Chapter 36
Nursing Care of the Child with
an Alteration in Comfort–Pain
Assessment and Management
Pain Management in Children
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Pain Transmission in the Nervous
System #1
 Transduction
o Nociceptors (specialized nerve cell endings) are
activated when exposed to noxious stimuli
 Mechanical, chemical, or thermal
 Transmission
o Stimuli are converted to electrical impulses and
relayed to spinal cord and brain by afferent nerve
fibers and unmyelinated small C fibers
o Neurotransmitters facilitate transmission process to
the brain
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Pain Transmission in the Nervous
System #2
 Perception
o Nerve fibers divide in the dorsal horn of the spinal cord,
cross to the opposite side, and rise upward to the
thalamus
o Thalamus quickly sends a message to somatosensory
cortex of the brain where impulse is interpreted as pain
 A-delta fibers lead to sharp, stabbing, local pain
 C fibers lead to diffuse, dull, burning or aching pain
 Pain threshold is the point where a person feels the lowest
intensity of painful stimulus
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Pain Transmission in the Nervous
System #3
 Modulation
o Neuromodulators modulate the pain sensation
 Naturally occurring examples include serotonin,
endorphins, enkephalins, and dynorphins
 Pharmacologic treatments can interrupt or
modulate the perception of pain
o Pain sensation can be modified peripherally (at the
site) or centrally (in the brain)
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Physiology of Pain
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Question #1
Is the following statement true or false?
The nurse accurately explains to a child’s parents that the
point at which a person feels the highest intensity of a
painful stimulus is termed the pain threshold.
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Answer to Question #1
False. The point at which a person feels the lowest
intensity of a painful stimulus is termed the pain threshold.
Rationale: In addition to sending a message to the
cerebral cortex, the thalamus also sends a message to the
limbic system, where the sensation is interpreted
emotionally, and to the brain stem centers, where
autonomic nervous system responses begin.
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Classifications of Pain
 Duration
o Acute or chronic
 Etiology
o Nociceptive or neuropathic
 Source/location
o Somatic or visceral
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Factors Influencing Pain
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Age
Gender
Cognitive level
Temperament
Previous pain experiences
Family and cultural background
Situational factors
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Myths and Misconceptions About Children
and Pain
 Newborns don’t feel pain
 Exposure to pain at an early age has little or no effect later
 Infants and small children have little memory of pain
 Intensity of the child’s reaction to pain indicates intensity of pain
 A child who is sleeping or playing is not in pain
 Children are truthful when asked if they are in pain
 Children learn to adapt to pain and painful procedures
 Children experience more adverse effects of narcotic analgesics than adults do
 Children are more prone to addiction to narcotic analgesics
Not true!
 (Adapted from The Hospital for Sick Children. (2005). Myths vs facts of children’s pain. Retrieved June 16, 2020, from
https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/GlobalYearAgainstPain2/
20052006PaininChildren/pdfist.pdf)
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Indicators of Pain in Infants
 Behavioral
o Facial expressions, body movements, crying, increased
irritability, refusal to move injured body part,
interrupted sleep
 Physiologic
o Changes in heart rate, respiratory rate, oxygen
saturation levels, vagal tone, plantar or palmar
sweating
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Using Age-Appropriate Language to
Assess Pain in Older Children
 Toddlers are likely to understand words such as “owie” or
“boo-boo”
 Preschoolers may need to be coaxed to discuss their pain
as they feel it is something to be expected
 School-age children can usually report type, location, and
severity because of their well-developed language skills
 Teens concern about body image and fear of losing
control may result in denying pain or refusing medication
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Question #2
Is the following statement true or false?
The nurse assessing pain in children is correct in
stating that the school-age child is usually able to
communicate the type, location, and severity of pain.
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Answer to Question #2
True. The school-age child is usually able to communicate
the type, location, and severity of pain.
Rationale: Children older than the age of 8 years can use
specific words, such as sharp as a knife, burning, or pulling,
to describe their pain. However, they may deny pain in an
attempt to appear brave or to avoid further pain related to
a procedure or intervention.
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Factors Affecting Children’s Responses
to Pain
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Type of pain
Extent of pain
Age/developmental level
Cultural/family norms surrounding expression of pain
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Key Principles of Pain Assessment
(QUESTT)
 Question the child
 Use a reliable and valid pain scale
 Evaluate the child’s behavior and physiologic changes to
establish a baseline and determine the effectiveness of
the intervention
 Secure the parent’s involvement
 Take the cause of pain into account when intervening
 Take action
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Health History Data Related to Pain
Assessment
 Location, quality, severity, and onset of the pain, as well as
the circumstances in which the child experiences the pain.
