Pain Assessment in the Neurologically Impaired Child

The inability of nonverbal children to communicate pain and discomfort is a major barrier for pain assessment and management. Nurses must institute specific measures to detect pain and evaluate interventions in this population.
Pain assessment in children with neurological impairments has been the focus of scientific trials only in the last five to six years, despite the fact that these children are at increased risk for experiencing acute, chronic and procedural pain (Hunt, 2002). According to the International Journal of Nursing Studies, this evidence suggests that pain is not adequately treated because it is not adequately recognized, making this already vulnerable population endure an additional burden of unnecessary pain.
“Respect for human dignity, the first principle in the “Code of Ethics for Nurses” directs nurses to provide and advocate for humane and appropriate care” (Herr, 2006). Nurses are obligated to follow the ethical principles of beneficence (the duty to benefit another) and nonmalficence (the duty to do no harm), therefore to provide management and comfort to all patients, including those individuals who can not speak for themselves. According to the authors (Herr, 2006), the gold standard for pain assessment has always been self reporting, if this is not a viable option then there must be other actions that nurses should be prepared to take.
The American Society of Pain Management Nursing, points out general objective assessment strategies, such as using the hierarchy of pain management techniques, establishing a procedure for pain assessment, using of behavioral pain assessment tools, as appropriate, minimizing emphasis on physiologic indicators, and reassessing and documenting.
No single objective assessment strategy is sufficient by itself. The following examples are recommended by the authors (Herr, 2006). Searching for potential causes of pain such as upcoming procedures, should trigger an intervention by the nurse, even when there are no behavioral indicators. It is always a good idea to assume that pain is present. If there is reason to suspect pain, an analgesics trial can be therapeutic as well as diagnostic. Hunt (2003) suggests that “[p]ain assessment needs to be seen not as an objective process, but as an intersubjective process in which the professional engages with the child and family and endeavors to reach an understanding of the meaning that the pain experience has for them”(p. 181). Awareness of an individual’s baseline and familiarity with the patient is crucial in identifying subtle, less obvious changes in behavior patterns that may be indicative of the presence of pain.
An analgesic trial should be initiated if pain behavior continues after all the basic needs and comfort measures have been met. Based on the patient’s analgesic history and pathology, a nonopioid analgesic may be given initially (e.g., acetaminophen every four hours for 24 hours.), if behaviors improve, then assume pain was the cause. The authors suggest that, if behaviors continue, give a single, low dose, short acting opioid (e.g., hydrocodone, oxycodone, or morphine) and observe effects. If the nurse observes no change in patient behavior, she should titrate the dose upward by 25-50%. Continue to increase the dose if there is no change in behavior, observing and assessing continuously until either a therapeutic effect is seen, bothersome side effects occur or no benefit is determined. If behaviors continue the nurse must explore other potential causes (Herr, 2006).
The evidence suggests that the use of behavioral pain assessment tools may assist in recognizing and evaluating attempts to relieve pain in this population. “Standardized tools promote consistency among care providers and care settings and facilitate communication and evaluation of pain management treatment decisions. The appropriateness of a scale must be assessed patient by patient, and no one scale should be an institutional mandate for all patients in a certain group”(Herr, 2006). The authors of Pediatric Anesthesia propose that there is no standard measure of pain that exists for this population. However they propose the revised Face, Legs, Activity, Cry and Consolability (FLACC) observational pain tool as a valid and reliable measure to evaluate pain in children with cognitive impairment. Originally the FLACC tool was designed as a simple observational tool to assess pain in children who could not self report. It contains five categories, which are scored from zero to two to provide a total score ranging from zero to ten. A previous study demonstrated that the original behavior descriptors were not comprehensive, specifically the Legs and Activity categories. The authors point out that some individuals with neurological impairment exhibit a different constellation of pain behaviors compared to the healthy cognitively intact child. “The revised FLACC tool incorporates several additional behavioral descriptors, including: verbal outbursts, tremors, increased spasticity, jerking movements, and respiratory pattern changes such as breath holding and grunting” (Malviya, 2005). This study suggests that adding the specific behavioral descriptors to the relevant FLACC categories improved the reliability of pain assessment in these children. Additionally this allows for individualization via open-ended descriptors in each category. In addition, the authors recommend that incorporating a simple numeric scale for parent-identified descriptors, would better facilitate the assessment of pain in these children. Virtually half of the children in this study were described by their parents as having unique pain behaviors, such as, distinctive facial expressions, leg and body activity including self stimulating behaviors, specific verbalizations, and consoling techniques. This study showed that several parents noted a lack of expression, crying or responsiveness, was the most indicative sign of pain in their children (Malviya, 2006).
