Pain Management For The Pediatric Emergency Department

Optimal postoperative pain control is of utmost importance in the surgical population. 1-2 Analgesic techniques in paediatric patients having surgery are often delayed by the inherent difficulties of conducting a large randomized clinical trial in those patients. 3,-4 The optimal dose of local anaesthetics in paediatric regional anaesthetic techniques remain unknown. 5- 6

In a study conducted by Hatfield and Young (2007), 1,727 procedures such as venipuncture, intravenous (IV) catheter placement, intramuscular (IM) injections, urinary catheterizations, and nasogastric tube placement in 1,210 children have been reviewed. Their findings reveal that almost none of the patients received pain management. Although traumatic for the patient, these procedures are considered to be minor by many nurses, and the culture of pain management has not been seen as the standard of care (Hatfield & Young, 2007). Nursing staff is encouraged to change the culture by embracing their role as patient advocate. Every patient deserves a triage pain assessment with ongoing assessments as necessary. Pain control measures must be implemented prior to beginning potentially painful procedures. Discussion must take place between the parents and healthcare staff in order to deliver the best comfort measures on a case-by-case basis.

The practice of patient-controlled analgesia (PCA) has been around for approximately four decades now. During this time there have been improvements to the technology and the understanding of how to use this form of patient pain control; however, there continues to be concern related to the safety and efficacy of PCA. As this analysis proceeds it will briefly explain what PCA is and how it is used, then delve into the benefits and the safety issues surrounding PCA use as it pertains to the patient and the nurse. Some of the benefits of PCA include improved pain management, improved use of nursing resources, increased patient satisfaction, and reduced pulmonary issues (Hicks, Sikirica, Nelson, Schein & Cousins, 2008). Some of the safety

According to surveys, up to 80% of patients reported moderate to severe post-surgical pain, which can sometimes be left undertreated (Sinatra et al., 2005). Postoperative pain is generally managed with opioids, which carry numerous side effects. Side effects can be bothersome and possibly cause a delay in the postoperative healing process (Beard, Leslie, & Nemeth, 2011). IV acetaminophen can possibly decrease opioid consumption, minimize side effects, increase patient satisfaction, and decrease costs (Wininger et al., 2010). The purpose of this paper is to dive further into the research to present data on the effectiveness of IV acetaminophen in decreasing opioid usage and whether it produces an additive effect causing more effective pain management in the postop patient.

This paper is a research critique of the article titled, “ Effect of distraction on children’s pain during intravenous catheter .” Sadeghi, Mohammadi, Shamshiri, Bagherzadeh & Hossinkhani (2013) conducted the study using a soft ball for the children to press during intravenous catheter insertion. This paper will critique the design, sample and setting, ethical considerations, data collection and analysis, and the results with recommendations of the researchers.

Despite recent advances in information regarding perioperative care, postoperative pain continues to go undermanaged. Postoperative pain is the pain patients experience after a surgical procedure. According to Gan, 80% of all people who undergo surgeries experience postoperative pain, and 75% of them rate their pain at a moderate, severe, or extreme level (as cited by Cooney, 2016). Furthermore, inadequately managed pain can lead to patient dissatisfaction, decreased patient outcomes, and overall higher cost of care (Penprase, Brunetto, Dahmani, Forthoffer & Kapoor, 2015). In order to provide higher quality pain management,

Neonates were once thought to be too developmentally immature to experience pain, it has been now understood that neonates even if very premature are able to process pain sensations and respond to that pain (Boyle, 2011). Although it is now understood that neonates can sense pain, it has been found that procedures have not changed to adequately address pain in the neonate. It has been found that pain in neonates that is over a long period or multiple acute pain experiences has long term effects on how pain is perceived into childhood (Boyle, 2011). One intervention that has been found to decrease pain experienced by a neonate is sucrose. It has been found that sucrose takes about two minutes to take effect and provides an analgesic

There are a number of ways to assess pain in paediatric patients. These assessment methods can be broadly defined as self-report, behavioural observation and psychological observation. They should be used in combination with each other, as they have varying levels of reliability due to the influence of other factors that are unrelated to pain.

