WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.470 fast. Welcome to the emergency room. Welcome 00:00:47.470 --> 00:00:49.869 back to the Deep Dive. We are glad to have you 00:00:49.869 --> 00:00:53.009 with us. Today we are wading into waters that, 00:00:53.149 --> 00:00:56.270 let's be honest, they can terrify. even the most 00:00:56.270 --> 00:00:58.750 seasoned nurses, let alone students who are getting 00:00:58.750 --> 00:01:01.130 ready for their boards. Oh, absolutely. We are 00:01:01.130 --> 00:01:04.510 talking about pediatric pain, specifically the 00:01:04.510 --> 00:01:06.909 assessment and management of it. And I was looking 00:01:06.909 --> 00:01:08.709 through the stack of articles and the textbook 00:01:08.709 --> 00:01:10.510 chapters, all the clinical guidelines we're covering, 00:01:10.709 --> 00:01:13.530 especially chapter 14. And it just it hit me. 00:01:13.590 --> 00:01:17.650 This is arguably the most subjective high stakes 00:01:17.650 --> 00:01:20.430 game of poker you can play in medicine. It absolutely 00:01:20.430 --> 00:01:22.590 is. I mean, the stakes are just incredibly high 00:01:22.590 --> 00:01:25.049 because you're dealing with a population that 00:01:25.150 --> 00:01:27.769 often can't advocate for itself. You're looking 00:01:27.769 --> 00:01:30.590 at a patient demographic that ranges from what, 00:01:30.730 --> 00:01:33.629 a 24 week preemie and an incubator who literally 00:01:33.629 --> 00:01:36.209 lacks the anatomy to speak, all the way up to 00:01:36.209 --> 00:01:39.069 a 17 year old linebacker who is just refusing 00:01:39.069 --> 00:01:41.650 to speak because he thinks admitting pain makes 00:01:41.650 --> 00:01:44.890 him look weak. And if you, as the clinician, 00:01:45.409 --> 00:01:48.049 if you get this wrong, if you miss the signs, 00:01:48.590 --> 00:01:50.930 The consequences aren't just oh the kid has a 00:01:50.930 --> 00:01:53.769 bad afternoon. We're talking about real physiological 00:01:53.769 --> 00:01:57.450 damage long -term neural sensitization and frankly 00:01:57.450 --> 00:02:00.049 Massive ethical failures right and looking at 00:02:00.049 --> 00:02:02.549 the sheer volume of material here. I mean it 00:02:02.549 --> 00:02:05.290 is dense You've got developmental theories a 00:02:05.290 --> 00:02:08.430 dozen different pain scales pharmacology profiles 00:02:08.430 --> 00:02:11.919 legal frameworks. It's It's overwhelming. And 00:02:11.919 --> 00:02:14.840 too much to memorize. Exactly. So for this deep 00:02:14.840 --> 00:02:17.520 dive, we are going to apply the Pareto Principle. 00:02:17.539 --> 00:02:20.479 The 80 -20 rule. I love this approach for complex 00:02:20.479 --> 00:02:22.400 clinical topics. It just cuts through the noise. 00:02:22.539 --> 00:02:25.159 It really does. The whole premise is that 80 00:02:25.159 --> 00:02:27.979 % of your results, or in this case, 80 % of the 00:02:27.979 --> 00:02:30.960 safety questions on the NCLEX and 80 % of the 00:02:30.960 --> 00:02:32.979 lifesaving decisions you make at the bedside, 00:02:33.120 --> 00:02:35.039 they come from just 20 % of the information. 00:02:35.900 --> 00:02:37.900 So our mission today is to filter the stack. 00:02:38.039 --> 00:02:40.800 We want to clearly distinguish the need to know, 00:02:41.180 --> 00:02:42.919 the stuff that keeps you out of court and keeps 00:02:42.919 --> 00:02:45.139 your patients safe from the nice to know, which 00:02:45.139 --> 00:02:47.139 is, you know, the deeper context that helps you 00:02:47.139 --> 00:02:49.400 understand the why, but it isn't necessarily 00:02:49.400 --> 00:02:51.620 the make or break data point for a tiered exam. 00:02:51.680 --> 00:02:54.460 Which is so crucial because exam writers love 00:02:54.460 --> 00:02:57.159 pediatric pain. Oh, they do. It's a favorite 00:02:57.159 --> 00:02:59.960 target. It really is. It forces you to synthesize. 00:03:00.060 --> 00:03:01.599 You can't just memorize a drug dose. You have 00:03:01.599 --> 00:03:04.120 to look at a whole scenario, interpret a behavior, 00:03:04.300 --> 00:03:07.240 navigate a complex family dynamic, and spot the 00:03:07.240 --> 00:03:09.340 trap. And believe me, there are so many traps 00:03:09.340 --> 00:03:11.500 in this topic. OK, so let's map this out. We're 00:03:11.500 --> 00:03:13.479 going to structure this logically, essentially 00:03:13.479 --> 00:03:15.580 following the nursing process. We'll start with 00:03:15.580 --> 00:03:17.639 section one, the mindset shift. This is where 00:03:17.639 --> 00:03:20.419 we have to dismantle the myths that cause students 00:03:20.419 --> 00:03:23.500 to fail. Then section two is the framework. That's 00:03:23.500 --> 00:03:25.919 the quest new to mnemonic. Section three is the 00:03:25.919 --> 00:03:29.060 tools, specifically the rules on which scale 00:03:29.060 --> 00:03:31.460 applies to which age. The rules are everything 00:03:31.460 --> 00:03:33.639 there. Section four is the detective work reading 00:03:33.639 --> 00:03:36.280 the body when the mouth is silent. Section five 00:03:36.280 --> 00:03:39.310 is pharma. safety protocols for drugs. And finally, 00:03:39.370 --> 00:03:42.050 section six, the art of nursing, all the non 00:03:42.050 --> 00:03:44.550 -pharmacologic interventions. It's a really solid 00:03:44.550 --> 00:03:46.789 roadmap. And I think starting with the mindset 00:03:46.789 --> 00:03:50.689 shift is it's non -negotiable. Because historically, 00:03:50.849 --> 00:03:52.449 the medical community has gotten this wrong for 00:03:52.449 --> 00:03:55.189 a long, long time. If you walk into a pediatric 00:03:55.189 --> 00:03:57.789 room with the wrong assumptions, you will undertreat 00:03:57.789 --> 00:04:00.750 pain every single time. OK, let's unpack that. 00:04:00.789 --> 00:04:04.539 Section one, the mindset shift. The source material 00:04:04.539 --> 00:04:07.919 highlights several myths or misconceptions. And 00:04:07.919 --> 00:04:10.759 looking at the need -to -know bucket or 80 -20 00:04:10.759 --> 00:04:13.879 core, there is one trap that just seems to catch 00:04:13.879 --> 00:04:17.000 everyone, the sleeping track. This is the number 00:04:17.000 --> 00:04:19.439 one red flag on exams and in clinical practice. 00:04:20.160 --> 00:04:22.180 Let's paint a picture here. Let's say you have 00:04:22.180 --> 00:04:25.100 a patient. Let's call him Lucas. Lucas is four 00:04:25.100 --> 00:04:27.220 years old. He had an appendectomy this morning. 00:04:27.279 --> 00:04:29.779 You walk in at 2 p .m. to do your rounds. Lucas 00:04:29.779 --> 00:04:32.199 is curled up in bed, eyes closed, fast asleep. 