Communication tools help manage children's pain

Nurses learn pain is what the patient says it is

A team effort to focus more attention on the pain experienced by neonates and small children has produced a dramatic change in practice at the Cardinal Glennon Children's Hospital in St. Louis.

While pain assessment in children and babies is always difficult, a hospital initiative to increase compliance with Agency for Health Care Policy and Research guidelines on pain control is paying off. A spot check of nursing practices after the program was introduced found dramatic improvements in the number of nurses using objective pain ratings and frequency of pain assessments.

The process began about five years ago when a team was formed to spearhead the project. It started by gathering data on whether nurses were: using an objective and age-appropriate pain rating scale, how frequently they were assessing pain, and how frequently as-needed analgesics were given, says Sue McCool, RN, MSN, director of nursing practice and development.

The team examined 122 closed medical records covering 14 different medical and surgical DRGs. it collected data on the 24-hour period post-admission for medical diagnoses and post-surgical for surgery diagnoses. The data showed that improvements were needed in medication underdosing, pain evaluation, and documentation of pain trends in patients.

McCool says team members were interested in a pain management program at the University of Iowa Hospital and Clinics in Des Moines. "We used their standard of care which guided us in developing our own standard. That was the benchmark we used," she explains.

The written standards of care for pediatric pain management that resulted included:

· developing patient/parent education;

· screening for potential pain and/or initial pain rating value from the patient at admission;

· meeting with parents to establish patient/family response to pain, any distinctive family or cultural practices, their expectations regarding pain management;

· assessing patient using an age-appropriate assessment tool, family perceptions, and nursing observations of behavioral and physiologic signs of pain, and documentation of pain (even if none) every four hours;

· reassessing within 30 to 60 minutes after any intervention for pain;

· reassessing more frequently if pain is poorly controlled.

The methods used to satisfy the standards include use of the CRIES scale, an acronym for the indicators of a neonate's pain that was developed at the University of Missouri/Columbia, says Genie Mollohan, RN, MSN, clinical nurse specialist in Glennon's neonatal intensive care unit. Each measure is given a score from zero to two. A total score of four or greater signals a need for intervention, Mollohan says. CRIES stands for:

    C crying: none, high pitched, or inconsolable;

    R requires more oxygen (as measured by a pulse oximeter);

    I increase in heartbeat or blood pressure: within 10% of baseline, 11% to 20%, or greater than 20%;

    E expressions such as grimaces: none, grimace, or grimace with grunting;

    S sleep pattern: continuously sleeping, sleeping at intervals, or awake constantly.

An Infant/Non-Verbal Pain Scale is used with non-neonates up to speaking age. The Faces of Pain Scale can be used with children between the ages of 3 and 10 years old. It shows five line drawings of different faces, from happy and smiling to frowning and crying. The faces and accompanying pain levels are described to the child who is asked to choose the face that best describes how he or she is feeling. Children older than 10 are asked to rate their pain on a scale from one to five, with five being the worst pain.

The team developed a program of nursing education to familiarize nurses with the effects of pain on children, the new standards of care, a new documentation sheet, the assessment tools, other assessment strategies, and nonpharmaceutical as well as pharmaceutical pain relief measures.

Nonpharmaceutical measures implemented include parent presence, rocking, privacy, lower noise levels, soft lighting, and distraction. Team members also developed traveling posters and offered nurses self-study inservices.

As a result of the project, a spot check of nurses found that 88.9% were using an objective pain rating scale, compared to 10.3% previously. It also found that nearly three-fourths of the nurses were reassessing patients' pain at least every four hours, compared to slightly more than half beforehand.