hospitalized child, end of life care and...

Hospitalized Child, End of Life Care and Pain

Unit 4Chapters 16,17 ,18, 22

Child HealthNursingPartnering with

Children & Families

Chapter 18

Pain Assessment and Management

Jane W. BallRuth C. Bindler

Pathophysiology of Pain

• Definition of pain– Acute– Chronic

• Physiology of pain– Nociceptors

• Location• Purpose

– Neural fibers• A-delta• C-polymodal

– Location– Purpose

FIGURE 18–1 Nociceptors transmit pain impulses along A-delta and C fibers to the dorsal horn of the spinal cord. After the sensory information reaches the dorsal horn of the spinal cord, the pain signal may be modified depending on the presence of other stimuli, from either the brain or the periphery. Along the nerve conduction pathways between the periphery, spinal cord, and the brain are “gates” that control the number of impulses sent to the brain. Nonpain impulses can compete with pain impulses for transmission along the spinal tracts to the brain. Once the impulse reaches the brain, the pain is perceived.

Pathophysiology of Pain (continued)

• Physiology of pain– Substantia gelatinosa

• Purpose– Brain

• Factors that increase intensity• Autonomic nerve system response• Gate control theory

Facts

• Unrelieved pain in children can permanently change their nervous system and may prime them for having chronic pain

• Children do not tolerate pain better than adults

Operational Definition of Pain

• “Pain is whatever the experiencing person says it is, existing whenever he says it does.”

• BELIEVE THE PATIENT• BELIEVE THE FAMILY

• Ref: McCaffery and Pasero: Pain: Clinical Manual, 1999

Goal of Pediatric Pain Management

• The goals of therapy when treating children are the same as those used in teaching adults. However, an additional goal when treating the pediatric patient is to offer relief and solace to the parents or guardians. It is a terrible event for a parent to have a child in pain.

Assessment of Pain in ChildrenThe Fifth Vital Sign

• Physiological changes • Self Report• Behavior changes

Physiological effect– Stress response

• Respiratory• Alkalosis• Retained secretions• Decreases oxygen saturation

Physiologic Response to Pain

• Neurological– Increase in heart rate, blood sugar, cortisol levels– Altered sleep patterns

• Metabolic– Increase in fluid and electrolyte losses

• Immune system• Gastrointestinal

Physiological Indications of Acute Pain

• Dilated pupils• Increased perspiration• Increased rate/force of heart rate• Increased rate/depth of respirations• Increased blood pressure• Decreased urine output• Decreased peristalsis of GI tract• Increased basal metabolic rate

FACT

• What is painful to an adult is painful to an infant or child unless proven

otherwise.

Pain receptors are the same in the pediatric patient compared to the adult. There is not more or less pain

but they do have increased fear and anxiety.

Self Report

Fact

• Children at any age may deny pain if the questioner is a stranger, if they believe they are supposed to be brave, if they are fearful, or if they anticipate receiving an injection for pain

Use a valid tool to assist the child articulate the pain

experience

Types of Pain Rating Scales

• Behavior/physiologic signs• Numbers• Visual analogue• Words• Colors• Faces

Pain Assessment Tools• Newborn/infant

– CRIES– NIPS– Premature infant pain scale

• Toddler– FLACC– Oucher– Faces pain–relating scale

Pain Assessment Tools (continued)• Preschooler

– Oucher– Faces pain-relating scale– FLACC– Body outline

Pain Assessment Tools (continued)

• School age– Oucher– Faces pain-relating scale– Poker chip – Work graphic– Visual analogue

Pain Assessment Tools (continued)

• Adolescent– Oucher– Faces pain-relating scale poker chip– Work graphic– Visual analogue– Adolescent pediatric pain tool

How to chose a specific toolChoice of a tool may change over the course of

treatment depending of several factors

• Developmental considerations• Cultural considerations• Organizational policy• Medical status

