Age Age Appro Appropriate priate Care Care & Pa Pain - - PowerPoint PPT Presentation

Age Age Appro Appropriate priate Care Care & Pa Pain Manage in Management ment

Self Learning Module – Developed by Staff & Community Education Revised 10/98; 7/01; 5/03; 11/07 Reviewed 9/10; 9/11; 9/12

Normal Vital Signs

Adult vital signs

Pulse 60 to 100 beats per minute Blood Pressure 90 to 140 mmHg (systolic) 60 to 90 mmHg (diastolic) Respirations 12 to 20 breaths per minute

Child vital signs (age 1 to 8 years)

Pulse 80 to 100 beats per minute Blood Pressure 80 to 110 mmHg systolic Respirations 15 to 30 breaths per minute

Infant vital signs (age 1 to 12 months)

Pulse 100 to 140 beats per minute Blood Pressure 70 to 95 mmHg systolic Respirations 25 to 50 breaths per minute

Neonatal vital signs (full-term < 28 days)

Pulse 120 to 160 beats per minutes Blood Pressure >60 mmHg systolic Respirations 40 to 60 breaths per minute

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Eyes are closed much of the time even when awake.  Aversion to bright lights  Tear ducts do not function  Cannot support own head  Umbilical site heals to form navel  Reflexes present: moro, stepping, smiling, grasping, rooting, sucking, protective head turning, and tonic neck  Neonates are especially sensitive to electrolyte imbalance and to their environment in terms of body heat regulation  Anterior Frontal Fontanelle is soft and will be until around 4 months of age.  Rapid Growth  Average head circumference 13.5"  Able to fixate on an object visually  Prefers the human face  Prefers complex patterns to simple patterns  Prefers medium lighted

• bjects

 Sleep is major activity  Begins to develop sense of touch  Begins to recognize parents  Involve parents in care  Teach about feeding, hygiene, safety and other ways to promote healthy development  Support head  Observe fontanelles for tenderness, bulging or depression  Have bulb syringe available in case of need for suctioning  Keep crib siderails up at all times  Encourage parents to assist with care  Smile at the neonate  Provide basic needs, while maintaining a safe environment  Teach parents the importance of car seat safety and the danger of the child ingesting objects (baby-proof the environment)  Provide support to head and neck  Position on back to go to sleep to prevent SIDS (Sudden Infant Death Syndrome)  If giving IV fluids, use a volume control unit  Pain is indicated by irritability, restlessness, brow bulge, or vigorous cry

0-1 Month Neonate

0-1

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Rapid growth  Weight doubles by 5 months and triples by 1st year  Posterior fontanelle closes

• 2 months

 Begins teething  Bladder and bowel patterns develop  Primitive reflexes diminish toward end of 1st year  Raises head, turns

• ver, rolls over,

sits up, scoots, creeps, crawls, pulls themselves up and walks.  Reaches and grasps objects bringing to mouth  Begins to feed themselves  Reactions advance from reflexes to intentional  Recognizes parents, primary caregivers (0-3 months)  Cries when mother, father

• r primary

caregiver leaves (7-9 months)  Begins to speak and mimic sounds  Learns by imitation  Active learning  Shows range of emotions (ex: anger, frustration, affection, fear with separation, and anxiety with strange situations and people, etc.) (10-12 months)  Obeys simple commands  Establish trust  Smiles spontaneously at human faces (2 months)  Plays social games (peek-a- boo and patty cake)  Involve parents or primary caregivers in care  Encourage parents to assist with care  Keep siderails up on crib at all times.  Keep parents in baby's line of vision  Utilize distraction techniques as appropriate  Respond to baby's bid for help  Monitor toys for removable parts and safety approval  Provide familiar objects  Provide opportunity for return demonstration of new procedures by parents or primary caregivers  Provide basic needs while maintaining a safe environment  Offer age appropriate toys  Cuddle an upset child and talk in soothing tones  Pain in an infant is demonstrated by irritability, restlessness, brow bulge, or vigorous cry.  Teach parents the importance of car seat safety and the danger of the child ingesting objects (baby-proof the environment)

1-12 Month Infant

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age- specific Care  Decreased appetite and food intake  Abdomen protrudes  Developing bowel and bladder control  Improved balance  Places foreign