00:04:32.620 --> 00:04:34.339 Or maybe he's awake and he's playing Mario Kart 00:04:34.339 --> 00:04:37.240 on an iPad. The instinct, the trap, is to chart 00:04:37.240 --> 00:04:41.040 010 -0 pain and walk away. Which feels intuitive, 00:04:41.180 --> 00:04:43.620 right? I mean, if I'm in agony, I am not sleeping 00:04:43.620 --> 00:04:45.779 and I'm certainly not playing video games. I'm 00:04:45.779 --> 00:04:48.600 writhing. That is adult logic. You're applying 00:04:48.600 --> 00:04:51.459 adult logic to a pediatric brain. And that is 00:04:51.459 --> 00:04:53.839 where you fail. The source material is just... 00:04:53.680 --> 00:04:56.779 It's explicit on this. A child who is sleeping 00:04:56.779 --> 00:04:59.860 or playing is not necessarily pain -free. In 00:04:59.860 --> 00:05:02.040 fact, they could be in severe pain. So what's 00:05:02.040 --> 00:05:04.100 actually happening there physiologically? Why 00:05:04.100 --> 00:05:06.540 would a child in pain be asleep? It's a coping 00:05:06.540 --> 00:05:11.189 mechanism. And sometimes it's just pure unadulterated 00:05:11.189 --> 00:05:13.910 exhaustion. I mean, think about Lucas. He's been 00:05:13.910 --> 00:05:15.610 in a strange environment. He's been poked with 00:05:15.610 --> 00:05:18.629 needles. He's had major surgery. His body's flooded 00:05:18.629 --> 00:05:20.870 with cortisol. He might have spent the last three 00:05:20.870 --> 00:05:23.750 hours fighting the pain, crying, tensing up all 00:05:23.750 --> 00:05:27.209 his muscles. Eventually, the battery just runs 00:05:27.209 --> 00:05:30.370 out. He crashes. He isn't sleeping because he's 00:05:30.370 --> 00:05:32.050 comfortable. He's sleeping because he has nothing 00:05:32.050 --> 00:05:35.129 left in the tank. If you wake him up... or if 00:05:35.129 --> 00:05:37.410 you just check his vitals, you might find his 00:05:37.410 --> 00:05:39.149 heart rate is still racing, his breathing is 00:05:39.149 --> 00:05:41.670 still shallow. So sleep can be a form of shutting 00:05:41.670 --> 00:05:44.689 down. It's not a sign of peace. Exactly. And 00:05:44.689 --> 00:05:46.730 regarding the video games, distraction is an 00:05:46.730 --> 00:05:49.189 incredibly powerful analgesic, but it's also 00:05:49.189 --> 00:05:52.250 a wall. A child might focus so intensely on that 00:05:52.250 --> 00:05:54.490 screen because the second they look away, the 00:05:54.490 --> 00:05:56.889 pain rushes back in. It's a dissociation technique. 00:05:57.149 --> 00:05:59.410 Got it. So for the exam writers, this is key. 00:05:59.790 --> 00:06:02.310 If you see a question asking, the child is sleeping 00:06:02.310 --> 00:06:05.600 post -op, do you wake them to assess? Or, do 00:06:05.600 --> 00:06:07.899 you administer the scheduled pain med? The answer 00:06:07.899 --> 00:06:11.500 is always yes. You assess. You never ever assume 00:06:11.500 --> 00:06:14.339 sleep equals comfort. That is a critical distinction. 00:06:14.839 --> 00:06:18.720 It's not just let sleeping dogs lie. It's check 00:06:18.720 --> 00:06:21.399 if the dog is actually unconscious from exhaustion. 00:06:21.540 --> 00:06:23.639 That's a perfect way to put it. Okay, the next 00:06:23.639 --> 00:06:26.439 big one in the need to know category is the newborn 00:06:26.439 --> 00:06:30.970 myth. And this one is hay. Well, it's horrifying 00:06:30.970 --> 00:06:32.930 when you look at the history of it. It is. I 00:06:32.930 --> 00:06:35.170 mean, we don't have to go back that far maybe 00:06:35.170 --> 00:06:38.569 to the 80s to find a time when major surgeries 00:06:38.569 --> 00:06:41.769 were performed on infants with minimal or sometimes 00:06:41.769 --> 00:06:44.750 no anesthesia. That's unbelievable. The belief 00:06:44.750 --> 00:06:47.389 was that their nervous systems weren't myelinated 00:06:47.389 --> 00:06:50.649 enough to transmit pain signals, like the wires 00:06:50.649 --> 00:06:52.550 just weren't hooked up yet. Which we now know 00:06:52.550 --> 00:06:55.610 is completely false. 100 % factually incorrect. 00:06:56.050 --> 00:06:58.610 The 80 -20 takeaway here is really simple. Newborns 00:06:58.610 --> 00:07:01.310 do feel pain. Their neurologic system is absolutely 00:07:01.310 --> 00:07:03.610 intact enough to perceive it. In fact, in some 00:07:03.610 --> 00:07:06.410 ways, they feel it more intensely because they 00:07:06.410 --> 00:07:08.689 lack the descending inhibitory pathways that 00:07:08.689 --> 00:07:10.670 adults have to kind of dampen the signal. So 00:07:10.670 --> 00:07:12.290 they just get the raw feed? They get the raw 00:07:12.290 --> 00:07:14.709 feed, no filter. And this connects directly to 00:07:14.709 --> 00:07:18.149 the next one, the memory myth. The old idea was, 00:07:18.189 --> 00:07:20.110 well, even if it hurts them, they won't remember 00:07:20.110 --> 00:07:22.069 it, so it doesn't matter. They're babies. They 00:07:22.069 --> 00:07:24.319 don't have narrative memory. And that part is 00:07:24.319 --> 00:07:26.800 true. Lucas won't remember the specific nurse 00:07:26.800 --> 00:07:28.660 who poked his heel when he was two days old. 00:07:29.220 --> 00:07:31.240 But his spinal cord remembers. This is the whole 00:07:31.240 --> 00:07:34.279 concept of sensitization, or what we call windup. 00:07:34.399 --> 00:07:35.959 I was reading about this in the source material. 00:07:36.100 --> 00:07:39.399 It describes actual changes in the cellular structure, 00:07:39.540 --> 00:07:42.620 like physical changes. Yes. Think of the spinal 00:07:42.620 --> 00:07:45.879 cord like a volume knob. If you expose a newborn 00:07:45.879 --> 00:07:49.519 to repeated painful stimuli -like heel sticks, 00:07:50.019 --> 00:07:52.769 suctioning, intubation without adequate pain 00:07:52.769 --> 00:07:55.709 management. The cells in the dorsal horn of the 00:07:55.709 --> 00:07:58.750 spinal cord become hyper excitable. You are effectively 00:07:58.750 --> 00:08:01.610 turning the volume knob all the way up and then 00:08:01.610 --> 00:08:03.769 breaking it off. So fast forward five years. 00:08:03.829 --> 00:08:06.490 What does that look like? Exactly. Five years 00:08:06.490 --> 00:08:09.649 later, Lucas goes for a routine flu shot. A normal 00:08:09.649 --> 00:08:12.649 kid might say ouch and be fine 30 seconds later. 00:08:13.250 --> 00:08:15.970 But Lucas, whose system is sensitized, might 00:08:15.970 --> 00:08:20.079 experience a level 10 trauma. His body overreacts 00:08:20.079 --> 00:08:23.040 because that neural pathway was blazed wide open 00:08:23.040 --> 00:08:26.740 when he was a neonate. Wow. So treating pain 00:08:26.740 --> 00:08:28.980 in a newborn isn't just about kindness in the 00:08:28.980 --> 00:08:31.279 moment, it's about protecting the entire architecture 00:08:31.279 --> 00:08:33.179 of their developing nervous system. That adds 00:08:33.179 --> 00:08:35.460 so much weight to the decision to use analgesia. 00:08:35.519 --> 00:08:38.440 It's not just comfort, it's neurology. It's preventative 00:08:38.440 --> 00:08:40.240 neurology. Okay, let's move up the age bracket, 00:08:40.399 --> 00:08:42.500 the truthfulness trap. This seems to apply more 00:08:42.500 --> 00:08:45.259 to the toddlers and preschoolers. It does. The 00:08:45.259 --> 00:08:47.919 assumption here is... If it hurts, they will 00:08:47.919 --> 00:08:50.039 tell me. Which, again, seems logical. If I step 00:08:50.039 --> 00:08:52.200 on a Lego, I'm letting everyone in a five -mile 00:08:52.200 --> 00:08:54.379 radius know about it. But you're an adult with 00:08:54.379 --> 00:08:57.080 reasoning skills. Yeah. A child has completely 00:08:57.080 --> 00:08:59.600 different motivations. Let's go back to Lucas, 00:08:59.659 --> 00:09:02.740 our four -year -old. You walk in with a stethoscope 00:09:02.740 --> 00:09:04.860 and you've got a syringe in your pocket. You 00:09:04.860 --> 00:09:07.340 ask him, Lucas, does your tummy hurt? He looks 00:09:07.340 --> 00:09:09.840 at the syringe. He knows that if he says yes, 00:09:10.100 --> 00:09:11.919 you might come closer with that sharp thing. 