Pediatric Corner: Use standing orders for pain treatments
Use standing orders for pain treatments
Don't make children wait for relief
If a child comes to your ED in severe pain but without a life-threatening injury or illness, would that child have to wait for hours before receiving pain medications?
To speed care, ED nurses are using standing orders for pain management at triage. "Our triage nurses are empowered to begin pain management preparation from the start of the child's visit," says Marianne Hatfield, RN, BSN, system director of emergency services at Children's Healthcare of Atlanta.
Here are steps taken by ED nurses at triage:
- A topical numbing cream is placed onto common sites for intravenous (IV) lines, such as the back of the hand or the antecubital area of the arm, for any patient they suspect will require a peripheral IV or lab draw based on complaint, such as fever of unknown origin, vomiting, or abdominal pain. "We briefly explain to the parent/guardian the purpose of the cream at that time," says Hatfield. For example, ED nurses say, "Based on your child's current symptoms, it is possible that lab work may be required in order to diagnose and treat them. This cream is placed to numb the skin in preparation for this possibility, so that your child will not be subjected to unnecessary pain."
- Oral pain medications are given to children experiencing pain prior to placement in a treatment room, such as acetaminophen, ibuprofen, or acetaminophen and codeine for more severe pain.
- A topical form of lidocaine with epinephrine and tetracaine is applied to lacerations during the triage process to begin numbing the site in preparation for repair.
At Johns Hopkins Hospital's pediatric ED in Baltimore, children are screened for pain as part of the triage assessment. "The screening tool is selected by the nurse based on the patient's age and communication ability," says Mary Ellen Wilson, RN, BSN, nurse clinician III/base station coordinator at the ED. Assessment may include the intensity and location of the pain, alleviating or aggravating factors, effectiveness of the patient's present regimen, pain management history, effects of the pain on the child's daily life, physical examination, observation, and past medical history, says Wilson. "Acetaminophen and ibuprofen may be given for pain relief as a standing order by a nurse at the time of patient triage without a physician order," she says. Here are the indications:
- Pharmacologic management of pain is used for patients 6 months of age or older experiencing pain related to ear infection, sore throat without drooling or respiratory compromise, and orthopedic injury with no obvious deformity.
- Patient must not have a pre-existing condition that contraindicates the use of analgesics, such as hepatic dysfunction, clotting disorder, oncology patients, thyroid disorder, renal disease, or gastrointestinal bleeding.
- The patient must not have an allergy to either medication, and the patient must not have received a dose of the medication in the last four hours for acetaminophen or in the last six hours for ibuprofen.
Nonpharmacologic interventions also are initiated early and may be used in conjunction with pharmacologic management, says Wilson. "Physical comfort measures, such as splinting an extremity, cold or warm compresses, positioning, covering wounds, and massage may help minimize pain and are initiated at triage," she says. "For infants, stroking, cooing, or a pacifier can be comforting."
By having a standing order for pain management at triage, the patient may able to tolerate subsequent exams, procedures, or interventions more easily, says Wilson. "Pain can be very distracting to the child and may limit the physical exam and assessment," she explains. "Also, documentation of the patient's response to the intervention may assist with assessment and diagnosis. It also may contribute to a decrease in length of stay in the ED."
Triage nurses may be hesitant to administer medications in fear of masking a more serious illness or injury, notes Wilson. To address this concern, the ED's protocol at Children's Healthcare of Atlanta states, "There is no diagnostic or therapeutic benefit to being in pain. A single dose of oral analgesic rarely, if ever, delays surgical or medical treatment. In fact, reduction of pain sometimes clarifies a diagnosis. Our goal is to not only diagnose and effectively treat the cause of pain, but also to alleviate the symptom as quickly as possible."
Also, if pain relief has been obtained, the parent or caregiver may leave before the child is assessed, diagnosed, and treated. "This obstacle is minimized with good communication with the family, and well as frequent reassessment of the child's condition while in the waiting room or treatment area," says Wilson.
Sources
For more information on pediatric pain management, contact:
- Marianne Hatfield, RN, BSN, System Director of Emergency Services, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road N.E., Atlanta, GA 30342. Telephone: (404) 785-4968. E-mail: [email protected].
- Mary Ellen Wilson, RN BSN, Nurse Clinician III/Base Station Coordinator, Johns Hopkins Children's Center, Pediatric Emergency Department, 600 N. Wolfe St., Baltimore, MD 21287. Telephone: (410) 955-5680. E-mail: [email protected].
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