Pain is Subjective???

TexasPediRN · Mar 30, 2006

It can be very difficult with a pediatric patient to assess their pain level.

There is a chart, I beleive a Wong Baker Chart, which is 5 faces. The child can point to which face they feel like, happy, a little sad, more sad, and very very sad. It helps them to see the faces so they can tell you where their pain is.

Now, if a child says they hurt, and are grimacing, I wouldnt think twice to give them pain medication, even if its just motrin or tylenol.

An effective way to assess pain besides the chart, is to ask.

"does your tummy hurt?" "can you show me where?" "does it feel like you need to use the bathroom or no?"

As for the effect that parents have on patients, it completely depends on the parent. Some are overly 'protective' regarding pain medications and want their kid to be medicated at the slightest twinge or cramp. Others dont want you giving pain meds unless the child verbalizes pain or is crying. You always need to ask the child, not the parents.

I've never had a child with a PCA pump, I've mainly had appys, RSV's, and gasto Peds patients. I would think a teenager is more likely to use a PCA then a preschool aged child.

I hope that helps! And yes, children are extremly resilient! Thats why I love working with them so much!!

kids · Mar 31, 2006

I did have an experience where a post-operative 5 year-old patient was complaining of pain. He verbalized his pain as well as had non-verbal cues such as grimacing and guarding. My reference nurse said that he was "being a baby".

Your resource nurse make me twitch.

The 5yo wasn't being a baby, he was giving both verbal and nonverbal cues that he was in pain.

My experience with PCA in Peds is with a couple of older (7-8) year olds who had spinal surgery, both were above average developmentally and neither were able to "get the hang" of using the PCA.

I found this study on Medscape that discussed PCA use in older peds (8-21) http://www.medscape.com/viewarticle/434089, you'll need to register (free) to see it.

At the top of the forum is a pain stickie, it it ate links to several different pediatric pain assessment tools, including the FACES scale mentioned above.

jillyk*rn · Mar 31, 2006

Absolutely that child was in pain:angryfire .

I work peds and "pain is what the patient says it is".

We use 2 scales to measure pain - Wong/baker (the faces) and for the babies the FLACC scale (it measures by crying, consolability, etc). Just because a child cannot verbalize the pain, doesn't mean it isn't there.

The hospital I work at is excellent about providing pain meds (where I worked before - good luck:uhoh3: ).

You were right, and seem to have wonderful instincts. Keep using them.

LovelyLyn · Apr 1, 2006

Thank you for the wonderful reply. The link was very helpful. Your patients are lucky to have such a wonderful, compassionate nurse.

LovelyLyn · Apr 3, 2006

One can see that pain is subjective. Determine whether a PCA would be beneficial to a pediatric patient can be subjective as well. "PCA is prescribed mostly for children 5 years old and older" (Holden & Patt, 1995). "Children selected for PCA should be able to push the injection button and should understand that pushing the button will give them medication to relieve pain" (London, 2003). In another clinical experience I had an eight-year-old patient who had a NG-tube and a PCA. When I assessed his pain on a 0 to 10 scale he rated his pain as a 9. After further questioning I discovered that he correlated the discomfort of the NG-tube to the PCA. He believed that every time he pushed the PCA it went down his throat causing more discomfort. Obviously some patient teaching was needed... And I think it is inorder to say that this patient was not developmentally delayed and would be age appropriate using the Tanner's Stages of Development.

Findings from the article, Patient-Controlled Analgesia for the Pediatric Patient (Orthopaedic Nursing, 2003) concluded that children must be carefully screened for their cognitive and physical ability to manage their pain using PCA. Family-controlled analgesia and nurse controlled analgesia may be considereed in select cases as alternatives to PCA in children with cognitive or physical disabilities.

One can see that there are many obstacles using a PCA with pediatric patients. What is your experience with this? Is it the physician or the nurses responsibility to assess the cognitive ability of the patient? Are 5 year olds able to effectively regulate their pain with a PCA?

soliant12 · Apr 3, 2006

I completely disagree that pain is what the patient says it is. I have worked peds and seen patients that are playing video games and having a great time but they and their parents watch the clock for the pain meds in anticipation to avoid having pain they wanted the morphine or nubain so the child would always be completely pain free. The child would say his pain was really bad when I asked but 2 seconds before was playing video games without a hitch. Then I tried explaining to mom that her child would not being going home on morphine and she about couldn't understand why no matter how hard I explained. Working ER with migraines is a whole other story with patients claiming a 10 on 10 scale for migraine pain but laughing it up with their friends in the room.

