Pain After Tonsillectomy and Adenoidectomy: “Ouch It Did Hurt Bad”

Original Articles Pain After Tonsillectomy and Adenoidectomy: “Ouch It Did Hurt Bad” yyy Shirley A. Wiggins, PhD, RN,* and Roxie L. Foster, PhD, RN, FAAN†

y

ABSTRACT:

Severe pain experiences for children at home after tonsillectomy and adenoidectomy (T & A) have been described for more than a decade. Children and their parents are responsible for pain and symptom management during the postoperative home recovery. The purpose of this research was to more fully explore the pain experience and home management practices from the child’s perspective. Diaries were used by 34 children (4-18 years of age) to document their pain and other symptoms. A home interview, stories, art work, and personal notes were also explored to fully capture the experience. From the evening of surgery through the second postoperative day, children reported mean pain intensity ratings of 3.1-3.3 out of a possible 4. Pain awakened 64.7% of the children from nighttime sleep and 52.9% reported vomiting associated with nausea. Children received an average of only 50% of the analgesic doses prescribed. Across the 3 postoperative days studied, pain remained severe and interventions offered minimal relief. Neither older children (␹2 ⴝ 1.357, n ⴝ 13, df ⴝ 2, p ⴝ .259) nor younger children (␹2 ⴝ 1.357, n ⴝ 12, df ⴝ 2, p ⴝ .507) reported significant differences in their mean pain intensity across the first 3 postoperative days. Results supported concerns for inadequate home pain management practices in the pediatric T & A population. © 2007 by the American Society for Pain Management Nursing From the *University of Nebraska Medical Center College of Nursing, Lincoln, Nebraska; and the † University of Colorado at Denver & Health Sciences Center and The Children’s Hospital, Denver, Colorado. Address correspondence to Shirley A. Wiggins, PhD, RN, P.O. Box 880220, Lincoln, NE 68588-0220. E-mail: [email protected] 1524-9042/$32.00 © 2007 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2007.07.002

The purpose of the present research was to give voice to children’s descriptions of their pain experiences at home after tonsillectomy and adenoidectomy (T & A). This surgical procedure remains one of the most frequently experienced and most painful postoperative home recovery experiences for children (Hamers & Abu-Saad, 2002; Idvall, Holm, & Runeson, 2005). Today, children are discharged within hours of a T & A and the majority of their postoperative pain management occurs at home. The published research on children’s recovery at home after T & A describes moderate to severe pain, other distressing symptoms, and pharmacologic and nonpharmacologic interventions. Although research has included the children’s pain intensity reports, the focus has been on the parental perspective of the postoperative experience (Homer, Swallow, & Semple, 2001). Parental Pain Management Nursing, Vol 8, No 4 (December), 2007: pp 156-165

Pain After Tonsillectomy and Adenoidectomy

proxy ratings (use of parent pain ratings of their children’s pain) are considered adequate substitutions, but only if a child is unable to self-report pain (Singer, Gulla, & Thode, 2001). Self-report from the child remains the best evidence for evaluating the effectiveness of the pain management plan (American Pain Society, 2006). Full description from the child is essential for development of effective pain and symptom interventions. Thus, the purpose of the present study was to explore children’s experiences of postoperative T & A pain and home management of recovery.

