Microsoft PowerPoint - obs pain ppt

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					                                                  Observational Pain
 Observational Pediatric Pain                       Assessment
        Assessment
                                          • Relies on            • Especially
                                            behaviors and          important in pre-
             Janlyn Rozdilsky               physiologic            verbal infants &
                RN MN CNCCP(C)              indicators             non-verbal
            Clinical Nurse Educator                                children
         PICU Royal University Hospital
               Saskatoon, Sask.




      Behavioral Response                       Behavioral Response
• Few tools developed                     • Cry/Vocalizations-Infant
• Most rely on assessment of:               – Commonly associated with general
                                              distress and discomfort (anger, hunger,
  – Cry
                                              fear)
  – Facial expression                       – Way for parents and professionals to judge
  – Motor Movement                            pain
  – Interaction/Sleep state                 – Pain cry different in duration, latency,
                                              intensity and pitch




      Behavioral Response                       Behavioral Response
• Cry/Vocalizations-Older Child           • Facial Expression
     • moaning, grunting, sighing,          – Infant-eyebrows lowered & drawn together
       gasping, repeated non-sensical         with bulge between brows. Eyes tightly
                                              closed. Cheeks raised with furrow
       phrases, swearing, complaining
                                              between nose and upper lip. Mouth open
                                              and stretched in square shape




                                                                                           1
          Facial Expression
                                                             Behavioral Response
                                                       • Facial Expression
                                                         – Child
                                                            • frown, grimace, clenched teeth, skin
                                                              around mouth tight, tearing




       Behavioral Response                                   Behavioral Response
                                                       • Motor Movement-Older Child
                           • Motor Movement-
                                                            • Initially combative (fight or flight) to
                             Infant
                                                              source of pain
                              – Response not
                                                                –kicking, thrashing part or entire body
                                localized
                                                            • Increased muscle tone
                              – Entire body
                                startle-like                • Wariness to being moved
                                movement with               • Limit movement of affected area
                                outstretched, rigid             –holding, rubbing of affected area,
                                limbs, tremors.                   rocking, very still




       Behavioral Response
                                                            Physiological Response
• Activity/Environmental Interaction
                                                                                • Also includes:
  – Irritability, restlessness, agitation, combative
                                                                                  – Dilated pupils
  – Initially may be hyperviligent but as pain         • Vital signs
    continues...                                                                  – Changes to skin
                                                         – HR                       blood flow-pallor
  – Withdrawn, lack of expression, lack of
                                                         – RR                       or flushing
    interest in surroundings or parents
                                                         – B/P                    – Perspiration
  – “Psychomotor interia”
                                                         – O2 saturation            especially on
  – Sleep and sedation are not indicative of no                                     hands, forehead
    pain or pain relief
                                                                                  – Nausea/vomiting




                                                                                                          2
    Physiological Response
                                               • Assume pain is present and give
• “At present, no one physiological              analgesic and sedation
  measure is suffienct to capture the pain           – Understand physiology of condition
  experience.”
       – Sweet & McGrath, 1998
                                               • Absence of vital sign changes does not
                                                 indicate absence of pain




  Behavioral & Physiological
                                                                  Special Challenges
         Responses
• More pronounced with acute pain              •   Pre-verbal Infant
• Under rate persistent pain                   •   Mechanically Ventilated Child
• Pain needs to be differentiated from         •   Chemically Paralyzed Child
  other reasons for behavior or                •   Neurologically Impaired Child
  physiological change & treated as
  specific entity




         Preverbal Infant                                                 FLACC Scale
                                               Catagory                                      Score
         Non-verbal Child
                                                                  1                          2                            3
                                               Face               No particular              Occasional grimace           Frequent to constant
• Use tool specific for age/condition                             expression                 or frown, withdrawn,
                                                                                             disinterested
                                                                                                                          quivering chin,
                                                                                                                          clenched jaw
                                               Legs               Normal position            Uneasy, restless,            Kicking, or legs
  – Be sure patient able to respond to all                        or relaxed                 tense                        drawn up
    categories of behaviors listed             Activity           Lying quietly,
                                                                  normal position,
                                                                                             Squirming, shifting
                                                                                             back and forth,
                                                                                                                          Arched, rigid or
                                                                                                                          jerking
                                                                  moves easily               tense
  – Focus on present behavior & observe for    Crying             No cry (awake or           Moans or whimpers;           Crying steadily,
    changes in those behaviors with                               asleep)                    occasional
                                                                                             complaint
                                                                                                                          screams or sobs,
                                                                                                                          frequent complaints
    interventions                              Consolability Content, relaxed                Reassured by
                                                                                             occasional touching,         Difficult to console
                                                                                             hugging or being             or comfort
                                                                                             talked to, distractible

                                              Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is
                                              scored from 0-2, which results in a total score between 0 and 10.




                                                                                                                                                 3
 Chemically Paralyzed Child                                Neurologically Impaired Child
• Neuromuscular blocking agents                            • Neurological disease may change pain
  suppress any pain behaviors                                perception, nature of response,
                                                             language used to express pain, &
• Vital signs only parameter for
                                                             understanding of pain itself
  assessment
     • Heart Rate increase
        – preterm infant-decrease HR                       • Use caregivers to help interpret
     • B/P increase > 30% above baseline                     behaviors & note cues for pain on Care
     • SpO2 decrease > 5% below baseline
                                                             Record
     • Also increased gastric residuals, need for
       ventilator change, pallor, cyanosis, diaphoresis,
       tearing




 Neurologically Impaired Child                               Role of Clinical Expertise...
• “stiff, spastic, tense, rigid”                           • “…clinical expertise is a legitimate
     • McGrath et al, 1998                                   component of evidence-based
                                                             practice….Expert nursing judgment is
• clenched jaw, grinding teeth, rocking,                     not limited to observation of physiologic
  moaning                                                    cues; it also includes monitoring of the
                                                             child’s response to sedatives and
                                                             analgesia.”
                                                                • Foster, 2001, JSPN




                                                                     Common Pain Tools
                                                                • CHEOPS: Children's Hospital of Eastern Ontario Pain
                                                                  Scale (McGrath et al., 1985) (tested in 1 to 5 years of
• Analgesic Trial                                                 age; Post Anesthesia Care Unit, surgical pain)
  – empiric trial of pain medication if pathologic
    conditions or procedures likely to cause
    pain exist                                                  • COMFORT Behavior Scale (van Dijk et al., 2000,
                                                                  2005) (tested in neonate to 3 years of age; intensive
• monitor for changes at peak and trough                          care setting, surgical pain. Revised scale of
                                                                  COMFORT (Ambuel et al., 1992; Canenvale, &
  of drug action                                                  Razack, 2002) measures other constructs than pain
                                                                  (tested in newborn to 9 years of age, intensive care
                                                                  setting, mechanically ventilated).




                                                                                                                            4
            Common Pain Tools                                          Common Pain Tools
       • CRIES: (Krechel & Bildner, 1995) (tested in neonates;
         neonatal and pediatric intensive care setting, procedural
         and surgical pain)
                                                                       • PIPP: Premature Infant Pain Profile
                                                                         (Stevens, 1996) (tested in premature and
       • DSVNI: Distress Scale for Ventilated Newborn Infants
         (Sparshott 1996) (tested in ventilated newborns,
                                                                         term neonates; neonatal settings,
         intensive care setting; procedural pain)                        procedural pain)

       • FLACC: Faces, Legs, Activity, Cry, Consolability              • RIPS: Riley Infant Pain Scale (Schade et
         Observational Tool (Manworren & Hynan, 2003; Merkel             al., 1996) (tested in newborn to 3 years of
         et al., 1997; Willis et al., 2003) (tested in 2 months to 7
         years of age; Post Anesthesia Care, intensive care,
                                                                         age; acute care setting; surgical pain)
         acute care settings, surgical pain and acute pain)




                    References
• Foster, R. 2001. Nursing judgment: The key to pain
  assessment in critically ill children. JSPN 6 (2) 90-93.
• Herr, K., Patrick, J. C., Key, T., Manworren, R., et al. 2006.
  Pain assessment in the nonverbal patient: Position statement
  with clinical practice recommendations. Pain Management
  Nursing 7 (2) 44-52. On-line at:
  http://medscape.com/viewarticle/533939
• Kwekkeboom, K. L., & Herr, K. 2001. Assessment of pain in
  the critically ill. Critical Care Nursing Clinics 181-196.
• McGrath, P.J. 1998. Behavioral measures of pain. In G. A.
  Finley & P. J. McGrath (Eds) Measurement of pain in infants and
  children: Progress in pain research and management. (vol 10,
  pp. 83-102) Seattle: IASP Press
• Oakes, L.L. 2001. Assessment and management of pain in the
  critically ill pediatric patient. Critical Care Nursing Clinics




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