Manage children’s pain with communication tools
Nurses learn pain is what the patient says it is
Assessing and relieving pain in infants and small children can be especially difficult because children often cannot or will not report pain. Some even fear the treatment for pain. Unfortunately, unrelieved pain in children has negative physical and psychological consequences, and children in pain can even regress.
Members of the nursing quality improvement council at Cardinal Glennon Children’s Hospital in St. Louis were interested in the issue and set a goal to increase the hospital’s compliance with guidelines on pain control published by the Washington, DC-based Agency for Health Care Policy and Research (AHCPR) about three years ago, says Sue McCool, RN, MSN, director of nursing practice and development.
A team was formed, and its first step was to develop a data-gathering form so it could determine the following:
• if nurses were using an objective pain rating scale;
• if nurses were using an age-appropriate pain rating scale;
• how frequently the patient’s pain was reassessed;
• how frequently as-needed analgesics were given.
Using the data collection tool, team members looked at 122 closed medical records covering 14 different medical and surgical DRGs. They collected data on the 24-hour period post-admission for medical diagnoses and post-surgical for surgery diagnoses. (See copy of data collection tool, pp. 9-10.)
Based on their assessment, team members determined they had the following opportunities for improvement:
• decrease underdosing of medication;
• improve the objective methods of evaluating pain;
• improve documentation of pain so patient trends can be evaluated.
McCool says team members had read about and were impressed with the pain management program at the University of Iowa Hospital and Clinics in Des Moines. "We used their standard of care which guided us in developing our own standard. That was the benchmark we used," she explains.
Team members developed written standards of care for pediatric pain management. The standards call for:
• developing patient/parent education;
• screening for potential pain and/or initial pain rating value from the patient at admission;
• meeting with parents to establish patient/family response to pain, any distinctive family or cultural practices, their expectations regarding pain management;
• assessing patient using an age-appropriate assessment tool, family perceptions, and nursing observations of behavioral and physiologic signs of pain, and documentation of pain (even if none) every four hours;
• reassessing within 30 to 60 minutes after any intervention for pain;
• reassessing more frequently if pain is poorly controlled.
The standards call for the use of a variety of self-reporting methods, including the following:
• The CRIES scale, an acronym for the indicators of a neonate’s pain, was developed at the University of Missouri/Columbia and has undergone reliability and validity testing, says Genie Mollohan, RN, MSN, clinical nurse specialist in Glennon’s neonatal intensive care unit.1 Each measure is given a score from zero to two. A total score of four or greater signals a need for intervention, Mollohan explains. CRIES stands for:
crying: none, high pitched, or inconsolable;
requires more oxygen (as measured by a pulse oximeter);
increase in heartbeat or blood pressure: within 10% of baseline, 11% to 20%, or greater than 20%;
expressions such as grimaces: none, grimace, or grimace with grunting;
sleep pattern: continuously sleeping, sleeping at intervals, or awake constantly.
• The Infant/Non-Verbal Pain Scale is used with non-neonates up to speaking age.
• The Faces of Pain Scale can be used with children between the ages of three and 10 years old. It shows five line drawings of different faces, from happy and smiling to frowning and crying. The faces and accompanying pain levels are described to the child who is asked to choose the face that best describes how he or she is feeling.
• Children older than 10 are asked to rate their pain on a scale from one to five, with five being the worst pain.
The team developed a program of nursing education to familiarize nurses with the effects of pain on children, the new standards of care, a new documentation sheet, the assessment tools, other assessment strategies, and nonpharmaceutical as well as pharmaceutical pain relief measures. Nonpharmaceutical measures include parent presence, rocking, privacy, lower noise levels, soft lighting, and distraction. Team members developed traveling posters and offered nurses self-study inservices to spread the word.
The team plans to conduct another chart review this summer, one year after the changes were made, to assess the effectiveness of their interventions. In September 1996, they conducted a "spot-check" to see how nurses were progressing. They found some promising results, including:
• nurses using objective pain rating scale 10.3% in February 1995, 88.9% at spot check;
• nurses reassessing patients’ pain at least every four hours 51.5% before; 74.1% at spot check.
[For more information, contact Sue McCool, director of nursing practice and development, Cardinal Glennon Children’s Hospital, 1465 S. Grand Blvd., St. Louis, MO 63104-1095. Telephone: (314) 577-5367.]
Reference
1. Bildner J, Rechel S. Increasing staff nurse awareness of post-operative pain management in the NICU. Neonatal Network 1996; 1:11-16.
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