BACKGROUND Research has consistently reported children’s pain during home recovery from T & A as moderate to severe in nature (Hamers & Abu-Saad, 2002; Helgadóttir & Wilson, 2004; Huth, Broome, & Good, 2004; Idvall et al., 2005; Seid & Varni, 1999; Sutters et al., 2004) and lasting more than 7 days (Warnock & Lander, 1998). In one study, children described the passage of time and medication as contributors to pain relief (Sutters et al., 2004). Researchers have documented the throat, ears, and head as sites of pain after T&A (Helgadóttir & Wilson, 2004; Rømsing, Hertel, Harder, & Rasmussen, 1998). However, none of the earlier research on T & A recovery included the use of body outline maps. This is of interest because children who are offered body outline tools to locate their pain have been shown to mark more sites than they verbally report (Savedra et al., 1989). The body outline also assists younger children (4-7 years of age) to better describe the full dimensions of the painful site (VanCleve & Savedra, 1993). Patterns of pain intensity may vary. Studies have reported severe pain during the first 3 days (Sutters et al., 2004), a small decline in throat pain on day 4 only to have throat pain replaced with severe ear pain (Warnock & Lander, 1998), and pain with or without swallowing (Helgadóttir & Wilson, 2004). Sutters et al. (2004) found that although swallowing pain declined over the recovery period, there were no significant differences in the children’s pain intensity ratings with or without swallowing during the first 3 postoperative days. Intensity ratings that do not vary with swallowing suggest the unrelenting nature of the pain. Other Symptoms In addition to moderate to severe pain, children have reported nausea and vomiting, difficulty swallowing, decreased fluid intake, sleep disruptions, bleeding, constipation, and inability to return to daily activities such as play and school (Sutters et al., 2005;

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Kankkunen, Vehviläinen-Julkunen, Pietilä, & Halonen, 2003). Symptom frequency and severity have been shown to correlate with the severity of the pain intensity for children at home after T & A. In one study, children with higher pain intensity ratings also reported less fluid intake, significantly more sleep disturbances (␹2 ⫽ 8.24, p ⫽ .004), and more behavioral changes (␹2 ⫽ 10.2, p ⫽ .001) than children with intensity scores of 0 or 1 (Sutters & Miaskowski, 1997). The incidence of postoperative nausea and vomiting is higher after ambulatory T & A than in other pediatric ambulatory surgeries (Sutters et al., 2005). Nausea and vomiting combined with swallowing pain and hypovolemia contribute to potential problems with dehydration (Sutters et al., 2005; Sutters & Miaskowski, 1997). Sutters et al. (2005) reported that 33% of the children in their sample experienced moderateto-severe nausea on the first evening after the procedure and 25% reported moderate-to-severe vomiting. Because some children report continuing problems with nausea and vomiting into the second and third postoperative days, additional research must examine pharmacological management of these symptoms (Sutters et al., 2005). Comfort Measures Used by Children Children’s responses to a variety of analgesics have been described, including plain acetaminophen, nonsteroidal antiinflammatory medications (NSAIDs), and combination medications using acetaminophen with opioids (Finley et al., 1996; Hamers et al., 1999; Hamunen & Kontinen, 2005; Homer et al., 2001; Rømsing et al., 1998; Seid & Varni, 1999; Sutters & Miaskowski, 1997; Sutters et al., 2004; Warnock & Lander, 1998). Although medications provided some relief from T & A pain, plain acetaminophen (Hamers et al., 1999; Hamers & Abu-Saad, 2002; Rømsing et al., 1998) or NSAIDS alone were not effective for moderate to severe pain (Rømsing et al., 2000; Sutters et al., 1995). Helgadóttir and Wilson (2004) reported that children who had severe night pain took fewer pain medications during the night. Around-the-clock scheduling of pain medications for children recovering at home following T & A did not significantly reduce pain intensity ratings but increased the number of doses of pain medications that the children reported taking (Rømsing et al., 1998; Sutters et al., 2004). Two studies described children’s responses to nonpharmacologic comfort measures: imagery and parental presence (Huth et al., 2004; Kankkunen et al., 2003). Children who used an imagery intervention to reduce pain in the ambulatory setting reported significantly less pain than children who did not use imagery. This finding was not supported, however, for use

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TABLE 1. Demographic Information for Child Participants (n ⴝ 34)

Total Group Age Female Male Caucasian Hispanic Cognitive Groups Younger Age Female Male Middle Age Female Male Older Age Female Male

n

%

22 12 32 2

65% 35% 94% 6%

13

38%

6 7 8

46.2% 53.8% 24%

5 3 13

62.5% 37.5% 38%

8 5

61.5% 38.5%

Mean

How did the children describe the home recovery experience? What additional symptoms were reported by the children? What comfort measures and interventions (pharmacologic and nonpharmacologic) were used by the children to manage their pain?

