MULTIDIMENSIONAL TOOLS: APPLICATION OF PAIN QUALITY CARDS IN CHILDREN 1

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1 Artigo Original Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): MULTIDIMENSIONAL TOOLS: APPLICATION OF PAIN QUALITY CARDS IN CHILDREN 1 Liabelle Mariano Roato 2 Fernanda Milani Magaldi 3 Roato LM, Magaldi FM. Multidimenional tool: application of pain quality card in children. Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): Thi pilot, decriptive and field exploratory tudy aimed to verify the repreentative of the quality of pain, applying the Pain Quality Card to 50 children and teenager hopitalized in the firt half of 2004, after being approved by the Ethic Commiion. Reult have hown that there i no relationhip between the age group and the number of poitive anwer. The identification of the card wa different to each group, 61,1% of the card were identified for the pre-cholar, 77,8% for the cholar and 27,8 for the teenager. The ue of the intrument ha revealed itelf ucceful and able to evaluate, dicriminate and meaure the different dimenion of pain. DESCRIPTORS: pain meaurement; child; nuring INSTRUMENTOS MULTIDIMENSIONALES: APLICACIÓN DE LAS TARJETAS DE LAS CUALIDADES DEL DOLOR EN NIÑOS Etudio piloto, decriptivo y exploratorio de campo. El objetivo fue verificar la repreentatividad de la cualidade del dolor de niño y adolecente, aplicando la Tarjeta de la Cualidade del Dolor a 50 niño y adolecente en el primero emetre de 2004, depué de obtener la autorización del comité de ética de la ecuela de la enfermería. Lo reultado apuntaron no haber correlación entre grupo de determinada edad y número de repueta afirmativa. La identificación de la tarjeta fue ditinta para cada grupo, e decir, 61,1% de la tarjeta fueron identificada para el pre-ecolar, 77,8% para el ecolar y 27,8% para el adolecente. La utilización del intrumento motró er factible y capaz de evaluar, dicriminar y menurar la ditinta dimenione del dolor. DESCRIPTORES: dimenión del dolor; niño; enfermería INSTRUMENTOS MULTIDIMENSIONAIS: APLICAÇÃO DOS CARTÕES DAS QUALIDADES DA DOR EM CRIANÇAS Etudo piloto, decritivo e exploratório de campo. O objetivo foi verificar a repreentatividade da qualidade da dor de criança e adolecente, aplicando o Cartõe da Qualidade da Dor a 50 criança e adolecente no primeiro emetre de 2004, apó obter a aprovação do Comitê de Ética da Ecola de Enfermagem, USP. O reultado apontaram não haver correlação entre faixa etária e número de repota afirmativa. A identificação do cartõe foi diferente para cada grupo, ou eja, 61,1% do cartõe foram identificado para o pré-ecolar, 77,8% para o ecolar e 27,8% para o adolecente. A utilização do intrumento motrou er factível e capaz de avaliar, dicriminar e menurar a diferente dimenõe da dor. DESCRITORES: medição da dor; criança; enfermagem 1 CNPq Scientific Initiation Project; 2 Faculty, roato@up.br; 3 Undergraduate Nuring tudent. Univerity of São Paulo at School of Nuring Diponível em língua portuguea na SciELO Brail

2 Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): Multidimenional tool: application... Roato LM, Magaldi FM. 703 INTRODUCTION Pain enation are feared by people of all age, mainly by children. However, there i a trong popular belief that the latter do not feel pain. Although without any cientific foundation, many health profeional till maintain thi belief. Variou reaon explain why pain in children doe not receive the ame attention a adult pain, including health profeional difficulty to meaure infant pain, either becaue they do not ak if they are feeling pain or becaue they do not know that younger children experience greater communication difficultie. Myth occupy a ignificant place among argument for the inufficient treatment and identification of pain, highlighting opioid a caue of phyical dependence, tolerance, pychological dependence and repiratory depreion. Moreover, profeional limited knowledge and training about pain, diinformation and confuion among concept of tolerance, phyical and pychological dependence and repiratory depreion, which impede effective communication about thi ubject, reult in the inadequate and imprecie aement and handling of infant pain (1). Until the 1970, the belief wa that children were incapable of quantifying abtract phenomena like pain intenity. Study reult have demontrated that they are capable of indicating the level of their uffering, provided that adult give them an adequate intrument, uch a a cale, diagram or drawing (1). There are variou pain aement intrument. Unidimenional tool only dimenion intenity, wherea