• bjects in
• rifices

 Shakes, sniffs, and visually examines all new objects  Feeds self  Walks up and down stairs  Stands on 1 foot  Throws a large ball  Utilizes fantasy and magical thinking and/or mental play to adapt to fears and anxieties  Shares what they want to be true, believing what they are saying instead of stating facts  Play is a form of learning experience  Understands simple directions and requests  Verbal skills are improved  Short attention span  The toddler has trouble understanding pain, and may think it is a punishment  Parents are significant people  Discovers/develops sense of will  Separation/stranger anxiety present  Develops/asserts independence  Everything is "mine"  Puts away toys  Plays simple games  Have little control

• ver their emotions

 Involve parents in care  Encourage parents/primary caregiver to stay with child, especially at night  Allow to express feelings  Explain what you'll be doing before beginning  Use play as a means of preparing and explaining but be firm and direct  Don't give anything small enough to fit in a body orifice  Utilize stories to explain what is happening and use their belief in magic  Allow choices if possible  Utilize distraction techniques  Provide opportunity for return demonstration of new procedures by parents or primary caregivers  Provide basic needs while maintaining a safe environment  Explain procedures to parents and the child in simple terms. Allow time for questions  Educate parents on home safety,

• utlets, windows, poisons, and using

the car seat until child weighs 40 lbs

1-3 years Toddler

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age- specific Care  Slow and regular growth  Becomes taller and thinner  Toilet training completed  Bounces large ball with both hands progressing to one hand  Skips, hops, jumps rope, roller skates  Prints own name (5 years)  Washes and dries hands

• bathes self

 Dresses self  Throws and catches ball  Increased vocabulary but uses words without understanding meaning  Ritualistic  Retains magical thinking  Expresses feelings through actions during play  More fears than any

• ther age group (ex:

body mutilation, death)  Frequently believes illness/injury is punishment for some real or imagined misdeed  Fears loss of body integrity  Enthusiastic, asks questions and acts on impulse  Imitates adults - role playing  Parents, siblings and peers are significant  Learns to recognize and deal with physical and emotional separation from parent  Others  Aware of others’ feelings  May use aggression  Identifies behavior modification by rewards and punishment  Enjoys playing with

• ther children and

making friends  May have fears, for example about being separated from parents or being injured  Involve parent/primary caregiver in care  Use simple instructions  Prepare for procedures by pretending with actual equipment. Explain the procedure just before you perform it  Hold their hand  Tell stories to explain what is happening  Utilize belief in magic  Provide opportunity for return demonstration of new procedures by parents or primary caregiver  Provide basic needs maintaining a safe environment  Avoid words that might be scary  Provide reassurance that painful procedures are not punishment, explain any expected pain  Safety- ensure protected environment, bicycle helmet, seat belt, and car seat as appropriate

3-6 years Preschool

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Permanent teeth erupt  Pubescent changes  May become fatigued  Proficient in games and sports  Refines motor strength and coordination:

• gross: bike

riding, batting, dancing, skateboarding

• fine: ties

shoes, fastens clothes, writing, musical instrument  Cares for pets  Ready and willing to learn  Inquisitive - asks many questions  Learning to separate reality from fantasy and give up magical thinking  Advancing from simple logic to abstract thinking  Increased ability to read, write, and do math  Able to understand cause and effect  Parents/primary caregivers/ siblings/teachers are significant  Interacts with adults outside immediate family  Develops concept

• f self

 Develops friendship skills  Establishes conscience  Recognizes rules for society  Practices self- discipline  Concerned about body changes  Fear of body mutilation, death and dying  Involve parents or primary caregiver in care  Explain/reinforce rules  Provide simple factual information  Keep instructions short and simple. Avoid getting carried away with details and facts  Use hands-on activities and play while demonstrating procedures. This approach aids in their understanding and gains cooperation.  Allow them to ask questions  Distract as needed  Provide opportunity for return demonstration

• f new procedures.