METHODS Participants and Setting A descriptive design guided this study. Both quantitative and qualitative methods were used to provide more complete descriptions of children’s pain experiences. A convenience sample of children were recruited from the ambulatory care units of two Midwestern regional hospitals in the, U.S. These hospitals, located approximately 50 miles apart, serve residents from towns and rural communities and provide a population from similar cultures and occupations. Each

SD

Range

10.35

10

4.63

4-18 yrs

5.5

5

1.19

4-7 yrs

9.88

9.50

1.36

8-12 yrs

1.51

13-18 yrs

15.46

of imagery at home (Huth et al., 2004). Younger children had significantly less pain at home during T & A recovery when their parents played with them (p ⫽ .002) and held them (p ⫽ .001) (Kankkunen et al., 2003). The literature provides evidence of the inadequate treatment of T & A postoperative pain and supports the need for further research. The purpose of the present study was to explore children’s experiences of postoperative T & A pain and home management of recovery using diaries to best capture their experiences. This research asked the following questions:

Median

15

site was served by a separate medical practice of ear, nose, and throat specialists. Children were invited to participate if they met the following inclusion criteria: a) 4-18 years of age; b) ability to communicate using the English language; c) admitted to the ambulatory setting for a tonsillectomy or tonsillectomy with adenoidectomy; d) length of stay 24 hours or less; e) no risks or complications due to the surgical intervention; and f) custodial parent(s) able to speak, read, and write English. For ease of analysis and interpretation, children were grouped into three age categories (4-7, 8-12, and 13-18 years). A total of 47 participants and their parent(s) were invited to participate, and 44 were enrolled (93.6% enrollment rate). Of those children enrolled, 34 (78%) returned completed diaries. Only the 34 children who returned the Hurt/Pain Diaries were considered for invitation in the interview portion of the study. A purposive sample was selected for the home interview based on the following criteria: children from all three age groups, children reporting a variety of pain experiences in their daily Hurt/Pain Diary and diary content that described different types of recovery. All of the children who were invited to participate in the home interview consented to do so (n ⫽ 7). Demographic information about the participants is included in Table 1. Children’s ages were consistent with their reported grade level in school. Ethnicity was representative of the Midwestern communities surrounding the two ambulatory settings. The majority

Pain After Tonsillectomy and Adenoidectomy

of children experienced a tonsillectomy and adenoidectomy (76.5%) as opposed to a tonsillectomy (23.5%). Many of the children had previous hospitalizations (64.7%). Instruments A Hurt/Pain Diary was developed for this study. A developmentally appropriate diary format was constructed for each of the 3 age groups, using the same questions. Content validity of the diaries was established by review from a nurse researcher, two pediatric staff nurses, and a parent and child from each of the three age categories (4-7, 8-12, and 13-18 years). The children provided diary information for 3 days (after the procedure). The daily diary page consisted of: a) a pain intensity ledger (Hester, 1995) where the time and pain intensity ratings were recorded before and 1 hour after pain medication administration; b) a questionnaire with open-ended questions and categoric responses; and c) the Body Outline for children aged 4-7 years (Van Cleve & Savedra, 1993) and 8 years or older (Savedra et al., 1989) for marking pain locations. The children were asked to enter their first recording in their diary after returning home on the day of surgery and to continue this daily through the second postoperative day. Information in the child’s diary was to be reported strictly from the child’s perspective, although parents were encouraged to assist the younger children (4-7 years) with reading and recording information. The Poker Chip Tool (PCT) (Hester, 1979) was used to quantify the pain intensity rating and relief score within the Hurt/Pain Diary. Each child in the study was given four red poker chips to use at home to rate their pain, with 0 (no chips) corresponding to no hurt or pain and all four chips corresponding to the worst possible hurt or pain. The tool has been shown to be reliable, valid, and appropriate for children beginning at age 4 (Stinson et al., 2006). The PCT has convergent validity with three other pain assessment tools (Oucher, a visual analog scale, and the Pain Ladder) (Beyer & Aradine, 1987, 1988; Hester, Foster, & Kristiansen, 1990). There are low associations reported between the PCT, the Hospital Fears Rating Scale (r ⫽ ⫺0.004), and the Scare Scale (r ⫽ 0.039), which suggests that this tool measures pain intensity and not emotional fear. Generalizability (over time, with three raters: the child, parent, and nurse; and between two pain intensity rating tools) of the PCT was 0.70 established across four independent pain ratings (Hester et al.). The Body Outline (Savedra et al., 1989; Van Cleve & Savedra, 1993) was marked daily by the children for the 3 days that children described the pain sites. The

