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pain 2.4. measurements Behavioural
Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [ 44 ]. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [ 45 ]. The following section describes scales commonly used with this age group. It consists of 13 facial actions: The CFCS has been useful with acute short-duration procedural pain [ 47 ].
The tool is used to assess pain intensity. Faces Pain Scale It was developed by Wong and Baker and is recommended for children ages 3 and older [ 51 ]. The scale requires health care professionals to point to each face and describe the pain intensity associated with it, and then ask the child to choose the face that most accurately describes his or her pain level [ 51 ]. Most pain rating scales using faces that portray degrees of distress are divided into two categories: Results showed that children exposed to smiling scale had considerably higher pain scores in the no pain categories and lower scores for positive pain than children who used the neutral faces scale [ 52 ].
A study by Chambers and colleagues indicated that children's pain ratings differ depending on the types of faces scale used, and that faces scales with smiling faces may confuse emotional states with pain ratings [ 52 ].
It does not contain smiling faces or tears thus avoiding the confounding of affect and pain intensity [ 45 ]. It is an ethnically based self-report scale, which has three versions: Caucasian, African-American, and Hispanic [ 54 , 55 ].
Even though it covers a wide array of patients, it still has limits. For example, females are not represented, as well as other cultures. It is used for children older than 5 years [ 55 ]. The tool has two separate scales: Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel [ 56 ]. Health care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults.
At roughly 7 to 8 years of age children, begin to understand the quality of pain [ 57 ]. Self-report visual analogue and numerical scales are effective in this age group.
A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [ 58 , 59 ]. A brief discussion of these tools is presented here. The children are asked to mark on the line the point that they feel represents their pain at this moment [ 60 ]. A color analogue scale can also be used, where darker more intense colors i.
The questionnaire usually takes about 10—15 minutes to complete [ 62 ]. Adolescent Pediatric Pain Tool APPT It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity, location, and quality of pain in children older than 8 years of age [ 63 ].
The APPT is most useful with children and adolescents who are experiencing complex, difficult to manage pain [ 59 ]. It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity. Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice.
For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [ 3 ]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable.
To assess pain and, specifically chronic pain, the adolescent pediatric pain tool see above section or the McGill pain questionnaire are helpful. It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location [ 68 ].
The questionnaire uses word lists separated into 4 classes to assess the total pain experience. The categories are 1 sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness, 2 affective category which describes pain in terms of tension, fear, and autonomic properties, 3 evaluative, and 4 miscellaneous. Scores vary from 0—78 with the higher score indicating greater pain [ 68 ].
Pain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [ 70 ]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate.
It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. The child and family should be active participants in the procedure.
In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [ 70 ]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel.
Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [ 70 ]. It is most effective when adapted to the developmental level of the child [ 71 ].
Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure [ 72 ].
Distraction has also proven to be more economical than using certain analgesics [ 73 ]. Distraction is divided into two main categories: Interventions used to minimise pain are classified into three main categories cognitive, behavioral, or combined [ 75 ].
Cognitive Interventions They are mostly used with older children to direct attention away from procedure-related pain e. The following are a few examples of cognitive interventions: The child is asked to imagine an enjoyable item or experience e. The procedure and feelings associated with the procedure are explained to child in an age appropriate manner. The child is taught to repeat a set of positive thoughts e. The parents or family members are taught one of the above interventions to decrease their stress, as decreasing the parent's distress will often lead to a decrease in the child's distress [ 77 ].
These may be used to distract children from the painful procedures [ 81 ]. A few examples are: The child is taught to concentrate on deep breathing. To engage younger children, health care professionals can use party blowers, or blowing bubbles [ 82 ]. The child may watch another child or adult going through the procedure, and rehearse these behaviors [ 83 ]. This is a step-by-step approach to coping with the painful stimuli.
It involves slowly introducing the procedure and tasks involved, and effectively dealing with easier tasks before moving to the next one [ 77 ]. The child is rewarded with positive statements or concrete gifts, after the painful procedure e. The parents are instructed to enthusiastically encourage the child to use these strategies [ 84 ].
Our goal in this section is to provide various forms of distraction that are proven effective with different age groups. When performing painful procedures on infants, it is important to take into consideration the context of the procedure i. The procedural environment should also be developmentally sensitive [ 86 ].
In fact, reducing noise and lighting, use of soothing smells and clustering procedures to avoid over handling, reduces pain reactions in infants [ 86 ]. Distraction techniques used with this age group are mostly passive. Cognitive strategies used to reduce pain perception in infants are either visual or auditory interventions.
