Pain assessment - Indications
- 1 x per shift
- Report of pain
- Before/after analgesic
- On activity
Special:
- Oral analgesia - 4hrly
- IV or complex analgesia - 1hrly + sedation scores
QUESTT
- Question child and caregiver - COLDSPA
- Use pain rating scales - numeric, FLACC, Wong-Baker.
- Evaluate behaviour and physiological symptoms
- Secure parent/caregiver involvement
- Take cause of pain into account
- Take action and evaluate outcomes
3 Pain assessment tools
- Self-report (GOLD STANDARD)
- Behavioural assessment
- Physiological cues
Numeric Scale
Age - 8+ years
“Can you rate your pain on a scale of one to ten, where one is no pain and ten is the worst possible pain?”
Wong-Baker Faces
Age - 3-8 years
“Can you show me which face feels like you? From very happy to the worst possible pain.”
FLACC
Age - 2months - 8 years OR impaired cognition/communication.
Face - normal, occasional grimace or withdrawn, frequent frown/clenched jaw/quivering chin.
Legs - normal, uneasy/restless, kicking or drawn up.
Activity - normal, squirming/tense, rigid/arched/jerking.
Cry - nil, moans/whimpers or occasional complaints, steady cry/screaming or frequent complaints.
Consolability - relaxed, reassured by touch or distractible, difficult to comfort.
ABCs of pain management
- Ask and assess - regular and systematic.
- Believe the patient and parent/caregiver - reports of pain, effects of analgesia.
- Choose appropriate pain control options
- Deliver interventions - timely, logical and coordinated.
- Empower patients and caregivers - choice, participation and information.
Non-pharmacological interventions (infants)
- Swaddling, massage or skin-to-skin contact
- Feeding or dummy use
- Distractions - music, bubbles, toys
- Low stimulus environment
- Parental presence
Non-pharmacological interventions (children)
- Comforting touch or comfort items
- Hot/cold therapy
- Distractions - music, videos, games, toys.
- Breathing or relaxation techniques
- Parental presence
WHO analgesic ladder
- Mild-moderate pain - non-opioid +/- NSAID/adjuvant
- Moderate-severe pain - strong or weak opioid (or regional block), non-opioid and NSAID/adjuvant.
Mild-moderate pain (drugs)
- Sucrose (0-18months)
- Paracetamol
- Ibuprofen
Sucrose
- PO - drop onto anterior tongue
- 0.5-1ml (<1 yr) or 1-2ml per procedure
- Administer 2min pre-procedure.
Paracetamol
- PO, PR or IV
- 15mg/kg/4-6 hrs (max 1g/dose) (*6hrly for IV)
- max 60mg/kg/day (max 4g/day)
- PR ONLY if PO not tolerated/contra
Ibuprofen
- PO - with food.
- 10mg/kg/8hrs (max 400mg)
- max 2.4g/day
- precautions - renal impairment, dehydration, bleeding or anticoagulants.
Oxycodone
- PO (IR)
- 6-12 months - 0.05-0.1mg/kg/4hrs (max 5mg)
- > 1 yr - 0.1-0.2mg/kg/4hrs (max 10mg)
Fentanyl
- Intranasal - use 1ml syringe with atomiser, divide dose between nares.
- > 1 yr - 1.5mcg/kg (max 100mcg)
- max 2 x doses
Morphine
PO (IR):
- 1-12months - 80-200mcg/4hrs
- > 1 yr - 200-500mcg/4hrs (max 5mg)
SQ:
- 1-24months - 100mcg/kg/4-6hrs
- > 2 yrs - 100-200mcg/kg/4hrs (max 2.5mg)
IV:
- bolus - 100mcg/kg/4-6hrs
- infusion - 10-30mcg/kg/hr (1-6months) or 20-30mcg/kg/hr (> 6months)
Topical agents
- Open wounds - ALA/laceraine
- Venepuncture - ELMA cream (lidocaine/prilocaine)
- NGT - cophenylcain nasal spray
- Teething - salicylate gel, lignocaine gel.
- Eye - amethocaine drops.
- Ear - 2% lignocaine drops.
Buzzy
Vibrating case +/- icepack.
Confuses local nerve signals and numbs area to relieve mild pain - e.g. needles, splinters and stings. Apply 30 sec before procedure and place 2-5cm proximal to site (best numbing is directly distal to centre of Buzzy motor).
Avoid ice pack in < 2 years and sickle-cell patients.