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Body Outline has no gender indications. There is one outline map designed for younger children 4-7 years of age (VanCleve & Savedra, 1993) and another for older children 8-17 years of age (Savedra et al., 1989). Savedra et al. (1989) reported a strong correlation (r ⫽ 0.83) between the sites the child marked on the outline and those recorded by a nurse blinded to the child’s markings. Concurrent validity for the Body Outline for the older children indicated that at least one of the pain sites for 172 body outlines marked by the children was confirmed by a blinded investigator 98% of the time. Van Cleve and Savedra (1993), on the Body Outline for children 4-7 years, reported alternate forms of reliability correlation (r ⫽ 0.57) between the child’s markings on the body outline and a blinded investigator recording the site based on the child’s pointing. On the final page of the diary, the child was given the option to draw a picture or write a story about the experience. Younger children (4-7 years) most frequently provided drawings and older children provided drawings, stories, and written descriptions about their experience. Procedures The study was approved by the university and hospital Institutional Review Boards. Parental consent and child assent were obtained from all participants (n ⫽ 44). The first author approached parents in the hospital short stay setting. The children were invited to participate once they were fully awake and asking and responding to questions. Parents completed a demographic information profile before discharge from the short stay setting. Children’s medical records (before discharge) were reviewed for: a) type of surgery; b) child’s weight; c) name, dosage, and frequency of the pain medications prescribed for home pain management; and d) risks or complications occurring during the surgery. All instructions for completion of the diary and use of the pain rating and body outline tools were given before discharge. Diaries were returned in a stamped and addressed envelope. Families in the purposive sample (n ⫽ 7) were telephoned and invited to complete an audiotaped interview. The first author scheduled the interview in the participants’ homes approximately 12-14 days after the date of surgery. During the home interview, the entire family was usually present. Interviews began with the question, “What was the most memorable part of this experience?” Additional questions included, “What was it like when you first came home from the hospital?” “Tell me about the hurt/pain,” “When did the hurt/ pain go away?” and “If you were going to tell other

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TABLE 2. Highest Pain Rating by Age Group

Pain Intensity Rating

Younger Group, 4-7 yrs, n ⴝ 13

Middle Group, 8-12 yrs, nⴝ8

Older Group, 13-18 yrs, n ⴝ 13

No pain (0) A little pain (1) More pain (2) A lot of pain (3) The worst pain (4)

0 1 0 3 9

0 1 0 0 7

0 0 1 2 10

children about having their tonsils out, what would you say?” Quantitative data were analyzed using nonparametric statistics, with an alpha level of .05 established as statistically significant. Qualitative data were analyzed using content analysis and the constant comparative method to identify themes (Strauss & Corbin, 1990).