Visual aids can include pictures, cartoons, mobile phones, and mirrors [ 87 ]. Auditory aids include music, lullabies sung by parents or health care professionals [ 88 ]. Music is more frequently being used to improve painful outcomes in infants [ 89 ]. Studies suggest that music can significantly impact behavioral reactions to pain, but not physiological measures [ 89 ]. The combination of different strategies to provoke different senses has been shown to be more effective [ 91 ].
Examples of behavioral strategies include the following. For young children, explaining the procedures with age appropriate information is useful, in addition to providing them with the opportunities to ask questions [ 70 ]. Examples for active distraction used with this age group include, allowing them to blow bubbles, providing toys with lots of colour or toys that light up. Initiating distracting conservations e.
What did you do at your birthday party? Passive distraction techniques include: Older children have a better understanding of procedures and why they are being done, thus providing them with age appropriate information is also important [ 70 ].
Providing children with a choice e. Educating school-aged children about passive and active techniques available will help them cope with the distress and anxiety of the procedure [ 70 ]. Active techniques for this age group include blowing bubbles, singing songs, squeeze balls, relaxation breathing and playing with electronic devices [ 74 ]. Passive distraction can include watching videos, listening to music on headphones, reading a book to the child or telling them a story [ 74 ].
It is essential to always ensure a private setting for procedures with adolescents especially as they sometimes tend to deny pain in front of friends, and family. Giving them the power to choose the type of distraction, or whether they want friends and family present is helpful [ 70 ]. Striking conversations, using squeeze balls or having them play with electronic devices are examples of active techniques, while passive distractions include watching videos, training them to breathe deeply in from the nose, count to 5 and out through the mouth , and listening to music [ 74 ].
Although there is an overwhelming amount of data regarding effective paediatric pain assessment and management, it is often not being effectively applied. Current studies demonstrate pain management in children remains undertreated. It is the responsibility of health care professionals to educate their peers and advocate for appropriate pain treatment in children. Infants and children present a unique challenge that necessitate consideration of their age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs.
There is a need for more research to illuminate optimal pain management and strategies that take these special needs into consideration, to improve the treatment of pain in children. International Journal of Pediatrics. Indexed in Web of Science. Subscribe to Table of Contents Alerts. Table of Contents Alerts. Abstract Pain perception in children is complex, and is often difficult to assess. Introduction For pediatric patients presenting to the emergency department, medical procedures are often painful, unexpected, and heightened by situational stress and anxiety leading to an overall unpleasant experience.
Pain Assessment Tools Accurate pain measurements in children are difficult to achieve. View at Google Scholar G. Von Baeyer, and W. View at Google Scholar P. View at Google Scholar S.
View at Google Scholar M. View at Google Scholar B. View at Google Scholar R. NRS are valid and demonstrate positive and significant correlations with other measures of pain intensity . They have also demonstrated sensitivity to treatments that are expected to have an impact on pain intensity . The NRS is extremely easy to administer and score and therefore can be used with a greater variety of patients e.
It is also useful for telephone assessments. The simplicity of the measure means that individuals comply better than with other tools. The only real drawback is, as for the other rating scales, that it assesses only pain intensity. Picture or face scales employ photographs or drawings that illustrate facial expressions or persons experiencing different levels of pain severity  , .
Patients are asked to indicate which one of the illustrations best represents their pain experience. Each face has a number representing the rank order of the pain illustrated and the number of the picture chosen by the patient represents that patient's pain intensity score.
These types of scales do not require patients to be literate and provide an option for those patients who have problems with written language. They are particularly useful in the paediatric population where scales have demonstrated validity through their association with other measures of pain intensity  ,  and through their ability to detect the effects of analgesics . Children also seem to prefer face scales .
There is also evidence that they are valid for use in adults . The DDS-I consists of a list of 12 descriptors describing different levels of pain intensity . Patients are asked to rate the intensity of their pain as being more, or less than each descriptor on the list. If their pain is worse than the descriptor, they place a mark to the right of the word in proportion to how much greater their pain is. If their pain is less than the descriptor, they place a mark on the left of the chart.
If the descriptor exactly describes their pain, they place a mark directly below the descriptor. There are 10 points along which patients can rate their pain intensity to the right and left of each descriptor, so the pain is rated on a 21 point scale for each descriptor. Pain intensity is defined as a mean of the ratings and can range from 0 to The scale is valid and reliable and is associated with other measures of pain intensity  and is sensitive to treatment effects .