 Conditions, if any, that preceded the onset of pain and
conditions that followed the onset of pain
 Any measures that increase or decrease the pain
 Any associated symptoms, such as weight loss, fever,
vomiting, or diarrhea, that may indicate a current illness
 Any recent trauma, including any interventions that were
used in an attempt to relieve the pain
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Pediatric Pain Assessment Tools
 FACES pain rating scale (ages 3+, emoticon-like faces)
 Oucher pain rating scale (ages 3+, actual photos of
children, must know number values)
 Poker chip tool ( ages 3+, uses 1 to 4 poker chips to
describe pain)
 Visual analog and numeric scales (ages 5+, scales of
0–10)
 Adolescent pediatric pain tool (ages 8 to 15, measures
pain location, intensity, and quality)
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FACES Pain Rating Scale
(Source: Wong-Baker FACES Foundation 2019. Wong-Baker FACES® Pain Rating Scale. Retrieved June 9, 2020 with permission from
http://www.WongBakerFACES.org)
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Question #3
The nurse is assessing the pain of a 3-year-old child. Which
of the following pain assessment scales would be most
appropriate?
a. Visual analog scale
b. Visual numeric scale
c. Word-graphic rating scale
d. FACES pain rating scale
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Answer to Question #3
d. FACES pain rating scale. The FACES pain rating scale
would be most appropriate for a 3-year-old.
Rationale: The FACES pain rating scale is a self-report
tool that can be used by children as young as 3 or 4 years
of age. The word-graphic rating scale is useful for children
between 4 and 17 years old. The visual analog scale can be
used with children 7 years or older. The numeric scale can
be used with children 8 years or older.
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Pediatric Physiologic and Behavioral Pain
Assessment Tools
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Premature Infant Pain Profile
Neonatal Infant Pain Scale
Riley Infant Pain Scale
Pain Observation Scale for Young Children
CRIES Scale for Neonatal Postoperative Pain Assessment
FLACC Behavioral Scale for Postoperative pain in Young
Children
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Pain Management Guide for Children
 Individualize interventions based on the amount of pain
experienced and the child’s characteristics, such as
developmental level, temperament, previous pain
experience, and coping strategies
 Use nonpharmacologic and pharmacologic approaches to
ease or eliminate the pain
 Teach the child and family about pain-relief interventions
and techniques and discuss with the child and family
expectations of pain management
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Techniques for Pain Management
 Nonpharmacologic
o Relaxation, distraction, guided imagery, massage
 Pharmacologic
o Analgesics, patient-controlled analgesia, local
analgesia, epidural analgesia, conscious sedation
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Behavioral-Cognitive Pain Management
Strategies
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Relaxation
Distraction
Imagery
Biofeedback
Thought stopping
Positive self-talk
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Biophysical Interventions for Pain
Management
 Nonnutritive sucking with sucrose (infants or toddlers)
 Heat and cold applications
 Massage and pressure
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Factors Affecting the Choice of
Pharmacologic Interventions for Pain
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Drug being administered
The child’s status
The type, intensity, and location of the pain
Any factors that may be influencing the child’s pain
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Medications Used for Pain Management
 Analgesics
o Nonopioid and opioids
 Adjuvant
o Benzodiazepines
o Anticonvulsants
 Anesthetics
 Preferred routes
o Oral, rectal, intravenous, topical, or local nerve block routes
o Epidural administration and moderate sedation also can be
used
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Nurse’s Role in Pharmacologic Pain
Management
 Adhering to the rights of medication administration
 Knowledge about the drug’s pharmacokinetics and pharmacodynamics
 Assessment is crucial and ongoing
o Monitor physiologic parameters
 level of consciousness
 vital signs
 oxygen saturation levels
 urinary output
 monitor for signs of adverse effects (respiratory depression)
o Assess the child’s and parents’ emotional status
o Teach the child and parent’s about the drug
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Common Adverse Events Associated With
Use of Opioid Medications
 Constipation
 Pruritus
 Nausea and vomiting
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Required Interventions When a Child Is
Receiving Moderate (Conscious) Sedation
 Moderate sedation is a medically controlled state of
depressed consciousness
 Ensuring that emergency equipment is readily available
 Maintaining a patent airway
 Monitoring the child’s level of consciousness and
responsiveness
 Assessing the child’s vital signs (especially pulse rate,
heart rate, blood pressure, and respiratory rate)
 Monitoring oxygen saturation levels
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Nurse’s Role in Managing ProcedureRelated Pain
 Use topical anesthetic at site of a skin or vessel puncture
 Use nonpharmacologic strategies for pain relief
 Prepare child/family ahead of time about the procedure
 Use therapeutic hugging to secure the child
 Use the smallest-gauge needle possible
 Use intermittent infusion device or PICC for multiple samples
 Opt for venipuncture in newborns instead of heel sticks if large
amount needed
 Use kangaroo care for newborns before and after heel stick
 Provide nonnutritive sucking before the procedure
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Nurse’s Role in Managing Chronic Pain
 Similar to that for the child experiencing acute pain or procedurerelated pain
 Assessment of the child’s pain is key
o Onset, duration, intensity, and location of pain
o Alleviating or exacerbating factors
o Impact on child’s daily life
o Effect on child and family’s stress level
o Methods used to alleviate pain (including home remedies or
alternative therapies)
o Physical examination
 Multiple nonpharmacologic and pharmacologic strategies combined to
provide pain relief
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