00:09:12.299 --> 00:09:15.139 So he says no. He's trading long -term relief 00:09:15.139 --> 00:09:18.779 for short -term safety. Exactly. To him, the 00:09:18.779 --> 00:09:21.480 shot is terrifying. It's an immediate known threat. 00:09:21.919 --> 00:09:24.320 The pain in his belly is a constant dull threat. 00:09:24.679 --> 00:09:27.179 He chooses the devil he knows. And it's not just 00:09:27.179 --> 00:09:29.279 toddlers. What about a teenager? Oh, absolutely. 00:09:29.600 --> 00:09:31.480 A teen might deny pain because they want to feel 00:09:31.480 --> 00:09:33.600 in control or maybe they're an athlete and they've 00:09:33.600 --> 00:09:35.840 been taught their whole life to walk it off or 00:09:35.840 --> 00:09:38.320 play through the pain. Admitting pain feels like 00:09:38.320 --> 00:09:40.919 a failure of character to them. So the idea that 00:09:40.919 --> 00:09:42.940 self -report is the gold standard, it really 00:09:42.940 --> 00:09:45.700 comes with a big asterisk. A massive asterisk. 00:09:45.980 --> 00:09:48.620 It is the gold standard only if the child is 00:09:48.620 --> 00:09:51.399 capable and willing to be honest. If the child 00:09:51.399 --> 00:09:53.980 says, no pain, but they are grimacing, their 00:09:53.980 --> 00:09:57.639 body is rigid, and their heart rate is 140. You 00:09:57.639 --> 00:10:00.039 trust the body, not the mouth. That's the detective 00:10:00.039 --> 00:10:02.580 work we'll get to later. Before we leave the 00:10:02.580 --> 00:10:03.940 myths, we have to touch on the elephant in the 00:10:03.940 --> 00:10:06.580 room. Opioids. This comes up constantly with 00:10:06.580 --> 00:10:08.259 parents. Don't give him morphine. I don't want 00:10:08.259 --> 00:10:11.139 him to get addicted. This is a huge, huge barrier 00:10:11.139 --> 00:10:15.440 to effective care. The need to know here is crystal 00:10:15.440 --> 00:10:18.360 clear. Children are not more prone to addiction 00:10:18.360 --> 00:10:20.879 than adults when they're being treated for acute 00:10:20.879 --> 00:10:23.659 pain. And physically, they do not experience 00:10:23.659 --> 00:10:26.259 more adverse effects than adults. So the fear 00:10:26.259 --> 00:10:28.960 is largely unfounded, at least in the acute setting. 00:10:29.039 --> 00:10:31.179 In the context of treating a broken femur or 00:10:31.179 --> 00:10:34.019 post -surgical pain, yes, of course we are careful, 00:10:34.059 --> 00:10:37.399 we monitor closely. But we do not withhold necessary 00:10:37.399 --> 00:10:40.139 analgesia due to an irrational fear of creating 00:10:40.139 --> 00:10:42.779 an addict in three days. In fact, the source 00:10:42.779 --> 00:10:45.639 material emphasizes that untreated pain can actually 00:10:45.639 --> 00:10:47.980 be a driver for chronic pain issues later on, 00:10:48.240 --> 00:10:50.940 which is a far, far bigger risk factor for substance 00:10:50.940 --> 00:10:53.399 use disorders down the road. Okay, so that really 00:10:53.399 --> 00:10:56.240 covers the mindset shift. We know sleep is a 00:10:56.240 --> 00:10:58.700 trap, newborns are wired for pain, memories are 00:10:58.700 --> 00:11:01.179 physiological, kids might lie to avoid shots, 00:11:01.679 --> 00:11:03.600 and opioids are safe when they're managed properly. 00:11:04.360 --> 00:11:06.720 Let's look briefly at the nice -to -know context 00:11:06.720 --> 00:11:09.580 here. The sources mention things like culture 00:11:09.580 --> 00:11:12.289 and temperament. Right, and this is the... 80 00:11:12.289 --> 00:11:14.429 % the supporting info. It's good to have in your 00:11:14.429 --> 00:11:16.870 back pocket. Just be aware that pain is filtered 00:11:16.870 --> 00:11:19.649 through culture. In some families, a boy crying 00:11:19.649 --> 00:11:22.710 is seen as shameful, so it'll be stoic. In others, 00:11:23.070 --> 00:11:25.549 expressive vocalization is encouraged and expected. 00:11:25.870 --> 00:11:29.809 You have to read the room. And temperament, an 00:11:29.809 --> 00:11:32.250 easy temperament child might just whimper quietly 00:11:32.250 --> 00:11:34.950 when they're in agony, while a difficult or intense 00:11:34.950 --> 00:11:37.909 child might scream bloody murder over a hangnail. 00:11:38.029 --> 00:11:39.809 You have to calibrate your assessment to the 00:11:39.809 --> 00:11:42.250 baseline personality of that specific. context 00:11:42.250 --> 00:11:44.690 is everything okay let's move to section 2 the 00:11:44.690 --> 00:11:47.970 framework we have a mnemonic here quest and that's 00:11:47.970 --> 00:11:51.570 quest with two T's Q U E S T T this is your safety 00:11:51.570 --> 00:11:53.669 net if you freeze up in an exam or in a real 00:11:53.669 --> 00:11:55.710 clinical situation just walk through these letters 00:11:55.710 --> 00:11:58.289 it'll guide you let's break it down Q question 00:11:58.289 --> 00:12:00.629 the child this is always the first step but as 00:12:00.629 --> 00:12:03.110 we just discussed how you question them matter 00:12:03.110 --> 00:12:06.809 so much don't just ask do you have pain ask where 00:12:06.809 --> 00:12:09.309 is the hurt or can you tell me how your tummy 00:12:09.309 --> 00:12:12.600 feels You have to use their language, owie, boo 00:12:12.600 --> 00:12:15.840 -boo, whatever works. Use a reliable pain scale. 00:12:16.340 --> 00:12:19.220 And the emphasis there is on the word reliable. 00:12:20.019 --> 00:12:22.759 This is a huge exam point. You absolutely cannot 00:12:22.759 --> 00:12:25.659 use a scale designed for an adult on a toddler. 00:12:26.100 --> 00:12:28.220 You can't use a self -report scale on a baby. 00:12:28.639 --> 00:12:30.559 We're going to deep dive into the specific age 00:12:30.559 --> 00:12:32.700 rules in just a minute, but you as your reminder 00:12:32.700 --> 00:12:35.379 to pick the right tool for the job. Evaluate 00:12:35.379 --> 00:12:38.309 behavior and physiologic changes. This is your 00:12:38.309 --> 00:12:40.549 backup. This is what you do when the cue fails. 00:12:40.850 --> 00:12:42.909 If they can't talk or they won't talk, you look. 00:12:43.049 --> 00:12:44.509 You look at their face, their legs, their vitals. 00:12:44.769 --> 00:12:47.110 This is absolutely crucial for the nonverbal 00:12:47.110 --> 00:12:50.129 population. Secure parents' involvement. I feel 00:12:50.129 --> 00:12:51.909 like this can be a double -edged sword for some 00:12:51.909 --> 00:12:54.070 nurses. Sometimes the parent feels like an obstacle, 00:12:54.250 --> 00:12:57.169 not a help. And that is such a dangerous attitude 00:12:57.169 --> 00:13:01.029 to have. The need to know here is that the parent 00:13:01.029 --> 00:13:04.039 is the expert on that child. You've known Lucas 00:13:04.039 --> 00:13:06.740 for four hours. His mom has known him for four 00:13:06.740 --> 00:13:09.340 years. Good point. If she says he isn't acting 00:13:09.340 --> 00:13:12.480 right, or he looks like he's in pain, you believe 00:13:12.480 --> 00:13:15.759 her. You believe her. Even the monitor says his 00:13:15.759 --> 00:13:18.200 heart rate is within normal limits for his age. 00:13:18.600 --> 00:13:20.960 She knows his subtle cues, the way he holds his 00:13:20.960 --> 00:13:24.259 lip, the way he goes quiet before he cries. Securing 00:13:24.259 --> 00:13:26.500 their involvement means using them as a primary 00:13:26.500 --> 00:13:28.860 data source. That's a great clinical pearl. Never 00:13:28.860 --> 00:13:32.879 bet against the mom. Okay, TNT. First T. Take 00:13:32.879 --> 00:13:35.240 cause of pain into account. This is pathology. 