Acute Pain Assessment in Paediatric

The pain experience includes physiological, sensory, affective, behavioural, cognitive and sociocultural components. While in adults is more easy to assess the pain simptoms, in children pain assessment should consider age, cognitive level and the presence of eventual disability, type of pain and the situation in which pain is occurring. McGrath on the subject of assessment of pain in children states: ''Measurement of pain should be distinguished from the assessment of pain. Measurement refers to the application of a specific metric to a specific element of pain, usually the intensity of pain. Assessment is a much broader endeavor that includes the measurement of various elements that impact on the pain experience'' [4]. Despite this consideration, there are some commonly used methods of measurement of pain that have been proved to be reliable. Observational and behavioural measures consider child's reaction to pain. Self-report measures rely on the child's description of his experience of pain. Biological measures consider some physiologic parameters that may be modified by the presence of pain, such as heart and respiratory rates, blood pressure, etc. [5]. In infants and non-verbal children, self-report measures are unavailable, but behavioural indices (motor responses, vocalization, facial expressions, crying and complex behavioural responses such as the sleep-wake patterns) can be easily evaluated to assess pain. Different behavioural scales have been validated by several studies that enrolled infants and neonates [6, 7]. Behavioural

ITEM

BEHAVIOR

SCORE

DEFINITION

Cry

No try

1

Child ¡9 no! crying

Mowing

2

Child it meaning or quielly vocalizing jiltnl cry

Crying

2

Child IA crying, but the cry s gentle or whlmperng

Sc mm

i

Child ti In a lull-lunged cry; sobbing msytm scored witWwhilog! compi»«

Facia?

Compoaad

1

Neutral fecial expmi on

Grimace

2

Scar* on v if negative facial expression

Smiling

0

Score <xiry H definite pojrt.i-« (ecu) expression

Child verbal

Horn

1

Child nol telkrog

Cnhar complaint*

t

Child corspisinis. hut nol acout pjm

Pain complaints

Î

Ch Id compiamla about pain

Both eomplalntt

i

Child oompiarrHs about pain and aboul c'.h»"

thing)

PaeWve

0

Child makes any positive statement or' jlks about other things without comprint

Body

«KIM

1

Body (not limbs) is ai rest: torso it inactive

Sht/U1 ry

2

Body is is in motion in a shining or serpentine (athlon

Tanaa

2

Body is erched or rgid

Shtvatlng

1

Body is shuddering or shading Involuntarily

Upright

2

Child It Ifl a vertical or upright position

fte ttrttnad

2

Body Is restrained

Touch

Not touching

1

Child ts not touching or grafcbing at wound

Rtach

2

Child rt reaching for bul noi touching wound

Touch

2

Child is gontfly touching wound or wound area

Grab

2

Child n grabbing vigorously ai wound

Rmtralnad

2

Child's arms are restrained

Lag*

Neutral

1

Legs may be in any position but are relaxed

Squirming/

2

Definitive uneasy or restless movements In the legs or sinking out with feels

kicking

Drawn uprtwtaad

2

Legs tensed arxlior pulled up lightty lo body and kept there

Standing

2

Standing, emuchlng. or kneeling

Rattralnad

2

Child's legs are being held down

Fig. 1. CHEOPS Score. CHEOPS pain score: SUM (points for all 6 parameters), Minimum score: 4 (min pain); Maximum score: 13 (max pain)

Fig. 1. CHEOPS Score. CHEOPS pain score: SUM (points for all 6 parameters), Minimum score: 4 (min pain); Maximum score: 13 (max pain)

parameters, even if non-specific, may be usefully associated to physiologic parameters such as heart rate, cardiac rate, arterial blood pressure, transcutaneous oxygenation and palmar sweating [8-10]. The Children's Hospital of Estern Ontario Pain Scale (CHEOPS) is one of the commonest scales used for postoperative pain management (Fig. 1) [11]. Parents who are able to assess behavioural changes related to discomfort or pain may help differentiate pain from anxiety or stress due to other causes [12, 13]. Children aged 3 to 7 years are increasingly able to describe pain characteristics. Observational scales as well as self-report scales represent useful tools to assess pain in this period of life. Composite measures of pain have been developed combining behavioural and biological items, such as the Objective Pain Scale and the Comfort Scale (Figs. 2, 3). The Objective Pain Scale is used to assess both physiologic parameters and behavioural changes in children that may be modified by the presence of pain or discomfort after procedures and/or postoperative interventions [14, 15]. The Comfort Scale is used to assess the level of sedation and distress in the paediatric intensive care unit, but recent studies have validated this measurement method also in procedural and postoperative pain [16, 17]. Self-

Parameter

Finding

Points

Systolic blood pressure

increase < 20% of preoperative blood pressure

0

increase 20-30% of preoperative blood pressure

1

increase > 30% of preoperative blood pressure

2

Crying

not crying

0

responds to age appropriate nurturing (tender loving care)

1

does not respond to nurturing

2

Movements

no movements relaxed

0

restless moving about in bed constantly

1

thrashing (moving wildly)

2

rigid (stiff)

2

Agitation

asleep or calm

0

can be comforted to lessent the agitation (mild)

