Pediatrics : Complications

Complications

• Chronic and Recurrent Pain Assessment
  • Pain that persists for 3 months or longer than the expected period of healing
    • Complex regional pain syndrome
    • Chronic daily headache
    • Multidirectional rating scale
      • Physical functioning
      • Emotional functioning
      • Social functioning
      • School functioning
• Pain assessment in specific populations
  • Pain in neonates
    • Manifestations of Acute Pain in the Neonate
      • Physiological responses
        • Vital signs: Observe for variations
          • Increased heart rate
          • Increased blood pressure
          • Rapid, shallow respirations
        • Oxygenation
          • Decreased transcutaneous oxygen saturation (TcPO2)
          • Decreased arterial oxygen saturation (SaO2)
        • Skin: Observe color and character
          • Pallor or flushing
          • Diaphoresis
          • Palmar sweating
        • Other observations
          • Increased muscle tone
          • Dilated pupils
          • Decreased vagal nerve tone
          • Increased intracranial pressure
          • Laboratory evidence of metabolic or endocrine changes: Hyperglycemia, lowered pH, elevated corticosteroids
      • Behavioral Responses
        • Vocalizations: Observe quality, timing, and duration
          • Crying
          • Whimpering
          • Groaning
        • Facial expression: Observe characteristics, timing, orientation of eyes and mouth
          • Grimaces
          • Brow furrowed
          • Chin quivering
          • Eyes tightly closed
          • Mouth open and squarish
        • Body movements and posture: Observe type, quality, and amount of movement or lack of movement; relationship to other factors
          • Limb withdrawal
          • Thrashing
          • Rigidity
          • Flaccidity
          • Fist clenching
        • Changes in state: Observe sleep, appetite, activity level
          • Changes in sleep-wake cycles
          • Changes in feeding behavior
          • Changes in activity level
          • Fussiness, irritability
          • Listlessness
  • Children with communication and cognitive impairment
    • Children who have significant difficulties in communicating with others about their pain include those who have significant neurologic impairments are at a greater risk for undertreatment of pain
      • Cerebral palsy 
      • Cognitive impairment
      • Metabolic disorders
      • Autism
      • Severe brain injury
      • Communication barriers (e.g., critically ill children who are on ventilators or heavily sedated or have neuromuscular disorders, loss of hearing, or loss of vision)
    • They often experience spasticity, contractures, injury, infection, and orthopedic surgical treatment that may be painful. 
    • Behaviors include moaning, inconsistent patterns of play and sleep, changes in facial expression, and other physical problems that may mask expression of pain and be difficult to interpret.
    • Pain scales
      • Observational scales and interview questionnaires for pain may not be as reliable for pain assessment as self-report scales in children of Hispanic origin
      • Children of Asian descent, who may learn to read Chinese characters vertically downward and from right to left, may have difficulty using horizontally oriented scales.
  • Cultural differences
    • Expression of pain can be greatly affected by communication barriers
    • Cultural background may influence the validity and reliability of pain assessment tools developed in a single cultural context.
  • Children with chronic illness and complex pain
    • Questionnaires and pain assessment scales do not always provide the most meaningful means of assessing pain in children, particularly for those with complex pain  
    • Some children cannot relate to a face or a number that describes their pain
    • Other children, such as those with cancer, are experiencing multiple symptoms and may find it difficult to isolate the pain from other symptoms.
    • In addition to asking the child or parent when the pain started and how long the pain lasts, the nurse can assess variations and rhythms by asking whether the pain is better or worse at certain times of the day or night.
    • If the child has had pain for a while, the child or parent may know which medications and doses are helpful.
    • The nurse may ask the child or parent to keep a diary of activities, positions, and other events that may increase or decrease the pain
      • A diary can help families identify triggers that may cause pain and interventions that work.