00:13:35.720 --> 00:13:37.919 If a child has sickle cell disease, that's ischemic 00:13:37.919 --> 00:13:40.559 pain. It is excruciating. Even if they're sitting 00:13:40.559 --> 00:13:43.139 quietly watching TV, you know the underlying 00:13:43.139 --> 00:13:46.220 pathology warrants aggressive pain control. Don't 00:13:46.220 --> 00:13:48.480 let a coping behavior override your knowledge 00:13:48.480 --> 00:13:50.679 of the disease process. Got it. And the last 00:13:50.679 --> 00:13:53.500 T. Take action. Assessment is completely useless 00:13:53.500 --> 00:13:55.899 without intervention. If you find pain, you must 00:13:55.899 --> 00:13:58.039 do something. Give medication, reposition them, 00:13:58.139 --> 00:14:00.740 use distraction, and then critically reevaluate. 00:14:01.019 --> 00:14:04.529 It's an action loop. Assess, act, reassess. Okay, 00:14:04.570 --> 00:14:07.889 let's get into the weeds. Section three, assessment 00:14:07.889 --> 00:14:11.169 tools. I feel like if there was a red alert section 00:14:11.169 --> 00:14:14.009 for testing, this has to be it. Exam writers 00:14:14.009 --> 00:14:16.429 just love to give you a scenario, a four -year 00:14:16.429 --> 00:14:19.200 -old boy. and then ask you which scale to use. 00:14:19.720 --> 00:14:21.379 Absolutely. This is probably the highest yield 00:14:21.379 --> 00:14:23.639 section of our entire discussion. If you use 00:14:23.639 --> 00:14:27.059 the wrong scale, your data is garbage. It's meaningless. 00:14:27.519 --> 00:14:30.460 And on the NCLEX, using the wrong scale is a 00:14:30.460 --> 00:14:33.120 safety violation. You fail the question. So let's 00:14:33.120 --> 00:14:35.559 lay down the age rules. Let's start with the 00:14:35.559 --> 00:14:38.039 most famous one, the Wong Baker Faces Scale. 00:14:38.100 --> 00:14:40.659 We've all seen it. The little cartoon faces ranging 00:14:40.659 --> 00:14:43.559 from a happy smiley face to a full -on crying 00:14:43.559 --> 00:14:46.100 frowning face. Right. The target age for the 00:14:46.100 --> 00:14:48.200 Faces Scale, the number to burn into your brain, 00:14:48.500 --> 00:14:50.899 is three years and older. Three seems young. 00:14:50.980 --> 00:14:52.600 I mean, can a three -year -old really understand 00:14:52.600 --> 00:14:55.100 that concept? They can, but, and this is a huge 00:14:55.100 --> 00:14:57.019 need to know, you have to explain it correctly. 00:14:57.100 --> 00:14:58.600 You can't just point to the chart and say, pick 00:14:58.600 --> 00:15:00.740 a face. What do you say? You have to anchor the 00:15:00.740 --> 00:15:04.019 scale in pain, not emotion. You have to explain 00:15:04.019 --> 00:15:07.019 this face pointing to the zero has no hurt at 00:15:07.019 --> 00:15:10.220 all This face pointing to the two hurts a little 00:15:10.220 --> 00:15:13.580 bit this face pointing to the ten hurts the most 00:15:13.580 --> 00:15:16.759 Oh, so you use the word hurt? Yes, the word is 00:15:16.759 --> 00:15:20.679 hurt or oh we not sad or happy Why is that distinction 00:15:20.679 --> 00:15:23.879 so important? Because a three -year -old might 00:15:23.879 --> 00:15:26.019 pick the crying face because they're sad that 00:15:26.019 --> 00:15:29.019 mommy went to the cafeteria or because they dropped 00:15:29.019 --> 00:15:31.399 their teddy bear on the floor, you have to clarify 00:15:31.399 --> 00:15:34.120 that the faces represent hurt, not just sad. 00:15:34.720 --> 00:15:37.860 If you skip that instruction, the tool is completely 00:15:37.860 --> 00:15:40.480 invalid. Okay, so faces is three and up with 00:15:40.480 --> 00:15:42.580 the right instructions. Now, what about the numeric 00:15:42.580 --> 00:15:44.860 scale, the standard zero to ten that we use for 00:15:44.860 --> 00:15:47.080 adults? The target age jumps up here. This is 00:15:47.080 --> 00:15:49.220 generally for five years and older. Why the two 00:15:49.220 --> 00:15:51.720 -year gap? Why can't Lucas, our four -year -old, 00:15:51.899 --> 00:15:53.399 use the numbers? He can probably count to ten. 00:15:53.720 --> 00:15:56.509 He can count, sure. but he doesn't understand 00:15:56.509 --> 00:16:00.529 value or quantity in an abstract way. To a four 00:16:00.529 --> 00:16:03.090 -year -old, numbers are just labels, like ABC. 00:16:03.990 --> 00:16:05.929 He doesn't inherently understand that 8 is twice 00:16:05.929 --> 00:16:09.029 as much as 4, or that 10 is a definitive limit. 00:16:09.559 --> 00:16:11.580 A five -year -old, on the other hand, typically 00:16:11.580 --> 00:16:14.019 has developed that cognitive numeracy. What would 00:16:14.019 --> 00:16:15.840 a four -year -old do if you asked them? They'll 00:16:15.840 --> 00:16:17.639 just guess a number they like. I'm a seven because 00:16:17.639 --> 00:16:19.799 I'm seven years old. Right. Or they'll just say 00:16:19.799 --> 00:16:22.120 ten every time. It's completely unreliable. That 00:16:22.120 --> 00:16:24.120 is a classic exam trap. Don't give the number 00:16:24.120 --> 00:16:26.600 line to the preschooler. Don't do it. Okay, so 00:16:26.600 --> 00:16:29.779 what if the kid is too young for faces? or they're 00:16:29.779 --> 00:16:32.799 non -verbal, or maybe they have a severe cognitive 00:16:32.799 --> 00:16:35.799 delay like cerebral palsy, and they can't communicate 00:16:35.799 --> 00:16:37.620 at a three -year -old level. When you abandon 00:16:37.620 --> 00:16:39.759 self -report entirely, you can't use it. You 00:16:39.759 --> 00:16:41.539 have to switch to an observational tool. And 00:16:41.539 --> 00:16:45.250 the gold standard here is the FLACC scale. or 00:16:45.250 --> 00:16:48.730 the revised version, our FLACC. FLACC. Break 00:16:48.730 --> 00:16:50.730 that down for us. It's another mnemonic. It stands 00:16:50.730 --> 00:16:54.529 for Face, Legs, Activity, Cry, Consolability. 00:16:55.169 --> 00:16:57.190 You observe the child for about one to five minutes 00:16:57.190 --> 00:17:00.029 and you score each of those five categories from 00:17:00.029 --> 00:17:02.340 a zero to a two. So you're looking at their physical 00:17:02.340 --> 00:17:05.140 presentation, their body language. Exactly. Face. 00:17:05.519 --> 00:17:07.700 Are they dremising or clenching their jaw? That's 00:17:07.700 --> 00:17:11.220 a two. A slight frown is a one. Legs. Are they 00:17:11.220 --> 00:17:13.400 relaxed or are they kicking and drawn up tightly 00:17:13.400 --> 00:17:16.180 to their chest? Activity. Are they lying quietly 00:17:16.180 --> 00:17:18.359 or are they arching their back or jerking around? 