Absolutely that child was in pain:angryfire .
I work peds and "pain is what the patient says it is".
We use 2 scales to measure pain - Wong/baker (the faces) and for the babies the FLACC scale (it measures by crying, consolability, etc). Just because a child cannot verbalize the pain, doesn't mean it isn't there.
The hospital I work at is excellent about providing pain meds (where I worked before - good luck:uhoh3: ).
You were right, and seem to have wonderful instincts. Keep using them.

kids · Apr 4, 2006

I completely disagree that pain is what the patient says it is. I have worked peds and seen patients that are playing video games and having a great time but they and their parents watch the clock for the pain meds in anticipation to avoid having pain they wanted the morphine or nubain so the child would always be completely pain free. The child would say his pain was really bad when I asked but 2 seconds before was playing video games without a hitch. Then I tried explaining to mom that her child would not being going home on morphine and she about couldn't understand why no matter how hard I explained. Working ER with migraines is a whole other story with patients claiming a 10 on 10 scale for migraine pain but laughing it up with their friends in the room.

A child who is able to be distracted by a video game may very well be in significant pain, just as an adult in pain may fall asleep. Good pain management involves medicating proactively and not waiting until the pain is severe.

Post-op pain is a big worry for both children and their parents and a good deal of pre-op teaching is devoted to reassuring both everything will be done to manage post-op pain.

I think it is a bit over the top to compare children watching the clock to people you believe to be drug seekers in the ER.

rn/writer, RN · Apr 4, 2006

Kids are funny little things when it comes to pain. Especially those under ten. You can't always go by what you see.

Part of this post raised a flag for me.

I have worked peds and seen patients that are playing video games and having a great time but they and their parents watch the clock for the pain meds in anticipation to avoid having pain they wanted the morphine or nubain so the child would always be completely pain free.

Playing video games with a parent can provide enough endorphins to give some pain relief, but that doesn't mean it's a good long-term substitute for actual analgesic meds.

Also, providing meds in anticipation of certain types of pain (post op ortho being a prime example) is not only appropriate, in some cases it's the only decent thing to do. If you give the med and the child does not show signs of oversedation (as opposed to being relaxed enough to enter peaceful sleep), then the med was needed. If a child has morphine or nubain prescribed (usually only 24-48 hours post-op), then there is usually a darn good reason for it.

The normal course of pain management is to provide narcotic meds via IV push or PCA for the first 24-48 hours, then switch over to NSAIDs. Often, there is a period of overlap during which narcs are being weaned. It takes a thorough assessment of a combination of factors to arrive at an accurate decision about medicating a particular child.

My daughter has a son with spina bifida. He's nine now and has had more than 30 surgeries, many of which involved serious pain management. We have had to educate the staff about his pain cues. The difficulty with him is that he tries to hide the fact that he is hurting because he's afraid that it means he won't be allowed to go home.

After many frustrating circumstances, the hospital now automatically refers him to the pain team any time he is admitted. According to team members, kids are far more likely to be under medicated than over medicated.

If you are concerned about giving too much pain medication, use whatever sedation scale your hospital uses and assess the results. As I said earlier, if the child is awake or sleeping but rousable, you did NOT over medicate.

Trauma Columnist · Apr 4, 2006

Patients need pain relief - end of story! Pain is what the patient says it is. It takes a little more on the assessment side sometimes to ferret out pain in peds patients. However, not medicating a child because they are playing video games or watching TV isn't right. In our ER, we use the Faces scale or the FLACC scale for those kids that aren't verbal. These are both reliable methods of pain assessment.

Also, if a patient is already on narcotics or is narc-dependent, it doesn't mean you don't give pain meds, you actually must individualize the care plan and give MORE narcotics for effect.

Please don't under-medicate patients - that's cruel.

P_RN, ADN, RN · Apr 4, 2006

one universal means of controlling pain is distraction. didn't they teach us that in fundamentals?

pain is what the patient says it is.

cubsfan · May 2, 2006

How dare anyone minimize anyone's expression of pain! Whether that child truly had physiologic or psycholgic pain he was expressing pain and it needed to be addressed. Your concern should be commended. He may have been afraid or been looking for attention, but our job is to find out if he is in pain and if he is not find a way to distract him. That is what Child Life is for. Please take this experience with you to your practice. Any expression of pain must be believed, until proven otherwise. Our patients are innocent until proven guilty. Sorry for going on, but I am sick and tired of nurses and doctors that don't believe patients that express pain in unorthodox ways.

Good luck in your career.