multidimenional one ae qualitie and different dimenion (2). Tool like the viual analogue cale, numerical cale, cup cale and color cale, ae children pain intenity and are related to their development level. To undertand them, children need notion of arithmetic, beide color dicrimination kill (3). The face cale alo aee pain intenity, i contituted by ix face and eem to be more adequate for pre-chool children who have learned neither to read nor write, nor any arithmetic knowledge (3). In our context, we highlight a tool developed for pain intenity aement in chool-age children. Thi face cale conit of character deigned by the renowned cartoonit Maurício de Souza and well-known to Brazilian children (4). Another national tudy applied thi cale to hopitalized children with pain complaint (1). Pain aement i one of the mot challenging problem health care provider are faced with. We believe that pain aement i not only aimed at determining intenity, a hown by the above cale. Literature emphaize the need for reearch about pain quality, duration and influence in the pycho-affective phere, upporting diagnoi, therapy choice and efficacy evaluation (5). The ue of pain aement tool guarantee the evaluation of what the child i feeling, and not what the profeional believe ()he i feeling. For the ake of better pain comprehenion, the procee the child experience, both the phyical and mental development tage need to be taken into conideration. Lack of knowledge of adequate intrument, in combination with children difficultie to expre their pain, can be conidered one of the obtacle nure face in aeing child pain (6). Nure are in a privileged poition to ae pain in children, and are particularly able to influence pain control, provided that they have autonomy to ae and precribe medication if neceary. Thi oppoition hould alo be ued to etablih link between infant pain reearch and hopital practice, in the attempt to decreae or mitigate uffering, learning to ae children with pain through a variety of approache. An exiting gap in child pain quality aement till remain, due to the abence of adequate tool for children cognitive development level. Therefore, pain aement intrument need to be teted which not only ae, but alo ditinguih and meaure different dimenion of children pain experience. Thi tudy, which ued an aement tool to etimated behavioral and perceptual pain dimenion (7), i jutified by it potential contribution to a more complete child pain evaluation. Thu, thi tudy aimed to verify the repreentativene of pain qualitie in hopitalized children and adolecent. METHODOLOGY We carried out a pilot, decriptive and exploratory field tudy. The population conited of

3 Multidimenional tool: application... Roato LM, Magaldi FM. Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): pre-chool and chool-age children and adolecent, between three and 16 year of age. The total number of participant amounted to 50 hopitalized children with pain complaint, in the firt emeter of The following election criteria were adopted: pre-chool, chool or adolecent age; preenting pain complaint at the moment the card were applied or being a child with chronic pain, preenting pain complaint or not at the moment the tool wa applied; beide the ability to communicate and verbalize or indicate one need. Firt, the reearch project wa approved by the Ethic Committee for Reearch Project Analyi at the Univerity of São Paulo College of Nuring. After obtaining approval, a grantee tudent collected data at the pediatric hopitalization unit of a public hopital in the city of São Paulo. Before the tart of data collection, the children and adolecent received information about the tudy goal. They received the guarantee that their identitie would be preerved and that, in cae of any ign of pain or dicomfort, the interview would be immediately interrupted, with the poibility to retart or top collaborating at any time, without any effect on hopital care. The interviewee were timulated to talk about each of the card, tarting from two motivating quetion: I Cebolinha in pain? and Tell me what hi pain i like and what he i feeling. The card repreented by the 18 pain quality decriptor (7) to ae whether they attributed imilar meaning to the pain decriptor and to the illutration. Next, participant were aked to indicate the card that bet repreented their pain. The reult were organized in three figure and a table, with percentage and abolute figure. In repone to tatitical advice, the neceary tatitical tet (8) were applied to the card reult, in order to ummarize information about the card core. RESULTS The tudy