 Maintaining a safe environment  Ask the child about friends, interests, accomplishments and concerns (for example, body changes)  Praise cooperative behavior  Teach about healthy and safe habits, wearing a bicycle helmet, seat belt, not taking part in risky behaviors (including not using alcohol, tobacco, drugs)

6-12 years School Age

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Rapid growth  Onset of menarch for females  Onset of nocturnal emission in males  Attains physical maturity  Vital signs equal adults  Eating disorders may be a concern  Improves fine motor skills  Capable of performing any skill an adult can perform  Easily fatigued  Utilizes logic and abstract reasoning and applies formal principles of logic to situations they have never experienced  Fear loss of self concept and body image  Developing an identity  May not acknowledge degree

• f pain

 May have emotional swings  May be self- conscious about body image  Pain- have a good understanding of pain and its causes.  Adolescents want to be in control  Smiling and laughing mask frustrations and fear  Peer opinions are important  May face peer pressure  Lives for the here and now  Maturing physically and compare their

• wn body growth and

development with their peers  Interested in the

• pposite sex

 Dependence vs independence  Become interested in close relationships  Privacy is extremely important  Develop a relationship of trust and mutual respect  Be open, honest and straight forward  Read between lines  Ask them what slang terms mean  Be tactful and thoughtful  Do not take sudden mood swings personally  Allow them to maintain as much control as safely possible  Encourage involvement in care and decisions  Provide basic needs maintaining a safe environment  Allow to wear own clothing and have own possessions when possible  Provide opportunity for return demonstration

• f new procedures

 Provide information on pain control methods, assessment scale, schedule for pain management, need to ask for pain medication when pain begins, provide information on pain relief and reduction  Provide privacy for procedures and teaching  Teach about healthy habits (nutrition, exercise, hygiene and safety, STD & pregnancy prevention)  Encourage parents to stay involved in their child’s life

12-17 years Adolescents

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Men attain full adult height in their 20's  Peak muscular strength 25-30 years  Skin begins to lose moisture Older adults:  Menopause - female: decreased energy level, strength and endurance  Senses may be diminished  Adults ages 40-64 begin to experience physical changes, such as decreased endurance  Onset of chronic health problems Older adults:  Visual changes  Reflexes slow  Loss of hearing and taste  Decreased balance and coordination  Abstract thought and comprehensive view of problems  Mental abilities peak during 20's  Accepts responsibility for themselves and

• thers

 Productive, creative and achievement

• riented

 Begins to be concerned with health  Developing relationships  Midlife crisis  Measuring accomplishments against goals  Recognizes limitations  Prepare for retirement  When communicating, take into consideration the patient’s culture and lifestyle  Be supportive - talk about stress  Organize teaching from simple to complex utilizing a logical train of thought  Present information illustrating how it will affect their lives  Encourage him/her to talk about feelings and concerns, and about how an illness or injury may affect plans, family and finances  Individualize teaching methods  Involve significant others and patient in plan of care  Provide opportunity for return demonstration of new procedures  Provide basic needs, maintain a safe environment  Provide culturally competent care in regard to religion and norms Older Adults:  Safety- risk for falls, infection, pressure ulcers, poor nutrition  Taking multiple medications “poly pharmacy”  Pain assessment scales need to be used and control of chronic pain if it is present

18-65 years Adult

Physical Motor/Sensory Adaptations Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care  Decreased tolerance to hot and cold  Decreased bladder capacity/ control  Decline in all sensory abilities  Osteoporosis  Skin becomes thin and fragile  Decreased GI absorption rate, cardiac output and airway capacity  Loss of adipose tissue  Many geriatric adults have chronic diseases and co- morbidities  Wide variation across this population in physical and mental ability and health status  Decreased mobility  Paresthesia  Decreased sense of balance, depth perception  Stronger stimulation is needed for all senses to experience sensation  Ability to respond quickly to stimuli decreases  May develop cataracts  Shares wisdom with

• thers

 Drop in performance  Focuses on abilities  Keeps mentally stimulated  Decreased short-term memory  Reduced attention span  Adjusts to retirement  Adjusts/ accepts death of spouse/ friends  Develops dependence on

• thers

 Relocation to a care facility  Needs to feel useful, independent and in control  Adults 80+ may feel isolated. They may lose self-confidence as their abilities decline.  Encourage self care and independence/Assess skin  Use tape/bandaids sparingly and remove with care  Provide time for rest as needed  Provide opportunities for decision making relating to care  Provide opportunity for return demonstration of new procedures involving caregivers as needed  Provide mental stimulation / Provide more time to learn  Provide for bowel and bladder needs  Provide written instructions. Use larger-print materials  Utilize short, specific instructions repeating as needed  Provide instructions when rested and alert. Avoid rushing  Respect them / Concentrate on strengths  Stress the need for immunizations, checkups and screenings.  Give chances to reminisce, to help promote a positive self image  Possibly discuss option of an advance directive or Living will.  Pain – Older adults may minimize their pain, be aware that there may be a communication barrier (nonverbal, dementia) Use appropriate pain scale  Safety- risk for falls, infection, pressure ulcers, poor nutrition  Taking multiple medications “poly pharmacy”