Chronic, acute, somatic and oncologic are all types pain - each with their own symptoms, reliefs, and evaluations. As pain has been explored, we have learned more about it; however, it remains an anomaly. In the postoperative setting, nurses are the first line of pain management. Their assessments of the patient’s pain, including questions and scaling is imperative when dosing medications and evaluating the patient. Studies continue to determine that healthcare providers undertreat and mismanage pain control and assessment. According, to the American Society of Interventional Pain Physicians, “80% to 90% of physicians have had no formal training in prescribing controlled substances, and only five out of one hundred thirty-three medical schools in the U.S. have required courses on pain management” (Glowacki, p. 37). The American Nurse Credentialing Center reported that “as of 2013, only one thousand six hundred seventy two registered nurses in the U.S. were certified in pain management” (Glowacki, p. 37). According to the CDC, about 50% of postoperative patients report unrelieved pain (Centers for Disease Control and Prevention, 2013). Effective postoperative pain control is necessary for successful care and treatment. Inadequate relief of postoperative pain can contribute to postoperative complications such as atelectasis, deep vein thrombosis, and delayed wound healing (Francis &

The management of postoperative pain has received much interest nowadays. The intensity of postoperative pain depends on many factors such as type and duration of the surgery, type of anesthesia and analgesia used, and the patient’s mental and emotional status (11).

According to John Hopkins Medicine (n.d.), pain is an uncomfortable feeling that tells you something may be wrong. It can be fixed, throbbing, stabbing, aching, pinching, or described in many other ways. Pain is categorized as either acute or chronic. Acute pain is usually severe and brief, and is often a signal that your body has been injured. Chronic pain can vary from mild to severe and is there for long periods of time (John Hopkins Medicine, n.d). This paper will discuss a scenario that entails which person is experiencing the most pain, how two people can have the same procedure experience different levels of pain, factors that contribute to each person’s pain level, and two complementary/alternative methods of pain control.

Pediatric pain management is measured subjectively because it is based off of what the patient says or how the nurse interprets the pain scale. Pain is rated using different scales, unfortunately these different scales could yield different results. Nurses are trained to use pediatric pain scales to analyze and treat pain but parents are not supplied with the tools to manage pain when the patient goes home. With 84% of all pediatric surgical procedures performed on an outpatient basis, the importance of teaching parents how to assess for and manage pain has become more important than ever (Rony, Fortier, Chorney, Perret, & Kain, 2010). According to Rony’s et al. (2010) study, it is apparent that pediatric pain is not being treated effectively. The study showed that 58.8% of children were receiving less than the daily recommended does prescribed by the pediatrician (p.1). Results of the study also showed that parents had false assessments on if their child was actually in pain. 36% of parents believed that if their child was in pain, they would cry out for the parent , 30% agreed that their child would always tell them if they are in pain, while 22% said that the child would report their pain immediately (Rony, Fortier, Chorney, Perret, & Kain, 2010, ). Children do not always verbalize when they are in pain. Sometimes the pain can be so intense that a child is unable to talk. If the child catches on to the parents negative perception of pain medications, the child may not

Policies and resources are important tools to use for guidance on developing a plan of care for pediatric pain management. Nurses must look at their hospital policies to determine the appropriate actions to take. The Doernbecher Children’s Hospital in Oregon developed a policy using a multi-modal approach for the staff to follow. A multi-modal approach is where pain management is provided before, during, and after all procedures that may cause pain and/or anxiety for the child (Oregon Health & Sciences University, 2012). Team huddles are used before procedures to discuss the appropriate pain management approach that will be used based on the child. The nurse’s report and assessment on the child’s past perceptions of pain, any current symptoms the child is facing, and cultural background are important for other members of the healthcare team to create a proper plan during huddle. If the child’s nurse feels that the child needs more pain interventions, the nurse may stop the procedure to provide the child with additional comfort measures (Oregon Health & Sciences University, 2012). The policy in place at Doernbecher Children’s Hospital is developed in order to provide the child with compassionate care while alleviating pain and anxiety that will decrease any physical or psychological effects caused by untreated pain. All hospitals must have a pain policy in place for guidance on how to provide quality care.

Although there is increased awareness of pain management in adult patients [20, 21], pain management in pediatric patients should be given a high priority by all health care professionals through advocating for optimal use of comforting strategies that reduce pain distress during painful procedures[3, 21]. However, our study demonstrated the use of few evidence based comforting strategies for pediatric pain management during IV line insertion by the participating health care providers at the Mulago national referral and teaching hospital. This may be attributable to the fact that the hospital receives many visiting professors annually who may be the source of information for practice change as they participate in the care of patients.

In emergency rooms across the United States one of the most common complaints is pain. Recently, there have been reports on the news saying that doctors have a problem with prescribing too much pain medication. That may be true for adults but the same cannot be said for pediatric patients. A study of 24,707 Emergency Department (ED) visits reported that one 44% of pediatric patients have very little pain control in spite of pain documentation (Ramira, Instone, & Clark, 2016, p. 39). Sometimes it seems as though health care professionals take the pain of an adult more serious than a child’s. In the article, Pediatric Pain Management: An Evidence-Based Approach conducted by Maria Ramira, APRN, Susan Instone, APRN, and Mary Clark, PhD RN seeks to address this issue and introducing methods that might improve pediatric pain management.