reult are preented below, conidering the population identification and ditribution according to the correlation between the card and the pain decriptor. The reearch ubject were 50 children, 24 (48%) boy and 26 (52%) girl. Thirteen (26%) ubject were in the pre-chool group, 20 (40%) in chool age and 17 (34%) in the adolecent group. Among the boy, even (30%) belonged to the pre-chool group, 11 (45%) to the chool-age group and ix (25%) to the adolecent group. Among the girl, ix (25%) were in the pre-chool group, nine (35%) in the chool-age group and 11 (40%) in the adolecent group, a hown in Figure 1. Figure 1 - Gender and age ditribution of interviewee. São Paulo, 2004 The reult were organized in frequencie of imilarity and non-imilarity between the children anwer and each card actual meaning. Moreover, they were eparated per group (pre-chool, chool and adolecent) and analyzed by mean of a binomial tet for mall ample. In thi type of tet, the proportion between two level of a factor i analyzed in one ample. The binomial ditribution indicate a relation between the ize of ample N and the number of cae X of the analyzed factor, the repective probability value that can be aociated with the predetermined ignificance level p < The general reult of thi type of analyi are decribed below. Each group poitively identified a different number of card (Figure 2). The age range i not correlated with the number of affirmative anwer. The Chi-Square tet for the proportion of correctly identified card per group indicate that group and anwer are mutually independent (oberved chi = 9.45, critical chi = 5.991, degree of freedom = 2). A to the number of tatitically correct anwered per group for the total of 18 card, in the pre-chool group, five (28%) card were recognized and 13 (73%) were not. In the chool group, 14 (78%) card were recognized, wherea only four (22%) were not. In the adolecent group, 11 (62%) card were recognized and even (38%) were not, a hown in Figure 2.

4 Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): Multidimenional tool: application... Roato LM, Magaldi FM. 705 The tudy reult preented the ability of children aged three or older to identify the location of their pain, a well a to ue word that decribe their pain (9). To ae pain in mall children, uch a prechool children for example, pecial attention hould be given to the way they perceive the painful experience, a children in thi age range perceive pain a a phyical experience and live with it in an egocentric way (9). Figure 2 - Contingency of poitive and negative anwer about the identification of the tudy card. São Paulo, 2004 Each group identified the card differently (Table 1). For the pre-chool group, the binomial tet indicated that 61.1% of the card were identified correctly, againt 77.8% for the chool group and 27.8% for the adolecent group. The following card were correctly identified by all group (queeze and bite): Table 1 - Card identification and recognition in each tudy group. São Paulo, 2004 Pain Decriptor Card Dipleaed Prick Terrifying Tormented Tireome Painful Strong Maddening Squeeze Naueated Scattered Hook-like Itching Cold Throbbing Bite Burning Jerking Pre-chool School Adolecent The figure below diplay each group Bite Squeeze A majority of card wa identified by two group, i.e. thoe repreenting (prick, terrifying, tormented, tireome, painful, trong, naueated, cattered, itching, throbbing and burning). Only two card (maddening and jerking) were identified by one group; thee were not identified by the pre-chool and chool group and by the pre-chool and adolecent group, repectively. ne of the group correctly identified the card repreenting dipleaed, cold and hook-like: Dipleaed Cold Hook-like recognition of the card according to the enorial, affective, evaluative and micellaneou component. Pre-chool children identified four card with enorial component (painful, itching, bite and throbbing), chool children recognized even (jerking, painful, itching, throbbing, prick, burning and bite) and adolecent identified three (prick, burning and bite). In the affective component, pre-chool children did not recognize any card, chool-age children identified four (terrifying, tormenting, tireome and naueated) and adolecent five (terrifying, maddening, tormenting, tireome and naueated). Within the evaluative component, prechool children did not recognize any card either, and chool-age children and adolecent identified only one (trong pain). In the micellaneou component, pre-chool children recognized one (queeze) and chool-age and adolecent two card (cattered and queeze).