65+ years Geriatric

Pain Management

• 1. Jameson Health System is committed to maintaining a patient’s pain level at less than a “4” when possible or

maintaining the pain level at the patient’s established comfort goal. Keeping the patient as comfortable as possible is the true goal of pain management.

• 2. The patient knows better than anyone else what his or her pain feels like. It is important to treat pain based on

what the patient says, not one’s own opinion. The most reliable indicator of pain is the patient’s self report.

• 3. Age has nothing to do with the level of pain a person feels.
• 4. Some people cope with pain by staying calm and quiet.
• 5. Many people in pain are unwilling to admit it because of cultural, social, and

personal reasons.

• 6. Physical dependence means the body has learned to tolerate a certain drug;

and must adjust when the drug is no longer needed to relieve pain.

• 7. Addiction is a psychological need for a drug that leads to physical, emotional, and social harm. When properly

monitored and balanced, pain medications may be safely taken on a long-term basis.

• 8. Pain negatively affects patients both physically and mentally. Untreated pain can lead to: poor wound healing,

weakness, muscle breakdown, decreased physical movement, sodium and water retention, elevated blood pressure and heart rate, anxiety, depression, decreased immune response. (www.medscape.com)

Pain Management

Older Adults: Often have chronic and acute pain at the same time May use words such as ache or sore instead of pain Feel pain just as intensely as younger adults Are more likely not to ask for additional or stronger medication Cognitively impaired patients: Assess the need to treat pain that is typically experienced by patients undergoing a certain procedure Consult the physician regarding an around-the-clock analgesic regimen. Observe the patient for: facial expressions, unusual movements such as guarding or bracing, change in behavior Listen for vocalizations such as sighing, moaning, groaning Use the FLACC SCALE Children: Children exhibit and cope with pain differently than adults. They may be less verbal or may exhibit a wide range of responses To determine an infant’s level of pain, staff must rely on diagnosis, the infant’s response to routine comfort measures, assessment of facial expressions, body movements, crying, groaning, or changes in vital signs. Use the UWCH Pain scale or the Wong-Baker scale according to age

Jameson Hospital New Castle, Pennsylvania

0 – 10 Numeric Rating Scale

Indications: Adults and children (greater than 9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain

Wong–Baker Faces Pain Rating Scale

Indications: For children 3 – 12 and adults who are unable to verbalize self report.

Jameson Hospital New Castle, Pennsylvania

UWCH Pain Scale for Preverbal and Nonverbal Children

2 – 4 6 – 8 10

Vocal/Cry

No cry Occasional whimpers Moaning, gentle cry or whimpering Consistent cry that increases in volume and duration

Facial

Smiling, calm, relaxed Neutral expression, frowning, occasional grimace Occasional tense expression, slightly negative expression (e.g. grimace) brow bulge, shallow nasolabial furrow Marked distress. Brow bulge, eyes squeezed shut, open mouth, taut tongue, deepening of nasolabial furrow

Behavioral

Neutral, moves easily, interacts with people or environment, strong rhythmic suck on pacifier Easy to console with holding, position change, or sucking; winces when touched/ moved Consoles with moderate difficulty; sucks for very short periods, followed by crying; cries out when moved/touched Inconsolable; absent or disorganized sucking; high pitched cry or scream when touched or moved

Body Movement/ Posture

Normal motor activity, baseline muscle tone Fidgeting, mild hypertonicity above baseline Moderate agitation or moderate immobility, intermittent flexion; moderate hyper-tonicity above baseline Thrashing, flailing, incessant agitation or strong voluntary immobility; pronounced flexion; strong hypertonicity above baseline

Sleep

Sleeping quietly with easy respiration; normal sleep/rest Restless while asleep Sleep periods shorter than normal, awakes easily, sleeps intermittently Unable to sleep or sleeping for prolonged periods of time interrupted by jerky movements

