HINT: How to assess pain in a child who cannot self-report?
Connected Care Quick Hits are up to date and evidence based recommendations for the care of children with medical complexity & technology dependence, from hospital to home.
HINT: How to assess pain in a child who cannot self-report?
SITUATION:
This week’s QuickHit! comes from a consult initiated by a home care nurse who asked for help in assessing pain in a child with neurocognitive impairment and who is nonverbal.
BACKGROUND:
Pain can be acute or chronic. Acute pain often comes and goes quickly, and acts as a warning sign that something is wrong. It is often caused by damage to tissues as a result of infection, disease, injury, or procedures. Chronic pain can be continuous or reoccurring pain that typically lasts longer than three months.
For children who are unable to explain their pain using words, it is important that healthcare providers and families pay attention to subtle cues and use assessment tools specifically developed for this paediatric population .
ASSESSMENT:
Behavioural observation and parental report are the primary methods for assessing pain in preverbal, nonverbal or cognitively impaired infants and children. Physiological signs can also be cues to the child’s pain experience.
It is also important to consider how you are measuring pain, the patient's context and the impact pain is having on the child's experience or enjoyment of life. When measuring pain, use a tool that can:
Quantify the intensity or frequency
Assigns values to quantities (e.g., 8/10)
Focuses on one parameter at a time
RECOMMENDATION:
For this consult, Connected Care recommended that the home care nurse become familiar using the revised Face, Legs, Activity, Cry, and Consolability(r-FLACC) scale. It is a measure used often by nurses at SickKids in partnership with parents to assess pain.
The revised FLACC (r-FLACC) scale is an observational pain measure based on the FLACC scale that has been amended to include additional pain behaviors often found in children who are non-verbal or with cognitive impairment. It includes the additional items that parents report about individualized behaviors for their child, within each category.
How to use the Revised FLACC
Review with family caregivers, the descriptors within each category of the FLACC. Click here to view FLACC Tool
Revise the FLACC by asking the family caregiver which additional behaviors are indicators of pain for their individual child? Add these to the tool in the appropriate category (see examples in red type below).
Observe child for 1-3 mins (if awake) 5 mins (if asleep). Observe legs and body uncovered. Gently reposition child, if possible, and assess for tenseness and tone. Console the child if needed.
Score pain, ranking each category from 0-2, grading the behaviors based on severity. Add to a total score out of 10.
The overall score is recorded as:
0 = Relaxed and comfortable
1 to 3 = Mild discomfort
4 to 6 = Moderate pain
7 to 10 = Severe discomfort/pain
Sample r-FLACC tools like the one below are widely available on-line
Ways to build pain assessment into your routine practice when caring for children from hospital to community/home community/ home care:
Partner with family caregivers in selecting a pain assessment tool and plan for its routine use
Assess pain before and after giving analgesics or other key times when a child’s pain may fluctuate
Document pain assessments at least once per shift so that the child's pain experiences may be monitored for changes over time
Select an evidence-based strategy to promote pain management for the child
Collaborate with the child, family and their point-of-care teams to evaluate the effectiveness of pain management strategies.
Click here for more information about pain assessment in children from AboutKidsHealth
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