5 Multidimenional tool: application... Roato LM, Magaldi FM. Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): Figure 3 - Card recognition according to component. São Paulo, 2004 We compared our reult with another pain decriptor tudy (enorial-ditinguihing, motivational-affective and cognitive-evaluative). Six anwer preent cognitive-evaluative content, indicated by word that determine a pain value or degree (quite, little, no, much) (1), in according with the other tudy. The enorial-ditinguihing claification i preented a a complement of an anwer, in which the child ue the word hot to refer to a thermal enation (1). The motivational-affective claification i not conidered in the reearch anwer (1), but appear in the reult of the other tudy. DISCUSSION The tudy reult howed that our tudy objective wa achieved. In other word, we managed to verify the repreentativene of pain qualitie in hopitalized pre-chool and chool children and adolecent with pain complaint or in chronic pain, through the application of the Pain Quality Card (7). Figure 2 diplayed how many tatitically right anwer were given by each group, in a total of 18 card. The pre-chool group recognized five (28%) card and did not identify 13 (73%) card. In the chool-age group, 14 (78%) card were recognized and four (22%) were not. In the adolecent group, 11 (62%) card were recognized, wherea even (38%) were not. The reult howed no correlation between age range and the number of affirmative anwer. The pre-chool group identified 61.1% of the card, againt 77.8% for the chool-age group and 27.8% for the adolecent group. Two card (maddening and jerking) were identified by one ingle group. ne of the group managed to correctly identify three card (dipleaed, cold and hook-like). Thi tudy contribute by preenting the ucceful application of the Pain Quality Card (7), becaue it conider more component of pain dimenion, helping profeional to determine and ae pain treatment, and alo by howing the need to ue uch a tool, confirmed by the limitation of the intrument preented at the tart of thi article, which only ae child pain intenity. Nure need to undertand the characteritic of child development and behavior to be able to ae and meaure pain in children. The tudy author alert about the inexitence of an adequate intrument for all children (11). Figure 3 how how each group recognized the card according to the enorial, affective, evaluative and micellaneou component per group. Pre-chool children identified four card (painful, itching, bite and throbbing), chool children recognized even (jerking, painful, itching, throbbing, prick, burning and bite) and adolecent identified three (prick, burning and bite). In the affective component, a hown by Figure 3, pre-chool children did not recognize any card, chool-age children recognized four (terrifying, tormenting, tireome and naueated) and adolecent identified five (terrifying, maddening, tormenting, tireome and naueated). With repect to the evaluative component, the pre-chool children did not recognize any card either, while chool-age children and adolecent identified only one (trong pain). In the micellaneou component, pre-chool children recognized one (queeze) and chool-age and adolecent two (cattered and queeze). Study reult how that children aged five or ix identified enorial-ditinguihing word more frequently than motivational-affective or cognitiveevaluative word (12). Another tudy etablihed the ue of 17 enorial-ditinguihing and one cognitive-evaluative word for pain decription by children between nine and 15 year old (13). Analytic paradigm are under contruction, preenting ome conideration by the author, who expoe argument reulting from human intelligence

