Jacqueline A. Ellis

Pain in hospitalized pediatric patients: how are we doing?

ObjectiveThe purpose of this study was to provide a baseline description of the prevalence of pain and pain management strategies in a pediatric hospital and to compare the prevalence of pain in this hospital to that in published reports in the literature. MethodsTwo hundred thirty-seven children ranging in age from 10 days to 17 years and 223 parents participated in an 8-hour survey on 5 inpatient units. Information about pain intensity and pain affect was collected from the children older than 6 years of age and from parents of those who were younger at 4 2-hour intervals. Information about procedural pain was collected from children, parents, and health care professionals over this 8-hour period. The type and amount of analgesia were also noted. ResultsMore than 20% of the children had clinically significant pain at each of the 2-hour intervals, and 7 had pain scores of 5/10 or greater for the majority of the study day. At least 50% of the children were found to be pain-free during the 4 intervals, and there was a high level of agreement between parents and childrens pain-intensity ratings. One hundred fifty-seven children had medication ordered and 80 children had no analgesia ordered. There was no significant correlation between characteristics of the patients and amounts or types of medication given. No analgesia was administered via intramuscular or subcutaneous injection. DiscussionAlthough these results are encouraging in that a significant portion of the children were pain-free during the study day, the number of children who had clinically significant pain was too high. The results of this study compare with others in that a significant number of children were inadequately treated for pain. Clinical implications are discussed.

Testing factorial validity and gender invariance of the pain catastrophizing scale.

Recent research has indicated that the Pain Catastrophizing Scale (PCS) is a reliable measure that taps three dimensions of a singular construct. Gender differences have been found consistently in catastrophizing, with women reporting significantly higher scores than men on the PCS. This study was designed to cross-validate the factor structure of the PCS, independently for men and women, through second-order confirmatory factor analysis. Results indicate that the second-order models provide a good fit to the data. The conceptualization of catastrophizing as a singular latent construct, within a hierarchical factorial structure that consists of three first-order factors—rumination, magnification, and helplessness, was supported for both men and women. The second research objective was to test the two models for gender equivalence. Results indicate that all constraints held across gender. Together, these findings support the psychometric soundness of the PCS and indicate that the gender differences found are not due to an inadequate fit of the measurement or structural model.

Cognitive-behavioral interventions for children's distress during bone marrow aspirations and lumbar punctures: A critical review

Children with cancer often have difficulty coping with the invasive medical procedures that are part of diagnosis and treatment. Bone marrow aspirations and lumbar punctures are painful and cause some children severe anxiety and distress. The increased risk and expense of general anesthesia and the relative ineffectiveness of sedatives and anxiolytics has prompted clinicians to examine nonpharmacologic methods for controlling pain and distress. This report critically examines intervention studies that focus on cognitive-behavioral strategies such as distraction, imagery, or hypnosis for reducing procedural distress in children with cancer.

Chronic neuropathic pain in spinal cord injury: the patient's perspective.

BACKGROUND Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is recognized as severely compromising, in both adjustment after injury and quality of life. Studies indicate that chronic pain in SCI is associated with great emotional distress over and above that of the injury itself. Currently, little is known about the SCI patients perception of the impact of living with chronic neuropathic pain. OBJECTIVES The purpose of this study was to explore the experience of CNP in SCI patients in relation with physical, emotional, psychosocial, environmental, informational, practical and spiritual domains, and to identify effective and ineffective pain coping strategies. METHODS Three focus groups were conducted that included 24 SCI individuals living in the community. Participants were selected to maximize variation in terms of type of SCI, Frankel classification, years since onset of SCI, age and sex. The sessions were audiotaped and tapes were transcribed. A qualitative analysis of data involved a constant comparison approach, in which categories and themes were identified. RESULTS Many complex themes emerged including: nature of pain; coping as process and product; medication failure; and the impact of CNP on physical, cognitive, emotional, interpersonal, social and life activities. CONCLUSIONS Medication failure was identified as a common outcome, while strategies including use of warm water, swimming, increased activity and distraction provided temporary pain relief. Learning to live with the pain appeared to be related to acceptance of pain, which in turn seemed to facilitate adjustment. Further research is warranted to determine the process by which SCI patients learn to live with CNP and coping strategies that facilitate adjustment to CNP in SCI patients.

Pain Practices: A Cross-Canada Survey of Pediatric Oncology Centers

Before implementing a pain education program, the Canadian Association of Nurses in Oncology conducted a national survey on cancer pain management. The survey focused primarily on adult cancer pain and a second survey was undertaken to describe the supports in place across Canada for best practice pediatric cancer pain management. Twenty-eight pediatric cancer centers re sponded to a survey that was composed of 48 questions about the types of supports that are in place related to pain assessment, management, and pain- related staff and family education. Results of the survey indicated that, for the most part, children have access to the components of best practice pain manage ment. In addition, areas of strength and areas that need to be further developed

Coping With Adolescent Cancer: It's a Matter of Adaptation

Adolescents with cancer face many stresses that challenge their ability to cope. Using the framework of the Roy model, common adaptation problems and nursing interventions are discussed as they pertain to adolescents with cancer.

