Chapter 39 Pain Management in Children

Nursing Process Overview for a Child in Pain

 Be aware that some children may be reluctant to admit pain because they are trying to be
brave. As a rule, it is most efficient to assess pain levels using an appropriate scoring tool along
with a vital sign measurement.
 Nursing diagnoses for children with pain focus not only on the pain but also on the stress, fear,
or anxiety that pain produces.
 The mark of efficient pain control is to anticipate when pain will occur and plan interventions to
prevent it rather than let it occur and then relieve it.
 Implementation for pain relief includes choosing the specific method of pain relief that is best
for each child.
 An evaluation of expected outcomes is a key aspect of managing pain because no one pain relief
measure is effective for everyone. After a child is given an analgesic, look for nonverbal clues,
assess vital signs, and listen to the child’s statements about pain to determine whether a drug
was effective.

KEY POINTS FOR REVIEW

 Many children and infants are undermedicated for pain relief because of common
misperceptions by healthcare personnel, such as infants do not feel or remember pain. Infants
do experience pain and so need pain management the same as all other groups.
 Inviting parents and the child, if preschool age or older, to participate in assessment and pain
management is an important aspect of pain therapy. It not only helps in planning nursing care
that meets QSEN competencies but also best meets the family’s total needs.
 Pain in children is best assessed by means of a standardized self-report tool such as the Poker
Chip or Wong-Baker FACES Pain Rating Scale tools. Without self-report forms, both nurses and
parents may underestimate children’s pain.
 Many nonpharmacologic pain relief measures such as imagery, distraction, and TENS are
available for children based on the gate control theory of pain management.
 Many children benefit from a combination of nonpharmacologic and pharmacologic methods of
pain management such as an oral analgesic followed by a distraction technique.
 Anesthetic cream to help dull the pain of injections or other brief procedures can be helpful to
allow for suturing or venipunctures. Think ahead to use these because a child has to wait 30 to
60 minutes to feel the anesthetic effect.
 Few analgesics are administered intramuscularly to children. For acute pain, IV administration
has become the method of choice. PCA, a technique that gives a child a sense of control, can be
used effectively with children.
 Conscious sedation is useful with potentially frightening procedures. With this, protective
reflexes are left intact, and the child can respond to instructions during the procedure.

KEY TERMS

acute pain - means sharp pain. It generally occurs abruptly after an injury. The pain of a pinprick is an
example.
chronic pain - is pain that lasts for a prolonged period or beyond the time span anticipated for healing.
Acute pain usually causes extreme distress and anxiety; chronic pain can lead to depression and
decrease patient’s ability to achieve relief as the threshold to sense pain lowers and creates a “feedback
loop”

conscious sedation - refers to a state of depressed consciousness usually obtained through IV analgesia
therapy. The technique allows a child to be both pain free and sedated for a procedure.

cutaneous pain - is pain that arises from superficial structures such as the skin and mucous membrane.
A paper cut is an example.

Distraction - allows the cells of the brain stem that register an impulse as pain to be 2337 preoccupied
with other stimuli so a pain impulse cannot register.

epidural analgesia - an injection of an analgesic agent into the epidural space just outside the spinal
canal, can be used to provide analgesia to the lower chest, abdomen, and lower body for 12 to 24 hours
or longer if needed.

gate control theory - of pain attempts to explain how pain impulses travel from a site of injury to the
brain, where the impulse is registered. This theory envisions gating mechanisms in the substantia
gelatinosa of the dorsal horn of the spinal cord that, when activated, can halt an impulse at that level of
the cord. This prevents the pain impulse from being received at the brain level and interpreted as pain.

hyperalgesia - defined as an increased sensitivity to pain and is seen when patients have a heightened
response to minimal painful stimuli.

Pain - The sensation of pain is whatever the person experiencing it says it is, and it exists whenever the
person says it does

pain threshold - refers to the point at which the child first senses pain. This varies greatly from person to
person and is probably most influenced by heredity.

pain tolerance - All people also have a point above which they are not willing to bear any additional
pain. This is a person’s pain tolerance. Pain tolerance levels are probably most affected by cultural
influences.

patient-controlled analgesia (PCA) - allows a child or a parent to self-administer boluses of medication,

usually opioids, with an IV medication pump

referred pain - is pain that is perceived at a site distant from its point of origin. The pain of right lower
lobe pneumonia, for example, is often first thought to be abdominal pain because the pain is referred or
felt in the abdomen.

somatic pain - is pain that originates from deep body structures such as muscles or bones. The pain of a
sprained ankle is somatic pain.

substitution of meaning - or guided imagery is a distraction technique to help a child place another
meaning (a nonpainful one) on a painful procedure

thought stopping - is a technique in which children learn to stop anxious thoughts by substituting a
positive or relaxing thought in its place.
transcutaneous electrical nerve stimulation (TENS) - involves applying small electrodes to the
dermatomes that supply the body portion where pain is experienced

visceral pain - involves sensations that arise from internal organs such as the intestines. The pain of
appendicitis is visceral pain.