Examples of behaviour usually expected of patients with pain include grimacing, rigid body posture, limping, frowning or crying. Vital signs are also expected to be elevated.
However, it may not be appreciated that both physiological and behavioural adaptation occurs leading to periods of minimal, or no signs of pain. Absence of signs does not necessarily mean absence of pain. When pain is sudden or severe, behavioural and physiological indicators may be present, but only for a brief time. However, very quickly the patient may make an effort to cease behaviours, such as crying or moaning, because it may be seen as unacceptable.
This is especially true within Western cultures. The patient may also be exhausted. Physiological indicators, such as increased blood pressure and pulse rate may also disappear as the body seeks to maintain homeostasis. The patient may have a medical condition or may be undergoing treatment, which may prevent physiological reactions e. The guidelines from the American Pain Society  offer the following advice on using behavioural and physiological assessments:.
Therefore, behavioural and physiological indictors should not be used for patients who are able to self-report and indicate to the health carer that they are in pain. However, there are some patients who may not be able to tell you that they are in pain yet we need to try and assess their pain in some meaningful way. Cognitively impaired adults, children, and the very young fall into this category and nonverbal communication can be a source of information in this instance .
To sum up, no ideal pain assessment tools exists so it is important to use pain tools that are valid and reliable. There are many myths and misconceptions that need to be confronted to ensure that when a patient is reporting his or her pain, it is believed. Behavioural tools, while useful for those who are unable to self report, can assess fear, anxiety and depression also so care is needed when interpreting them in clinical practice.
Where possible, self report pain tools should be used and pain scores documented as the 5 th vital sign. Study Learning Materials Bibliography. Pain Assessment Tools Time Required: Learning Outcomes To be able to recognise the importance of utilising a validated pain assessment tool To accurately describe a variety of validated tools and recognise when their individual use is indicated To discuss the advantages and disadvantages of multiple pain assessment tools To recognise the limitations of behavioural assessment tools Pain Assessment Tools A pain assessment tool requires reliability, consistent results when performed under similar conditions or circumstances and validity the measurement does actually scale 'pain' and not some other quantity such as anxiety; this is problematic in assessment tools that assess behaviour in those unable to respond.
The ideal pain assessment tool would have the following attributes but when you consider these attributes and measure them against the tools available you realise that no one tool has all attributes: Sensitive and free from bias; Immediate information about accuracy and reliability; Distinguishes between pain, unpleasantness and emotion; Assesses experimental and clinical pain; Absolute rather than relative scales; Estimates confidence of predictions.
Verbal rating scales The VRS consists of a list of adjectives describing different levels of pain intensity. Other issues are that: Visual analogue scales and graphic rating scales A VAS consists of a line, usually 10cms long whose ends are labelled as the extremes of pain - 'no pain' to 'worst pain'. The problems with VAS include: Numerical rating scale A NRS involves asking the patient to rate his or her pain from 0 to 10 11 point scale or from 0 to point scale with the understanding that 0 is equal to no pain and 10 or is equal to worst possible pain.
Picture or Face Scales Picture or face scales employ photographs or drawings that illustrate facial expressions or persons experiencing different levels of pain severity  , .
There are problems with face scales in clinical practice and these include: The guidelines from the American Pain Society  offer the following advice on using behavioural and physiological assessments: Observations of behaviour and vital signs should not be used instead of self report; Physiological measures e.
Textbook of pain , 4thth ed. Comparison of fixed interval and visual analogue scales for rating chronic pain. The use of pain scales in assessing the efficacy of analgesics in post-operative dental pain. A comparison of three ways of measuring pain. Rheumatol Rehabil, Rheumatol Rehabil 21, The measurement of clinical pain intensity: Pain, Pain 27, The subjective experience of acute pain. An assessment of the utility of 10 indices.
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Pain Assessment Tools
Whereas, feasibility and validity of behavioral pain scales have been . Validity. The validation of an instrument measuring a subjective variable (such as . ESCID is valid and reliable for measuring pain in mechanically ventilated unable to For these patients, the behavioral pain scale (BPS) and the critical care pain .. pain scores when the procedures were carried out: (BPS) and Jul 31, Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain . Purpose: The Behavioral Pain Scale (BPS) and Critical-Care Pain .. Study procedures. The bedside nurse screened and included.