Box 18–3 Assessing Readiness for Use of Pain Scales

Table 18–7 FLACC Behavioral Pain Scale

Table 18–6 Neonatal Infant Pain Scale (NIPS)

Box 18–4 Situational Factors Influencing Pain in Children

Wong-Baker FACES Pain Rating Scale

Spanish translation of Faces Scale• Expliquele a la persona que cada cara representa una persona que

se siente feliz porque no tiene dolor o triste porque si ente un poco o mucho dolor. Cara O se siente muy feliz porque no tiene dolor. Cara 1 tiene un poco de dolor. Cara 2 tiene un poquito más de dolor. Cara 3 tiene más dolor. Cara 4 tiene mucho dolor. Cara 5 tiene el dolor más fuerte que usted pueda imaginar, aunque usted no tieneque estar Ilorando para sentirse asi de mal. Pidale a la persona quees coja la cara que mejor describe su proprio dolor. Esta escala se puede usar con personas de tres años de edad o más.

• http://www3.us.elsevierhealth.com/WOW/facesTranslations.html

FIGURE 18–5 Use the Oucher version that is the best match for the ethnicity of the child. After determining that the child has an understanding of number concepts, teach the child to use the Oucher. Point to each photo and explain that the bottom picture is “no hurt,” the second photo is a “little hurt,” the third photo is a “little more hurt,” the fourth photo is “even more hurt,”the fifth photo is “a lot of hurt,” and the sixth photo is the “biggest or most hurt you could ever have.” The numbers beside the photos can be used to score the amount of pain the child reports. *In the form presented in this book, the Oucher is for educational purposes only and cannot be used for patient care. aReliability is the extent to which the same score is obtained when an instrument or scale is used either by different persons or by the same person at different times. Validity is the extent to which an instrument or scale measures what it is supposed to measure. bA, The Caucasian version of the Oucher, developed and copyrighted by Judith E. Beyer, RN, Ph.D., 1983. B, The African-American version of the Oucher, developed and copyrighted by Mary J. Denyes, RN, Ph.D., and Antonia M. Villarruel, RN, Ph.D., 1990. Cornelia P. Porter, RN, Ph.D. and Charlotta Marshall, RN, MSN, contributed to the development of the scale. C, The Hispanic version of the Oucher, developed and copyrighted by Antonio M. Villarruel, RN, Ph.D., and Mary J. Denyes, RN, Ph.D., 1990. www.oucher.org.

A B C

FIGURE 18–6 The Numeric Pain Scale or Visual Analogue Scale is used for older school-age children and adolescents. Teach the child to use the scale by saying that 0 is no pain and 10 is the most pain ever felt. In between are numbers that can be used to report small or large amounts of pain. Ask the child to make a mark any place along the line that is the best match for the amount of pain felt. From PAIN28.27–38, Varni, J. W. et al. © 1987 International Association for the Study of Pain. Used with permission.

Have child locate pain by:

• Marking body parts on a human figure drawing

• Point to the area with one finger on self, doll, stuffed animal

• Point to “where mommy or daddy would put a bandage”

Table 18–5 CRIES Neonatal Postoperative Pain Measurement Tool

Table 18–5 (continued) CRIES Neonatal Postoperative Pain Measurement Tool

FIGURE 18–3 Use a body outline for children to identify the location of pain either with a marker or crayon. Children have the opportunity to mark all the different locations of pain. Different color crayons can be used to identify different amounts of pain. This tool can be used independently or as part of the Adolescent Pediatric Pain Tool.

What if the child is unwilling or unable to self report?