Physiologic indicators such as changes in heart rate, blood pressure and respiratory rate are often used to document the presence of pain. According to the authors, these indicators are not sensitive for discriminating pain from other sources of distress. The nurse should minimize emphasis on the use of vital sign changes, since there is little research to support this theory for identifying pain. An absence of abnormal vital signs does not indicate an absence of pain (Hunt, 2002).
Each patient must be reassessed regularly and overtime with tools and specific pain indicators that are appropriate for that patient. All assessments should be properly documented in a readily visible and consistent manner that is accessible to all health care providers involved in the management and assessment of pain (Herr, 2006).
In summary, the resolution of unnecessary pain in children who cannot self report requires frequent assessment, use of the right assessment tools and administration of analgesics. Foster (2001) declares that “nurses must be able to feel confident in their expert judgment. Judgments are based on comprehensive data gathered in the overall baseline assessment of each child and honed through keen observation of subtle changes in response to physiologic and environmental stimuli.”(p. 90). Nurses must possess a passion and be committed to eliminating pain as an emotional and physiological stressor for these vulnerable children. “When the passion is empowered by evidence based nursing judgment, children receive the best possible care” (Foster, 2001, p 93).
Intervention #1
Physiologic indicators such as heart rate, blood pressure and respiratory rate are often used to document the presence of pain
Disadvantage #1
The cornerstone to this intervention is using vital signs to determine pain in the nonverbal patient. However, physiologic indicators are not always sensitive for discriminating pain from other sources of distress. The nurse should minimize emphasis on the use of vital sign changes, since there is little research to support this theory for identifying pain. An absence of abnormal vital signs does not indicate and absence of pain. (Herr, 2006)
Disadvantage #2
“Physiological changes in variables such as respiratory rate, and heart rate are only loosely correlated with painful events and may occur in response to many other states such as exertion or fever”. An elevated heart rate could be associated with medications, anxiety, or excitement. (von Baeyer, 2006).
Intervention #2
Use of behavioral pain assessment tools such as FLACC (Face, Legs, Activity, Cry, Consolability) may assist in recognizing and evaluating pain.
Disadvantage #1
No one scale is appropriate for all types of pain or across all developmental levels. The FLACC tool was recommended only for procedural pain and other brief painful events, such as postoperative pain measured in the hospital. According to the authors this method can not be used in the home setting. (Foster, 2007)
Disadvantage #2
Not knowing – three forms of knowledge are required for optimal pain assessment and management. Knowing the child, familiarity with children with the same or similar conditions, and knowing the science (Hunt, 2002). Undertreatment of pain in nonverbal children is a danger because of their dependency on caregiving adults. “One of the most notable and serious social barriers to effective pain management has been the persistent myth that children do not experience pain. Of greater importance are the undocumented but countless actions of health care practitioners who have inflicted pain on children or failed to provide analgesia because of these beliefs.” (Kenneth, 1996)
Nurses must be able to feel confident in their expert judgment. The Nurse must be able to identify the subtle responses to physiologic and environmental stimuli to correctly titrate analgesics (Foster, 2001). If nurses lack the skills and abilities to recognize pain in the first place, a decision about how to effectively treat pain can not be made. (Hunt, 2002)

References
Herr, K., Coyne, P., Key, T., Manworren, R., McCaffery., Merkel, S., et al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. The American Society for Pain Management Nursing, 7(2), 44-52. Retrieved January 15, 2008 from Pubmedcentral database.
Hunt, A., Mastroyannopoulou, K., Goldman, A., & Seers, K., (2003). Not knowing-the problem in children with severe neurological impairment. International Journal of Nursing Studies, (40), 171-183. Retrieved January 15, 2008 from Pubmedcentral database.
Malviya, S., Voepel-Lewis, T., Burke, C., Merkel, S., & Tait, A., (2006). The revised FLACC Observational Pain Tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, (16), 258-265. Retrieved January 15, 2008 from Pubmedcentral database.
Foster, R., (2001) Nursing Judgment: The key to pain assessment in critically ill children. Journal of Specialized Pediatric Nursing 6(2), 90-96. Retrieved January 15, 2008 from CINAHL database.
von Baeyer, C., Spagrud, L., (2006). Systematic review of observational (behavioral) measures of pain for children ad adolescents aged 3-18 years. International Association for the Study of Pain, (127), 140-150. Retrieved May 6, 2008 from Pubmedcentral database.
Craig, K., Lilley, C., Gilbert, C.,(1996). Barriers to optimal pain management in infants, children, and adolescents social barriers to optimal pain management in infants and children. The Clinical Journal of Pain,12 (3), 232-242. Retrieved May 6, 2008 from Pubmedcentral database.