RESULTS Children’s Reports of Pain Intensity, Location, and Patterns Findings were compared between the two sites for all reported variables. Because there were no significant differences between the variables from the two locations, the child-related variables were combined in this report. Pain intensity was measured using the PCT; a score of 4 was the highest pain intensity rating recorded. To describe the pain experience of the sample, each child’s highest daily recorded pain intensity rating was used in computing a group average for each of the 3 days. The mean rating was 3 (SD 1.2) on the day of surgery, 3.24 (SD 0.955) on the first postoperative day, and 3.02 (SD 1.09) on the second postoperative day. The pain intensity reports were explored by age group (Table 2) for each of the 3 days of diary information. A majority of the children in each of the three age groups rated their highest pain rating during their recovery after T & A as a 4. Only one child from each of the three age groups reported their highest pain intensity rating as a 1. Because the small group sizes precluded adequate evaluation of the distributional assumptions of the parametric repeated measures analysis of variance (RM-ANOVA), data were analyzed using the nonparametric Friedman two-way analysis of variance by ranks. With a sample of 34, a RM-ANOVA would have power of at least 0.80 if the mean pain rating declined by 0.5 standard deviations over the 3

days and within-subject correlations were 0.6 or greater. The power of the Friedman test would be less than the RM-ANOVA when data are normally distributed, but greater when they are not. Nevertheless, it is likely that the tests within age group were not adequately powered and should be interpreted primarily for their descriptive value. There were no significant differences in the mean pain ratings across the 3 reporting days for children in the younger group (␹2 ⫽ 1.357, n ⫽ 12, df ⫽ 2, p ⫽ .507) or older group (␹2 ⫽ 1.357, n ⫽ 13, df ⫽ 2, p ⫽ .259). Ratings for children in the middle group, however, showed a decline in the pain intensity by the second postoperative day (␹2 ⫽ 6.5, n ⫽ 5, df ⫽ 2, p ⫽ .039). When the means of the highest pain ratings were examined by gender for each of the 3 days of diary information, girls indicated that they experienced moderate to severe amounts of pain daily during all 3 days of recovery (3.16 SD 1.01, 3.21 SD 1.03, and 3.18 SD 0.989, respectively). Their pain did not decline significantly across the reporting period (␹2 ⫽ 1.5, n ⫽ 19, df ⫽ 2, p ⫽ .472). Information from the boys in the sample indicated they gave their highest pain ratings (means) on the day of surgery (3.45, SD 0.688) and postoperative day one (3.54, SD 0.688). By the second postoperative day, the highest (mean) pain intensity ratings of all of the boys were significantly lower (2.86, SD 1.10; ␹2 ⫽ 7.517, n ⫽ 11, df ⫽ 2, p ⫽ .023). All children marked the location of their pain on the Body Outline once daily for the 3 days. The number of pain sites marked ranged from one to five for the day of surgery and the first postoperative day. On the second postoperative day the number of pain sites marked ranged from zero to five. The mean number of pain sites marked on the day of surgery was 2.32 (SD 1.09), on the first postoperative day 2.26 (SD 1.19), and on the second postoperative day 2.09 (SD 1.31). For the sample as a whole, there were no significant differences in the number of pain sites marked across the 3 days or in pain sites marked based on gender of the children. Pain sites marked included the throat, ears, stomach, mouth, lips, tongue, and head. By the second postoperative day, only the throat, ears, stomach, and head were marked. Other pain locations marked by the children included previous intravenous and heart monitor sites, shoulders, neck, chest, cracked/chapped lips, and a body rash. There were significant differences in the number of pain sites marked by two of the age groups of children over the 3 days. The middle group (␹2 ⫽ 12.579, n ⫽ 8, df ⫽ 3, p ⫽ .006) and older group (␹2 ⫽ 21.606, n ⫽ 13, df ⫽ 3, p ⫽ .01) had significant differences in the number of pain sites marked on the Body Outline across the 3 days. Children aged 8 and

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Pain After Tonsillectomy and Adenoidectomy

