Pain Management

Objectives
1.
2.

3.

Define Pain
Review basic principles of
pain assessment
Discuss Interventions
1.
2.
3.

Non-pharmacological
Pharmacological
WHO Principles of
Pediatric Acute Pain
Management

What is Pain?
Pain is whatever the person experiencing it
says it is, existing whenever the person says
it does. (McCaffery, 1999)
Pain is a subjective experience and is probably
the most bewildering and frightening
experience kids will have.

Tipes of Pain
Acute Pain

1.

brief duration:
usuallyless than 3
months
Identifiable cause /
injury / surgery or
disease
predictable end
subsides with healing

2. Chronic Pain
Peristent pain lasting
longer than 6 months that
is generally associated
with a prolonged disease
process

Barriers

Myth that children and especially infants do not feel

pain the same as adults
No untoward consequences to not treating pain
Lack of assessment skills
Lack of pain treatment knowledge
Notion that addressing pain takes too much time
Fears of adverse effects of analgesia respiratory
depression, addiction
Personal values and beliefs; i.e. pain builds character
AAP 2001 Task Force on Pain in Infants, Children and Adolescents

Consequences of Pain
Endocrine:
stress hormone, metabolic rate, heart
rate & water retention
Immune:
Impaired immune functions
Pulmonary:
flow and volume retained secretions and
atelectasis

Cardiovascular:
cardiac rate
systemic vascular resistance
peripheral vascular resistance
coronary vascular resistance
blood pressure and myocardial
oxygen consumption
Gastrointestinal:
Delayed return of gastric and bowel
function
Musculoskeletal:
Decreased muscle function, fatigue and
immobility

Principles

Children often cannot or will not report

pain to their health care providers
Routine assessment increases the
health care professionals knowledge of
the child which, in turn, optimizes the
assessment of pain and its subsequent
management

Principles

Unrelieved pain has negative physical and

psychological consequences
Prevention is better than treatment
Successful assessment and control of
pain depends partly on a positive
relationship between the health care
professionals and the children and their
families.

Principles
Techniques are now available that make
pain reduction to acceptable levels a
realistic goal in the majority of
circumstances

Factors that Modify Pain

Perceptions

Age
Cognition
Gender
Previous pain experience
Temperament
Cultural and family factors
Situational factors

Personalizing the Approach

Tailor assessment strategies to the childs

developmental level and personality style
and to the situation
Obtain a pain history from the child and/or
the parents.
Learn what word that child uses for pain
(hurt, boo-boo, owie)

Personalizing the Approach

Elicit from the family culturally determined

beliefs about pain and medical care
Measure the childs pain using self-report
and/or behavioral observation tools.

Infants
There is not easy or scientific way to tell
how much pain an infant is having

Not crying
Moaning or quietly crying
Gently crying or whimpering
Stop crying when picked up and comforted
Not stop crying when picked up and
comforted

Toddlers

May become very quiet and inactive

while in pain or may become very active
May use only one word (owie, booboo)
Parents report that they arent acting like
they normally do

Behavioral Observations
Use behavioral observation with preverbal and
nonverbal children

Vocalizations
Verbalizations
Facial expressions
Motor responses
Body posture
Activity
Appearance

Behavioral Observations
Interpret behaviors cautiously
Use parents report of pain when the child is
unwilling or unable to give a self-report
Use physiologic measures (eg. Heart rate and
blood pressure) only as adjuncts to selfreport and behavioral observation (neither
sensitive nor specific as indicators of pain)

School-age and Older

Can often tell you more about pain

using units of measure (0 is no pain
and 5 is bad pain)
Can color on body outlines where they
hurt and show parents and health care
providers where they hurt

Adolescents

Can explain pain more clearly

because they understand words and
concepts that younger children dont
They can use specific words to
describe the character of the pain

ASSESSMENT
The single most reliable
indicator of the existence and
intensity of acute pain - and
any resultant affective
discomfort or distress- is the
patients self-report

PQRSTU
mnemonic
1.
2.

3.
4.

5.

6.

Provocative/Palliative factors (For example, "What

makes your pain better or worse?")
Quality (For example, use open-ended questions such
as "Tell me what your pain feels like," or "Tell me
about your 'boo-boo'.")
Region/Radiation (For example, "Show me where your
pain is," or "Show me where your teddy hurts.")
Severity: Ask child to rate pain, using a pain intensity
scale that is appropriate for child's age,
developmental level, and comprehension.
Consistently use the same pain intensity tool with the
same child.
Timing: Using developmentally appropriate
vocabulary, ask child (and family) if pain is constant,
intermittent, continuous, or a combination. Also ask if
pain increases during specific times of the day, with
particular activities, or in specific locations.
How is the pain affecting you (U) in regard to
activities of daily living (ADLs), play, school,
relationships, and enjoyment of life?

Goal of Pain Rating

Scale
Identify characteristics of pain
Establish a baseline assessment
Evaluate pain status
Effects of intervention

Wong Baker Faces

Interpretation
0
= Relaxed and comfortable
1-3 = Mild discomfort
4-6 = Moderate pain
7-10 = Severe discomfort/pain

Interventions
Guiding principles
Minimize intensity and duration of
pain
Maximize coping and recovery
Break the pain-anxiety cycle

Therapeutic Alliance
l

Pain is managed within a therapeutic alliance

among the child, his or her parent, nurses,
physicians, and other health care
professionals

Non-pharmacological

No pharmacological
intervention
should be provided
without a
non-pharmacological
intervention
Julie Griffiths

Pharmacological

World Health Organization (WHO)

Principles of
Pediatric Acute Pain Management

By the clock
With the child
By the appropriate route
WHO Ladder of Pain Management

By the Clock
Regular scheduling ensures a steady
blood level
Reduces the peaks and troughs of PRN
dosing
PRN = as little as possible???

With the Child

Analgesic treatment should be
individualized according to:

The childs pain

Response to treatment
Frequent reassessment
Modification of plan as required

Correct Route
Oral
Nebulized
Buccal
Transdermal
Sublingual
Intranasal
IM
IV / SC
Rectal

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