00:17:19.019 --> 00:17:21.539 Cry. Is it just a little whimper or a full -blown 00:17:21.539 --> 00:17:24.180 scream? And consolability. This is a big one. 00:17:24.440 --> 00:17:26.539 Can you distract them? If you pick them up or 00:17:26.539 --> 00:17:29.240 rock them, do they stop crying? Or are they just 00:17:29.240 --> 00:17:31.279 completely inconsolable? You tally all that up 00:17:31.279 --> 00:17:33.559 to get a score out of 10. And this is the go 00:17:33.559 --> 00:17:36.720 -to for infants and toddlers. Infants, toddlers, 00:17:36.740 --> 00:17:38.740 and this is important, non -verbal children of 00:17:38.740 --> 00:17:41.700 any age. If you have a 12 -year -old with a severe 00:17:41.700 --> 00:17:44.400 developmental delay who cannot speak, you use 00:17:44.400 --> 00:17:47.559 the FLACC. You don't try to force the FACES scale 00:17:47.559 --> 00:17:49.579 on a child who doesn't understand the concept 00:17:49.579 --> 00:17:51.819 of matching their feeling to a drawing. There's 00:17:51.819 --> 00:17:54.140 one more mentioned in the 80 -20 list, the Outcher 00:17:54.140 --> 00:17:57.099 Scale, which sounds kind of aggressive, but I 00:17:57.099 --> 00:17:59.630 guess it's accurate. The outter is similar to 00:17:59.630 --> 00:18:02.509 faces, but instead of cartoon drawings, it uses 00:18:02.509 --> 00:18:05.069 actual photographs of children expressing different 00:18:05.069 --> 00:18:07.589 levels of pain. It's also for three years and 00:18:07.589 --> 00:18:10.430 older. The need to know nuance here is cultural. 00:18:10.890 --> 00:18:12.549 The outter comes in different versions. There's 00:18:12.549 --> 00:18:14.690 a Caucasian version, an African -American version, 00:18:15.130 --> 00:18:17.569 a Hispanic version, so the child can identify 00:18:17.569 --> 00:18:20.089 with the face they're seeing. It helps with reliability. 00:18:20.269 --> 00:18:22.630 That makes perfect sense. Representation matters 00:18:22.630 --> 00:18:25.059 even in pain assessment. What about the nice 00:18:25.059 --> 00:18:27.660 -to -know stuff here? The source mentioned some 00:18:27.660 --> 00:18:30.900 specific NICU scales. Yeah, unless you're planning 00:18:30.900 --> 00:18:33.220 to go into the NICU, you probably don't need 00:18:33.220 --> 00:18:35.380 to memorize the scoring grids for these, but 00:18:35.380 --> 00:18:38.859 you should recognize the acronyms. NPS, that's 00:18:38.859 --> 00:18:42.680 the neonatal infant pain scale, CRYSS, which 00:18:42.680 --> 00:18:46.140 is specifically for post -op neonates, and PIPP, 00:18:46.220 --> 00:18:48.319 the premature infant pain profile. If you see 00:18:48.319 --> 00:18:50.859 these on an exam, just associate them with newborn. 00:18:51.119 --> 00:18:52.779 That's usually enough. Them for the older kids. 00:18:52.980 --> 00:18:56.829 Any other tools? There is the APPT, the adolescent 00:18:56.829 --> 00:19:00.910 pediatric pain tool. This is for ages about 8 00:19:00.910 --> 00:19:04.150 to 15. It's much more sophisticated. It has a 00:19:04.150 --> 00:19:06.329 body outline where they can actually color in 00:19:06.329 --> 00:19:08.690 where the pain is. It asks about the quality 00:19:08.690 --> 00:19:10.730 of the pain. Is it burning? Is it stabbing? Is 00:19:10.730 --> 00:19:13.450 it throbbing? It treats the child more like a 00:19:13.450 --> 00:19:16.190 mini adult, capable of a more detailed assessment. 00:19:16.430 --> 00:19:18.789 OK, that's a great overview of the tools. So 00:19:18.789 --> 00:19:21.019 moving on to section four. Developmental clues. 00:19:21.359 --> 00:19:23.259 We've picked our tool, but now we have to actually 00:19:23.259 --> 00:19:24.920 do the assessment. We need to play detective. 00:19:25.259 --> 00:19:27.019 Let's walk through the age groups because the 00:19:27.019 --> 00:19:29.500 presentation of pain just changes so drastically 00:19:29.500 --> 00:19:31.579 as the brain develops. Let's start with the infants. 00:19:31.859 --> 00:19:34.700 The babies. With them, you are entirely dependent 00:19:34.700 --> 00:19:37.180 on spotting the physiologic changes. Think fight 00:19:37.180 --> 00:19:39.119 or flight. So the sympathetic nervous system 00:19:39.119 --> 00:19:41.400 just kicks right in. It goes into overdrive, 00:19:41.680 --> 00:19:44.400 heart rate goes up, respiratory rate goes up. 00:19:44.700 --> 00:19:47.099 But here is a critical exam detail that people 00:19:47.099 --> 00:19:50.750 often miss. Oxygen saturation goes down. Why 00:19:50.750 --> 00:19:53.690 does the O2 sat drop if they're breathing faster? 00:19:53.970 --> 00:19:55.809 It's a great question. There are a few reasons. 00:19:56.150 --> 00:19:57.630 They might be holding their breath while they're 00:19:57.630 --> 00:20:00.809 crying, which is called Valsalva. Or their breathing 00:20:00.809 --> 00:20:02.910 becomes really shallow and rapid to chipnia, 00:20:03.369 --> 00:20:05.529 which isn't efficient for gas exchange at all. 00:20:05.849 --> 00:20:08.289 So if you see a baby desaturating on the monitor, 00:20:08.750 --> 00:20:10.430 pain should be high on your list of possible 00:20:10.430 --> 00:20:12.670 causes. What else are we looking for? Palmar 00:20:12.670 --> 00:20:15.450 or plantar? Sweating. just touch their little 00:20:15.450 --> 00:20:17.589 hands and the soles of their feet. If they're 00:20:17.589 --> 00:20:19.890 clammy, that's a stress response. Changes in 00:20:19.890 --> 00:20:23.410 vagal tone. And behaviorally. The biggest thing 00:20:23.410 --> 00:20:25.930 is to look for guarding. Guarding? What does 00:20:25.930 --> 00:20:27.950 that look like in an infant? It's a refusal to 00:20:27.950 --> 00:20:30.309 move a body part. If an infant has a sore arm 00:20:30.309 --> 00:20:32.529 from an IV, they will hold it perfectly still, 00:20:32.809 --> 00:20:35.109 flexed against their body. If you try to extend 00:20:35.109 --> 00:20:37.710 it, they will scream. That rigidity is their 00:20:37.710 --> 00:20:40.250 way of splinting the injury themselves. And the 00:20:40.250 --> 00:20:43.140 cry? Oh, the cry. Listen to the cry. A pain cry 00:20:43.140 --> 00:20:45.299 is distinct. It's high pitched. It's shrill. 00:20:45.420 --> 00:20:47.779 It's harsh. It sounds completely different than 00:20:47.779 --> 00:20:51.180 a hungry cry or a wet diaper cry. Experienced 00:20:51.180 --> 00:20:53.980 NICU and PEDS nurses can hear the difference 00:20:53.980 --> 00:20:56.500 from down the hall. OK, let's grow up a little 00:20:56.500 --> 00:21:00.140 bit. The toddlers and preschoolers. The Lucas 00:21:00.140 --> 00:21:02.420 age group. We already talked about how they might 00:21:02.420 --> 00:21:04.539 lie to you, but what else is going on in their 00:21:04.539 --> 00:21:06.640 little heads? This is where magical thinking 00:21:06.640 --> 00:21:10.259 comes into play. Cognitively, toddlers often 00:21:10.259 --> 00:21:13.839 view pain as punishment. Punishment for what? 00:21:14.140 --> 00:21:17.019 For being bad. I hit my brother earlier, so now 00:21:17.019 --> 00:21:20.240 my tummy hurts. Or I didn't clean my room, so 00:21:20.240 --> 00:21:22.700 now the nurse is sticking me with a needle. they 00:21:22.700 --> 00:21:25.099 really struggle to separate the physical cause 00:21:25.099 --> 00:21:28.240 from their own behavior. That is absolutely heartbreaking. 00:21:28.539 --> 00:21:31.299 It adds this whole layer of guilt and fear on 00:21:31.299 --> 00:21:33.160 top of the physical pain. It does. And that's 00:21:33.160 --> 00:21:35.440 why they might kick, bite, or try to run away. 00:21:35.839 --> 00:21:37.660 In their mind, they're fighting off the punishment. 