TABLE 3. Mean Number of Analgesic Doses by Age Group Group

Mean

SD

Median

Mode

Range

Younger (4-7 yrs), n ⫽ 13 Middle (8-12 yrs), n ⫽ 8 Older (13-18 yrs), n ⫽ 13

10.38 7.88 14.77

4.39 4.36 3

10 9 15

Multiple 11 17

3-17 2-13 9-19

older noted fewer pain sites across the 3 days as they continued their postoperative recovery at home than the children 4-7 years of age. Younger children consistently continued to mark the same number of pain sites daily over the 3 days. Pain awakened 64.7% (n ⫽ 22) of the children from nighttime sleep. Half of the middle group of children reported that they slept through the night and the other half reported their pain awakened them from sleep during the night. Younger children (4-7 years) reported early morning awakenings, 83.3% (n ⫽ 12) related to pain. These children described that the pain disturbed their usual sleep patterns. Additional Symptoms Reported by the Children Nausea associated with vomiting was reported by 52.9% of the children. Postoperative emesis occurred more than once on the day of surgery for 38.2% of the children. On the first postoperative day, 23.5% of the children reported one or more emeses and approximately 8.8% of the children reported having one or more emeses on the second postoperative day. Children also described nausea, dizziness, or emesis during the drive home from the ambulatory site. Children who described stomach pain associated it with ingestion of pain medications or their inability to eat food (severe hunger). Four (11.8%) of the children reported that they did not eat any food during the 3 days. Children who were able to eat reported eating soft foods, including soup, gelatin, pudding, applesauce, pasta, ice cream, cooked eggs, and mashed potatoes. Children reported that swallowing pain, nausea, and stomach pain affected their ability to take in fluids as well as soft food. The mean number of glasses of fluid taken daily during the 3 days of data collection was 6.5 (SD 3.18) with a range of 0 to 16 glasses. Comfort Measures and Interventions Described by the Children Each ledger entry made in the child’s diary that contained pre- and postanalgesic pain ratings was counted as a pain intervention. Some postanalgesic ratings were missing because children fell asleep. Only those interventions that contained both pre- and postanalge-

sic pain ratings were analyzed. Thirty-three children recorded a total of 400 pain interventions across the 3 documentation days. The number of interventions used per child ranged from 2 to 19 (Table 3). Children in the older group reported using more pain medications. The difference between the preintervention pain intensity ratings and postintervention pain intensity ratings (1 hour after administration of the pain medication) was considered a pain relief score. A mean relief score was calculated for all of the interventions each child recorded during the 3 days of diary documentation. Relief scores for the age groups from youngest to oldest demonstrated limited pain relief and included: 4-7 years: 1.18 (SD 0.8479); 8-12 years: 1.21 (SD 0.3842); and 13-18 years: 0.852 (SD 0.4813). The children 13-18 years of age reported using more pain medication interventions (Table 3) and had the smallest relief scores of the three age groups. There were no significant differences reported in pain relief scores based upon gender of the children (p ⫽ .97) or age group (␹2 ⫽ 2.277, df ⫽ 2, p ⫽ .32). Recommended therapeutic ranges have been established for pediatric pain medications (American Pain Society, 2003). Relative analgesic doses prescribed for children in the present sample were examined by using the highest recommended mg/kg analgesic dose as the denominator and the highest prescribed mg/kg dose as the numerator. Percentages closer to 100% indicated a prescribed dose nearer the maximum recommended starting dose. Acetaminophen with codeine was prescribed for the majority of the children in this sample. The average prescribed dose was 80% of the maximum recommended starting dose of this drug. Children were administered an average of 50% of their prescribed analgesic doses over the 3 days. When children were asked in their diaries to list what things made them feel better, they indicated medicine (35.1%), sleep (17.6%), and family presence (8.8%). Nonpharmacologic measures described included sleep, television, movies, computer games, music, holding security toys (blankets, teddy bears, and other soft toys), drinking fluids or very cold foods such as

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TABLE 4. Exemplars of Pain Experience Themes Children’s Description