Behavioral Changes

Behavioral Effects of Paindevelopmental issues

• Behavioral effect– Infant

• Less than 6 months• 6 to12 months

– Toddlers• Aggressive behavior• Physical resistance

– School age• 7 to 9 years• 10 to 12 years

– Adolescent

Fact: Behavioral Indicators of Pain include

• Restless and agitated or hyper alert • Short attention span• Irritability• Facial grimacing, posturing, guarding a painful

joint by avoiding movement• Anorexia• Lethargy• Sleep disturbance• Agression

FIGURE 18–2 Neonatal characteristic facial responses to pain include bulged brow; eyes squeezed shut; furrowed nasolabial creases; open angular, squarish lips and mouth; taut tongue, and a quivering chin. Redrawn from Carlson, K. L., Clement, B. A., & Nash, P. (1996). Neonatal pain: From concept to research questions and the role of the advanced practice nurse. Journal of Perinatal Neonatal Nursing, 10(1), 64–71.

Table 18–7 (continued) FLACC Behavioral Pain Scale

Table 18–4 Behavioral Responses and Verbal Descriptions of Pain by Children of Different Developmental Stages

Does a sleeping child mean that there is no pain?

QUESTT

• Question the patient• Use pain rating scale• Evaluate behavior and physiologic signs• Secure family’s involvement• Take cause of pain into account • Take action and assess effectiveness

Intervention

• Make a pain plan

Pharmacological Intervention

• Acetaminophen• Nonsteroidal anti-inflammatory drugs

(NSAIDS)• Opiods (narcotics)

Non pharmacological Methods of Pain Relief

• Distraction• Psychological/cognitive• Hypnosis• Imagery• Relaxation• Comfort measures

– Quiet presence– Music– Massage– Heat/cold– Baths– Vibrations

Evaluation

• Observe for an Improvement in Behavior Following an Analgesic

Nursing Care Plan of Children Experiencing Acute Pain

• Assessment– Cognitive and developmental status– Emotional status– Previous pain experience– Parental input– Assessment scale findings

Table 18–9 Pediatric Pain History for Children and Parents

Nursing Care Plan of Children Experiencing Acute Pain

(continued)• Diagnoses

– Acute pain– Anxiety– Sleep pattern disturbance– Breathing

Nursing Care Plan of Children Experiencing Acute Pain

(continued)• Planning/implementation

– Pharmacological• Analgesia• Anesthesia

– Complimentary therapies• Reassessment of therapies

Table 18–10 Complementary Therapies for Pain Management by Age Group

Box 18–5 Questions to Assess the Child’s Pain Medication Management

Box 18–6 Guidelines for the Prevention and Management of Pain in Newborns

Nursing Care Plan of Children Experiencing Acute Pain

(continued)• Planning/implementation

– Planning with families– Teaching

• Evaluation

Nursing Management of the Pediatric Client Receiving

Opioids/NSAIDS• Opioids

– Routes of administration– Purpose– Common side effects– Major side effects

• Respiratory depression• Addiction

– Assessment of effectiveness

Medications Opioid Analgesics and Recommended Doses for Children and Adolescents

Table 18–8 Signs and Symptoms of Opioid or Sedative Withdrawal

Nursing Management of the Pediatric Client Receiving

Opioids/NSAIDS (continued)• NSAIDS

– Route of administration– Purpose– Assessment of effectiveness

Medications Recommended Doses of Acetaminophen and NSAIDs for Children and Adolescents

Nursing Management of the Child Having Sedation/Analgesia

for a Medical Procedure• Sedation

– Definition– Purpose– Types

• Light• Deep

Table 18–11 Characteristics of Light Sedation and Deep Sedation

Nursing Management of the Child Having Sedation/Analgesia

for a Medical Procedure (continued)

• Nursing goals– Prevent/relieve pain and anxiety– Prevent life-threatening complications– Facilitate procedural processes

• Nursing management– Pre-operative

• Analgesia usage– Topical agents

Medications Used for Sedation

Nursing Management of the Child Having Sedation/Analgesia

for a Medical Procedure (continued)

• Nursing management– Intra-operative

• Cardiovascular assessment• Respiratory assessment• Vital signs• Complications assessment

– Respiratory depression– Deepening sedation– Antagonist agents– Resuscitation equipment usage

FIGURE 18–13 When painful procedures are planned, use EMLA cream to anesthetize the skin where the painful stick will be made. A, Apply a thick layer of cream over intact skin (1/2 of a 5-g tube). B, Cover the cream with a transparent adhesive dressing, sealing all the sides. The cream anesthetizes the dermal surface in 45–60 minutes.

