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Journal of Nursing

Maximizing Pain Relief in Pediatric Patients 

by Andrea Calvani, BSN, Paula Bylaska-Davies, BSN, MSN [email protected]


Research Problem:  


Pain management is a complex issue that has become increasingly significant in the nursing profession; so much so that the assessment of pain has become known as the fifth vital sign. This issue becomes even more crucial when attempting to manage pain in pediatric patients. Assessing pain becomes complicated with children as the nurse must account for the child’s developmental stage and chronological age.  Though it is important for the nurse to monitor physical findings, such as pulse and blood pressure, it is even more necessary to receive a self-report from the child regarding her pain due to the fact that pain is a subjective experience (Pillitteri, 2010).  A recent study by Kortesluoma, Nikkonen, and Serio (2008), focused on the subjective nature of pain and declared that children should be considered an “expert” on managing their pain; therefore, it is crucial for nurses to inquire information regarding how the child relieves his pain, and attempt to include this in the child’s plan of care.   


Hospitalized pediatric patients often undergo procedures which cause pain; therefore, nurses must have knowledge regarding various pain management methods. Recently, a study was conducted that explored the rationale for the poor management of pediatric pain by nurses.  According to Twycross (2010), nurses today have a knowledge deficit concerning pediatric pain and continue to believe many fallacies regarding pain management in children. Nurses continue to disregard the subjective aspect of pain, and according to Kortesluoma et al., (2008), there have been limited studies that have addressed a child’s preferred pain management strategies and less is understood about the strategies performed by pediatric patients themselves. Little attention has been given to the pediatric patient’s perception of pain, nor to the interventions that the nurse can provide in order to effectively manage a child’s pain.  


Most current studies have focused primarily on pain relief methods initiated by healthcare workers rather than the pediatric patient’s perception of pain or her preferred pain management strategies (Kortesluoma et al., 2008). The purpose of this paper will be to explore the importance of inquiring about the patient’s self-imposed pain relief methods, and the role of the nurse in assisting the child to minimize his pain.  For this paper, the term self-imposed will be used to identify any strategy initiated by the pediatric patient himself to relieve pain. 


Review of the Literature: 


Pain management in pediatric patients has been extensively examined by many researchers, although, less is known about the pediatric patient’s perception of pain relief and the self-imposed methods the patient uses to relieve pain.  A study completed by Kortesluoma et al., in 2008 studied the pediatric patient’s self-help strategies for pain relief. The authors concluded that hospitalized children utilized a variety of self-help methods during episodes of pain. Nineteen self-imposed pain relief methods were identified including strategies such as:  massaging the painful site, deep breathing, changing body position, exercise, positive self-talk, crying, applying ice and/or heat, and attention diversion.


 According to Kortesluoma et al., (2008), a child’s perception of pain and his self-help methods to reduce pain should be the most reliable source when developing a plan to manage care, as pain is an entirely subjective experience.  In this same study, it was concluded that children also identified nurse-initiated pain relief methods to be very beneficial when attempting to achieve pain relief.  The children stated the desire for nursing services to help manage pain, and they sought out the assistance of nurses on a regular basis.  The findings support identifying self-imposed pain relief methods when attempting to develop a plan to manage pediatric patients’ pain.  The authors identified that children rely on nurses to help relieve pain; therefore, it is important that nurses include the pediatric patient’s preferred self-help methods when assessing pain and developing a plan of care. 


Though children reported that nurses are important in managing their pain, nurses continue to perform suboptimal pain management. According to Twycross (2010), nurses lack knowledge regarding pharmacological and non-pharmacological pain management techniques, as well as the psychological factors that may play a role in managing pain. She also discovered that nurses consider pain management to have a low priority in nursing care, and that many nurses incorrectly assume that some pain is to be expected during a child’s hospitalized stay.  Twycross (2010), observed that nurses tend to assess pain using only developmental and behavioral milestones, and continuously negate the child’s self-reported pain.  The results of this study support the idea that further research is needed regarding the usefulness of including the pediatric patient’s self-imposed pain relief methods as part of the nursing pain assessment.   


Many of the self-imposed pain relief techniques identified by Kortesluoma et al., (2008) such as:  massage, deep breathing, and hot/cold therapy can be considered forms of complementary therapy.  Gerik (2005), studied the importance of mind-body complementary therapies in achieving pain relief for procedure-related pain.  She concluded that cognitive-behavioral training, such as distraction and relaxation, effectively decreased fear and pain in pediatric patients. Many of the methods identified by Gerik (2005) as effective pain relief measures were similarly identified by Kortesluoma et al., (2008) as the self-help methods reported by pediatric patients for pain relief strategies. A strong connection can be made between the effectiveness of the self-reported methods and pain relief.   This research supports the need to identify the preferred self-imposed pain relief methods in pediatric patients.   


Though the use of complementary therapies has been researched and shown to be effective at managing pain, the use of these therapies is rarely discussed by physicians.  A study conducted by Roth, Lin, Kim, and Moody (2009) researched pediatric oncologists’ views of the use of complementary therapies in children with cancer.  The pediatric oncologists believe that therapies such as prayer, guided imagery, and exercise have significant potential to relieve pain in their patients. Many of these complementary therapies are utilized as self-help pain relief methods for pediatric patients (Kortesluoma et al., 2008 & Gerik, 2005). The researchers concluded that 99% of pediatric oncologists believe it is important to know what complementary therapies are used by the patient. However, less than half of these physicians actually ask their patient about complementary therapies stating a lack of time as a rationale for the omission; therefore, the role of the nurse may be essential in providing information and advocating for their patients regarding complementary therapies.


Nursing Implications  


The identification of the pediatric patient’s preferred self-imposed pain management methods will significantly affect the delivery of nursing care for these patients.  The ability to recognize the child’s preferred interventions will allow the nurse to better assess and care for the child’s pain. Interventions can be developed accordingly that will significantly decrease the child’s overall level of pain. Many nurses do not place significant emphasis on managing pain in pediatric patients. Performing a more thorough pain assessment is an issue of great importance for the nursing community.  While performing this pain assessment, nurses will be able to incorporate information regarding complementary therapies to help alleviate the patient’s pain. Currently, nurses use a variety of pain scales to assess a child’s pain and pain relief measures are initiated based on this nursing assessment.  Though pain assessments are routinely completed, nurses often fail to question the child regarding the self-imposed pain relief methods utilized to relieve pain.  Listening to the patient regarding self-imposed pain management strategies and including complementary pain management options will help to augment pharmacological methods, which will help to greatly reduce the child’s pain.   


 


References


Gerik, S. (2005). Pain Management in Children:  Developmental Considerations and Mind-body  


Therapies. Southern Medical Journal, 98(3), 295-302. 


Kortesluoma, R., Nikkonen, M., & Serlo, W. (2008). "You just have to make the pain go away children's experiences of pain management. Pain Management Nursing, 9(4), 143-149.  


Retrieved from CINAHL with Full Text database. 


Pillitteri, A. (2010). Maternal & child health nursing: care of the childbearing & childrearing family (6th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.  


Roth, M., Lin, J., Kim, M., & Moody, K. (2009). Pediatric Oncologists’ Views Toward the Use Of Complementary and Alternative Medicine in Children with Cancer. Journal of   Pediatric Hematology Oncology, 31 (3),177-182. 


Twycross, A. (2010). Managing pain in children:  where to from here?Journal of Clinical Nursing, 19, 2090-2099.

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