Theme

“During the night time the ear and throat pain were the worst” “The second morning after surgery the pain woke me up and I cried” “At night was when I had my worst hurt” “I didn’t feel much surgery day, but the second day and third were the worst” “My tongue swelled so I felt like I couldn’t breathe real well” “My mouth felt so inflated like I could swallow it” “Felt like thorns in my throat” “It hurt to swallow, drink, and raise my head” “It hurts for awhile and it didn’t stop hurting” “The hurt went away more than a week and a day later” “It hurt more than I thought” “I lost weight, I couldn’t eat afterwards because they hurt my throat”

popsicles, ice bags placed over the throat, holding family pets, having a humidifier at their bedside when they slept, visits from friends, and doing homework. Family activities that children described as comforting included having someone read to them, playing board games, getting a back rub, and the presence of a parent. Children’s Own Words Audiotaped interviews were transcribed for analysis. Coded words and text segments were organized into categories and themes. The major themes were the “untimely visitor,” the “difficult passage,” and the “hurt that doesn’t go away” (Table 4). Untimely visitor. Children often felt relieved (on the day of surgery) that the experience was over and therefore expressed little initial hurt. Pain came later as an untimely visitor when they expected to feel better. “After the ride home and the numbing wore off then the pain came.” Children’s diary responses indicated that the length of the recovery made returning to school and the routines of family life difficult. Difficult passage. Older children and teens provided rich details of their worst pain, describing a difficult passageway to healing and recovery. Concerns included fears of choking, feeling breathless, and the sensation of having one’s mouth and throat swollen shut. The “thorny” sensation of pain was a constant companion as the period of recovery became exhausting. Hurt that doesn’t go away. When children were asked to describe what they would remember about this experience, the theme that emerged was “the hurt that does not go away.” Older children and teens often expressed concerns about keeping up at school because of the length of the recovery. One teen reported

The untimely visitor

The difficult passage

The hurt that doesn’t go away

dropping a high school class because she could not attend the required number of days to pass the material, owing to the lengthy home recovery. These teens described that they would tell others who were to have this same experience that the recovery time could be lengthy, to take parent-signed pain medication permits to the school nurse so that pain medication could be administered at school, and to drink more fluids once the pain medication started to relieve the pain. One thoughtful teen responded, “I would tell them, but not scare them . . . reassure them . . . it will hurt.” Children shared drawings and other comments that further described the experience. Several younger children drew pictures which included details of the pain. One younger school age child drew a self-portrait to summarize this experience and entitled her drawing “Ouch, it did hurt bad” (Fig. 1). A teen described her frustration: “I took some meds, slept, woke up, took meds, slept. Mom said I couldn’t do this tomorrow, she doesn’t want me to sleep all the time. Maybe tomorrow I can eat some oatmeal . . . without medicine I can’t sleep or eat.”

DISCUSSION The present study explored children’s experiences with pain at home after T & A. The duration of the pain experience was described as the “hurt that doesn’t go away” and was consistent with the length of pain recovery (14 days) reported in previous research (Homer et al., 2001). Although previous research listed the throat and ears as primary sites of pain (Sutters et al., 2004), children in the present study readily used a body outline to describe more specific locations and aspects of their pain. Younger children

Pain After Tonsillectomy and Adenoidectomy

FIGURE 1.

y A young participant’s self-portrait.

indicated that intravenous sites and cardiac monitor sites were painful several days after T & A. Fears that a swollen tongue would occlude their airway, headache pain, chapped lips, body rash, and chest and abdominal pain suggested that more attention should be directed to discharge information to assist children and families with symptom interpretation. Gedaly-Duff and Ziebarth (1994) also reported misinterpretation of pain cues with home recovery. Attention to postoperative education regarding the meaning of symptom cues may provide improved home recovery. Hydration was a concern for this sample. Children reported drinking a mean of 6.5 glasses (1560 ml) of fluid daily for the 3 days they kept a diary. Curran and Barness (2000) suggested that daily water requirements for children from 4 to 18 years of age in normal conditions (using mean weights for ages) should be 1863-2700 ml per 24 hours. Nausea and vomiting, which further influenced hydration, was reported by 52.9% of this group. Sutters et al. (2005) described an increase in the incidence of nausea and vomiting when oral opioids were administered close to the time of discharge. In research with 161 children, Hamers and Abu-Saad (2002) reported that 63% described problems eating and 46% had difficulty with fluid intake. With the average daily fluid intake of 1560 ml, a limited intake of foods that provide added fluid sources, and the high incidence of nausea and vomiting, children in this study were at risk for dehydration.