00:21:38.099 --> 00:21:40.579 They also have very poor body boundaries. If 00:21:40.579 --> 00:21:43.019 you put a band -aid on them, they might honestly 00:21:43.019 --> 00:21:45.000 believe that band -aid is the only thing keeping 00:21:45.000 --> 00:21:47.359 all their insides from falling out. So when you're 00:21:47.359 --> 00:21:49.460 assessing them, you need to be very reassuring. 00:21:49.599 --> 00:21:51.799 So reassuring. You didn't do anything wrong. 00:21:51.839 --> 00:21:53.640 This medicine is just to help your tummy feel 00:21:53.640 --> 00:21:56.980 better. That reassurance is absolutely key. Now, 00:21:57.259 --> 00:22:01.400 the adolescents. The teenagers. They are cognitively 00:22:01.400 --> 00:22:03.839 capable of understanding pain, but they come 00:22:03.839 --> 00:22:07.099 with so much social baggage. Huge social baggage. 00:22:07.799 --> 00:22:10.480 Their primary developmental drive is identity 00:22:10.480 --> 00:22:13.539 and independence. And their biggest fears are 00:22:13.539 --> 00:22:17.089 body image and loss of control. So how does that 00:22:17.089 --> 00:22:19.329 manifest when they're hurting? It often looks 00:22:19.329 --> 00:22:21.509 like stoicism. We mentioned the football player 00:22:21.509 --> 00:22:24.630 earlier. A teen might sit there, stone -faced, 00:22:24.890 --> 00:22:27.170 scrolling on their phone while their pain is 00:22:27.170 --> 00:22:29.789 an 8 out of 10. They are terrified of losing 00:22:29.789 --> 00:22:32.210 control of crying in front of you or their parents 00:22:32.210 --> 00:22:33.910 or, God forbid, their friends who might visit. 00:22:34.190 --> 00:22:36.670 They don't want to look like a baby. So with 00:22:36.670 --> 00:22:39.589 a teenager, a calm exterior could just be a mask? 00:22:39.829 --> 00:22:42.049 It's often a mask, yes. Yeah. You have to give 00:22:42.049 --> 00:22:43.869 them permission to be vulnerable and you have 00:22:43.869 --> 00:22:45.849 to give them choices. Do you want the pill now? 00:22:46.009 --> 00:22:48.349 or in 15 minutes. Do you want your mom to stay 00:22:48.349 --> 00:22:49.910 in the room or do you want her to step out for 00:22:49.910 --> 00:22:52.430 this part? Giving them back just a tiny bit of 00:22:52.430 --> 00:22:55.009 control can lower their anxiety, which we know 00:22:55.009 --> 00:22:57.230 actually lowers their perception of pain. That 00:22:57.230 --> 00:22:59.950 connects nicely to the nice to know notes here. 00:23:00.410 --> 00:23:02.589 School age kids, that middle group, they're usually 00:23:02.589 --> 00:23:05.009 the easiest to assess, right? Generally, yes. 00:23:05.349 --> 00:23:07.390 The six to 12 year olds. Yeah. They have the 00:23:07.390 --> 00:23:09.329 language to describe the pain. It feels like 00:23:09.329 --> 00:23:13.190 a knife versus it just aches. And they understand 00:23:13.190 --> 00:23:15.430 cause and effect. I fell off my bike, so my knee 00:23:15.430 --> 00:23:18.869 hurts. They're usually your most reliable historians 00:23:18.869 --> 00:23:21.329 in the pediatric world. All right. We've assessed 00:23:21.329 --> 00:23:23.170 the pain. We've found it. Now we have to treat 00:23:23.170 --> 00:23:27.089 it. Section five, pharmacologic management. This 00:23:27.089 --> 00:23:29.869 is the heavy lifter. This is where safety is 00:23:29.869 --> 00:23:31.990 absolutely paramount. This is the section where 00:23:31.990 --> 00:23:34.690 the 80 -20 rule really saves lives. We need to 00:23:34.690 --> 00:23:37.410 talk about the drugs, the side effects, and what 00:23:37.410 --> 00:23:39.299 I call the assessment loop. Let's start with 00:23:39.299 --> 00:23:41.940 the big three categories mentioned in the text. 00:23:42.259 --> 00:23:44.619 How should we organize these in our minds? It's 00:23:44.619 --> 00:23:47.660 a simple framework. Number one, analgesics. This 00:23:47.660 --> 00:23:50.079 is your main pain fighting category. It includes 00:23:50.079 --> 00:23:52.720 non -opioids like acetaminophen, Tylenol, and 00:23:52.720 --> 00:23:55.059 NSI. It's like ibuprofen. And then it includes 00:23:55.059 --> 00:23:57.960 the opioids morphine, fentanyl, hydromorphone. 00:23:58.319 --> 00:24:02.430 Number two, adjuvants. These are drugs that aren't 00:24:02.430 --> 00:24:04.910 primarily painkillers, but they help with specific 00:24:04.910 --> 00:24:07.950 types of pain or with the anxiety that comes 00:24:07.950 --> 00:24:11.869 with pain. Think benzodiazepines, like Valium, 00:24:12.130 --> 00:24:16.230 for muscle spasms, or anticonvulsants, like gabapentin, 00:24:16.589 --> 00:24:19.569 for neuropathic or nerve pain. And number three, 00:24:19.789 --> 00:24:23.009 anesthetics. These are the numbing agents, lidocaine 00:24:23.009 --> 00:24:25.670 that you inject or EMLA cream that you put on 00:24:25.670 --> 00:24:27.710 top of the skin. Let's focus on the analgesics 00:24:27.710 --> 00:24:30.829 first. The text mentions something called a sealing 00:24:30.829 --> 00:24:33.789 effect. This feels like a classic nuance that 00:24:33.789 --> 00:24:36.230 exam writers would test on. It is. It's a key 00:24:36.230 --> 00:24:39.210 distinction. Non -opioids, like ibuprofen, have 00:24:39.210 --> 00:24:41.450 a sealing effect. That means there is a maximum 00:24:41.450 --> 00:24:44.150 dose where you get maximum pain relief. If you 00:24:44.150 --> 00:24:45.990 give more than that dose, you don't get any more 00:24:45.990 --> 00:24:47.730 pain relief. You just get more side effects like 00:24:47.730 --> 00:24:50.430 liver or kidney toxicity. The curve basically 00:24:50.430 --> 00:24:52.849 flattens out at the top. Exactly. But opioids, 00:24:53.190 --> 00:24:55.250 specifically the pure agonists like morphine, 00:24:55.369 --> 00:24:57.509 do not have a sealing effect. Theoretically, 00:24:57.549 --> 00:24:59.430 the more you give, the more pain relief you get. 00:24:59.650 --> 00:25:01.710 So why don't we just give massive doses and wipe 00:25:01.710 --> 00:25:03.789 out all the pain? Because the side effects also 00:25:03.789 --> 00:25:07.190 have no sealing. The limiting factor with opioids 00:25:07.190 --> 00:25:10.250 isn't efficacy. It is respiratory depression. 00:25:10.589 --> 00:25:12.650 You stop increasing the dose because the patient 00:25:12.650 --> 00:25:15.250 stops breathing. And that brings us to the number 00:25:15.250 --> 00:25:17.950 one need -to -know adverse event, respiratory 00:25:17.950 --> 00:25:21.710 depression. This is the ABCs of nursing. Airway, 00:25:22.089 --> 00:25:25.730 breathing, circulation. It is. But in practice, 00:25:26.089 --> 00:25:28.529 we need to be very specific about what that looks 00:25:28.529 --> 00:25:31.109 like. It's not just, he's not breathing. It's 00:25:31.109 --> 00:25:33.410 a progression. It's a slide. What's the first 00:25:33.410 --> 00:25:35.829 sign? First, the patient gets sedated. They get 00:25:35.829 --> 00:25:38.349 drowsy. Then the respiratory rate starts to slow 00:25:38.349 --> 00:25:40.410 down. Then the depth of their breathing becomes 00:25:40.410 --> 00:25:42.880 shallow. And only then does the oxygen saturation 00:25:42.880 --> 00:25:45.119 drop. So if you wait for the O2 sat alarm to 00:25:45.119 --> 00:25:47.079 start beeping, you are late to the party. You 00:25:47.079 --> 00:25:50.019 are very late. The O2 sat is a lagging indicator. 