MENNONITE COLLEGE OF NURSING
At Illinois State University
Nursing Care of Children 317
PAIN ASSESSMENT OF THE CHILD
Teaching - Learning Principles
PAIN:Sensory and emotional response.
When assessing pain in a child, use the following tool:
QUESTT
-Question child
-Use pain-rating scale
-Evaluate behavior and physiologic changes
-Secure parents' involvement
-Take cause into account
-Take action and evaluate results
"Q" - Question Child
-Describe pain
-Use familiar words to describe pain: "an owie", "boo-boo", "hurts"
-Have child locate pain - on self or doll
-Remember that some children will deny pain because they think they will get an injection if they say they are in pain
-Other kids may think they deserve the pain (possibly as a consequence for something they did)
-They may more easily tell a parent about their pain as compared to a stranger (the nurse)
"U" - Use Pain Rating Scale
-Various scales exist - based on child's developmental level
1. Behavioral Pain Assessment Scales—See Table 7-1 (pp. 181-182, 9th ed.) and Table 5-1 (p. 153, 10th ed.). KNOW FLACC Scale
-Use the same scale with the child to avoid confusion
-Teach them about the scale pre-operatively, if possible
-Five (5) scales are discussed in table 5-2 (pp.155-156, 10th ed.); Oucher Scale and Poker Chip scale omitted
1.Wong Baker Faces Scale - commonly used; ages 3 years and up; ‘smiley” faces numbered from 0 to 10 to make it comparable to the 1-10 PRS used with adults.
2.Oucher Scale
a.photographs of faces
b.numbers from 0-100
3.Poker Chip Scale - "pieces of hurt"; no chips used in "no hurt", all 4 chips used if "most hurt"
4.Word Graphic Scale - no pain --> mild-moderate-a lot-very bad --> worst pain
5Numeric Scale—0-10 scale based on ‘no pain’ to ‘severe pain’. Children 5 yrs and older may be able to use this if they have concept of numbers.
6.Visual Analogue Pain - child chooses point on line from "no pain" --> "worst pain"
7.Color Scale - Uses crayons/markers (8 total); the child chooses colors that remind them of a little
hurt (pain) or more hurt. Child colors on a body outline where it hurts.
"E" - Evaluate Behavior & Physiologic Changes
-“Children’s Responses to Pain at Various Ages” p. 153 (10th ed.) (good reference)
-Children's behavior will vary according to their age and their personality
-Cultural background also affects how a child responds to pain
-Examples of physiologic responses to pain may include:
1.B/P, pulse, sweating, respirations
2.Skin flushed**YOU MUST KNOW THE
3.RestlessNORMS TO ASSESS FOR
4.Pupils dilatedCHANGES (see inside cover of text)
-Other Behaviors displayed may be:
1.Pulling on ears - ear ache
2.Fetal position - stomachache
3.Limping - foot or leg pain
*With persistent pain --> body adapts and above responses often decrease in severity.
**Any change in a child's behavior can indicate pain (parents are good sources of this type of information).
"S" - Secure Parents' Involvement
-Again, parents are very sensitive to changes in their child's behavior
-May want to ask parents how child has previously reacted to pain
-Teach parents non-verbal pain behaviors to recognize
"T" - Take Cause of Pain into Account
-What is causing the pain? Venipuncture vs. bone marrow puncture (MORE PAINFUL!)
**"Whatever is painful to an adult is painful to an infant or child until proven otherwise."
"T" - Take Action & Evaluate Results
-We assess pain to relieve it!
-Combination of pharmacologic & non-pharmacologic methods are BEST
-No one technique is effective for every child
(Chart what methods work for your patient so others can also use these methods.)
Care Plan - "Child in Pain"
WAYS TO MINIMIZE PAIN:
1.Non-pharmacologic - often used in conjunction with pharmacologic methods. Effectiveness of this method varies with the child.
See p. - "Non-Pharmacologic Pain Management"
Specific strategies listed:
-distraction/diversionary activities
-relaxation
-guided imagery
-positive self-talk
-breathing
2.Pharmacologic - 4 rights – IMPORTANT to remember:
-NSAIDS (non-opioids) (e.g.-acetaminophen, children’s Motrin) - for mild to moderate pain.
- Work on peripheral nervous system
-Opioids - for moderate to severe pain (p. 171, 10th ed.)
- Work on central nervous system
-Combination of the above two (2) analgesics is very effective because it can provide analgesia without side effects. ** (Around the Clock preventative pain management schedule is the best.)
Preparing children for procedures
Assessment
What is the patient/child being admitted for?
How much do they/their parents know?
Look at all data - physical/mental assessment.
Plan
Preparation for procedures ((p. 112 Table 4-2, 10th ed.)
What were identified nursing diagnoses?
Take into account the child's age & developmental level as well as those of the parents.
Implementation
Get patient and family involved in the learning process.
Evaluation
Were interventions effective?
How can you alter interventions to be more effective?
Teaching Children - Communicating with Children (pp. 95-99, 10th ed.)
(Verbal & Non-Verbal)
-Communication is essential when working with children.
-The child's development stage must be taken into account when teaching them.
(See pages in Hockenberry text regarding educational strategies for different developmental ages.)
-The use of visual aids (models, posters, videos, photos) always helps. When teaching psychomotor skills, always allow child/parent time to practice the skill.
Teaching Tools - BE CREATIVE:
Get patient to help you create puppets, charts...to use when teaching them (i.e. rubber gloves, tongue blades, paper cups - can all be used). Coloring books can also be used for pre-op teaching.
(See Box 4-3pp. 98-99, 10th ed. in Hockenberry) Creative Communication Techniques with Children—great resource!