Overall rating (circle):

2 – 4 6 – 8 10

Cultural Considerations: Cultures vary in when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desired. Explore generic beliefs about pain/discomfort with the client. (Clinical Nursing Skills & Techniques, Perry and Potter, Mosby 6th Ed. Page 132, 2006) Revised 12/06; 11/07

FLACC SCALE

Face No particular expression or smile 1 Occasional grimace or frown, withdrawn, disinterested. 2 Frequent to constant frown, clenched jaw, quivering chin. Legs Normal position or relaxed 1 Uneasy, restless, tense 2 Kicking, or legs drawn up Activity Lying quietly, normal position, moves easily 1 Squirming, shifting back and forth, tense 2 Arched, rigid or jerking Cry No cry (awake or asleep) 1 Moans or whimpers,

• ccasional complaint

2 Crying steadily, screams or sobs, frequent complaints Consolability Content or relaxed 1 Reassured by occasional touching, hugging, or “talking to”. Distractible. 2 Difficult to console or comfort Overall Rating (0 – 10) Indications: (For patients who are unable to communicate)

Cultural Aspects of Pain Management Culture is the framework that directs human behavior in a given situation. The meaning and expression of pain are influenced by people’s cultural background. Pain is not just a physiologic response to tissue damage, but also includes emotional and behavioral responses based on a person's past experiences and perceptions of pain. Not everyone in every culture conforms to a set of expected behaviors or beliefs; so cultural stereotyping (assuming a person will be stoic

• r very expressive about pain) can lead to inadequate assessment and treatment of pain. Many studies have shown that

patients from minority groups and cultures different from that of health care professionals treating them receive inadequate pain management. Heath care professionals need to be aware of their own values and perceptions, as they affect how they evaluate the patient’s response to pain and ultimately how pain is treated. Even subtle cultural and individual differences, particularly in nonverbal, spoken, and written language between health care providers and patients will impact care. To be culturally competent, you must: Be aware of your own cultural and family values Be aware of your personal biases and assumptions about people with different values than yours Be aware and accept cultural differences between yourself and individual patients Understand the dynamics of the difference Adapt to, and respect, diversity You must listen with empathy to the patient’s perception of their pain, explain your perception of the pain, acknowledge the differences and similarities in perceptions, recommend treatment, and negotiate agreement. Questions that staff can use to help assess cultural differences in order to better assess and work out an appropriate pain management plan with a patient and family include: What do you call your pain? What do you think caused your pain? Why do you think it started when it did? How severe is your pain? http://www.cityofhope.org/prc;pdf/Cultural

Bibliography Age-specific competency. Med Source website. Available at: www.medsrc.com/Age-Specific.htm. Accessed October, 2007. Joint Commission of Accreditation of Healthcare Organizations website. http://www.jointcommission.org/. Accessed October, 2007. Bombard, C. RN, MHA, CPHQ FACHE. One Size Doesn’t Fit All with Age-Specific Competencies. Accessed October 2007. https://www.nurseweekce.net/edr_course_print.asp Pain Management Fast Facts, Cultural Aspects of Pain Management. http://www.cityofhope.org/prc/pdf/Cultural%20Aspects%20of%20Pain%20Management.pdf, Accessed October, 2007. Perry, A.G., RN, MSN, EdD, FAAN., Potter, P.A. RN, PhD, CMAC, FAAN.(2006). Clinical Nursing Skills & Techniques (6th ed.). Mosby, Inc. Kozier, B., Erb, G. et al. Fundamentals of Nursing Concepts, Process, and Practice.(2004). Fundamentals of Nursing Concepts, Process and Practice (7th ed.). Prentice Hall. Pain Management Made Incredibly Easy. 2003. Lippincott Williams & Wilkins. Philadelphia

Parse, R. PhD, RN, FAAN, Illuminations: The Human Becoming Theory in Practice and Research. National League for Nursing Press, New York, March 1999.

Nursing 2001, Volume 31, Number 7: Controlling Pain Channing L. Bete Co, Inc., Age-Specific and Cultural Competencies.2000 McCaffey, M. RN, MS, FAAN, Pasero. C. RN, MSN, Pain Clinical Manual. Second Edition. Mosby 1999.