Chapter 40 Nursing Care of a Family When a Child Has a Respiratory Disorder

Nursing Process for a Child with a Respiratory Disorder

 Respiratory illness can begin as early as moments after birth if a neonate has difficulty initiating
a first breath or establishing regular respirations. Rating a neonate using an Apgar score can help
to quickly identify a newborn who may be experiencing respiratory difficulty at this early stage.
 Nursing diagnoses established for children with respiratory disorders focus both on the
alteration in mechanisms of breathing and on the emotional distress such problems can create.
“Ineffective airway clearance” is a common diagnostic category used in this area. The problem
may be characterized through presentations such as an ineffective/absent cough, nasal flaring,
excessive sputum, or adventitious breath sounds (extra or abnormal breathing sounds)
 If a child is experiencing an acute respiratory problem, the expected outcomes and plan of care
will focus on supporting the child and family through prescribed therapy and keeping caregivers
informed about their child’s health status and response to treatment.
 Collaborative nursing interventions in the care of a child with respiratory dysfunction include
suctioning to remove respiratory secretions, administering oxygen, and providing
humidification.
 An acute respiratory illness can be extremely frightening for parents as well as the child.
Support, reassurance, and education are important components in successful home
management.

KEY POINTS FOR REVIEW

 Respiratory tract disorders tend to occur more frequently in children than adults because the
lumens of children’s bronchi are narrow and obstruction and infection are more likely to occur.
Planning nursing care that includes assurance not only meets Quality & Safety Education for
Nurses (QSEN) competencies but also best meets the family’s total needs.
 Acute nasopharyngitis (the common cold) is the most common infectious disease in children.
Treatment should include comfort measures.
 Tonsillitis is infection and inflammation of the palatine tonsils. Adenitis is infection and
inflammation of the adenoid tonsils. Children with recurring infections may have their tonsils
surgically removed.
 Laryngotracheobronchitis (croup) is inflammation of the larynx, trachea, and major bronchi.
Epiglottitis is inflammation of the epiglottis. Both of these conditions can severely impair the
airway. Children with epiglottitis should never be assessed for a gag reflex using a tongue blade
because the elevated epiglottis can occlude the airway.
 Bronchiolitis is inflammation of the fine bronchioles.
 Respiratory syncytial virus (RSV) accounts for the majority of lower respiratory tract infections in
young children. Infants with RSV infections must be observed closely for signs of increased
respiratory distress.
  Asthma, a type I hypersensitivity reaction, is a diffuse and obstructive airway disease with
wheezing as the most common symptom. Newer drugs such as leukotriene receptor antagonists
and careful environmental control have aided in the management of asthma.
 Cystic fibrosis is a disease in which there is generalized dysfunction of the exocrine glands. This
results in malabsorption and tenacious pulmonary secretions, leading to infections and poor
nutrition. Lung transplantation may be used to replace the diseased lung tissue and to increase
the child’s life span.

KEY TERMS

adventitious breath sounds - extra or abnormal breathing sounds

aspiration - (inhalation of a foreign object into the airway) occurs most frequently in infants and
toddlers.

Atelectasis - the collapse of lung alveoli, may be a primary or secondary condition.

clubbing – a change in the angle between the fingernail and nail bed because of increased capillary
growth in the fingertips

cyanosis - a blue tinge to the skin, can indicate hypoxia.

expiration - breathing out

hypoxemia - deficient oxygenation of the blood

hypoxia - decreased oxygen in body cells

inspiration - breathing in

paroxysmal coughing - refers to a series of expiratory coughs after a deep inspiration. Commonly, this
occurs in children with pertussis (whooping cough) or in those who have aspirated a foreign body or a
liquid they attempted to drink.

Percussion - involves striking a cupped or curved palm against the chest to determine the consistency of
tissue beneath the surface area. This technique causes a loud, thumping noise that sounds as if it hurts,
but you can assure a child or parents it does not.

Pneumothorax - is the presence of atmospheric air in the pleural space, causing atelectasis. It can occur
when external puncture wounds allow air to enter the chest

rales - fine crackling sounds

retractions - intercostal spaces draw inward

steatorrhea - Bowel movements become large, bulky, and greasy

stridor - a harsher, strident sound on inspiration

tachypnea - an increased respiratory rate

tracheostomy - is an opening into the trachea to create an artificial airway. It is most often performed in
infants who require prolonged ventilation but can provide a more stable airway in older children as well
tracheotomy – The procedure to create the airway

vibrations - produced as air is forced past an obstruction, such as mucus in the nose or pharynx, cause a
snoring sound (rhonchi).