00:25:50.539 --> 00:25:52.940 The need to know assessment parameters are sedation 00:25:52.940 --> 00:25:55.660 level and respiratory rate. If Lucas is on a 00:25:55.660 --> 00:25:57.740 morphine drip and he is unarousable, you can't 00:25:57.740 --> 00:25:59.960 wake him up by shaking his shoulder. That is 00:25:59.960 --> 00:26:02.660 an emergency. Even if his O2 sat is still 95 00:26:02.660 --> 00:26:05.259 percent, he is on the verge of respiratory failure. 00:26:05.319 --> 00:26:07.579 And the intervention in that moment? Stop the 00:26:07.579 --> 00:26:09.920 infusion immediately. Stimulate the patients. 00:26:10.220 --> 00:26:13.730 Shake them. call their name and have naloxone 00:26:13.730 --> 00:26:18.369 or Narcan ready. But remember Narcan reverses 00:26:18.369 --> 00:26:20.569 the pain control too. Lucas will wake up screaming 00:26:20.569 --> 00:26:23.210 in agony. So you use it very carefully titrating 00:26:23.210 --> 00:26:25.569 it if possible to just bring his respiratory 00:26:25.569 --> 00:26:27.710 rate up without completely eliminating his pain 00:26:27.710 --> 00:26:29.910 relief. Let's talk about the other side effects. 00:26:30.170 --> 00:26:31.809 The ones that won't kill them but will make them 00:26:31.809 --> 00:26:34.930 miserable. Constipation. This is basically guaranteed. 00:26:35.450 --> 00:26:38.049 Opioids slow down bowel motility to a crawl. 00:26:38.630 --> 00:26:41.289 If a child is on opioids for more than 48 hours, 00:26:41.509 --> 00:26:43.829 they must be on a bowel regimen. Stool softeners, 00:26:44.029 --> 00:26:46.069 laxatives. You do not wait for them to get impacted. 00:26:46.410 --> 00:26:49.490 Prevention is key. And pruritus. Itching. Ah, 00:26:49.490 --> 00:26:52.349 yes. This is the classic sake allergy trap on 00:26:52.349 --> 00:26:55.529 exams. You give a dose of IV morphine. Five minutes 00:26:55.529 --> 00:26:57.109 later, the parent hits the call bell and says, 00:26:57.430 --> 00:26:59.289 he's scratching his nose. He's allergic. The 00:26:59.289 --> 00:27:01.690 new nurse panics and thinks, oh my god, anaphylaxis. 00:27:01.910 --> 00:27:04.799 Is he allergic? Probably not. Opiaries can cause 00:27:04.799 --> 00:27:07.279 histamine release, which causes itching, especially 00:27:07.279 --> 00:27:09.660 around the face and nose. It is a very common 00:27:09.660 --> 00:27:11.420 side effect, not necessarily a true allergy. 00:27:11.740 --> 00:27:13.819 So how do you tell the difference between a side 00:27:13.819 --> 00:27:16.660 effect and a life -threatening allergy? You look 00:27:16.660 --> 00:27:19.099 for the other signs of anaphylaxis. Are their 00:27:19.099 --> 00:27:21.940 hives urticaria all over the body? Is their child 00:27:21.940 --> 00:27:24.400 wheezing? Do you hear stride or is their blood 00:27:24.400 --> 00:27:26.859 pressure dropping? If it's just an itchy nose, 00:27:26.940 --> 00:27:28.539 it's a side effect. You can treat it with an 00:27:28.539 --> 00:27:30.960 antihistamine like Benadryl or you can talk to 00:27:30.960 --> 00:27:33.140 the provider about switching to a different opioid. 00:27:34.559 --> 00:27:37.700 But don't immediately label that kid allergic 00:27:37.700 --> 00:27:41.059 to morphine without a full assessment. You might 00:27:41.059 --> 00:27:43.619 block them from getting necessary pain control. 00:27:43.759 --> 00:27:45.640 for the rest of their life. That is a crucial 00:27:45.640 --> 00:27:48.000 distinction. Now the assessment loop, the source 00:27:48.000 --> 00:27:50.599 text is very, very firm on this. The assessment 00:27:50.599 --> 00:27:53.420 loop is your legal and ethical requirement. It 00:27:53.420 --> 00:27:55.779 is not enough to give the pill or push the IV 00:27:55.779 --> 00:27:59.119 med. You must reassess. The standard of care 00:27:59.119 --> 00:28:02.079 is typically 15 to 30 minutes after an IV medication 00:28:02.079 --> 00:28:05.539 and 45 to 60 minutes after an oral medication. 00:28:05.859 --> 00:28:07.579 You have to go back to the bedside. And what 00:28:07.579 --> 00:28:09.940 are you checking for specifically in that reassessment? 00:28:10.299 --> 00:28:13.680 Three things. Number one, did it work? What's 00:28:13.680 --> 00:28:16.599 the new pain score? Number two, are they safe? 00:28:17.079 --> 00:28:19.359 What are their vitals? What is their respiratory 00:28:19.359 --> 00:28:21.539 status and sedation level? And number three, 00:28:21.980 --> 00:28:23.740 are there any side effects? Are they itching? 00:28:23.900 --> 00:28:26.640 Are they nauseous? If you document the administration, 00:28:26.720 --> 00:28:29.059 but you don't document the reassessment legally, 00:28:29.420 --> 00:28:31.559 you abandon that patient. Abandon the patient. 00:28:31.720 --> 00:28:33.859 That's a phrase that just chills the blood. It 00:28:33.859 --> 00:28:36.079 should. Okay. Let's wrap up pharma with a need 00:28:36.079 --> 00:28:39.299 to know regarding dosing. PADES is different 00:28:39.299 --> 00:28:42.920 from adults because... Weed -based gosing. Everything 00:28:42.920 --> 00:28:45.640 is per kilogram. Milligrams per kilogram per 00:28:45.640 --> 00:28:48.220 dose. Which means math. Which means errors. The 00:28:48.220 --> 00:28:50.180 single most common cause of medication error 00:28:50.180 --> 00:28:52.660 in pediatrics is a calculation error. Moving 00:28:52.660 --> 00:28:55.640 the decimal point one spot to the right is a 00:28:55.640 --> 00:28:58.339 tenfold overdose. If Lucas is supposed to get 00:28:58.339 --> 00:29:00.440 two milligrams of morphine and you accidentally 00:29:00.440 --> 00:29:03.740 give him 20 milligrams, that is likely fatal. 00:29:03.880 --> 00:29:06.619 So the rule is? Double check. Triple check. Many 00:29:06.619 --> 00:29:09.059 hospitals require a two nurse check for high 00:29:09.059 --> 00:29:11.730 alert medications like opioids and insulin. But 00:29:11.730 --> 00:29:14.049 even if they don't, you do your own math twice. 00:29:14.730 --> 00:29:17.549 Verify the weight, never ever guess. Alright, 00:29:17.789 --> 00:29:21.109 section six. We are in the home stretch. Non 00:29:21.109 --> 00:29:23.890 -pharmacologic and procedural management. This 00:29:23.890 --> 00:29:25.990 is what I call the art of PEDS nursing. It's 00:29:25.990 --> 00:29:28.849 not just pushing meds, it's managing the environment 00:29:28.849 --> 00:29:31.490 and using your creativity. And honestly, for 00:29:31.490 --> 00:29:34.470 a lot of minor procedures, needle sticks, IV 00:29:34.470 --> 00:29:36.930 starts, these are your primary interventions. 00:29:37.259 --> 00:29:39.359 or at least should be used in combination with 00:29:39.359 --> 00:29:42.420 meds. Let's talk about sucrose, the sweeties. 00:29:42.779 --> 00:29:44.759 This sounds like an old wives' tale. It sounds 00:29:44.759 --> 00:29:47.059 like it, but it's pure evidence -based magic 00:29:47.059 --> 00:29:51.539 for infants. It's a 24 % sucrose solution, basically 00:29:51.539 --> 00:29:53.880 concentrated sugar water. You dip a pacifier 00:29:53.880 --> 00:29:55.599 in it, or you can put a few drops directly on 00:29:55.599 --> 00:29:57.920 the tongue. And how on earth does sugar stop 00:29:57.920 --> 00:30:01.079 pain? It stimulates the release of endogenous 00:30:01.079 --> 00:30:03.000 opioids and endorphins in the infant's brain. 