Educators Group and expert panel Registered nurses and medical staff in the Children s Hospital

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1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Date of submission September 03 Date on which guideline must be reviewed (this should be one to five years) P03. Pain assessment for babies, children and young people Michelle BennettClinical Nurse Specialist in Children s Pain Management Nottingham Children s HospitalFamily Health Directorate September 08 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words All patients cared for at Nottingham Children s Hospital This is an update to a current guideline in use within the Children s Hospital Pain assessment Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (-6) NICE Guidance, Royal College Guideline, SIGN (please state which source). a b 3a 3b meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience Peer reviewed by another Nurse Specialist, Consultant Paediatric Anaesthetist, PDM and clinical educators group Evidence base:. Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) (008). Good Practice in Post operative and procedural pain. APA guidelines,. DoH (00) Essence of Care 00: Benchmarks for the prevention and management of pain. HMSO. London. 3. Royal College of Nursing Institute (009) Clinical Practice Guidelines: The recognition and assessment of acute pain in children recommendations. RCN, London 5 and 6 Nottingham Children s Hospital Clinical Educators Group and expert panel Registered nurses and medical staff in the Children s Hospital This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines P03 after the review date.

2 NOTTINGHAM CHILDREN S HOSPITAL Nursing Guideline P03 Pain assessment for babies, children and young people Standard Statement Babies, children and young people will have their pain recognised, assessed, treated and evaluated if they are experiencing pain, using appropriate assessment tools. Introduction Providing effective pain management for children is widely recognised as a complicated and challenging aspect of nursing (Gibson and Llewellyn 997). The Department of Health s National Service Framework (003) identifies that all areas treating children should assess pain carefully and have a policy in place, which deals with, pain management. Selection of validated pain assessment tools meets both the RCN Clinical Guideline recommendation (009) and that of the Royal College of Paediatrics and Child Health (003). The Healthcare Commission (007) recommends that 50% of nurses working with children should be trained in assessing children s pain. Healthcare professionals are in the ideal position to assess children s pain and should include the parent and carer s views. The use of pain assessment tools help to provide an organised standardised approach using a common language for written and visual observations. Whenever possible, behavioural measurement of pain should be used in conjunction with selfreport and physiological signs. When self-report is not possible, interpretation of pain behaviours and decisions regarding treatment of pain require careful consideration of the context in which the pain behaviours are observed. Equipment Pain Assessment Tools appropriate for a baby, child or young person s age and cognitive ability. (Nottingham University Hospitals has standardised the use of three validated pain assessment tools; FLACC, Faces and VAS.) P03

3 The FLACC Tool For infants 0-3 years and children unable to verbally communicate FACE 0 No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin LEGS 0 Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up ACTIVITY 0 Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking CRY 0 No cry (awake or asleep) CONSOLABILITY 0 Content, relaxed Moans or whimpers, occasional complaints Reassured by occasional touching, hugging or talking to, distractible Crying steadily, screams or sobs, frequent complaints Difficult to consol or comfort Merkel, S., Voepel-Lewis, T., Malviya, S. (00) The FACES scale for young children Happy no pain Hurts a little Hurts a bit more The worst pain 0 3 Whaley, L., Wong, D. (987) The visual analogue scale For older children /adolescents No Pain Worst pain P03 3

4 How to use the pain measurement tools Pain score should be documented on the PEWS or PICU / PHDU observation chart at the same time as other observations. If pain is scored in the shaded boxes (moderate/severe), action should be taken and recorded. Pain should be recorded when: The child complains of pain When the child is on regular analgesia ½ hour following action taken to evaluate effectiveness of intervention If pain develops at a different site Whenever possible, behavioural measurement of pain should be used in conjunction with self-report and physiological signs. When self-report is not possible, interpretation of pain behaviours and decisions regarding treatment of pain require careful consideration of the context in which the pain behaviours are observed. Behaviour scales FLACC Each category is scored on the 0 scale, which results in a total score of = Relaxed and comfortable 3 = mild discomfort 4 6 = moderate pain 7 0 = Severe discomfort or pain or both Faces scale self report Ask the child to indicate which face describes their pain, using the pain words below the face. This will need to be explained according to the child s level of understanding. The child does not have to be crying to experience severe pain. This should be the child s score, not the parent s or nurses interpretation of the score. If the child is unable to self-report, then a behavioural scale should be used. 0 = Happy no pain none = Hurts a little mild = Hurts a little -moderate 3 = The worst pain severe Visual analogue scale self report The child/young person should be asked to score their pain by explaining to them that 0 = no pain at all, = very slight pain up to 0 = the worst pain they have ever experienced. Score = none - 4 = mild 5 7 = moderate 8 0 = severe P03 4