Wheezing - the sound of air being pushed through constricted bronchioles

Chapter 41 Nursing Care of a Family When a Child Has a Cardiovascular Disorder

Nursing Process for Care of a Child with Cardiovascular Disorder

 Assessment of a child with a cardiovascular disorder includes both careful history taking and
physical examination because many signs and symptoms of cardiac complications in children can
be subtle.
 Nursing diagnoses associated with heart disease in children usually address the effect of
compromised cardiac function or the impact a serious disorder can have on the child or parents.
 Nursing planning is essential to help parents and children understand heart anatomy because a
sound knowledge base can help them understand the need for diagnostic testing, medication
compliance, and ongoing follow-up.
 An equally important role is teaching prevention of heart disease such as promoting a home
environment free from smoke and encouraging a healthy lifestyle through exercise, maintaining
an appropriate weight, and eating a low-fat diet.
 Outcome evaluation should include both immediate and future outcomes for the child and
family because cardiac disorders may be long term.

KEY POINTS FOR REVIEW

 Cardiovascular disorders in children may be either structural, such as congenital heart disease,
or acquired, such as Kawasaki syndrome, rheumatic fever, or cardiomyopathy. Assessment of
children with heart disease includes history and physical examination. Echocardiogram, MRI,
and cardiac catheterization are procedures used frequently to aid with diagnosis and
management.
 Congenital heart disorders are classified as those associated with increased pulmonary blood
flow, decreased pulmonary blood flow, and obstruction to blood flow. Single-ventricle defects
are classified separately due to their complex anatomy and physiology.
 Common signs of CHF seen in children include tachycardia, tachypnea, enlarged liver, dyspnea,
and poor weight gain. Signs tend to be subtle in infants and may be manifested chiefly by
difficulties with feeding and gaining weight due to increased caloric consumption due to
tachypnea and increased work of breathing.
 Cardiac catheterization and surgery both offer palliative and corrective options for children born
with congenital heart disease. Catheterization also can provide diagnostic information to ensure
optimal management of heart disease.
 The families of children undergoing cardiac surgery need a great deal of support from
healthcare personnel so they can cope with this major event and provide effective support to
their child and other family members.
 SVT is the most common dysrhythmia in children, can be well tolerated, and does not typically
cause any activity restrictions. If the SVT is associated with WPW, a cardiologist should perform
 risk stratification before the child participates in competitive sports. Many dysrhythmias can be
addressed with an electrophysiologic study and ablation later in childhood if necessary.
 Kawasaki syndrome is a diagnosis of exclusion. If diagnosed, it is imperative that the child
receive IV immunoglobulin and high-dose aspirin therapy within 10 days of fever in an effort to
prevent coronary artery aneurysms.
 Hypertension in children usually occurs as a result of a secondary disorder. Helping families limit
saturated fat intake and follow a consistent exercise program to help children avoid obesity and
heart disease in later life is a strategy that not only meets QSEN competencies but also best
meets the family’s total needs.

KEY TERMS

acyanotic heart disease - If the blood shunts left to right, then oxygenated blood from the left side
mixes with blood in the right side of the heart and goes back to the lungs again. a heart defect that
affects the normal flow of blood

Afterload - amount of resistance met by the ventricles upon ejection

cardiac catheterization - is a diagnostic or interventional procedure where one or more small catheters
are passed through a large vein and/or artery into the heart.

Cardiomyopathy - is a disorder of the heart muscle and although rare, is a common cause of heart
failure in children and the most common cause of heart transplantation in children older than 1 year of
age

Compliance - the ability of the ventricles to stretch and fill

congestive heart failure (CHF) - is defined as the inability of the heart to supply adequate oxygenated
blood to meet the metabolic demands of the body.

contractility - ability to modulate the rate and force of fiber shortening

cyanotic heart disease – When venous blood from the right side of the heart mixes with blood on the
left side, this is a “right-to-left” shunt that delivers deoxygenated blood to the body. Heart defects with
this type of blood flow are termed cyanotic heart disease.

Diastole - Relaxation of the heart

heart murmur - are defined as turbulent flow through an abnormal valve, vessel, or chamber.

preload - the volume of blood in the ventricles at the point just before contraction; it is an indicator of
circulating blood volume.

Systole - the aortic and pulmonic valves are forced open and the ventricles contract, ejecting blood out
the aorta and pulmonary artery.

Vasculitis - inflammation of blood vessels

Chapter 42 Nursing Care of a Family When a Child Has an Immune Disorder

Nursing Process for a Child with an Immune Disorder

 An assessment focuses on the types of illnesses or problems the child is having in order to target
the part of the immune system which is mal- or nonfunctioning. A thorough history and analysis
of presenting symptoms is the best way to identify the problem and to develop appropriate
interventions.
 Nursing diagnoses specific to the child with allergies focus on the specific symptom.
 Outcome identification and planning for a child with an immune disorder should focus both on
present and future concerns. Relief of immediate symptoms is the first priority followed by
planning for long-term care and infection prevention.
 A major nursing intervention in the care of children with immune disorders is child and family
teaching.
 Outcome evaluation with immune disorders must be ongoing because these diseases are not
static. Children with allergies can develop new allergic triggers at any time.

KEY POINTS FOR REVIEW

 An antigen is a foreign substance capable of stimulating an immune response. The immune

system protects the body from invasion by such substances.
 Humoral immunity refers to immunity created by antibody production originated by B
lymphocytes. Cell-mediated immunity refers to T-lymphocyte involvement.
 Autoimmunity results from an inability to distinguish self from nonself, causing the immune
system to carry out immune responses against normal cells.
 HIV/AIDS is spread by the retrovirus HIV through blood and body secretions. Conscientious use
of standard infection precautions is essential to prevent transmission.
 Allergic disorders occur as a result of an abnormal antigen–antibody response. These generally
are long-term disorders, and children must participate in their own care to remain well, such as
avoiding allergens or conscientiously taking a medication to suppress reactions. Involving
children from the start both helps them play an active role in their own care and helps to plan
nursing care that not only meets Quality & Safety Education for Nurses (QSEN) competencies
but that also best meets a family’s total needs.
 Anaphylactic shock is an acute type I hypersensitivity reaction characterized by extreme
vasodilation and bronchoconstriction. If action is not taken immediately, the reaction can be
fatal. Epinephrine is the standard of care for treatment.
 Atopic disorders include allergic rhinitis, atopic dermatitis, and asthma.
 Environmental control refers to ways to reduce the number of allergens to which children are
exposed.
 Hyposensitization by subcutaneous or sublingual immunotherapy is a method to increase the
plasma concentration of IgG antibodies to prevent or block IgE antibody formation and allergic
symptoms.

KEY TERMS

Allergen - during the immune response, mediating substances are released that cause tissue injury and
allergic symptoms
Anaphylaxis - can be caused by exposure to foods such as milk, egg, peanut, and tree nuts; stinging
insects including yellow jackets, honeybees, paper wasps, hornets, and fire ants; certain drugs, primarily
antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and neuromuscular blocking agents; and
latex.

Antigen - The cells either recognize or react against foreign substances

atopic dermatitis - eczema

autoimmunity - is the result of the immune system being unable to distinguish self from nonself,
causing the immune system to trigger immune responses against normal cells and tissue rather than
invading antigens

cell-mediated immunity - is the type of immune response caused by T-lymphocyte activity.

chemotaxis - “calling” leukocytes into the area

complement - is composed of 20 different proteins that are normally nonfunctional molecules;

however, when activated by antigen–antibody contact, these molecules begin a cascade response that
leads to increased vascular permeability, smooth muscle contraction

cytotoxic response - cells are detected as foreign and immunoglobulins directly attack and destroy them
without harming surrounding tissue.

delayed hypersensitivity - A wheal-and flare response occurs because of the accumulation of

lymphocytes around small blood vessels, which results in minor destruction of blood vessels (see Fig.
42.2). This response is termed delayed hypersensitivity if the T-lymphocyte activity occurs solely without
an accompanying humoral response. It is this response that causes transplant rejection.

environmental control - involves limiting exposure to allergens in a child’s environment.

humoral immunity - refers to immunity created by antibody production or Blymphocyte involvement.

hypersensitivity response - The underlying cause of all allergic disorders appears to be an excessive
antigen–antibody response when the invading organism is an allergen rather than an immunogen. This
is termed a type I response, or a hypersensitivity response, when it happens immediately

hyposensitization – or Immunotherapy, is done when the child’s allergy symptoms cannot be controlled
by avoidance of an allergen or conventional drug therapy

immune response - is the body’s action plan devised to combat invading organisms or substances by
leukocyte and antibody activity

immunity - the ability to destroy like antigens

immunogen - If an antigen is one that can be readily destroyed by an immune response

immunoglobulins - also known as antibodies

lymphokines – the purpose of which is to contain or prevent the migration of antigens as well as to call
other lymphocytes into the area
lysis - killing

macrophages – mature white blood cells

phagocytosis - or the destruction of the invaders

tolerance - “sustained unresponsiveness”