Clinical Guidelines (Nursing)

Procedural Pain Management

  • Introduction 

    Aim

    Definition of Terms

    Assessment and Measurement

    Special Considerations

    Companion Documents

    Links

    References

    Evidence Table


    Introduction

    Children receiving health care are exposed to multiple and ongoing invasive medical procedures as part of their treatment [1]. The pain associated with these medical procedures is reported as the most significant and distressing cause of pain for hospitalised children [2]. The cumulative effects of these painful experiences can result in adverse psychological outcomes for the child and their family, including fear and the rapid development of conditioned anxiety response to medical procedures [3]. The negative experiences associated with medical procedures can have a lifelong impact [3]. Due to this, it is imperative that any exposure to a painful experience be the best experience possible for the child. Every child has a right to be kept from harm and it is the responsibility of health care professionals that ensure that every step is taken to protect children from unnecessary pain [4].
    The goal of procedural pain management at RCH is to minimise pain, distress and anxiety associated with medical procedures for children. Managing procedural pain is best done with a multimodal approach that combines pharmacological and non-pharmacological interventions[4]. There are many simple and evidenced based interventions that have been demonstrated to reduce the pain and distress associated with medical procedures  for children [3]. 

    Aim 

    To aim of this guideline is to provide guidance to clinical staff regarding effective interventions to support the management of procedural pain and pain-related distress for children and young people receiving health care. 


    Definition of terms

    • Procedural pain: Short-lived acute pain associated with medical investigations and treatments conducted for the purpose of health care.
    • Pain related distress: The use of the term pain is often used in conjunction with distress to describe pain related fear, anxiety, depression and agitated behaviour that is often noticeable when children are undergoing a medical procedure [5]. In children, because it is often difficult to distinguish between pain, fear and anxiety, the combination is often referred to globally as pain related distress [6].
    • Procedural support: Procedural support is a process of preparing children and their families for medical procedures and coaching children to utilise coping skills to reduce the perception of procedural pain
    • Procedural support team: A multidisciplinary health professional team working in conjunction with the child’s caregivers form the basis of a procedural support team. The aim of the procedural support team is to promote coping and mastery of medical procedures for the child receiving healthcare. The multidisciplinary team may be comprised of medical, nursing, allied health and administration health professionals.
    • Procedural sedation: Procedural sedation is the technique of administering a sedative or dissociative agent +/- analgesia to induce a state of consciousness that allows patients to tolerate/cope with unpleasant procedures whilst preserving cardiorespiratory function.


    Procedural pain assessment and management


    Introduction to the key principles of procedural pain management

    There are 6 essential elements of procedural pain management that have been demonstrated to reduce pain and distress associated with medical procedures: 
    1. Planning
    2. Preparation 
    3. Pharmacological
    4. Physical
    5. Psychological
    6. Promoting recovery and resilience 


    Optimal procedural pain management maintains the comfort of the child during the 3 distinct phases of a medical procedure: (1) before, (2) during and (3) after the medical procedure. The essential elements can be applied to the continuum of the medical procedure with each stage requiring differing priorities to ensure the ongoing comfort of the child. Adherence to these key principles at each stage of the medical procedure will enhance the success of a procedural pain management plan.

    PPM Key Principles


    For more information on each phase of procedural pain management, please click the hyperlinks. 


    Before the medical procedure

    Planning for medical procedures
    Step 1:  Find out the child’s likes and dislikes
    Step 2: Assess previous procedural experiences
    Step 3:  Establish a procedural support plan
    Step 4: Communicate the procedural support plan
    Step 5: Refer children at high risk for procedural pain and distress
    Step 6: Consult with the appropriate procedural support team


    Preparing for medical procedures
    Step 1: Prepare the child
    Step 2: Prepare the family
    Step 3: Prepare the environment
    Step 4: Prepare the procedural support team


    Multimodal management of procedural pain

    It is recommended that a multimodal approach to pain management be provided to children receiving medical procedures.
    A multimodal approach to procedural pain management combines both pharmacological and non-pharmacological interventions with the purpose of targeting different areas involved in pain processing [26]. 

