Pain Assessment. Prof. Julia Downing Chief Executive ICPCN. Monday 14 th August 2017

Transcription

1 Pain Assessment Prof. Julia Downing Chief Executive ICPCN Monday 14 th August 2017

2 The essence of palliative care is the relief of suffering. (Derek Doyle) 2

3 What are the aims of good assessment? 3

4 Definitions of Assessment Assessment is the process of gathering, analysing and synthesizing data... (Hepworth & Larson, 1986: 65) Assessment is a purposeful and pragmatic process...provides information about the child s functioning within a system (Francisco La Grange & Joubert, 1988: 5) 5

5 Quality Care Provision There are five steps to the provision of quality children s palliative care with assessment being the first one i.e.: 1. Assess the child and family holistically; 2. Develop a problem list covering physical, psychosocial and spiritual needs; 3. Design a management plan for each of these problems; 4. Carry out the management plan; 5. Review and adapt the problem list and management plan as things progress. 5

6 Assessment of Children Impeccable assessment is an integral part of Palliative care. Assessment is an ongoing process. Assessment takes time and patience. There are specific aims, principals and areas that should be focused on when assessing a child. To assess you can utilise different tools and techniques. 6

7 Aims of Assessment 1. Get factual information on the child and family members; 2. Explore ideas, concerns and expectations of child and family members; 3. Develop a clear problem list; 4. Discuss and agree upon a clear management plan. Assessment is an ongoing process 7

8 Holistic Assessment PHYSICAL PSYCHOLOGICAL SOCIAL CULTURAL SPIRITUAL 10

9 Principles of Assessment Relationship with child most important! Process 2 hours, 2 days, 2 weeks. Keep in mind the physical well being and energy level of the child. Listen and observe constantly. Try to correlate information do not use different techniques in a vacuum. 9

10 Steps to Good Assessment 1. Make a good impression 2. Explain the process 3. Involve the child 4. Identify family situation, structures and dynamics 5. Establish the typical day 6. Establishing functional ability 7. Clinical assessment 8. Examining the child 9. Special investigations (Amery 2009) 10

11 Levels of Assessment 1 st level Observational assessment. Use eyes, ears, touch, smell to observe functioning of the child at home, in hospice, drop in centre etc. 2 nd level Deeper assessment. Use communication skills, play techniques to assess and evaluate. 3 rd level In depth assessment. When problems have been discovered in 2 nd level, refer to professional or specialist, for example sexual abuse, developmental problems etc. 23

12 Tools to Help with Assessment Variety of tools available Can be helpful to aid assessment Different tools for different age/ability of children Some for child and some for family Only use if helpful for you 24

13 Pain as the fifth vital sign Pain is so common and is present in so many clinical contexts that it should really become the fifth vital sign assessed as routinely as BP, pulse, temperature and respiratory rate.

14 1. How do we assess pain in children? 2. What are some of the challenges to pain assessment 14

15 Challenges to pain assessment Lack of age appropriate and validated painmeasurement tools Lack of knowledge as to which tools to use for which age children Lack of training on the use and implementation of tools Lack of knowledge on how to interpret a pain score Uncertainty as to how to differentiate between anxiety and pain Lack of understanding of children s experience of pain 15

16 Embark on a QUESTT to evaluate the child s pain. (Wong 2001)

17 QUESTT principle to assess children s pain Question the child and parent/caregiver Use pain rating scales Evaluate behaviour and physiological changes Secure parent/caregiver s involvement Take cause of the pain into account Take action and evaluate results

18 Questioning a child/ parent on pain: Precipitating/palliating/provoking factors Quality/quantity Region/radiation/related factors Site, severity Time course

19 Use pain rating scales if appropriate

20 Pain measurement Pain is a subjective phenomenon and objective measurement is not possible Pain rating scales are useful as they: Guide treatment Help monitor response to interventions

21 Pain rating scales There is no ideal rating scale Use one that is appropriate to the child s culture and developmental level May also have to consider ease and time taken to administer the scale Find one or two that you are comfortable to use Remember children may deny pain for fear of consequences

22 What can you see here?

23 FLACC SCALE <3 yrs, not communicating

24 Wong Baker FACES scale > 3 yrs Wong Baker FACES Pain Rating Scale Although the Wong Baker Faces Scale has been validated it is not always a practical tool to use. Find a tool you are happy using!

25 Revised faces pain scale

26 Variety of Scales Available 26

27 Hand Rating Scale Although not validated, this can be very useful.

28 Eland Body tool

29 Drawing pain

30 Simple Questions When does it hurt? What makes it worse? What makes it better? 30

31 Evaluate behaviour and physiological changes

32 Behavioural changes Newborn Young children School aged child Adolescent

33 Behaviour and physiological changes Crying Muscle rigidity Guarding Loss of appetite Change in sleeping patterns Increased pulse rate and BP Sweating, pallor, dilated pupils

34 Secure the parent/caregiver involvement

35 Parent/ caregiver involvement: Listen to mothers, fathers and caregivers: they know the child best Include them in decision making They are more tuned to subtle changes in behaviour They know what works best to comfort the child

36 Take the cause of pain into account

37 Consider the cause Consider the pathophysiology of the underlying problem into account: i.e. the cause of the pain. Descriptions of the type of pain help to determine its cause and management.

38 Take action and evaluate results.. Pain assessment is an ongoing process!

39 Take action and evaluate results: Assess pain Revise treatment Develop treatment plan Re assess Treat

40 APCA C POS Child Pain Symptoms Feeding Crying Feeling happy Playing Questions about sickness Carer Worry about child s illness Sharing feelings Information Help and advice Confidence in caring for the child 31

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42 Example This baby was grimacing, moaning constantly and did not stop crying when her mother picked her up. The FLACC scale can be used to assess her pain

43 In pairs, role play pain assessment in a 12 year old child, using QUESTT Role Play 43

44 QUESTT principle to assess children s pain Question the child and parent/caregiver Use pain rating scales Evaluate behaviour and physiological changes Secure parent/caregiver s involvement Take cause of the pain into account Take action and evaluate results

45 Any questions? 45

46 Final Tips (1) Have a flexible agenda always be willing to adapt when necessary. Always observe the child s reactions and be sensitive towards them Always work as part of a team. Be willing to adapt quickly. Clarify, clarify and clarify. Make sure that you understand clearly what the child means. 46

47 Final Tips (2) Do not make assumptions! Debrief! Always make notes and keep your records up to date. Do not be afraid to refer when necessary. Have sparkle in the eye 47

48 In Summary Impeccable assessment is an integral part of paediatric palliative care. Assessment is an ongoing process. Assessment takes time and patience. There are specific aims, principals and areas that should be focused on when assessing a child. To assess you can utilise different tools and techniques. 36

49 Pain is what the child says that it is There are many myths that exist about pain, but it is important to have a clear understanding of pain in children and that children do experience pain, and that we can manage pain. Children may experience different types of pain Generally children are able to tell you about their pain. QUESTT is a useful tool for assessing pain in children. Good pain assessment is key to effective pain management 49

50 Thank you