5 Procedure Action ) All babies, children and young people should have a suitable pain assessment tool available at the bedside ) A pain assessment tool should be discussed with the child/carer when possible and the appropriate chosen tool documented in the child s notes. 3) Pain should be assessed and recorded on the child s PEWS or PICU/PHDU observation chart at the following times: At the same time as other observations When the child complains of pain When the child is on regular analgesia Half an hour following analgesia or intervention If pain develops at a different site And the pain score should be incorporated into the PEWS score 4) Behavioural measurement of pain should be used in conjunction with self- report and physiological signs if applicable. 5) If pain scores indicate mild pain, comfort measures should be employed, these may include re positioning, toileting, distraction therapy, parents/carers presence or reducing environmental stress before giving analgesia. 6) Action should be taken and recorded if pain is scored moderate to severe. 7) If the child is identified as being at risk of experiencing pain they should have an appropriate pain assessment and management nursing care plan 8) Healthcare Professionals should be trained to recognise and assess pain. 9) Parents/carers should be encouraged to contribute to the assessment of their child s pain Rationale Children should have the opportunity to have their pain assessed. Morton (998), RCN (009) To ensure that all Healthcare professionals are using the same tool for each child. (RCN 009) To ensure that pain is accurately recorded and evaluated. DoH (003) NSF, Healthcare Commission (007) To meet requirements of local and national bench marks (DoH 00). To be able to pick up the signs and symptoms of pain in the baby, young child and children unable to verbalise their pain. Morton (998). To ensure that any discomfort is managed and re-evaluated prior to analgesia being administered. Morton (998) To ensure that analgesia is given promptly and the medical management plan or prescription is reviewed. Morton (998) To ensure individualised consistent nursing care and to meet requirements of local and national bench marks (DoH 00). Training is crucial to the effective management of pain in children. Healthcare Commission (007). Pain assessment in children is a mandatory training session on the induction program for Nottingham Children s Hospital. To ensure the parents/carer are partners in the pain management of their child and given the knowledge to assess their child s pain when discharged. RCN (009), RCPCH (003) P03 5

6 References Association of Paediatric Anaesthetists of Great Britain and Ireland (008) Good practice in postoperative and procedural pain management. last accessed Association of Paediatric Anaesthetists of Great Britain and Ireland (0) Good practice in postoperative and procedural pain management. Second edition. Pediatric Anesthesia, volume supplement July 0. DoH (003) Setting the Right Standards; National Service Framework for Children: Standards for Hospital Services. HMSO. London DoH (00) Essence of Care 00: Benchmarks for the prevention and management of pain. HMSO. London. Gibson. F. Llewellyn. N. (997) Learning about Paediatric Pain. Paediatric Nursing 9 (0): 0-3. Healthcare Commission (007) Improving Services for children in hospital: Improvement Review. Commission for Healthcare Audit and Inspection. London. Merkel, S., Voepel-Lewis, T., Malviya, S. (00) Pain assessment in Infants and Young Children: The FLACC Scale: A behavioural tool to measure pain in young children. American Journal of Nursing 0 (0) Morton, N.S. (998) Acute Paediatric Pain Management: A practical guide W.B. Saunders. London Royal College of Nursing Institute (009) Clinical Practice Guidelines: The recognition and assessment of acute pain in children recommendations. RCN, London last accessed Royal College of Paediatrics and Child Health (003) Acute Pain Recommendations. last accessed Whaley.L. Wong. D.L. (987) Nursing care of Infants and Children St. Louis, USA,Mosby Author: Michelle Bennett Date: 03 Review date: 08 Consultation: Sharon Douglass Ratified by: Clinical Educator s Group, Nottingham Children s Hospital: KW, RK, MW, AH, NM, JC Signed off by: Angela Horsley, Kerry Webb and Rachel Keay P03 6