    Principles of pharmacological pain management


    Topical anaesthesia

    • When to use topical anaesthesia
    • Uses for topical anaesthetics
    • Choosing a topical anaesthetics
    • Recommendations for the dosage of topical anaesthesia
    • Application of topical anaesthetics
    • Blood sampling or vascular access
    • Alternatives to topical anaesthetic agents


    Promote comfort of the child
    Assessment of procedural pain


    During the medical procedure

    Principles of non-pharmacological pain management

    Non-pharmacological methods of managing procedural pain are interventions that target the contextual, physical, behavioral and psychological factors related to procedural pain or pain-related distress [19]. 
    This Clinical Practice Guideline provides recommendations for the non-pharmacological management of procedural pain with:

    Physical interventions

    • Positioning for comfort
    • Procedural strategies for intramuscular injections


    Psychological interventions

    • Attention
    • Breathing
    • Break down the steps
    • Give control wherever possible
    • Procedural coaching
    • Coping and distress promoting behavior
    • Empower parents
    • Distraction
    • Distraction equipment
    • Using technology for distraction with children


    After the medical procedure

    Promote resilience and recovery

    • When medical procedures do not go as planned


    Special considerations


    Companion documents

    Procedural Sedation for Ward and Ambulatory Areas procedure (RCH access only)


    Links

     Comfort Kids Program http://www.rch.org.au/comfortkids/
     Educational Play Therapy http://www.rch.org.au/ept/
     Music therapy http://www.rch.org.au/musictherapy/
     Kids health info: 
     • Pain relief and comfort using sucrose solution
     • Reduce children's discomfort during tests and procedures
     http://www.rch.org.au/kidsinfo/fact_sheets
     B positive videos http://www.rch.org.au/be-positive/
     Okee in medical imaging http://www.rch.org.au/okee/
     Paediatric Integrated cancer Service: procedural pain management e-learning for health professionals https://education.eviq.org.au/modules/paediatric-procedural-pain
     Australian Pain Society: Pain in Childhood Special Interest Group https://www.apsoc.org.au/pain-in-childhood 


    References

    1. Stevens, B.J., et al., Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ: Canadian Medical Association Journal, 2011. 183(7): p. E403-10 1p.
    2. Birnie, K.A., et al., Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag, 2014. 19(4): p. 198-204.
    3. Taddio, A., et al., Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal, 2015.
    4. Twycross, A., S. Dowden, and E. Bruce, Managing pain in children: a clinical guide. 2009, Wiley-Blackwell: United Kingdom.
    5. Franck, L.S., C.S. Greenberg, and B. Stevens, Pain assessment in infants and children. Pediatr Clin North Am, 2000. 47(3): p. 487-512.
    6. Berde, C. and J. Wolfe, Pain, anxiety, distress, and suffering: interrelated, but not interchangeable. Journal of Pediatrics, 2003. 142(4): p. 361-3.
    7. Flowers, S.R. and K.A. Birnie, Procedural Preparation and Support as a Standard of Care in Pediatric Oncology. Pediatric Blood & Cancer, 2015(S5): p. 668.
    8. Srouji, R., S. Ratnapalan, and S. Schneeweiss, Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics, 2010. 2010: p. 11.
    9. Schechter, N.L., et al., Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics, 2007. 119(5): p. e1184-98.
    10. Czarnecki, M.L., et al., Procedural pain management: a position statement with clinical practice recommendations. Pain Manag Nurs, 2011. 12(2): p. 95-111.
    11. Spence, K., et al., Evidenced-based clinical practice guideline for management of newborn pain. J Paediatr Child Health, 2010. 46(4): p. 184-92.
    12. Young, K., Pediatric Procedural Pain. Annals of Emergency Medicine, 2005. 45(2): p. 160-171.
    13. Kleiber, C., et al., Development of the Distraction Coaching Index. Children's Health Care, 2007. 36(3): p. 219-235 17p.
    14. Blount, R.L., et al., Pediatric procedural pain. Behav Modif, 2006. 30(1): p. 24-49.
    15. Taddio, A.B.M.P., Setting the Stage for Improved Practices During Vaccine Injections: A Knowledge Synthesis of Interventions for the Management of Pain and Fear. Clinical Journal of Pain, 2015. 31 Supplement(10S): p. S1-S2.
    16. Paediatric Integrated Cancer Service. Procedural Pain Management.  [cited 2016 28th of February].
    17. Pillai Riddell, R., et al., Nonpharmacological management of procedural pain in infants and young children: an abridged Cochrane review. Pain Res Manag, 2011. 16(5): p. 321-30.
    18. Young, K.D., Pediatric procedural pain. Ann Emerg Med, 2005. 45(2): p. 160-71.
    19. Pillai Riddell, R.R., et al., Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev, 2011(10): p. CD006275.
    20. The Royal Australasian College of Physicians, Guideline Statement: Management of Procedure-related Pain in Children and Adolescents, P.C.H. Division, Editor. 2005, The Royal Australasian College of Physicians Sydney.
    21. Jaaniste, T., B. Hayes, and C.L. Von Baeyer, Providing Children With Information About Forthcoming Medical Procedures: A Review and Synthesis. Clinical Psychology: Science and Practice, 2007(2): p. 124.
    22. Czarnecki, M.L., et al., Barriers to Pediatric Pain Management: A Nursing Perspective. Pain Management Nursing, 2011. 12(3): p. 154-162.
    23. Young, K.D., Pediatric procedural pain. Annals of Emergency Medicine, 2005. 45(2): p. 160-71.
    24. Friedrichsdorf, S. Reducing and eliminating procedural pain related to needles: the four essential (non-negotiable) components. 2014  [cited 2015 8th of October]; Available from: http://blog.apsoc.org.au/2014/08/21/reducing-and-eliminating-procedural-pain-related-to-needles-the-four-essential-non-negotiable-components/.
    25. Boles, J., Speaking up for children undergoing procedures: the ONE VOICE approach. Pediatr Nurs, 2013. 39(5): p. 257-9.
    26. Yaster, M., Multimodal analgesia in children. European Journal of Anaesthesiology (EJA), 2010. 27(10): p. 851-857 10.1097/EJA.0b013e328338c4af.
    27. Lander, J.A., EMLA and Amethocaine for reduction of children's pain associated with needle insertion. Cochrane Database of Systematic Reviews, 2014(3).
    28. Lander, J.A., B.J. Weltman, and S.S. So, EMLA and amethocaine for reduction of children's pain associated with needle insertion. The Cochrane Database Of Systematic Reviews, 2006(3): p. CD004236.
    29. O'Brien, L., et al., A Critical Review of the Topical Local Anesthetic Amethocaine (Ametop™) for Pediatric Pain. Pediatric Drugs, 2005. 7(1): p. 41-54.
    30. Australian Medicines Handbook, Children's Dosing Companion (online). 2016, Australian Medicines Handbook Pty Ltd: Adelaide.
    31. Pillai Riddell, R.P., et al., Psychological Interventions for Vaccine Injections in Young Children 0 to 3 Years: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials. Clinical Journal of Pain, 2015. 31 Supplement(10S): p. S64-S71.
    32. Boerner, K.E.B., et al., Simple Psychological Interventions for Reducing Pain From Common Needle Procedures in Adults: Systematic Review of Randomized and Quasi-Randomized Controlled Trials. Clinical Journal of Pain, 2015. 31 Supplement(10S): p. S90-S98.
    33. Taddio, A.B.M.P., et al., Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials. Clinical Journal of Pain, 2015. 31 Supplement(10S): p. S20-S37.
    34. Chambers, C.T., et al., Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther, 2009. 31 Suppl 2: p. S77-S103.
    35. Mesibov, G.B., D.M. Browder, and C. Kirkland, Using Individualized Schedules as a Component of Positive Behavioral Support for Students with Developmental Disabilities. JOURNAL OF POSITIVE BEHAVIOR INTERVENTIONS, 2002. 4: p. 73-79.
    36. Maclaren, J.E. and L.L. Cohen, Interventions for paediatric procedure-related pain in primary care. Paediatr Child Health, 2007. 12(2): p. 111-6.
    37. McCarthy, M., et al., Comfort First: an evaluation of a procedural pain management programme for children with cancer. Psychooncology, 2013. 22(4): p. 775-82.
    38. McMurtry, C.M., et al., When “don’t worry” communicates fear: Children’s perceptions of parental reassurance and distraction during a painful medical procedure. Pain (03043959), 2010. 150(1): p. 52-58.
    39. Cohen, L.L., Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics, 2008. 122 Suppl 3: p. S134-9.
    40. Birnie, K.A., et al., Systematic review and meta-analysis of distraction and hypnosis for needle-related pain and distress in children and adolescents. J Pediatr Psychol, 2014. 39(8): p. 783-808.
    41. Noel, M., et al., The influence of children's pain memories on subsequent pain experience. Pain, 2012. 153(8): p. 1563-1572.
    42. Manias, E., et al., Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards. Journal of Clinical Nursing, 2015. 24(1-2): p. 69-80.
    43. Harrison, D., S. Beggs, and B. Stevens, Sucrose for procedural pain management in infants. Pediatrics, 2012. 130(5): p. 918-25.
    44. Shah, P.S., et al., Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev, 2012. 12: p. CD004950.
    45. Harrison, D., et al., Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child, 2010. 95(6): p. 406-13.
    46. Harrison, D., et al., Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database Syst Rev, 2011(10): p. CD008408.
    47. Johnston, C., et al., Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev, 2014. 1: p. CD008435.
    48. Pillai Riddell, R., et al., Nonpharmacological management of procedural pain in infants and young children: An abridged Cochrane review. Pain Research and Management, 2011. 16(5): p. 321-330.
    49. Kurdahi Badr, L., Pain Interventions in Premature Infants. Newborn and Infant Nursing Reviews, 2012. 12(3): p. 141-153.

    Evidence Table

    The evidence table for this guideline can be viewed here


    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by Karin Plummer, Clinical Nurse Consultant, Anaesthesia and Pain Management, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2016.