A

FIGURE 18–13 (continued) When painful procedures are planned, use EMLA cream to anesthetize the skin where the painful stick will be made. A, Apply a thick layer of cream over intact skin (1/2 of a 5-g tube). B, Cover the cream with a transparent adhesive dressing, sealing all the sides. The cream anesthetizes the dermal surface in 45–60 minutes.

B

Nursing Management of the Child Having Sedation/Analgesia

for a Medical Procedure (continued)

• Nursing management– Postoperative

• Discharge criteria

Pediatric Palliative Care• Ippcweb.org• Initiative for pediatric palliative care.• Students are not responsible for the care of

children who are dying, but may be exposed to the emotions of staff who have dealt with a child’s death.

• It may be unavoidable that students be on the unit when a child dies.

• Be clear that the faculty is responsible for helping students deal with upsetting situations.

• Please bring concerns to faculty attention.

Pediatric Considerations in Disaster Preparedness

• Impact of disaster– Psychological

• General effects• Anxiety• Stress

– Fear

Pediatric Considerations in Disaster Preparedness (continued)

• Impact of disaster– Developmental considerations

• Toddler/preschooler • School age• Adolescent

Table 16–2 Responses to Disasters by Children of Different Age Groups

Table 16–2 (continued) Responses to Disasters by Children of Different Age Groups

Pediatric Considerations in Disaster Preparedness (continued)

• Preparedness– Pediatric drugs/supplies– Advance planning

• Medically fragile in community• Community disaster response systems• Family

– Resource package

– Anticipatory guidance

Table 16–3 Resources for Surviving a Disaster for 72 Hours

Child HealthNursingPartnering with

Children & Families

Chapter 17

Nursing Care of the Hospitalized Child

Jane W. BallRuth C. Bindler

The Child’s Understanding of Health and Illness

• Developmental aspects– Infant

• Separation/stranger anxiety

– Toddler• Separation anxiety

The Child’s Understanding of Health and Illness (continued)

• Developmental aspects– Preschooler

• Separation anxiety• Inability to distinguish fact/fiction

– School age– Adolescent

Table 17-2 Stressors of Hospitalization for Children at Various Developmental Stages

The Child’s Understanding of Health and Illness (continued)

• Psychological aspects– Infant

• Separation/attachment– Toddler

• Separation from parents• Disruption of routines

– Preschooler• Fear of dark • Loss of self-control• Injury

The Child’s Understanding of Health and Illness (continued)

• Psychological aspects– School age

• Pain• Bodily injury • Death

– Adolescent• Loss of control and independence• Fear of altered body image

The Effects of Hospitalization on the Child and Family

• Developmental considerations– Infant

• Separation anxiety• Stranger anxiety

– Toddlers• Fears

– Preschoolers• Fears• Regression

Table 17-3 Stages of Separation Anxiety

The Effects of Hospitalization on the Child and Family (continued)

• Developmental considerations– School age

• Fears• Regressions

– Adolescent• Fears

The Effects of Hospitalization on the Child and Family (continued)

• Parents– Fears– Coping abilities

• Siblings– Fears– Behavioral disruptions

Adaptation to Hospitalization

• Scheduled admission – Child/parent

• Preparation– Tours– Play– Written/visual material

• Anxiety

Box 17-4 Nursing Considerations in Preparing Parents and Child for Planned Short-Stay Admission

FIGURE 17–1 Allowing the child to dress up as a doctor or a nurse helps prepare the child for the hospitalization experience. This helps the child adjust to treatment, care, and the recovery process. Why? What might the child’s concerns be? Can you think of any concerns that might be related to cultural background?

