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2. Assessment and Diagnosis of Pain in Children
Children have the ability to feel pain. Infants feel more pain than do older children and adults because they lack the physiological ability to block the transmission of pain. Pain should be assessed, treated, and prevented as much as possible in all children. A diagnosis of HIV-infection in a child is not a contraindication to treatment.
Painful experiences in children should be anticipated and prevented as much as possible. Studies have shown that children as young as two to three days of age remember painful experiences as documented by their reactions to later painful experiences. Studies have also shown that children who are not medicated prior to their first painful experience never rate subsequent painful experiences (even though they are medicated) as mildly as children who are medicated prior to their first painful procedure. Children as young as three years of age can be taught to tell us where they are hurting and how much they are hurting. We have to learn to ask the right questions and use the right assessment tools. Some barriers to pain assessment may exist. These include:
1. Some children will lie because they know the consequence of disclosing pain is receiving an injection. They do not have the ability to rationalize that the little discomfort they will experience from the injection is going to take away the greater pain they are experiencing.
2. Some children, adolescents, and parents think health professionals know when they or their child is in pain and that the health professional will medicate them if necessary.
3. Some parents may believe that the doctors and nurses know what is best for their child and they will not ask for additional pain medication because they believe that if the doctor or nurse does not offer pain medication, the child does not need it.
4. The myth that children get accustomed to painful procedures. Children do not get accustomed to painful procedures no matter how many times they have endured the pain.
When assessing pain it is important to remember that behavioral manifestations may not accurately reflect pain or lack of pain. Behavioral styles may influence the care provider in her decision on whether or not to medicate, but this type of assessment should not be used. Some children may have a high intensity style, and this may influence a nurse to medicate him as opposed to medicating the high activity child, because the high intensity child may be crying and screaming, whereas the high activity child is in the playroom running and jumping. The high activity child may be in as much pain as the high intensity child. A child’s developmental level, coping abilities, cognitive level and temperament are all components of a child’s behavioral style.
Self-report is the best indicator of pain. The approach to pain management should be family centered. Parents know their child best and can tell the health professional about different coping styles their child may have. Parents are a comfort to their child and should be included while the child is having a painful procedure. Teaching the parent what to expect during a procedure and how she can help her child is helpful in decreasing the parent’s anxiety. If the parent is less anxious she will be more effective in helping her child through the painful procedure.
Pain is whatever the person experiencing it says it is. There are multiple ways of assessing pain in children. You may question the child and the family. You may teach the child to use a pain scale. You may evaluate behavior and physiologic signs. Pain assessment scales should be used before the child is in pain. The scale appropriate to the child’s cognitive level should always be used. The scale should be convenient to use. There are several different types of pain scales: FACES Pain Rating Scales, Oucher, Poker Chip Tool, Word-Graphic Rating Scale, Numeric Scale and Visual Analogue Scales.
Facial expression is probably one of the easiest scales to use universally. The only word you have to know to use it is the word pain in the language specific to the child, and he will know what to do with it. The Facial Pain Rating Scale developed by Wong and Baker is one such scale. It can be used with children as young as 3 years of age.
How is pain assessed when the child is too young to speak or complete a pain assessment scale? Studies have shown that vital signs are not good indicators of pain because the body cannot stay in a high state of stress for very long, and vital signs will adjust accordingly even if pain is present. Stress hormones can be measured and they could indicate if pain is present, but unfortunately they are expensive to measure. Blood glucose can be measured easily and is inexpensive and is a good indicator of pain. If the blood glucose is high, there is very good chance that the child is in pain.
Behavioral changes do occur when pain is present. Look for some of these signs. A child may lie very still in bed trying to avoid being moved or picked up because he has learned that lying still decreases his pain. A child with ear pain may pull at his ears. A child with abdominal pain may hold his knees to his chest. There is a universal facial expression for pain in infants. The forehead becomes wrinkled with furrows, the eyes are kept tightly closed, the nose bulges, the nasal labial fold becomes deep, the mouth is open and squarish, and when the baby cries the tongue quivers.
When assessing pain in children it is important to use logic. If you are going to do something to a child that will cause you pain, it is going to cause pain in the child. Remember to try to prevent pain and to try to control it as much as possible.
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