- Email: [email protected]
The Importance of Child Life and Pain Management DuringVascular Access Procedures in Pediatrics
The Importance of Child Life and Pain Management During Vascular Access Procedures in Pediatrics Gail A. Heckler-Medina, RN, SS
Abstract The author asks ofthe reader: Have you ever been called to start a peripheral intravenous (IV) catheter or place a peripherally inserted central catheter (P/CC) in a child. and you wished someone else could do it? Performing vascular access procedures on
children is considered by many one of the most stressful and difficult jobs. This article discusses the role ofcertified child life specialists (CCLSs) and some of the techniques used to assist children in coping with painfal procedures as well as the necessity for proper assessment and pain management. The goal of this article is 10 eliminate the uncertainty ofperforming these procedures on pediatric patients. By making a few changes in your practice, one could dramatically increase successful outcomes and improve the
overall quality ofcare provided to the patient.
One of the most frightening experiences for many children is being admitted to the hospital. If the child is not chronically ill, he or she will most likely be in an unfamiliar environment, away from home, toys, siblings, pets, and friends. Daily responsibilities such as career and upkeep of one's home and other children often make it even more stressful for everyone involved. Many times, the hospitalized child may be left alone or not see one or both parents for hours or even days at a time. Thinking back to your childhood, what comes to mind when you hear the words doctar's office. procedure, and shot? Are your memories positive? I remember going to have laboratory draws for a preoperative exam when I was five years old. Everything around me felt so big: the room, the chair, the laboratory technician, and especially that needle. "It is longer than my arm is
versus inferiority (middle childhood), identity versus role confusion (adolescence), intimacy versus isolation (young adulthood), generativity versus stagnation (middle adulthood), and ego integrity versus despair (older adulthood). Depending on the developmental stage, some children may feel that they are sick because they were "bad." However, what about the healthy child who is going to the doctor's office for hislher series of shots that are referred to as vaccinations. We tell the child this shot is for "your own good health" so that you will not get sick. The first question the child will usually ask is, "Is it going to hurt?" As health care providers is there a way to lessen the pain? Is there a way to help the sick child understand hislher illness and the cause of it? The answer to both of these
questions is "yes,"
wide!" "Is the entire needle going into my arm?" "Is it going to hurt? If so, how much will it hurt?" "Will it cause me to pop like a balloon?" "I will need a bandage to keep my insides from leaking out of the needle hole!" These are all statements that pediatric nurses hear frequently.
Technological Advancements and Research Prevail Over the past 10 years, there has been a growing demand for alternative vascular access, specifically, peripherally inserted central catheters (PICCs), and skilled professionals to place these
From the time we are born until the time we die. our identity
devices, As health care facilities across the nation are experiencing tremendous growing pains because of the ever-increasing need for medical attention. vascular access has never in history
of self and the ego continue to develop and go through successive stages that naturally unfold throughout the lifespan. Eric Erikson called this the "stages of development.'" The eight stages
are trust versus mistrust (infancy). autonomy versus shame and
been as important as it is today. Two topics I discuss are the use of certified child life specialists (CCLSs) and appropriate pain
doubt (toddlerhood), initiative versus guilt (preschool), industry
management interventions as they apply to vascular access, CCLS: An Integral Part of the Vascular Access Team A CCLS is a professional who is specially trained to help
Correspondence concerning this article should be addressed to [email protected] 001: I0.2309/java. I 1-3-10
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children and their families understand and manage challenging
life events and stressful or unfamiliar health care experiences, CCLSs are skilled in providing developmental, educational, and
therapeutic interventions for children and their families. They support growth and development while recognizing family strengths and individuality. The CCLSs recognize and respect different methods of coping. They help to take the mystery out of hospitalization, illness, and procedures. CCLSs have earned a bachelor's or master's degree with an educational background that includes human growth and development, education, psychology, and counseling, They are usually required to complete an internship program and a certification examination, Child life specialists are certified through a program administered by the Child Life Council (CLC).' Many children's hospitals across the nation are recognizing that having a team of CCLSs play an integral role into the successful outcomes of their patients, Intravenous (N) access is statistically one of the most stressful and dreaded events that occur during hospitalization, This is even more so in the pediatric popolation, Integrating a CCLS with a vascolar access department dramatically increases not only the number of successful PICC
linelIV insertions on the first attempt but increases the scores on patient satisfaction surveys. CCLSs are invaluable when used in conjunction with a vascular access program; this, however, requires a financial commitment from the hospital to establish, but the end result is a cost savings to the hospital that is sobstantive, Vascular access progmms that ose CCLSs havc a lower staff turnover than those that do not. Performing painful procedures on children is extremely stressful and challenging, When the chances of soccess are increased as much as possible, it is best for all involved, It also provides cost savings to the hospital for nonreimborsed supplies and what would have been a loss of revenue had thc child needed to remain in the hospital for an extra day or two awaiting PICC line placement for discharge,
games, catching grasshoppers, playing on the monkey bars, and
a famous cartoon character. By discovering what is important to Joey, the CCLS establishes a way to communicate with him and hold his attention. This allows the CCLS to begin building and facilitating an honest and trusting relationship. The CCLS explains to Joey what a PICC line is and what it is used for. He/she gives Joey a teddy bear with a PICC line and central line dressing on the bear's arm. This enables Joey to see what it will look like and how the PICC line feels after the procedure is finished. A big part of the CCLS responsibility is to ask a series of
questions during the evaluation process to see how he/she can best assist Joey with coping mechanisms during the PICC insertion. The CCLS asks him if he woold like to have his parents present during the procedure; ifhe would like to sing songs, read a book, or watch a DVD; ifhe wants to be told what is happening throughout the process; and whether he would like to watch the insertion procedure. Depending on the answers, the CCLS plays with Joey using either medical play or real PICC insertion supplies so that the equipment will be familiar to him. They look at a photo album detailing a step-by-step PICC-insertion procedure. This helps to
answer questions, alleviate fears. and decrease some of the anxiety that Joey may be harboring. After a thorough assessment, the CCLS communicates the findings to the VA nurse. Ideally, the CCLS stays with Joey throughout the PICC insertion. This keeps him focused on the coping techniques that work best for him. The CCLS is the liaison between Joey and the VA nurse. The CCLS makes suggestions that can ensure the best outcomes for Joey psychologically as well as procedurally. Because the VA nurse and CCLS worked together, Joey's PICC
