PAIN MANAGEMENT & MEDICATION ADMINISTRATION

TOPIC 2.5 & 2.6

SLO’S 2.5

 1. Compare the pain reactions of children, in various age groups.

 2. Describe pain assessment tools for children.
 3. Describe common pharmacological and non-pharmacological methods to manage pain in children.
 4. Utilize the nursing metaparadigm, nursing process, cultural competence, and growth and development theories
to determine appropriate nursing care to meet the expected outcomes of pain management in children and to assist
their families to cope with their child’s pain.
PAIN

 Subjective, unpleasant experience

 Pain can and does occur in children and babies
 Pain assessment is different in children
 Treatment may be similar or different
MANIFESTATIONS OF PAIN

 Crying
 Grimacing
 Guarding
 Staying still
 Fussing
 Restlessness
 Pulling on ears (otitis media)
 Withdrawing
PAIN IN INFANTS AND YOUNG CHILDREN

 Pain should be treated in children in these age groups

 Pain is experienced even by infants
 Look for changes in behavior to alert you to the presence of pain
 Changes in nutritional intake
 Excessive sleeping
 Repetitive behavior
 Acting out
ASSESSMENT OF PAIN

 Adapt to the child’s developmental level

 Child may be unable to rate pain or describe
it
 Many different assessment scales are
available
 Go over pain rating scales before surgery
 Don’t refer to “giving a child a shot” because
they may underreport pain
 Remember that pain is underestimated,
underreported, and undertreated
PAIN IN CHILDREN

 Complaints may be generalized

 May be unable to describe quality and/or location

 Use gentle assessment techniques to determine the location of the pain

 Tell them to let you know if it hurts, and that you will stop – and then FOLLOW THROUGH on
this
 Watch for referred pain
CAUSES OF PAIN

 Infectious process  Anatomical abnormality

 Appendicitis  Developmental dysplasia of the hip
 Osteomyelitis  Dysmenorrhea
 Tonsillitis  Idiopathic (“functional”)
 Injury  Abdominal pain
 Surgery  Migraines/headaches
 Fracture  Emotional discomfort expressed as pain
 Soft tissue injury
HISTORY AND NURSING CARING

 Onset
 Associated symptoms  Watch for manifestations of pain
 Vomiting  Ask about “where it hurts”
 Diarrhea  Use a term that is appropriate and that the child
 Coughing understands, such as “boo-boo”

 Activity disturbance  Tell them that you have medicine to help

 Waking up at night due to pain  Don’t wait for the child to ask
 Ask the child to jump if there is abdominal pain
PHARMACOLOGIC TREATMENTS

 Acetaminophen
 Ibuprofen
 Codeine and other narcotics/opioids
 NO ASPIRIN
 Remember weight-based dosing!
 Oral route is preferred
NARCOTIC ANALGESICS

 Not contraindicated in children

 Can be safely used without concern about respiratory depression
 PCA may be used in children 5 and up
 Reassure parents about addiction concerns
CONSCIOUS SEDATION

 Used for some ambulatory procedures

 Monitor respiration
 Monitor level of consciousness
 Emergency equipment should be available
TOPICAL ANESTHETICS

 EMLA cream may be used

 Apply at least 1 hour prior to procedure
 You can call it “magic cream”
 Injectable anesthetics may be used prior to a procedure such as IV insertion
 Make sure EMLA is used first
PHARMACOLOGIC VS NON-PHARMACOLOGIC TREATMENTS

Pharmacologic Non-Pharmacologic
 Use resources available on the unit  Distraction

 Weight based in pediatrics  Warm blanket

 Swaddle babies
 Teach children about side effects in words they
can understand  Cuddle with parent
 Thought-stopping
 Music
 Guided imagery
 Heat/cold
 CHARTING EFFECT

 May not be able to use pain scale

 Look for behavior changes
 Settled
 Sleeping
 Not crying
 Playing

“Child stated pain was 3 out of 4 poker chips. Morphine __ mg given IV in volutrol. Returned at __ time to check on child –
child sitting with mother listening to a story, not crying. PRN deemed effective.”
EDUCATION

 Explain what you’re doing to the parent

 Explain pain-related behaviors to the parent
 Educate parents as to safe medication use
 Educate older children as to the causes of pain
WARNING SIGNS

 Severe pain unrelieved by medication

 Pain accompanied by seizures, stiff neck
 Bulging fontanelles
 Pain that wakes a child up at night
 Rebound tenderness in the abdomen
QUESTION

 A 5-year-old boy has been crying when the nurse enters the room. He denies having any pain, although he is
cradling his fractured left arm. What would be the most likely reasons he denies having any pain?
A. He received an injection in the emergency room.
B. He thinks he needs to be brave.
C. He is afraid of going to sleep.
D. He is afraid of the nurse.
QUESTION

 Conscious sedation is a pain-management technique that is used with children. During conscious sedation for a
preschooler, which of the following actions would be most important?
A. Keeping the room absolutely quiet so the child can sleep.
B. Assessing vital signs frequently, because they can become depressed.
C. Asking the child to periodically count from 1 to 10.
D. Keeping the child’s head in a dependent position.
MEDICATION ADMINISTRATION
TOPIC 2.6
SLO’S TOPIC 2.6

 1. Calculate safe doses for medication administration to children.

 2. Identify age-appropriate routes and techniques for administering medication to children.
 3. Utilize the nursing metaparadigm, nursing process, and growth and development theory to determine
appropriate nursing care to meet the expected outcomes for children and their families regarding medication
administration.
 4. Describe the teaching needs of children who are receiving medications, and their families.
MEDICATION ADMINISTRATION

 Most children don’t like to take medication

 Medication administration factors:
 Age of child
 Special needs
 Type of medication
 Dosage calculations
 Weight of child
 Safe dose ranges
PHARMACOKINETICS

 Absorption?
 Distribution?
 Metabolism?
 Excretion?
CONTRAINDICATIONS

 Some medications are contraindicated in children:

 Tetracycline - contraindicated in children under 7 years of age. It may cause permanent staining of the teeth.
 Cold medications in children <5
 Antidepressants should be used cautiously due to increased suicide risk.
 Aspirin (with the exception of Kawasaki disease)
ADVERSE EFFECTS

 Watch for problems in newborns and breastfed infants

 May be processing medications absorbed in utero or from breastmilk
 Withdrawal symptoms may occur

 Watch for idiosyncratic reactions (unusual reactions that are not expected).
 Antihistamines can cause hyperactivity in some children.
 Clarithromycin can cause vomiting in children but not typically in adults
MEDICATION SAFETY

 Ten rights
 Make sure the medication room is locked
 Educate parents about medication safety in the home
 Medications kept away from children
 Monitor levels of OTC and prescription medications available if there are adolescents in the home; some medications may be
abused
DOSAGE CALCULATION

 Usually weight-based
 Weight is a vital sign in children
 Be precise – small errors can be magnified in children
 Have your calculations double-checked
ORAL MEDICATION

 Liquids
 Concentrated drops
 Syrups

 Chewable tablets
 Non-chewable tablets
 May be crushed – check the tablet
GIVING ORAL MEDICATIONS

 Oral syringe
 Inject slowly into the side of the mouth
 Don’t draw up more than you need

 Medication cup
 Offer a “chaser” if not contraindicated
 Offer the child a choice of what to drink, if possible
TIPS AND TRICKS

 Crush non-chewable tablets in a small amount of soft food

 Make sure you supervise the child taking medication
 NEVER call a medication “candy”
 Reward charts can be helpful for young children
 Don’t give the child a choice about taking the medication
 Provide comfort and praise afterward
 NEVER indicate that an injection will be used as a punishment or a threat
IM INJECTIONS VS S INJECTIONS

IM Injections SC Injections
 Use a large muscle mass  Arm or abdomen
 Use a 1-inch needle  Have parent hold child as described for
 Consider going to a treatment room IM
 Have the parent hold the child  For all injections:

 Sites and amounts?

IV MEDICATIONS

 Carefully check your guidelines

 Use a Buretrol/Volutrol set
 Have your calculations double-checked
 Follow your agency policy
 IV’S IN CHILDREN

 Hand or arm is the most common site

 Foot may be used – check agency policy
 Secure the IV carefully
 You may need an arm board with burn mesh and a
paper cup so the child won’t pick at the site http://what-when-how.com/nursing/fundamentals-of-pediatric-nursing-pediatric-nursing-part-3/
 Arm boards also help a child remember to keep an arm
still
 Check it at least every 1 hour
 IO route may be used if IV access is not available
 Any IV medication can be given IO

https://www.aplsonline.com/Module4/05_Skill_Stations/03_Skill_Stations/03_Cardiovascular_Proc/02_CardioSkill_1.pdf
 CENTRAL LINES

 May be used for long-

term infusion therapy
 Advise child and
parents regarding care
 Reassure the child that
the line can be hidden
by clothing
 Use EMLA cream for a
Port-A-Cath

Images:
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INHALED MEDICATIONS

 MDIs/DPIs/Turbuhalers
 For older children
 A spacer may be used
 Adult doses are used
 Teach appropriate inhalation technique

 Nebulizers
 For babies and very young children
TIPS AND TRICKS

 Have a parent hold a nebulizer for a young child

 Try to administer a nebulizer while the child is asleep – parent to hold the neb mask
 Teach older children how to use inhalers properly
 Always double-check pulse after giving a bronchodilator or racemic epinephrine
 May cause tachycardia
ADMINISTERING DROPS
Eye Drops
 This can be a toughie
 Young children can be held:
 Parent sits on ground with legs spread
 Hold the child so head is between parent’s legs and
arms are covered by parent’s legs
 This frees up the arms to hold the eye open and give the
drops
 A mummy wrap may also be helpful
Ear Drops
 Should ONLY be used for otitis externa
 May need help to hold the child on his/her side
 NEVER put the dropper directly into the ear
 NEVER give ear drops if the tympanic membrane is
not intact
 Ask about myringotomy tubes put in to drain fluid
TOPICAL MEDICATIONS

 Use steroids sparingly

 NEVER use strong steroids on a child

 Rub well into the affected area

 Let the child help with supervision
 Wash their hands afteward

 Cover with a Tegaderm if indicated

 This works well for EMLA cream
 Cover a patch with the child’s clothes so they won’t pull it off
ENEMAS/SUPPOSITORIES

 The parent’s help may be necessary

 Ensure that you have a bedpan close
 Never insert too far
TECHNIQUES FOR MEDICATION ADMINISTRATION

 Use age-appropriate explanations

 Get a staff member to help you
 The parent may not want to be involved so that he/she can provide support to the child afterward
QUESTIONS?