FIGURE 17–2 The child’s anxiety and fear often will be reduced if the nurse explains what is going to happen and demonstrates how the procedure will be done by using a doll. Based on your experience, can you list five actions you can take to prepare a school-age child for hospitalization?

FIGURE 17–3 Jasmine’s parents are taking the time to prepare her for hospitalization by reading a book recommended by the nurse. Such material should be appropriate to the child’s age and culture. Why do you think that having the parents readthis material is valuable?

Table 17-5 Sample Teaching Materials for Children Regarding Hospitalization and Healthcare

Adaptation to Hospitalization (continued)

• Unanticipated admission– Orientation to unit/environment

• Stress-reduction methods• Explanation of all procedures• Opportunities for parents/child to express fears

Box 17-3 Safety Measures for the Hospitalized Child

Adaptation to Hospitalization (continued)

• Parental adaptation– Psychological issues

• Confusion• Anger

Nursing Strategies to Improve the Illness/Hospitalization Experience

of Parents/Children

• Practice settings– General pediatric unit

• Orientation• Maintenance of safe environment

Box 17-5 Taking “Visitation” Out of the Pediatric Care Setting

Box 17-3 Safety Measures for the Hospitalized Child

Nursing Strategies to Improve the Illness/Hospitalization

Experience of Parents/Children (continued)

• Practice settings– Emergency department

• Psychological considerations– Same-day surgery

• Thorough discharge teaching instructions

Box 17-7 Preoperative Checklist

FIGURE 17–6 This child has just undergone surgery and is in the post anesthesia care unit (PACU). Although the child’s physical care is immediate and important, remember that both the child and the family have strong psychosocial needs that must be addressed concurrently. It is important to reunite the family as soon as possible after surgery.

Nursing Strategies to Improve the Illness/Hospitalization

Experience of Parents/Children (continued)

• Practice settings– Intensive care unit

• Psychological considerations– Parental decision making– Parental involvement in care

• Hospital care– Medication administration

• Developmental considerations

Table 17-6 Vacations In Medication Administration to Children

Table 17-6 (continued) Vacations In Medication Administration to Children

Nursing Strategies to Improve the Illness/Hospitalization

Experience of Parents/Children (continued)

• Hospital care– Procedure preparation

• Pre-operative• Intra-operative

– Therapeutic play• Assessment tools

FIGURE 17–5 This boy was formerly afraid of blood draws but with the aid of health professionals has overcome his fear and can now have the procedure done calmly. He shows his mastery over the situation. What can you do to help children afraid of procedures to develop coping mechanisms to assist them?

FIGURE 17–9 The nurse can use a simple gender-specific outline drawing of a child’s body to encourage children to draw what they think about their medical problem. Such drawings reveal a child’s interpretation, which the nurse can work with to provide enhanced teaching.

Table 17-9 Gellert Index of Body Knowledge

Table 17-9 (continued) Gellert Index of Body Knowledge

Nursing Strategies to Improve the Illness/Hospitalization

Experience of Parents/Children (continued)

• Hospital care– Educational needs

• Individual education plan– Teaching

• Partnering with parents• Various techniques

Strategies to Reduce Hospitalization Stressors

• Significant stressors– Separation from caregiver– Loss of self-control, autonomy, privacy– Pain/invasive procedures– Fear of bodily injury/disfigurement

Strategies to Reduce Hospitalization Stressors

(continued)• Nursing care management

– Assessment• Data collection• Partnering with parents/multidisciplinary team

Strategies to Reduce Hospitalization Stressors

(continued)• Interventions

– Infant– Toddlers/preschoolers– School age– Adolescent

Professional Practice Standards for Pediatric Nursing Practice

• Collecting health data• Analyzing the assessment data in

determining diagnoses• Identifying expected outcomes

individualized to the child and family• Developing a plan of care that prescribes

interventions to attain expected outcomes• Implementing the interventions identified in

the plan of care