Tamara Baird and Dr. Renea L. Beckstrand, Nursing
A nurse’s obligation to manage pain and relieve patients’ suffering is an integral part of the commitment to patient care. Adequate pain assessment and management benefits the patient by shortening the hospital stay, speeding recovery, reducing costs, and promoting physical activity. Specific populations who may have difficulty communicating their pain require special attention, especially children. Although many effective techniques are available for pain management in children, studies indicate that their pain is managed less well than pain in adults (United States Department of Health and Human Services, 1992).
Acute pain, defined as pain of short duration and resultant from a known cause such as surgery, is very easily treated due to the wide acceptance of the World Health Organization (WHO) guidelines for pain management. This includes use of the “pain ladder,” which allows the nurse to match the assessed number on the pain scale to the correct level of medication. This approach has led to efficacy results ranging from 70-95%. However, proper assessment is essential to proper treatment. Failure to properly assess pain is a major factor in the under-treatment of pain (Schickedanz, 2001). Children and their families should be informed that pain relief is an important part of the care they receive postoperatively because being in pain is thought to prolong the healing process by inhibiting the immune system.
Before undergoing surgery, the child and family must be prepared for the occurrence of postoperative pain using developmentally appropriate materials. Options of pain control should be explored and preferences, as well as concerns, should be discussed thoroughly. At this time, a plan should be developed for pain assessment and management. Teaching the child how to use the pain scale is helpful to ensure good communication of the patient’s pain level. A pain scale that is easy for pediatric patients to understand is imperative to ensure good communication of pain. The FACES pain scale by Wong and Baker (1988) is very easy to use and understandable by children. This FACES scale has been proven effective through analysis of variance (ANOVA) statistical calculations and has been found to have construct validity. Analysis of the scale has also shown that children as young as 4 to 5 years of age can use the scale successfully to rate their pain intensity.
Tonsillectomy surgery is one of the most common childhood procedures. A study by Sutters and Miaskowski (1997) found that children experience moderate to severe pain following tonsillectomy surgery and that this pain is often under treated. They also found that children with a higher pain intensity experienced more behavioral changes, sleep disturbances and poorer oral intake in the first 24 hours after surgery due to inadequate pain management.
This pilot study, assessed pediatric post-tonsillectomy patients’ pain at three specific time intervals: prior to surgery (to teach the child how to use the chart), immediately after surgery (when the child was awake enough to respond), and prior to discharge. The child’s pain was also assessed 15 minutes after they received any pain medication. My goals were to: (a) determine the intensity of the first memory of pain following post-tonsillectomy surgery using the FACES scale, and (b) note the pain intensity prior to discharge and (c) how often the nurse assessed the child’s pain. I also noted if pain medication administration decreased the child’s pain score.
This study is not yet fully completed. The subjects of this study will consist of 20 patients who underwent tonsillectomy surgery at Utah Valley Regional Medical Center. The subjects will range in age from 4 to 12 years because this is the largest population that participates in this type of surgery. The participants will not be cognitively impaired and will be able to understand English. Their parent(s) or guardian(s) must also be able to read and understand English. Nine subjects have been interviewed at the time of writing and preliminary data is presented.
My hypothesis was that results will manifest evidence of better pain management, as contrasted to the study reported by Sutters and Miaskowski (1997) and will be in the same range of efficacy as WHO reported as 70-95%. However, if the nurses do not respond to the patients’ pain levels, they may have an increased level of pain. The preliminary results support my hypothesis.
The average pain level pre-operatively was 0.4. I expected the pain level for all of the children to be 0, but two children reported pain due to a finger poke blood test. The average pain level immediately post-operatively was 5.1, and the average pain following medication administration was 5. The average discharge pain level was 2.4 and none of the subjects experienced surgical complications. The average time interval that the nurse assessed the child’s pain levels was every 50 minutes. The average age of the subjects was 8.3, with the vast majority being male. The study is only a few weeks from completion and 11 more subjects are needed. The final results are expected to remain at about the same levels.
With these tentative findings in mind, further research is needed to determine how the child’s preparation for the experience and the parental philosophy of pain management affects the child’s pain levels. In my observations from this study, the children that received pain medication had parents that were actively involved in advocating that the child be medicated. The child’s preparation also drastically affected the child’s experience. The behavior observed in the children with the highest reported pain levels were those that did not have adequate expectations of the surgery. The results of this pilot study can provide nurses with information regarding the assessment of pediatric post-tonsillectomy pain. It can also be very important to nursing practice so that current post surgery assessment and management of pain in children is at an acceptable level