Patient-controlled analgesia: optimizing the experience.

A patient-controlled analgesia (PCA) program was established on a surgical unit with children age 7 years and older. The primary objectives for the PCA program were safety and efficacy. A retrospective evaluation of the first 30 patients enrolled in the program suggested that it was safe and adequately controlled pain for all but 4 patients. A chart review of these patients indicated that the relation between the number of failed administration attempts, the total hourly analgesic intake, and the pain intensity score was key to optimizing the use of PCA. Recommendations to strengthen the PCA program were implemented based on information gained from these 4 patients with poorly controlled pain.

Pain, emotion, and the situational specificity of catastrophising

Two studies were designed to explore the cross-situational nature of catastrophising and the emotions associated with pain and catastrophising. The crosssituational consistency of catastrophising in response to a finger-pressure procedure and during an episode of headache pain was examined in the first study. The second study examined differences between catastrophisers and noncatastrophisers with respect to state and trait measures of positive and negative emotions. Results of study one indicated that almost half of the subjects remained consistent in their classification as catastrophiser or noncatastrophiser in both pain situations. The majority of subjects that switched classification changed from being classified as catastrophisers during the headache experience to noncatastrophisers during the finger-pressure procedure. Results of the second study indicated that catastrophisers experienced significantly greater fear, sadness, anger, hostility, guilt, disgust, and shame during the finger-pressure procedure as compared to noncatastrophisers. Unexpectedly, catastrophisers were not a homogeneous group in regard to the pattern of negative emotions reported. Catastrophisers with headaches experienced greater sadness in response to finger-pressure pain than catastrophisers without headaches. Theoretical and clinical implications of these findings are discussed.

Improved Practices for Safe Administration of Intravenous Bolus Morphine in a Pediatric Setting

Postoperative pain control is a clinical imperative, for which morphine is a preferred opioid. However, interpatient variability and drug accumulation with repeated doses, as well as medication errors, may result in respiratory arrest with this medication. Early detection of respiratory depression is essential for safe use of morphine, following both initial and repeated doses. A multidisciplinary team contributed to development of an intravenous (IV) bolus morphine monitoring guideline that reflects current knowledge of morphine pharmacokinetics. Monitoring over a 22-week period in a postsurgical unit was then assessed via record review. A total of 270 postsurgical patients received a first dose of IV bolus morphine, with 784 subsequent doses also administered. Complete monitoring (heart rate, respiratory rate, blood pressure, sedation score, oxygen saturation, and pain score) after the morphine bolus was documented at baseline and 10 and 20 minutes for 34%, 30%, and 23%, respectively, of the patients; partial monitoring (respiratory rate and oxygen saturation) was documented for an additional 22%, 15%, and 9% of patients; 43% of subsequent morphine doses were followed with complete monitoring, and an additional 30% with at least partial monitoring. Adherence to the monitoring procedure fluctuated over the study period with no consistent upward or downward trend. A small number of children exhibited a reduced respiratory rate potentially indicating respiratory depression, but no child required antidote or respiratory support. Despite suboptimal guideline adherence, potential signs of respiratory depression were detected that might otherwise have gone unnoticed. This validates the improved guideline and suggests that some incidents may have remained undetected. Front-line staff must be involved to optimize change, champion the initiative, and promote patient safety.

Establishing the psychometric properties and preferences for the Northern Pain Scale

Objectives. A culturally relevant, evidence-based pain assessment scale in Inuktitut is needed. Psychometric properties and preferences for the Northern Pain Scale (NorthPS), a revised version of the Wong-Baker FACES scale, were examined. Study design. This repeated-measures, within-subjects study involved 2 face-to-face interviews held 2 weeks apart. Methods. Participants were recruited from 2 schools and a community centre in Pangnirtung, Nunavut, Canada. Three pain scales (NorthPS, FACES and a numerical rating scale) were used to rate the pain portrayed in an adapted version of the Charleston Pediatric Pain Pictures (NorthCPPP, a series of 17 cartoon vignettes). Results. The study involved 188 participants ranging in age from 5 to 83 years. Compared with the established FACES and numerical scales, the concurrent validity of the NorthPS was acceptable, with all 3 pain scales producing similar scores for the North CPPP vignettes. The youngest children were slightly more accurate during the second interview; otherwise, scoring accuracy was similar during both interviews. Accuracy was also similar across pain scales. Spearman correlations between NorthPS and other scales were lowest for the “No” pain vignettes, and for the youngest children. Internal consistency was acceptable for the NorthPS when compared with FACES and numerical scales. FACES was preferred by the majority of children and NorthPS was preferred by the majority of adults. Conclusions. NorthPS, a pain scale adapted to Inuit language and culture, was validated using the NorthCPPP with children and adults. The NorthPS is a well-understood, culturally and linguistically adapted option for the assessment of pain for Inuktitut-speaking children and adults.