insertion was successful on the first attempt. Joey's mom was preCase Study Joey M" a six-year old hoy, is brought to the emergency room because he stepped on a nail. He receives a tetanus shot, blood
cultures are drawn, and an IV is started for antibiotics. The physician decides to admit him for cellulitis to rule out osteomyelitis, After a few days in the hospital and nine "pokes" later, the physician orders a PICC line to be placed for vancomycin administration. The vascular access (VA) nurse is notified of the pending PICC placement. On notification of the PICC order, the VA nurse gathers a tourniqoet, the ultrasound machine with gel, and a PICC consent form, and goes to Joey's room, The nurse introduces him-/herself to Joey and his parents, The nurse explains that a PICC line
has been ordered and answers any questions the parents have about the PICC prior to venous assessment, On determining that Joey is a candidate for PICC placement, the VA nurse obtains informed consent for the procedure and explains that a CCLS will be in soon to talk with Joey ahout the procedure and answer any questions he may have. The VA nurse then fills in the appropriate information on the Vascular Access/Child Life Procedure Form (see Figure I) and delivers it to the CCLS. The CCLS introduces him-/herself to Joey and his parents. Doring this introdoctory period, the CCLS inquires as to what interests Joey has. They talk about video
sent during the PICC insertion. She held his left hand as the CCLS talked with him ahout one of his favorite books. When Joey grimaced, the CCLS asked Joey if he was hurting anywhere and asked him to use his words to explain how he was feeling right then. The CCLS told Joey that it is okay to be scared and that this procedure was happening to help him get better, not as a result of anything that he had done. The CCLS continuously reinforced how Joey was doing such a good job by helping to hold his arm still and let him know that he would receive a surprise after the procedure was complete. Joey did not feel any pain during the PICC insertion. He was able to cope very well with the help of the CCLS. He received his surprise. He felt as if he had made a new friend and stated that he would not be afraid in the future if he needed another PICC line. He was happy to be on his way home. His family had a great experience and rated the quality of care as exceptional. The hospital, which usually operates at full capacity, had another available bed for a child in need. Although Joey coped very well with the procedure, not all children are able to cope. The inability to cope can be directly related to the procedure requiring multiple attempts, being too lengthy, too painful, and/or a result of traumatic experiences in the past. It can also be that the child is too young to hold still for such a procedure (le, toddlers). In a situation like this, one may wish to consider the
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PLACE PATIENT LABEUSTICKER HERE
This portion to be completed by vascular access nurse: Patient is scheduled on
(date) at
• Peripheral IV (PlY) • PICC Insertion • PICC Exchange • CVC Repair • PICC Removal ·Other:
(RN/NP/PNMD) (time) for the following
_
Patient Assessed by Nurse:Y N (circle one) Assessed with Ultrasound:Y N (circle one) PIV and PICC Insertions Only: Preferred Vein of Choice: Right/Left (circle one) • Basillic • Cephallic • Saphenous • Scalp • Popliteal ·Other:
_
Check all that apply to patient during procedure: • Anxiolysis
• Sedation • General Anesthesia • Fluoroscopy This portion to be completed by Certified Child Life Specialist: Patient Age:
,(CCLS)
_
Developmentally Appropriate for Age:Y N (circle one) If no, explain:
_
Coping Preferences:
• Would like family member present during procedure: • Wants to watch the procedure
(name)
• Wants to be told exactly what is happening during procedure
• Would like to read a book/watch a DVD/play with a toy: (which one) After assessment, I feel child can cope successfully for the scheduled procedure Y N (ci"c1e one)
Figure I. Vascular Access/Child Life Procedure Form. Copyright © 2006 P & A PICC, LLC. Reprinted with permission.
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use of sedation or general anesthesia prior to attempting the procedure. Nurse practitioners, physician assistants, and physicians are usually responsible for determining whether the child will receive sedation or anesthesia. The decision is based on the child's age, current medical condition, medical history, allergies, and an assessment of the child's coping abilities.
Pain Management Did the use of a CCLS make the PICC insertion a pain-free experience for loey? Mosby's Medical Dictionary defines pain as follows: "An unpleasant sensation caused by noxious stimulation of the sensory nerve endings. It is a subjective feeling and an individual response to the cause. Experiencing pain is influenced by physical, mental, biochemical, psychological, physiological, social, cultural, and emotional factors.'"
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003 0-10 Numeric Rating Scale (page 1 of 1)
o
2
-.l-None
Mild
3
4
5
6
Moderate
7
8
9
10
Severe
Indications: Adults and children (> 9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain. Instructions: 1.
2.
3.
The patient is asked anyone of the following questions: • What number would you give your pain right now? • What number on a 0 to 10 scale would you give your pain when it is the worst that it gets and when it is the best that it gets? • At what number is the pain at an acceptable level for you? When the explanation suggested in #1 above is not sufficient for the patient, it is sometimes helpful to further explain or conceptualize the Numeric Rating Scale in the following manner: • 0 = No Pain • 1-3 = Mild Pain (nagging, annoying, interfering little with ADLs) • 4-6 = Mod erate Pain (interferes significantly with ADLs) • 7·10 = Severe Pain (disabling; unable 10 perform ADLs) The interdisciplinary team in collaboration with the patienUfamily (if appropriate), can determine appropriate Interventions in response to Numeric Pain Ratings.
In 2001, the Joint Commission on Accreditation of Healthcare Organizations Reference (JCAHO) published Pain Assessmem and McCaffery, M., & Beebe, A. (1993). Pain: Clinical Manual for Nursing Practice. Baltimore: VV. Mosby Company. Management Standards-Ho!Jpitals,4 and in a PowerPoint presentation available on the Internet, Pain Assessment in Infants and Childl'en/ these standards are Figure 2. 0-10 Numeric Rating Pain Scale. Source: Nationallnstitutes of Health. explained. One of the standards makes pain rating the fifth vital sign. The reason that one would assess pain is to take action to relieve the pain. tion greater than 95%; I: increased vital signs; E: expresIn Joey's case sn,dy, not only was a CCLS present but approsion; S: sleepless) (32--{j0 weeks gestational age) by priate pain management measures were also taken. L4M~X4 Kretchel and Bildner, 1995" (Figure 5) (Fcmdale Laboratories, lnc; Femdale, MI) was placed on Joey's Checklist of Nonverbal Indicators (CNVI) (Figure 6) right arm in two different places prior to setting up for the procedure, and during the procedure lidocaine I% buffered with Pain is subjective and responses to pain vary widely among sodium bicarbonate was injected at the site very slowly. individuals. Different factors determine how individuals respond to pain, such as age, gender, specific diseases or injuries, health, pain threshold, fear, anxiety, the culture and background of the Pain Is Subjective There are many ways to identitY and quantitY pain in the pediindividual experiencing the pain, and the way the person expresses painful experiences. attic setting. The use of pain scales is recommended by JCAHo. Some samples' of Pain Rating Scales from the JCAHO Pain AssessOther factors associated with how children deal with pain may ment and Management Standards-Hmpital~ are as follows: include previous experiences with pain, how their parents treated the child when the child was in pain, and how parents respond 0-10 Numeric Scale (Figure 2) to pain when they thcmselves are hurting. Early expcriences of Visual Analog Scale (VAS)' Wong-Baker FACES Pain Rating Scale' (Figure 3) pain may produce permanent structural and functional reorganization of developing neural pathways, affecting future experiences of pain, For infants and nonverbal children, use appropriate observaStress response to pain increases breakdown of body tissue; tional scales such as the following: b NPASS (Neonatal Pain, Agitation and Sedation Scale) (preincreases the metabolic rate, blood cloning, and water retention; decreases immune function; triggers fight or flight response; maturity) by Hummel and Puchalski, 2002' causes diaphoresis or palmar sweating; increases heart rate, FLACC" (Face, Legs, Activity, Cry, and Consolability) (full term neonate--7 years) by Mcrkel et ai, 1997" (Figure 4) blood pressure, and shallow respirations; increases cough suppression; increases retention of pulmonary secretions; and CRIES (C: crying; R: requires oxygen to maintain satura-
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increases the delay of return of gastric and bowel function. 13 It is by far more effective and safer to prevent pain rather than to try to catch up and treat already existing pain,
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
WongriBaker Faces Pain Rating Scale (page 1 of 1)
The Use of Analgesics English Although it may be necessary at times to use sedation or general anesthesia for certain vascular access procedures, there are some reasonably priced analgesic o 2 6 8 • NO HURT HURTS HURTS HURTS HURTS HURTS products that could be used for most unLE61T unLE MORE EVEN MORE WHOLE LOT WORST patients who are not allergic. These would Espanol include, but are not limited to, the use of Sweet-Ease (Respironics, Pittsburgh, PAl, ethyl chloride, L-M-X4, EMLA (AstraZeneca LP, S6dertiilje, Sweden), and I% lidocaine subdermal/subcutaneous injection at the site. All of these NO DOlOR MUY lEVE lEVE MODERADA SEVERA MUY SEVERA require a physician or allied health professional's (AHP's) order. Indications: Adults and children (> 3 years old) in all patient care settings. Sweat-Ease is a 24% sucrose and water Instructions: solution. Sucrose produces analgesia through both endogenous opioid and nono1. Explain to the patient that each face is for a person who feels happy because he has no pain (hurt or, whatever word the patient uses) or feels sad because he has some or a lot of pain. pioid pathways. In neonates, the taste 2. Point to the appropriate face and state, "This face is . " receptors are an important consideration • 0 -1 - ~very happy because he doesn't hurt at aiL" • 2 - 3 - "hurts just a little bit." for pain management. Non-nutritive suck• 4 - 5 - "hurts a little more." ing with sucrose has the best effecl. It is • 6 - 7 - "hurts even more." • 8 - 9 - "hurts a whole lot" recommended to be given I to 2 minutes • 10 - 'hu1s as much as you can imagine, although you don't have to be crying to feel this bad." 3. Ask the patient to choose the face that best describes how he feels. Be specific about the pain prior to starting the procedure, either with location and at what time pain occurred (now or earlier during a procedure?). a syringe on the tongue or on the buccal 4. The interdisciplinary team in collaboration with the patienUfamily (if appropriate), can determine appropriate interventions in response to Faces Pain Ratings. surface followed by a pacifier. It should not be used on patients less than 27 weeks gesReference tational age, those who weigh less than 1000 grams or have cardiovascular instaWong, D. and Whalay, l. (1986). Clinical handbook of oediatric nursing ed. 2, p. 373. SI. Louis: C.V. Mosby Company. bility, or with neonates who have persistent pulmonary hypertension. Ethyl chloride spray, often referred to Figure 3. Wong-Baker Faces Pain Rating Scale. Source: National Institutes of Health. as "cold spray," temporarily numbs the skin on contact by making it feel very cold. The sensation is similar to effects of an ice pack. The botfor the administration of lidocaine I% during PICC placements. tle should be held approximately 7 inches from the skin and Lidocaine I% can be buffered with sodium bicarbonate in a 10: I ratio. This combination eliminates the stinging property of the sprayed continuously between three and 7 seconds. The skin will turn white when it is numb. This analgesic only lasts for approxlidocaine. It should be mixed under a hood in the pharmacy. It imately 30 seconds. When using this type of analgesic, it is of is recommended that no more than 4.5 mg/kg be administered utmost importance to act quickly. The child may consider the for procedures in children. frosty, cold, and tingling unfamiliar and mildly uncomfortable. It is important to write down the patient's pain history before pain is expected, such as before thc vascular access procedure. In It is best to show the child in advance how it feels and allow him/her to choose. addition, try to involve the family when possible. Families are L-M-X4 and EMLA are both topical creams that are applied often helpful in interpreting and recording response to pain relief directly to the proposed site. L-M-X4 contains lidocaine 4% and measures. Pain experienced during vascular access procedures is should be applied 15 to 30 minutes prior to the procedure. acute. Acute pain activates the body's fight or ftight slTess EMLA contains lidocaine 2.5%/prilocaine 2.5% and is recomresponse. When pain persists, the body begins to adapt and there is mended to be applied I to 2 hours prior to the procedure. Both a decrease in the sympathetic responses. In chronic pain, stress of these creams have anesthetic properties that reach to a depth response is absent or diminished. For this reason, chronically ill of 4 mm. They are very useful for peripheral IV insertions and patients may have a lower pain tolerance.
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NATIONAL INSTITUTES OF HEALTH Conclusions WARREN GRANT MAGNUSON CLINICAL CENTEl'l Pain is an unpleasant sensory and emotional experience arising from actual or PAIN INTENSITY INSTRUMENTS JULY 2003 potential tissue damage. The major responsibility for alleviating a child's pain FLACC Scale (page 1 of 1) during a vascular access procedure rests with the VA nurse. Pain is whatever the DATElTIME experiencing child says it is, and it exists Face o- No particular expression Of smile whenever he or she says it does. If using 1 - Occasional grimace or frown, withdrawn, disinterested CCLSs and appropriate pain management 2 - Freouent to constant Quiverina chin clenched "aw Legs interventions have such a positive effect O· Normal p osilion or relaxed on the outeomes of our ehildren, why do 1 - Una 35y, restless, tense 2· Kickina, or leas drawn uo hospitals not always use them consisActivity tently? It may be beeause of a lack of 0- Lying quietly, normal position, moves easily 1 • Squirming, shifting back and forth, tense funding or time. It may be inconvenient at 2· Arched. riaid or ierkino times for us, as health care professionals, Cry 0- No cry (awake or asleep) to take the time to apply a topical anal1 - Moans or whimpers: occasional complaint 2 - ervino steadil screams or sobs, freauenl comolaints gesic or consult with a CCLS. Consolability You may be part of a Vascular Access O· Content, relaxed 1 - Reassured by occasionallouching, hugging or being talked to, distractible Team who manages all IV therapy and 2 - Difficullla console or comfort vascular access devices or you could be a TOTAL SCOFtE one-person PICC "team" in a large facility. Using CCLSs and appropriate pain Indications: Infants and children (2 months· 7 years) unable to validate the presence of or quantify the severity of pain. management techniques may sound like a great idea. The need is evident. However, Instructions: many practitioners may believe that, 1. Each of the five (5) categories is scored from ()'2, which results in a total SCOfe between 0 although the concept is idealistic, it is not and 10. • (F) Faces realistic in the daily hospital setting. • (l) legs Having come from a large children's • (A) Activity • (Cl Cry hospital that operates at 100% capacity • (C) Consolability 2. The interdisciplinafy team in collaboration with the patienllfamily (if appropri;3te), can most days, a place where it seems there is determine appfopriate inlef'Ventions in response 10 FlACC Scale scores. never enough time in the day to accomReference plish all of the orders and respond to all of Merkel, SI, Voepel-lewis, T., ShayevilZ, JR, & Malviya, S. (1997). The FLACC: a behavioral the calls, I can say that it is important to scale fOf scoring postopefative pain in young children. Pediatric Nursing 23(3): 293-297. take the time and show you care. The remembrance of a positive experience is invaluable and will serve to make your job Figure 4. FLACC Pain Scale. Source: National Institutes of Health. much easier in the future should another vascular access procedure be necessary. Consider the loss of revenue and supplies that are not reim4. Joint Commission on Accreditation of Healthcare Organizations. Pain Assessment and Management Standards-Hm.pibursed, the frustration and nursing time it takes for one to repeatedly attempt a failed vascular access procedure, the fear that we tals [online]. Available at: http://www.jcrinc.com/subscribers/ have instilled in the child, and the dissatisfaction of the family. perspectives.asp?durki~3243&site=' I O&retum=.... Accessed Can we truly afford to sacrifice the quality of care we provide? July 28, 2006. The next time you are called on to "stick" a pediatric patient, 5. Wong DL. Pain Assessment in In/ants and Children [Online remember that this may be the child's first experience with vaspresentation]. Available at: www.mosby.comIWOW. cular access or it may be their hundredth. Why not make it their Accessed June I, 2006. best? The power to make a difference rests in your hands. 6. National Institutes of Health. Pain Intensity Scales [onlineJ. Available at: http://painconsortium.nih.gov/pain_scales/ index.hlm!. Accessed June I, 2006. References I. Sowden, B. Mosby s Pediatric Nursing Reference, 5th ed. St. 7. Johnson E. Visual Analog Scale (VAS). Am J Phys Med Louis, MO: MosbylElsevier; 2004. Rehabil.2001;80:717. 2. Child Life Council [website]. Available at: 8. Wong D, Baker C. Pain in children: comparison of assesshttp://www.childlife.org. Aeeessed June 1,2006. ment scales. Pediatr Nurs. 1988;14:9-17. 3. Mosby s Medical Dictionmy, 7th ed. St. Louis, MO: 9. Hummel P, Puchalski M. Establishing Initial Reliability and MosbylElsevier; 2006. Validity o/the N-PASS: Neonatal Pain, Agitation, and Seda-
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tion Scale-A Pilot Study. Presented at The Association of Women's Health, Obstetric and Neonatal Nurses 2002 Convention: Lighting the Way. Boston, MA. 10. Chambers CT, Giesbrecht, K, Craig KD, Bennet! SM, Huntsman E. A comparison of Faces Scales for the Measurement of Pediatric Pain: children's and parents' ratings. PAIN [serialonline]. 1999;83:25-35. Available from: Association for the Snldy of Pain International, Vancouver, Canada. Accessed May 29, 2006. 11. Merkel SI, Voepel-Lewis T, Shaycvitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nul's. 1997;23:293-297. 12. Krechel, Bildner 1. CRIES: a new neonatal postoperative pain measurement score-initial testing of validity and reliability. Paediatr Anaesth. 1995;5:53-61. 13. Straight A s in Pediatric Nursing. Philadelphia, PA: Lippincot! Williams & Wilkins; 2004.
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
CRIES Pain Scale (page 1 of 1)
DATElTIME
Crying - Characteristic cry of pain is high pitched. o - No cry or cry that is not high-pitched 1 - Cry high pitched but baby is easily consolable 2 - Crv hiah Ditched but babv is inconsolable Requires O2 for Sa02 < 95% - Babies experiencing pain manifest decreased oxygenation. Consider other causes of hypoxemia, e.g., oversedation, atelectasis, pneumothorax) o • No oxyge n required 1 - < 30% oxygen req uired 2 - > 30% oxv-aen reauired Increased vital signs (BP* and HR*) • Take BP last as this may awaken child making other assessments difficult 0- Both HR and BP unchanged or less than baseline 1 - HR or BP increased but increase in < 20% of baseline 2 - HR Of BP is increased> 20% over baseline. Expression. The facial expression most often associated with pain is a grimace. A grimace may be characterized by brow lowering, eyes squeezed shut, deepening naso-labial furrow, or open lips and mouth. O· No grimace present 1 • Grimace alone is present 2 - Grimace and non-crv vocalization orunt is Dresent Sleepless· Scored based upon the infanlis state during Ihe hour preceding this recorded score. o - Child has been continuously asleep 1 - Child has awakened al frequent intervals 2 - Child has been awake constantly
TOTAL SCORE
Cail Heckler-Medina, BS, RN, is a PICC line expert and vascular access nurse. She has assisted in the growth and development of the vascular access pro-
grams throughout the nation. Ms. HeckJerMedina is the founder of P & A Piee. LLe. an independent contracNng company that is responsible for education of stafl and the placement and maintenance of PICCs Gnd midline catheters. Ms. Heckler-
Medina is a clinical nurse educator and preceptor fOr BARD Access Systems.
• Use baseline preoperative parameters from a non-stressed period. Multiply baseline HR by 0.2 then add to baseline HR to determine the HR that is 20% over baseline. Do the same for BP and use the mean BP.
Indications: For neonales (0 - 6 months) Instructions: Each of the five (5) categories is scored from 0-2, which results in a total score between 0 and 10. The interdisciplinary team in collaboration with the patienVfamily (if appropriate), can determine appropriate interventions In response to CRIES Scale scores.
Reference Krechel, sw & BHdner, J. (1995). CRIES: a new neonatal postoperative pain measurement score - initial testing of validity and reliability. Paediatric Anaesthesia 5; 53-61.
Figure 5. CRI ES Pain Scale. Source: National Institutes of Health. Received 6/9/2005; revision received 7/27/2006; accepted 7/28/2006.
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NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
Checklist of Non·Yerballndlcators (CNYIl (page 1 of 1) With
At Rest
Movement Vocal Complaints - nonverbal expression of pain demonstrated by moans, groans, grunts, cries, gasps, sighs) Facial Grimaces and Winces - furrowed brow, narrowed eyes, lightened lips, dropped jaw, clenched teeth, distorted exoression Bracing - clutching or holding onto siderails, bed, tray table, or affected area durina movement Restlessness - constant or intermittent shifting of position, rocking, intermittent or constant hand motions,
inabilitv -to keeo still
RUbbing
massaging affected area
Vocal complaints verbal expression of pain using words, e.g., ~ouch· or ~that hurts; • cursing during movement, or exclamations of protest, e.g., ftstop· Of "that's enouQh.~
TOTAL SCORE
Indications: Behavioral Health adults who are unable to validate the presence of or quantify the severity of pain using either the Numerical Rating Scale or the Wong-Baker Faces Pain Rating Scale.
Instructions: 1. Write a 0 if the behavior was not observed 2. Write a 1 if the behavior even briefly during activity or rest 3. Results in a total score between 0 and 5. 4. The interdisciplinary team in collaboration with the patient (if appropriate), can determine appropriate interventions in response to CNVI scores.
Reference Feldt, KS. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing
1(1): 13-21.
Figure 6. Checklist of Nonverbal Indicators (CNVI).
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Abstract The author asks ofthe reader: Have you ever been called to start a peripheral intravenous (IV) catheter or place a peripherally inserted central catheter (P/CC) in a child. and you wished someone else could do it? Performing vascular access procedures on
children is considered by many one of the most stressful and difficult jobs. This article discusses the role ofcertified child life specialists (CCLSs) and some of the techniques used to assist children in coping with painfal procedures as well as the necessity for proper assessment and pain management. The goal of this article is 10 eliminate the uncertainty ofperforming these procedures on pediatric patients. By making a few changes in your practice, one could dramatically increase successful outcomes and improve the
overall quality ofcare provided to the patient.
One of the most frightening experiences for many children is being admitted to the hospital. If the child is not chronically ill, he or she will most likely be in an unfamiliar environment, away from home, toys, siblings, pets, and friends. Daily responsibilities such as career and upkeep of one's home and other children often make it even more stressful for everyone involved. Many times, the hospitalized child may be left alone or not see one or both parents for hours or even days at a time. Thinking back to your childhood, what comes to mind when you hear the words doctar's office. procedure, and shot? Are your memories positive? I remember going to have laboratory draws for a preoperative exam when I was five years old. Everything around me felt so big: the room, the chair, the laboratory technician, and especially that needle. "It is longer than my arm is
versus inferiority (middle childhood), identity versus role confusion (adolescence), intimacy versus isolation (young adulthood), generativity versus stagnation (middle adulthood), and ego integrity versus despair (older adulthood). Depending on the developmental stage, some children may feel that they are sick because they were "bad." However, what about the healthy child who is going to the doctor's office for hislher series of shots that are referred to as vaccinations. We tell the child this shot is for "your own good health" so that you will not get sick. The first question the child will usually ask is, "Is it going to hurt?" As health care providers is there a way to lessen the pain? Is there a way to help the sick child understand hislher illness and the cause of it? The answer to both of these
questions is "yes,"
wide!" "Is the entire needle going into my arm?" "Is it going to hurt? If so, how much will it hurt?" "Will it cause me to pop like a balloon?" "I will need a bandage to keep my insides from leaking out of the needle hole!" These are all statements that pediatric nurses hear frequently.
Technological Advancements and Research Prevail Over the past 10 years, there has been a growing demand for alternative vascular access, specifically, peripherally inserted central catheters (PICCs), and skilled professionals to place these
From the time we are born until the time we die. our identity
devices, As health care facilities across the nation are experiencing tremendous growing pains because of the ever-increasing need for medical attention. vascular access has never in history
of self and the ego continue to develop and go through successive stages that naturally unfold throughout the lifespan. Eric Erikson called this the "stages of development.'" The eight stages
are trust versus mistrust (infancy). autonomy versus shame and
been as important as it is today. Two topics I discuss are the use of certified child life specialists (CCLSs) and appropriate pain
doubt (toddlerhood), initiative versus guilt (preschool), industry
management interventions as they apply to vascular access, CCLS: An Integral Part of the Vascular Access Team A CCLS is a professional who is specially trained to help
Correspondence concerning this article should be addressed to [email protected] 001: I0.2309/java. I 1-3-10
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children and their families understand and manage challenging
life events and stressful or unfamiliar health care experiences, CCLSs are skilled in providing developmental, educational, and
therapeutic interventions for children and their families. They support growth and development while recognizing family strengths and individuality. The CCLSs recognize and respect different methods of coping. They help to take the mystery out of hospitalization, illness, and procedures. CCLSs have earned a bachelor's or master's degree with an educational background that includes human growth and development, education, psychology, and counseling, They are usually required to complete an internship program and a certification examination, Child life specialists are certified through a program administered by the Child Life Council (CLC).' Many children's hospitals across the nation are recognizing that having a team of CCLSs play an integral role into the successful outcomes of their patients, Intravenous (N) access is statistically one of the most stressful and dreaded events that occur during hospitalization, This is even more so in the pediatric popolation, Integrating a CCLS with a vascolar access department dramatically increases not only the number of successful PICC
linelIV insertions on the first attempt but increases the scores on patient satisfaction surveys. CCLSs are invaluable when used in conjunction with a vascular access program; this, however, requires a financial commitment from the hospital to establish, but the end result is a cost savings to the hospital that is sobstantive, Vascular access progmms that ose CCLSs havc a lower staff turnover than those that do not. Performing painful procedures on children is extremely stressful and challenging, When the chances of soccess are increased as much as possible, it is best for all involved, It also provides cost savings to the hospital for nonreimborsed supplies and what would have been a loss of revenue had thc child needed to remain in the hospital for an extra day or two awaiting PICC line placement for discharge,
games, catching grasshoppers, playing on the monkey bars, and
a famous cartoon character. By discovering what is important to Joey, the CCLS establishes a way to communicate with him and hold his attention. This allows the CCLS to begin building and facilitating an honest and trusting relationship. The CCLS explains to Joey what a PICC line is and what it is used for. He/she gives Joey a teddy bear with a PICC line and central line dressing on the bear's arm. This enables Joey to see what it will look like and how the PICC line feels after the procedure is finished. A big part of the CCLS responsibility is to ask a series of
questions during the evaluation process to see how he/she can best assist Joey with coping mechanisms during the PICC insertion. The CCLS asks him if he woold like to have his parents present during the procedure; ifhe would like to sing songs, read a book, or watch a DVD; ifhe wants to be told what is happening throughout the process; and whether he would like to watch the insertion procedure. Depending on the answers, the CCLS plays with Joey using either medical play or real PICC insertion supplies so that the equipment will be familiar to him. They look at a photo album detailing a step-by-step PICC-insertion procedure. This helps to
answer questions, alleviate fears. and decrease some of the anxiety that Joey may be harboring. After a thorough assessment, the CCLS communicates the findings to the VA nurse. Ideally, the CCLS stays with Joey throughout the PICC insertion. This keeps him focused on the coping techniques that work best for him. The CCLS is the liaison between Joey and the VA nurse. The CCLS makes suggestions that can ensure the best outcomes for Joey psychologically as well as procedurally. Because the VA nurse and CCLS worked together, Joey's PICC
insertion was successful on the first attempt. Joey's mom was preCase Study Joey M" a six-year old hoy, is brought to the emergency room because he stepped on a nail. He receives a tetanus shot, blood
cultures are drawn, and an IV is started for antibiotics. The physician decides to admit him for cellulitis to rule out osteomyelitis, After a few days in the hospital and nine "pokes" later, the physician orders a PICC line to be placed for vancomycin administration. The vascular access (VA) nurse is notified of the pending PICC placement. On notification of the PICC order, the VA nurse gathers a tourniqoet, the ultrasound machine with gel, and a PICC consent form, and goes to Joey's room, The nurse introduces him-/herself to Joey and his parents, The nurse explains that a PICC line
has been ordered and answers any questions the parents have about the PICC prior to venous assessment, On determining that Joey is a candidate for PICC placement, the VA nurse obtains informed consent for the procedure and explains that a CCLS will be in soon to talk with Joey ahout the procedure and answer any questions he may have. The VA nurse then fills in the appropriate information on the Vascular Access/Child Life Procedure Form (see Figure I) and delivers it to the CCLS. The CCLS introduces him-/herself to Joey and his parents. Doring this introdoctory period, the CCLS inquires as to what interests Joey has. They talk about video
sent during the PICC insertion. She held his left hand as the CCLS talked with him ahout one of his favorite books. When Joey grimaced, the CCLS asked Joey if he was hurting anywhere and asked him to use his words to explain how he was feeling right then. The CCLS told Joey that it is okay to be scared and that this procedure was happening to help him get better, not as a result of anything that he had done. The CCLS continuously reinforced how Joey was doing such a good job by helping to hold his arm still and let him know that he would receive a surprise after the procedure was complete. Joey did not feel any pain during the PICC insertion. He was able to cope very well with the help of the CCLS. He received his surprise. He felt as if he had made a new friend and stated that he would not be afraid in the future if he needed another PICC line. He was happy to be on his way home. His family had a great experience and rated the quality of care as exceptional. The hospital, which usually operates at full capacity, had another available bed for a child in need. Although Joey coped very well with the procedure, not all children are able to cope. The inability to cope can be directly related to the procedure requiring multiple attempts, being too lengthy, too painful, and/or a result of traumatic experiences in the past. It can also be that the child is too young to hold still for such a procedure (le, toddlers). In a situation like this, one may wish to consider the
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PLACE PATIENT LABEUSTICKER HERE
This portion to be completed by vascular access nurse: Patient is scheduled on
(date) at
• Peripheral IV (PlY) • PICC Insertion • PICC Exchange • CVC Repair • PICC Removal ·Other:
(RN/NP/PNMD) (time) for the following
_
Patient Assessed by Nurse:Y N (circle one) Assessed with Ultrasound:Y N (circle one) PIV and PICC Insertions Only: Preferred Vein of Choice: Right/Left (circle one) • Basillic • Cephallic • Saphenous • Scalp • Popliteal ·Other:
_
Check all that apply to patient during procedure: • Anxiolysis
• Sedation • General Anesthesia • Fluoroscopy This portion to be completed by Certified Child Life Specialist: Patient Age:
,(CCLS)
_
Developmentally Appropriate for Age:Y N (circle one) If no, explain:
_
Coping Preferences:
• Would like family member present during procedure: • Wants to watch the procedure
(name)
• Wants to be told exactly what is happening during procedure
• Would like to read a book/watch a DVD/play with a toy: (which one) After assessment, I feel child can cope successfully for the scheduled procedure Y N (ci"c1e one)
Figure I. Vascular Access/Child Life Procedure Form. Copyright © 2006 P & A PICC, LLC. Reprinted with permission.
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use of sedation or general anesthesia prior to attempting the procedure. Nurse practitioners, physician assistants, and physicians are usually responsible for determining whether the child will receive sedation or anesthesia. The decision is based on the child's age, current medical condition, medical history, allergies, and an assessment of the child's coping abilities.
Pain Management Did the use of a CCLS make the PICC insertion a pain-free experience for loey? Mosby's Medical Dictionary defines pain as follows: "An unpleasant sensation caused by noxious stimulation of the sensory nerve endings. It is a subjective feeling and an individual response to the cause. Experiencing pain is influenced by physical, mental, biochemical, psychological, physiological, social, cultural, and emotional factors.'"
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003 0-10 Numeric Rating Scale (page 1 of 1)
o
2
-.l-None
Mild
3
4
5
6
Moderate
7
8
9
10
Severe
Indications: Adults and children (> 9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain. Instructions: 1.
2.
3.
The patient is asked anyone of the following questions: • What number would you give your pain right now? • What number on a 0 to 10 scale would you give your pain when it is the worst that it gets and when it is the best that it gets? • At what number is the pain at an acceptable level for you? When the explanation suggested in #1 above is not sufficient for the patient, it is sometimes helpful to further explain or conceptualize the Numeric Rating Scale in the following manner: • 0 = No Pain • 1-3 = Mild Pain (nagging, annoying, interfering little with ADLs) • 4-6 = Mod erate Pain (interferes significantly with ADLs) • 7·10 = Severe Pain (disabling; unable 10 perform ADLs) The interdisciplinary team in collaboration with the patienUfamily (if appropriate), can determine appropriate Interventions in response to Numeric Pain Ratings.
In 2001, the Joint Commission on Accreditation of Healthcare Organizations Reference (JCAHO) published Pain Assessmem and McCaffery, M., & Beebe, A. (1993). Pain: Clinical Manual for Nursing Practice. Baltimore: VV. Mosby Company. Management Standards-Ho!Jpitals,4 and in a PowerPoint presentation available on the Internet, Pain Assessment in Infants and Childl'en/ these standards are Figure 2. 0-10 Numeric Rating Pain Scale. Source: Nationallnstitutes of Health. explained. One of the standards makes pain rating the fifth vital sign. The reason that one would assess pain is to take action to relieve the pain. tion greater than 95%; I: increased vital signs; E: expresIn Joey's case sn,dy, not only was a CCLS present but approsion; S: sleepless) (32--{j0 weeks gestational age) by priate pain management measures were also taken. L4M~X4 Kretchel and Bildner, 1995" (Figure 5) (Fcmdale Laboratories, lnc; Femdale, MI) was placed on Joey's Checklist of Nonverbal Indicators (CNVI) (Figure 6) right arm in two different places prior to setting up for the procedure, and during the procedure lidocaine I% buffered with Pain is subjective and responses to pain vary widely among sodium bicarbonate was injected at the site very slowly. individuals. Different factors determine how individuals respond to pain, such as age, gender, specific diseases or injuries, health, pain threshold, fear, anxiety, the culture and background of the Pain Is Subjective There are many ways to identitY and quantitY pain in the pediindividual experiencing the pain, and the way the person expresses painful experiences. attic setting. The use of pain scales is recommended by JCAHo. Some samples' of Pain Rating Scales from the JCAHO Pain AssessOther factors associated with how children deal with pain may ment and Management Standards-Hmpital~ are as follows: include previous experiences with pain, how their parents treated the child when the child was in pain, and how parents respond 0-10 Numeric Scale (Figure 2) to pain when they thcmselves are hurting. Early expcriences of Visual Analog Scale (VAS)' Wong-Baker FACES Pain Rating Scale' (Figure 3) pain may produce permanent structural and functional reorganization of developing neural pathways, affecting future experiences of pain, For infants and nonverbal children, use appropriate observaStress response to pain increases breakdown of body tissue; tional scales such as the following: b NPASS (Neonatal Pain, Agitation and Sedation Scale) (preincreases the metabolic rate, blood cloning, and water retention; decreases immune function; triggers fight or flight response; maturity) by Hummel and Puchalski, 2002' causes diaphoresis or palmar sweating; increases heart rate, FLACC" (Face, Legs, Activity, Cry, and Consolability) (full term neonate--7 years) by Mcrkel et ai, 1997" (Figure 4) blood pressure, and shallow respirations; increases cough suppression; increases retention of pulmonary secretions; and CRIES (C: crying; R: requires oxygen to maintain satura-
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increases the delay of return of gastric and bowel function. 13 It is by far more effective and safer to prevent pain rather than to try to catch up and treat already existing pain,
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
WongriBaker Faces Pain Rating Scale (page 1 of 1)
The Use of Analgesics English Although it may be necessary at times to use sedation or general anesthesia for certain vascular access procedures, there are some reasonably priced analgesic o 2 6 8 • NO HURT HURTS HURTS HURTS HURTS HURTS products that could be used for most unLE61T unLE MORE EVEN MORE WHOLE LOT WORST patients who are not allergic. These would Espanol include, but are not limited to, the use of Sweet-Ease (Respironics, Pittsburgh, PAl, ethyl chloride, L-M-X4, EMLA (AstraZeneca LP, S6dertiilje, Sweden), and I% lidocaine subdermal/subcutaneous injection at the site. All of these NO DOlOR MUY lEVE lEVE MODERADA SEVERA MUY SEVERA require a physician or allied health professional's (AHP's) order. Indications: Adults and children (> 3 years old) in all patient care settings. Sweat-Ease is a 24% sucrose and water Instructions: solution. Sucrose produces analgesia through both endogenous opioid and nono1. Explain to the patient that each face is for a person who feels happy because he has no pain (hurt or, whatever word the patient uses) or feels sad because he has some or a lot of pain. pioid pathways. In neonates, the taste 2. Point to the appropriate face and state, "This face is . " receptors are an important consideration • 0 -1 - ~very happy because he doesn't hurt at aiL" • 2 - 3 - "hurts just a little bit." for pain management. Non-nutritive suck• 4 - 5 - "hurts a little more." ing with sucrose has the best effecl. It is • 6 - 7 - "hurts even more." • 8 - 9 - "hurts a whole lot" recommended to be given I to 2 minutes • 10 - 'hu1s as much as you can imagine, although you don't have to be crying to feel this bad." 3. Ask the patient to choose the face that best describes how he feels. Be specific about the pain prior to starting the procedure, either with location and at what time pain occurred (now or earlier during a procedure?). a syringe on the tongue or on the buccal 4. The interdisciplinary team in collaboration with the patienUfamily (if appropriate), can determine appropriate interventions in response to Faces Pain Ratings. surface followed by a pacifier. It should not be used on patients less than 27 weeks gesReference tational age, those who weigh less than 1000 grams or have cardiovascular instaWong, D. and Whalay, l. (1986). Clinical handbook of oediatric nursing ed. 2, p. 373. SI. Louis: C.V. Mosby Company. bility, or with neonates who have persistent pulmonary hypertension. Ethyl chloride spray, often referred to Figure 3. Wong-Baker Faces Pain Rating Scale. Source: National Institutes of Health. as "cold spray," temporarily numbs the skin on contact by making it feel very cold. The sensation is similar to effects of an ice pack. The botfor the administration of lidocaine I% during PICC placements. tle should be held approximately 7 inches from the skin and Lidocaine I% can be buffered with sodium bicarbonate in a 10: I ratio. This combination eliminates the stinging property of the sprayed continuously between three and 7 seconds. The skin will turn white when it is numb. This analgesic only lasts for approxlidocaine. It should be mixed under a hood in the pharmacy. It imately 30 seconds. When using this type of analgesic, it is of is recommended that no more than 4.5 mg/kg be administered utmost importance to act quickly. The child may consider the for procedures in children. frosty, cold, and tingling unfamiliar and mildly uncomfortable. It is important to write down the patient's pain history before pain is expected, such as before thc vascular access procedure. In It is best to show the child in advance how it feels and allow him/her to choose. addition, try to involve the family when possible. Families are L-M-X4 and EMLA are both topical creams that are applied often helpful in interpreting and recording response to pain relief directly to the proposed site. L-M-X4 contains lidocaine 4% and measures. Pain experienced during vascular access procedures is should be applied 15 to 30 minutes prior to the procedure. acute. Acute pain activates the body's fight or ftight slTess EMLA contains lidocaine 2.5%/prilocaine 2.5% and is recomresponse. When pain persists, the body begins to adapt and there is mended to be applied I to 2 hours prior to the procedure. Both a decrease in the sympathetic responses. In chronic pain, stress of these creams have anesthetic properties that reach to a depth response is absent or diminished. For this reason, chronically ill of 4 mm. They are very useful for peripheral IV insertions and patients may have a lower pain tolerance.
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NATIONAL INSTITUTES OF HEALTH Conclusions WARREN GRANT MAGNUSON CLINICAL CENTEl'l Pain is an unpleasant sensory and emotional experience arising from actual or PAIN INTENSITY INSTRUMENTS JULY 2003 potential tissue damage. The major responsibility for alleviating a child's pain FLACC Scale (page 1 of 1) during a vascular access procedure rests with the VA nurse. Pain is whatever the DATElTIME experiencing child says it is, and it exists Face o- No particular expression Of smile whenever he or she says it does. If using 1 - Occasional grimace or frown, withdrawn, disinterested CCLSs and appropriate pain management 2 - Freouent to constant Quiverina chin clenched "aw Legs interventions have such a positive effect O· Normal p osilion or relaxed on the outeomes of our ehildren, why do 1 - Una 35y, restless, tense 2· Kickina, or leas drawn uo hospitals not always use them consisActivity tently? It may be beeause of a lack of 0- Lying quietly, normal position, moves easily 1 • Squirming, shifting back and forth, tense funding or time. It may be inconvenient at 2· Arched. riaid or ierkino times for us, as health care professionals, Cry 0- No cry (awake or asleep) to take the time to apply a topical anal1 - Moans or whimpers: occasional complaint 2 - ervino steadil screams or sobs, freauenl comolaints gesic or consult with a CCLS. Consolability You may be part of a Vascular Access O· Content, relaxed 1 - Reassured by occasionallouching, hugging or being talked to, distractible Team who manages all IV therapy and 2 - Difficullla console or comfort vascular access devices or you could be a TOTAL SCOFtE one-person PICC "team" in a large facility. Using CCLSs and appropriate pain Indications: Infants and children (2 months· 7 years) unable to validate the presence of or quantify the severity of pain. management techniques may sound like a great idea. The need is evident. However, Instructions: many practitioners may believe that, 1. Each of the five (5) categories is scored from ()'2, which results in a total SCOfe between 0 although the concept is idealistic, it is not and 10. • (F) Faces realistic in the daily hospital setting. • (l) legs Having come from a large children's • (A) Activity • (Cl Cry hospital that operates at 100% capacity • (C) Consolability 2. The interdisciplinafy team in collaboration with the patienllfamily (if appropri;3te), can most days, a place where it seems there is determine appfopriate inlef'Ventions in response 10 FlACC Scale scores. never enough time in the day to accomReference plish all of the orders and respond to all of Merkel, SI, Voepel-lewis, T., ShayevilZ, JR, & Malviya, S. (1997). The FLACC: a behavioral the calls, I can say that it is important to scale fOf scoring postopefative pain in young children. Pediatric Nursing 23(3): 293-297. take the time and show you care. The remembrance of a positive experience is invaluable and will serve to make your job Figure 4. FLACC Pain Scale. Source: National Institutes of Health. much easier in the future should another vascular access procedure be necessary. Consider the loss of revenue and supplies that are not reim4. Joint Commission on Accreditation of Healthcare Organizations. Pain Assessment and Management Standards-Hm.pibursed, the frustration and nursing time it takes for one to repeatedly attempt a failed vascular access procedure, the fear that we tals [online]. Available at: http://www.jcrinc.com/subscribers/ have instilled in the child, and the dissatisfaction of the family. perspectives.asp?durki~3243&site=' I O&retum=.... Accessed Can we truly afford to sacrifice the quality of care we provide? July 28, 2006. The next time you are called on to "stick" a pediatric patient, 5. Wong DL. Pain Assessment in In/ants and Children [Online remember that this may be the child's first experience with vaspresentation]. Available at: www.mosby.comIWOW. cular access or it may be their hundredth. Why not make it their Accessed June I, 2006. best? The power to make a difference rests in your hands. 6. National Institutes of Health. Pain Intensity Scales [onlineJ. Available at: http://painconsortium.nih.gov/pain_scales/ index.hlm!. Accessed June I, 2006. References I. Sowden, B. Mosby s Pediatric Nursing Reference, 5th ed. St. 7. Johnson E. Visual Analog Scale (VAS). Am J Phys Med Louis, MO: MosbylElsevier; 2004. Rehabil.2001;80:717. 2. Child Life Council [website]. Available at: 8. Wong D, Baker C. Pain in children: comparison of assesshttp://www.childlife.org. Aeeessed June 1,2006. ment scales. Pediatr Nurs. 1988;14:9-17. 3. Mosby s Medical Dictionmy, 7th ed. St. Louis, MO: 9. Hummel P, Puchalski M. Establishing Initial Reliability and MosbylElsevier; 2006. Validity o/the N-PASS: Neonatal Pain, Agitation, and Seda-
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tion Scale-A Pilot Study. Presented at The Association of Women's Health, Obstetric and Neonatal Nurses 2002 Convention: Lighting the Way. Boston, MA. 10. Chambers CT, Giesbrecht, K, Craig KD, Bennet! SM, Huntsman E. A comparison of Faces Scales for the Measurement of Pediatric Pain: children's and parents' ratings. PAIN [serialonline]. 1999;83:25-35. Available from: Association for the Snldy of Pain International, Vancouver, Canada. Accessed May 29, 2006. 11. Merkel SI, Voepel-Lewis T, Shaycvitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nul's. 1997;23:293-297. 12. Krechel, Bildner 1. CRIES: a new neonatal postoperative pain measurement score-initial testing of validity and reliability. Paediatr Anaesth. 1995;5:53-61. 13. Straight A s in Pediatric Nursing. Philadelphia, PA: Lippincot! Williams & Wilkins; 2004.
NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
CRIES Pain Scale (page 1 of 1)
DATElTIME
Crying - Characteristic cry of pain is high pitched. o - No cry or cry that is not high-pitched 1 - Cry high pitched but baby is easily consolable 2 - Crv hiah Ditched but babv is inconsolable Requires O2 for Sa02 < 95% - Babies experiencing pain manifest decreased oxygenation. Consider other causes of hypoxemia, e.g., oversedation, atelectasis, pneumothorax) o • No oxyge n required 1 - < 30% oxygen req uired 2 - > 30% oxv-aen reauired Increased vital signs (BP* and HR*) • Take BP last as this may awaken child making other assessments difficult 0- Both HR and BP unchanged or less than baseline 1 - HR or BP increased but increase in < 20% of baseline 2 - HR Of BP is increased> 20% over baseline. Expression. The facial expression most often associated with pain is a grimace. A grimace may be characterized by brow lowering, eyes squeezed shut, deepening naso-labial furrow, or open lips and mouth. O· No grimace present 1 • Grimace alone is present 2 - Grimace and non-crv vocalization orunt is Dresent Sleepless· Scored based upon the infanlis state during Ihe hour preceding this recorded score. o - Child has been continuously asleep 1 - Child has awakened al frequent intervals 2 - Child has been awake constantly
TOTAL SCORE
Cail Heckler-Medina, BS, RN, is a PICC line expert and vascular access nurse. She has assisted in the growth and development of the vascular access pro-
grams throughout the nation. Ms. HeckJerMedina is the founder of P & A Piee. LLe. an independent contracNng company that is responsible for education of stafl and the placement and maintenance of PICCs Gnd midline catheters. Ms. Heckler-
Medina is a clinical nurse educator and preceptor fOr BARD Access Systems.
• Use baseline preoperative parameters from a non-stressed period. Multiply baseline HR by 0.2 then add to baseline HR to determine the HR that is 20% over baseline. Do the same for BP and use the mean BP.
Indications: For neonales (0 - 6 months) Instructions: Each of the five (5) categories is scored from 0-2, which results in a total score between 0 and 10. The interdisciplinary team in collaboration with the patienVfamily (if appropriate), can determine appropriate interventions In response to CRIES Scale scores.
Reference Krechel, sw & BHdner, J. (1995). CRIES: a new neonatal postoperative pain measurement score - initial testing of validity and reliability. Paediatric Anaesthesia 5; 53-61.
Figure 5. CRI ES Pain Scale. Source: National Institutes of Health. Received 6/9/2005; revision received 7/27/2006; accepted 7/28/2006.
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NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER PAIN INTENSITY INSTRUMENTS JULY 2003
Checklist of Non·Yerballndlcators (CNYIl (page 1 of 1) With
At Rest
Movement Vocal Complaints - nonverbal expression of pain demonstrated by moans, groans, grunts, cries, gasps, sighs) Facial Grimaces and Winces - furrowed brow, narrowed eyes, lightened lips, dropped jaw, clenched teeth, distorted exoression Bracing - clutching or holding onto siderails, bed, tray table, or affected area durina movement Restlessness - constant or intermittent shifting of position, rocking, intermittent or constant hand motions,
inabilitv -to keeo still
RUbbing
massaging affected area
Vocal complaints verbal expression of pain using words, e.g., ~ouch· or ~that hurts; • cursing during movement, or exclamations of protest, e.g., ftstop· Of "that's enouQh.~
TOTAL SCORE
Indications: Behavioral Health adults who are unable to validate the presence of or quantify the severity of pain using either the Numerical Rating Scale or the Wong-Baker Faces Pain Rating Scale.
Instructions: 1. Write a 0 if the behavior was not observed 2. Write a 1 if the behavior even briefly during activity or rest 3. Results in a total score between 0 and 5. 4. The interdisciplinary team in collaboration with the patient (if appropriate), can determine appropriate interventions in response to CNVI scores.
Reference Feldt, KS. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing
1(1): 13-21.
Figure 6. Checklist of Nonverbal Indicators (CNVI).
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