6 Rev Latino-am Enfermagem 2006 etembro-outubro; 14(5): Multidimenional tool: application... Roato LM, Magaldi FM. 707 reearch, indicating that it are experience and not cognitive tructure that lead a peron to more elaborate level of thinking (14). The tudy reult demontrated that all children in thi tudy ued at leat one characteritic method of pain relief, which i ditraction, beide receiving the nure help for elf-care and their parent preence (15). Children between ix and 12 year old clearly defined the word pain a phyical or moral uffering, a orrow. The children managed to link pain with the fear of getting hurt or of invaive exam, confirming the hypothei that they are capable of expreing themelve about the pain, by mean of adequate intrument (16). In hopital, there i an urgent need for greater control of acute pain in children, uing a ytemized aement ytem and analgeia (17). In view of inherent limitation of child development, new tudie are needed to identify reource that can help children from pre-chool to adolecent age to preent information about their pain. CONCLUSION The reult of thi tudy reveal that: - each group identified the card differently; - only two card (Squeeze and Bite) were correctly identified by all group; - two card (Maddening and Jerking) were identified by only one group; - three card (Dipleaed, Cold and Hook-like) were not identified correctly by any of the group. The ue of the Pain Quality Card tool (7) i viable. The tool can not only ae, but alo ditinguih and meaure the different dimenion of the pain experience in children and adolecent. It ue hould be encouraged and acceible to health profeional, with a view to the qualitative evolution of care delivery to children and adolecent in pain. Thi require the inertion of the pain theme in the curricula of all medical, nuring and paramedical chool. Thi tudy i limited by the ize of the population. Therefore, new tudie with more participant are needed, with a view to broadening knowledge about the theme. REFERENCES 1. Roato LM. Utilizando intrumento para avaliação da percepção de dor em pré-ecolare face a procedimento doloroo. [diertação]. São Paulo (SP): Ecola de Enfermagem/USP; Soua FAEF. Dor: o quinto inal vital. Rev Latino-am Enfermagem 2002 maio-junho; 10(3): Wong DI, Baker CM. Pain in children: comparion of aement cale. Pediatr Nur 1998; 14(1): Claro MT. Ecala de Face para Avaliação da dor em criança: etapa preliminar. [diertação]. Ribeirão Preto (SP): Ecola de Enfermagem/USP; Pimenta CAM, Teixeira MJ. Quetionário de dor McGill: propota de avaliação para a língua portuguea. Rev Ec Enfermagem USP 1996; 30(3): Viana DL. Senibilizando-e para cuidar: a experiência da enfermeira frente a avaliação da dor na criança. [diertação]. São Paulo (SP): Ecola de Enfermagem/USP; Roato LM, Rodrigue AC, Godoy LDP, Santana XE, Pimenta CAM. Card pain of characteritic for ue with children. Proceeding of the 8th World Pain Congre; Augut 5-8; Vancouver, Canada. p Siegel S. Etatítica não paramétrica para a ciência do comportamento. São Paulo, (SP): McGraw-Hill; Setz VG, Pedreira MLG, Peterlini MAS, Harada MJCS, Pereira SR. Avaliação e intervenção para o alívio da dor na criança hopitalizada. Acta Paul Enfermagem 2001 maioagoto; 14(2): Stein P. Indice of Pain Intenity: contruct validity among prechooler. Pediatr Nur 1995 March-April; 21(2): Jerret M, Evan K. Children pain vocabulary. Journal of Adv Nur 1986; 11(4): Melzack R. The McGill Pain Quetionnaire: major propertie and coring method. Pain 1975; 1: Abu-Saad H. Aeing children repone to pain. Pain 1984; 19: Yoo HL. Children illne concept: old and new paradigm. Pediatric Nur 1994; 20(2): Polkki T, Pietila AM, Vehvilainen-Julkunen K. Hopitalized children decription of their experience with pot urgical pain relieving method. Int J Nur Stud 2003; 40(1): Soare VV, Vieira LJES. Percepção de criança hopitalizada obre realização de exame. Rev Ec Enfermagem USP 2004; 38(3): Jordan-Marh M, Hubbard J, Waton R, Hall RD, Miller P, Mohan O. The ocial ecology of changing pain management: do I have to cry? J Pediatr Nur 2004 June; 19(3): Recebido em: Aprovado em: