQ)

Frequently Asked Questions

Mrs. Chowet, an American Indian, is sitting next to her son Nathan, a 15-month-old, who has just been admitted to you following surgery for a ruptured appendix. Nathan had an open procedure and has a nasogastric tube, IV, and other standard postoperative orders. Thephysician has ordered morphine sulfate 0.4–0.8 mg IV every 4–6 hours prn pain. Nathan has not received any pain medication and is beginning to show signs of pain and discomfort. He whimpers and moans, isn’t comforted by his mother’s touch, moves restlessly, and his blood pressure is beginning to rise. You discuss your perceptions with Mrs. Chowet, and she requests that you do not give Nathan any pain medication, saying, “Nathan is probably just restless. Any pain he is having will help him recover more quickly.” How should you respond?

It will be important to take the time to teach Mrs. Chowet about pain and how it will impact Nathan’s recovery. Several misconceptions have existed over time regarding pain in children. One misconception is that infants do not experience pain. A second is that pain can be a positive experience, helping the child or infant to develop the characteristics of a good person. Another consideration is that Mrs. Chowet is a American Indian. Many of members of this culture believe that pain is an individual experience and should be endured. It will be important to teach Mrs. Chowet that pain can be very traumatic and can slow recovery time by impeding mobility, lessening or restricting deep respirations, and increasing stress and anxiety. Additional complications, such as pneumonia, may result from these factors. It will be important to teach Mrs. Chowet how you will evaluate Nathan’s pain, how frequently you may give the medication, and how you will know if it is working effectively. You should further clarify that Nathan may even be experiencing pain when asleep or dozing in her arms.

You have recently been hired to work on a children’s surgical unit. You have cared for adults for the past 10 years and are unsure of how to evaluate children’s pain. You are used to someone asking for pain medication, but what do children do when they are in pain?

It is important to keep in mind that children have different perceptions of their pain and of what is most helpful in alleviating it. Various pain assessment tools are available to assist the nurse in determining pain intensity. Objective pain measures work best for the infant or toddler, and for the child who is nonverbal or developmentally delayed. Objective pain-rating tools score behaviors and physiological changes. These tools are most useful for determining acute pain. For the child who can self-report pain, various tools are available and can be combined with objective pain-rating tools for more effective pain assessment. Available tools include the Oucher pain assessment tool, Wong/Baker FACES Pain Rating Scale, and the Visual Analog Scale. It is also important to discuss goals of pain management with the child (if appropriate) and the parents to encourage their involvement in determining assessment and pain management techniques.

Jeremy, age 13, and his parents have arrived on your unit for evaluation of his chronic pain secondary to cancer. Jeremy is a bright, articulate young man who appears pale, anxious, and very uncomfortable. He rates his pain at a 10 (on a scale of 1 to 10) 20 minutes after receiving a dose of morphine sulfate IV. The primary health care provider is ordering a pain consult. What nonpharmacologic techniques could you use while waiting for the pain management team?

There are a variety of nonpharmacologic techniques that might be used to assist in relieving Jeremy’s pain. It is important to discuss with Jeremy what these options are and to find out if he and his parents are willing to have you use them while waiting. Several techniques focus on relaxation. This is a good technique for the adolescent or school-age child. Another technique, known as “thought stopping,” focuses on positive thinking and is also helpful for chronic pain. Although helpful for short-term acute pain, distraction techniques may be helpful for only a short-term period. Other techniques you might think about include therapeutic touch and music therapy.

Susan, 6 years old, has been receiving IV morphine sulfate on a continuous basis for 3 days. The primary health care provider has written orders to begin weaning the morphine and to transition to oral pain medication. Two hours after beginning to wean the morphine you notice that Susan is difficult to arouse, her respirations are 6, and her oxygen saturation has dropped to 86%. What is the most likely reason for Susan’s respiratory depression?

Susan is most likely experiencing respiratory depression because of the cumulative effects of the morphine. Susan may need to receive Narcan and will need respiratory support until she is more awake and breathing more efficiently on her own.

Harold is a 2-month-old who is postoperative 1 day following repair of bilateral clubfoot and bilateral Achilles-tendon-lengthening procedures. Harold’s primary care provider has ordered ketorolac IV. In reviewing the drug handbook, you note that there is no indicated safe dose to administer. What should you do?

Ketorolac (Toradol) is a nonsteroidal anti-inflammatory drug often given as part of postoperative pain managment. It should not be administered for more than 5 continuous days or with other NSAIDs such as ibuprofen. A risk of giving ketorolac is that it can cause gastric bleeding and renal complications. Prior to administering the drug, contact the care provider or pharmacist and ask for information regarding ketorolac, its dosage guidelines, and suggested guidelines for administering it to the child.