Historical Perspective
Misconceptions about pain in childrenTaxonomyCase Study4 Components of the Pain Experience
Myth: CNS is Immature in kids so they don’t feel pain as much
Fact: All structures are in place for the transmission of pain by the 30th week of gestation.
Fact: substance P (neurotransmitter for pain) -16 wks; cutaneous sensory receptors - 20 wks; synaptic connections -24 wks; nociceptive nerve tracts completely myelinated-30 wks
Taxonomy
NociceptionPlasticityGate Control TheoryAddictionPhysical DependenceChronic painAcute pain
Expansion of Receptive field size
Sleeping nociceptorsSensitization
Nociception
“the activity produced in the nervous system by potentially tissue-damaging stimuli”
OR
* “the activation of nerve axons by thermal, chemical or mechanical energy sufficient to threaten the integrity of the cell”
Plasticity
Different responses to the same stimulus, presumably as a result of different environmental & psychological factors that can moderate the signals initiated by noxious stimuli & thereby change the individual’s perception & experience of pain
The younger the organism, the greater the plasticity!
Gate Control Theory
Ascending & descending pain-suppressing or pain-enhancing systems are activated by situational factors
Physical Dependence
A physiological state in which the body develops a need for the opioid drug in order to maintain equilibrium. Manifested by a drug-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, &/or administration of an
antagonist. Does NOT = addiction.
Addiction
Refers to overwhelming preoccupation with obtaining and using a drug for its’ psychic effects, not for pain relief
Include one or more of the following:impaired control over drug use, compulsive use, continued use despite harm, and craving (4 Cs)
EQUIANALGESIA
Refers to the fact that, when substituting one drug for another, use an equianalgesic chart so that the pain-relieving effects of the new drug will deliver the same response.
Overwhelmingness of the Pain Experience
Physiological disequilibrium
Behavioral disorganization
Long term consequences of under-treated pain
Overall stress response
Narcotics Always depress respirations in kids
Pain is a potent respiratory stimulantRespiratory tolerance escalates along with
the need for medicationSedation level check very important
The best way to administer analgesia is by injection-not!
IV bolus gives a predictable peak action & duration of action.
IVCD provides a steady blood level without peaks & valleys with their accompanying SEs.
Infants & children don’t remember pain
Remembered pain & currently experienced pain are different
Infant with heel stickAversion/anticipatory
vomiting
Children can’t tell you where they have pain
Good assessment skills are the cornerstone of adequate pain management
4 components of pain
NociceptionPainSufferingPain behaviors nociceptionnociception
pain
suffering
Pain behaviors
Definition of pain
“Pain is whatever the experiencing person says it is, existing wherever and whenever he or she says it does.” (McCaffery)
Chronic Pain: Pain that has outlived it’s usefulness
Acute Pain: An adaptive, beneficial response necessary for the preservation of tissue integrity
Topicals
ANE-cream (no-scream Cream)/proper application
Pain-EaseNew trials coming
up, new products; zingo, synera,etc
Sweet-ease-new P&P
TJC standards
Recognize the right of pts. to appropriate assessment & management of pain.
Screen for existence, nature & intensity of pain.
Make pain management a priority
Perform a comprehensive pain assessment; if pain is present, include location, quality, onset, frequency & intensity
Record results of assessment in a way that facilitates regular re-assessment & follow-up.
Determine & ensure staff competency in pain assessment & manage-ment. Address competency in orientation & continuing education.
Establish P&Ps that support attentive & aggressive pain management
TJC standards (cont’d)
Educate pts & families about importance of effective pain management.
Promise pts. effective pain relief upon admission.
Remember, while TJC accredits health care organizations, it is individual healthcare providers who manage pain.
Address pt needs for symptom management in discharge planning.
Include pt. outcomes in measuring effectiveness of pain assessment & management.
Ethical Considerations
As nurses we are bound morally and legally to act as patient advocates.
Thus, not to do good (beneficence=relieving pain), avoid harmful conditions (non-maleficience), or include pts in their own plan of care (respect for autonomy) is clearly unethical behavior.
Steps to take
Believe the patient!!! Preventive approach is
best.Rethink the meaning of prn>ATC
Treat anxiety & teach colleagues;empower & teach parents & pts about pain & rx
Involve pts/parents in the plan of care; initiate standardized MPC if pt. c/o pain
Use equianalgesia charts
Use a combination of strategies, pharmacological & non-pharmacological.
Don’t forget palliative care team!
Make a commitment to be aware of current trends in assessment & treatment of pain in children.
Make pain management a priority.