1

Cannot be comforted (hysterical)

2

Complains of pain

Asleep

0

states no pain

0

Cannot localize

1

localizes pain

2

Fig. 2. Objective Pain Scale (OPS). Minimum score: 0; Maximum score: 10, Maximum score if too young to complain of pain: 8, The higher the score the greater the degree of pain report measures of pain represent the gold standard in older children who can describe the subjective pain experience [18, 19]. These methods include different strategies such as routine and direct questioning, verbal and non verbal methods (i.e. pictorial scales) and self rating scales. Visual Analogue

ALLERTNESS

Time

Deeply asleep

1

Lightly asleep

2

Drowsy

3

Fully Awake and alert

4

Hyper-alert

5

CALMNESS/AGITATION

Calm

1

Slightly anxious

2

Anxious

3

Very anxious

4

Panicky

5

RESPIRATORY RESPONSE

No coughing and no spontaneous respiration

1

Spontaneous respiration with little or no response to ventilation

2

Occasional cough or resistance to ventilator

3

Actively breathes against ventilator or coughs regularly

4

Fights ventilator; coughing or choking

5

PHYSICAL MOVEMENT

No movement

1

Occasional, Slight movement

2

Frequent, Slight movement

3

Vigorous movement limited to extremities

4

Vigorous movement including torso and head

5

BLOOD PRESSURE (MAP) BASELINE

Blood pressure below baseline

1

Blood pressure consistently at baseline

2

Infrequent elevations of 15% or more (1-3)

3

Frequent elevations of 15% or more (more than 3)

4

Sustained elevation > 15%

5

HEART RATE BASELINE

Heart rate below baseline

1

Heart rate consistently at baseline

2

Infrequent elevations of 15% or more above baseline (1-3) during observation period

3

Frequent elevations of 15% or more above baseline (more than 3)

4

Sustained elevation > 15%

5

MUSCLE TONE

Muscles totally relaxed; no muscle tone

1

Reduced muscle tone

2

Normal muscle tone

3

Increased muscle tone and flexion of fingers and toes

4

Extreme muscle rigidity and flexion of fingers and toes

5

FACIAL TENSION

Facial muscles totally relaxed

1

Facial muscle tone normal; no facial muscle tension evident

2

Tension evident in some Facial muscles

3

Tension evident throughout Facial muscles

4

Facial muscles contorted and grimacing

5

Fig. 3. The Comfort Scale

Adapted r:OT L^CanervM Beetle A Pam. Clinical Manual'ar Nvrs'na Pracïcft SL Louts. MO CY MûïiïvCii 1M9 WW (ritn permission May w oui*cat«i a^ u5«iincinic3»c<ac(co

& 1

h.

3 4 5

¿ 1

k

9 i'o

No Pain

Mild

Discomforting

Úistiessing

Horrible

tuera elating

This scale incorporates a visual analogue scale, a descriptive word scale and a colour scale all in one tool

This scale incorporates a visual analogue scale, a descriptive word scale and a colour scale all in one tool

Fig. 4. Visual Analogue Scale (VAS) and Facial Pain Scale

Fig. 4. Visual Analogue Scale (VAS) and Facial Pain Scale

Scale (VAS) and Facial Pain Scale are two of the commonest self rating scales to assess pain intensity in children (Fig. 4) [20, 21]. In the VAS children rate the intensity of pain on a 10 cm line anchored at one end by a label such as ''no pain'' and at the other end ''severe pain''. The scores are obtained by measuring the distance between the ''no pain'' and the patient's mark, usually in millimetres. The VAS has many advantages: it is simple and quick to score, avoids imprecise descriptive terms and provides many measuring points. Disadvantages are represented by the need of concentration and coordination, which can be difficult post-operatively or in children with neurological disorders. Self reported measures require a cognitive and linguistic development related to the capacity to answer to different questions. They are reliable to monitor pain relief in every single patient, while are less specific and effective if utilized to compare different patients. Self reported measures include categorical scales that use words (from four to five) to describe the magnitude of pain. However, in specific categories of patients, they are not useful. Faces scales represent another form of self reported measures: faces express different amounts of distress. The Facial Pain Scale is the commonest used in young children who may have difficulty with more cognitively demanding instruments. The original scale was composed by seven faces without an absolute meaning, but related to children's experience [20]. Different versions exist, based anyway on the same measurement principle [21, 22]. In figure 4 we report one of them more used in the clinical practice. The Oucher Scale is a variant of the faces scale and is designed to measure pain intensity in children aged 312 years [23]. Adequate paediatric pain assessment can improve comfort in ill children and avoids pain undertreatment in several cases. Pain should be measured routinely with appropriated tools related to age and disease. Simple pain measurement methods would improve not only pain relief in children, but would also decrease nurses and health professional workload and create a common language and an adequate communication among the medical and nurse staffs [24].

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

This guide will help millions of people understand this condition so that they can take control of their lives and make informed decisions. The ebook covers information on a vast number of different types of neuropathy. In addition, it will be a useful resource for their families, caregivers, and health care providers.

Get My Free Ebook


Post a comment