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Clinicians and researchers need to continue to explore whether specific ambulatory interventions can prevent nausea and vomiting once the child returns home, identify home interventions for nausea and vomiting, and teach early recognition and intervention for dehydration. Pain which leads to nighttime or early morning awakening from sleep was a concern during home recovery for these children, as in previous research (Hamers & Abu-Saad, 2002; Helgadóttir & Wilson, 2004; Sutters & Miaskowski, 1997; Warnock & Lander, 1998). Maintenance of consistent blood levels of opioids, therapeutic prescription of pain medications, and around-the-clock dosing can promote improved pain management (McClain, 2006). Sutters et al. (2004) and Seid and Varni (1999) reported that around-the-clock medications and use of an algorithm for medication administration decisions increased frequency of medication administration and resulted in shorter recovery times. Inadequacy of pain relief for children in the present study is evidenced by the fact that children who were awakened by pain were sometimes unable to return to sleep even with the administration of prescribed pain medication. Little is known about what pain management interventions are feasible in a busy home environment. Children in the present and in earlier studies received approximately half of their prescribed daily pain medication, reported moderate to severe pain, and noted minimal relief with medication administration (Helgadóttir & Wilson, 2004; Sutters & Miaskowski, 1997; Sutters et al., 2004). These same children reported using a variety of nonpharmacologic pain relief measures while at home; however, none of the present sample reported using formal methods such as imagery. Imagery interventions have been effectively used for pain in the ambulatory setting (Huth et al., 2004), and further research is needed to more effectively use this intervention in the home (Tsao, Meldrum, & Zeltzer, 2006). Nurses must continue to explore methods to assist the child and family with the interpretation of pain cues and symptoms at home through evidence-based interventions developed from home pain management research. Discharge education for pain management at home should include information about the meaning and relationship of pain and symptoms, how to appropriately intervene, and how to prevent sleep alterations and dehydration. The small amount of pain relief reported by these children would not be an acceptable outcome in the ambulatory or acute care setting. Small pain relief reports should not be acceptable outcomes of home pain management. Reports of severe pain during home recovery after T & A have

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been documented for more than a decade; it is time to find feasible and effective interventions that will change the course of home recovery. Limitations This study had limitations, including a relatively small sample size. Children participating in this study came from two different ambulatory settings and two separate ear, nose, and throat clinics. Although site comparisons did not show significant differences in the parameters described in this study, having more consistency with surgical interventions, and more consistent analgesia recommendations would make the pain descriptions more meaningful. It was not possible to draw conclusions based upon age and development owing to the small sizes of the three age groups of children. Conclusions Children in this sample gave rich descriptions of their pain and symptoms during home recovery from T & A and were able to use a variety of pain assessment tools while at home. The findings were consistent with other research that described intense experiences of pain and symptoms. Pain, nausea and vomiting, dehydration, and sleep alterations were difficult for the children and lasted longer than they anticipated. This sample of children also described unique issues of pain

and symptom management at home, including more specific identification of pain sites and further evidence of the use of nonpharmacologic comfort strategies. Children and families deserve evidence-based educational preparation for home pain and symptom management. Further research in this area will provide continuing support for postdischarge preparation. Questions include whether some analgesics afford better pain relief than others, whether postdischarge antiemetics would hasten recovery, and whether standardized use of nondrug comfort measures would improve pain relief and fluid intake. Additional concerns call to question how current pain interventions can support sleep and maintain therapeutic levels of analgesia during the early postoperative recovery. At this point, however, the best evidence from the present study and the available literature suggests that children and families should be prepared for moderate to severe pain lasting several days. This knowledge will help them prepare for adequate pain management strategies including analgesic dosing regimens and nondrug comfort measures. Prolonged pain associated with swallowing also underscores concerns for dehydration, and families should be armed with information about adequate fluid intake and have the opportunity to discuss strategies to achieve fluid goals.

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