00:30:03.319 --> 00:30:05.200 It effectively drugs them with their own natural 00:30:05.200 --> 00:30:07.920 pain killer. That's wild. It works best for infants 00:30:07.920 --> 00:30:09.839 up to 12 months, although it's most effective 00:30:09.839 --> 00:30:11.940 under six months. You use it about two minutes 00:30:11.940 --> 00:30:14.000 prior to a procedure like a heel stick or an 00:30:14.000 --> 00:30:16.319 ID start. Combined with non -nutritive sucking, 00:30:16.480 --> 00:30:19.359 the pacifier, it significantly reduces pain scores. 00:30:19.900 --> 00:30:22.579 So sugar plus a pacifier equals a much happier 00:30:22.579 --> 00:30:26.619 baby. It's a proven formula. Next up. Therapeutic 00:30:26.619 --> 00:30:29.079 hugging. I love this term because the word restraint 00:30:29.079 --> 00:30:31.579 just sounds so barbaric. And it felt barbaric. 00:30:31.579 --> 00:30:34.220 We used to do that. Yeah. Papoose boards, holding 00:30:34.220 --> 00:30:37.180 kids down, spread eagle on a table. It was incredibly 00:30:37.180 --> 00:30:40.160 traumatizing for everyone involved. Therapeutic 00:30:40.160 --> 00:30:43.140 hugging is a secure holding position. Usually 00:30:43.140 --> 00:30:45.400 the parent sits on the bed or chair and holds 00:30:45.400 --> 00:30:47.519 the child on their lap, securing the child's 00:30:47.519 --> 00:30:50.119 arms and legs with their own body in what feels 00:30:50.119 --> 00:30:52.980 like a big tight hug. So the child feels held, 00:30:53.039 --> 00:30:55.980 not trapped or attacked. Correct. It provides 00:30:55.980 --> 00:30:58.380 comfort and immobility so the nurse can get the 00:30:58.380 --> 00:31:01.220 IV or the shot in safely. And it turns the parent 00:31:01.220 --> 00:31:03.880 into a protector and a helper rather than just 00:31:03.880 --> 00:31:06.900 a terrified spectator. What about topical anesthetics? 00:31:07.059 --> 00:31:10.059 Things like EMLA cream or LMX. These are creams 00:31:10.059 --> 00:31:12.799 that numb the skin. The absolute need to know 00:31:12.799 --> 00:31:15.619 here is timing. EMLA cream takes a full 60 minutes 00:31:15.619 --> 00:31:18.200 to work effectively. LMX is a bit faster. It 00:31:18.200 --> 00:31:20.059 takes about 30 minutes. So you have to plan ahead. 00:31:20.079 --> 00:31:21.859 You can't just decide to use it in the moment. 00:31:22.119 --> 00:31:24.779 You have to anticipate. If you know Lucas needs 00:31:24.779 --> 00:31:27.059 a blood draw at 10 a .m., you put the cream on 00:31:27.059 --> 00:31:29.660 at 9 a .m. If you walk in at 10 a .m. and say, 00:31:29.779 --> 00:31:31.700 oops, I forgot, it's too late, you're going to 00:31:31.700 --> 00:31:34.299 have to stick them without it. Anticipatory guidance 00:31:34.299 --> 00:31:36.980 is a huge part of good pediatric pain management. 00:31:37.380 --> 00:31:39.759 And for the tiniest patients, the preemies there 00:31:39.759 --> 00:31:43.880 is kangaroo care. Skin to skin contact. You just 00:31:43.880 --> 00:31:46.160 place the diaper -clad infant directly on the 00:31:46.160 --> 00:31:48.660 parent's bare chest. The research on this is 00:31:48.660 --> 00:31:51.579 so robust. It stabilizes their heart rate and 00:31:51.579 --> 00:31:54.519 improves their O2 saturation, and it significantly 00:31:54.519 --> 00:31:57.339 reduces pain scores during and after procedures. 00:31:57.900 --> 00:32:00.059 It's free, it's safe, and it promotes bonding. 00:32:00.579 --> 00:32:02.539 There's no reason not to do it. Let's talk about 00:32:02.539 --> 00:32:04.180 the procedure itself. Sometimes we have a choice 00:32:04.180 --> 00:32:06.099 in how we hurt them, right? We do. Procedural 00:32:06.099 --> 00:32:08.539 choice. This is especially true for newborns. 00:32:08.839 --> 00:32:11.180 If you need a significant amount of blood, the 00:32:11.180 --> 00:32:13.220 evidence clearly shows that a venipuncture drawing 00:32:13.220 --> 00:32:16.279 from a vein with a small butterfly needle is 00:32:16.279 --> 00:32:18.200 actually less painful than a heel stick. Really? 00:32:18.339 --> 00:32:20.519 The heel stick seems so routine, so much less 00:32:20.519 --> 00:32:23.279 invasive. But it involves squeezing the foot 00:32:23.279 --> 00:32:25.859 over and over to milk the blood out. That causes 00:32:25.859 --> 00:32:29.089 breathing and prolonged pain. A skilled phlebotomist 00:32:29.089 --> 00:32:31.730 doing a venipuncture is one quick poke, you get 00:32:31.730 --> 00:32:34.230 the blood flow, and you're done. So we should 00:32:34.230 --> 00:32:36.910 always advocate for the method that hurts less. 00:32:37.609 --> 00:32:40.710 And finally, cognitive strategies. Destruction. 00:32:40.970 --> 00:32:42.910 Bubbles. I always carry bubbles in my pocket. 00:32:42.950 --> 00:32:44.529 Do you know why they are the perfect tool? Because 00:32:44.529 --> 00:32:47.049 everyone loves bubbles. That's part of it. But 00:32:47.049 --> 00:32:50.089 there's a physiological reason. To blow a bubble, 00:32:50.109 --> 00:32:52.509 you have to take a deep breath in and then exhale 00:32:52.509 --> 00:32:55.650 slowly and controlled. It forces the child to 00:32:55.650 --> 00:32:58.589 do deep breathing exercises without even knowing 00:32:58.589 --> 00:33:00.750 they're doing it. Oh, that's brilliant. It lowers 00:33:00.750 --> 00:33:03.529 their heart rate, relaxes their muscles, plus 00:33:03.529 --> 00:33:06.289 watching the bubble float away is a powerful 00:33:06.289 --> 00:33:09.799 visual distraction. It helps gate the pain signal. 00:33:10.319 --> 00:33:12.900 The brain is so busy processing the bubble, it 00:33:12.900 --> 00:33:15.119 has less capacity to process the pain. It's a 00:33:15.119 --> 00:33:17.500 breathing exercise disguised as a toy. I love 00:33:17.500 --> 00:33:19.960 it. Guided imagery is another great one for older 00:33:19.960 --> 00:33:22.299 kids. Lucas, tell me about your favorite place. 00:33:22.559 --> 00:33:24.839 Is it the beach? What does the sand feel like? 00:33:24.920 --> 00:33:27.079 Can you hear the seagulls? Is the water cold? 00:33:28.240 --> 00:33:30.759 If you can get his brain to process all the sensory 00:33:30.759 --> 00:33:33.829 details of the beach. It has less bandwidth to 00:33:33.829 --> 00:33:35.829 process the pain signal coming from his abdomen. 00:33:36.269 --> 00:33:38.470 The brain can only focus on so much at once. 00:33:38.769 --> 00:33:40.609 We have covered a massive amount of ground here. 00:33:40.849 --> 00:33:42.849 Let's bring this in for a landing with the summary. 00:33:43.410 --> 00:33:45.349 If the listener is driving to their exam right 00:33:45.349 --> 00:33:47.710 now or walking onto the unit for their shift, 00:33:48.269 --> 00:33:50.349 what are the gold standard takeaways? Let's hit 00:33:50.349 --> 00:33:53.509 the top four. The absolute must -knows. Go for 00:33:53.509 --> 00:33:56.190 it. Number one, trust the assessment, but know 00:33:56.190 --> 00:33:59.910 the traps. Sleep does not equal comfort. Newborns 00:33:59.910 --> 00:34:02.289 feel pain. Kids will lie to you to avoid a shot. 00:34:02.470 --> 00:34:05.710 Believe the body. Okay, number two. Two. Use 00:34:05.710 --> 00:34:07.890 the right tool. Faith Ease is for three and up, 00:34:08.110 --> 00:34:09.590 but only if they understand the instructions. 00:34:09.989 --> 00:34:12.349 Numeric Scale is for five and up. And FLA CC 00:34:12.349 --> 00:34:13.969 is for everyone who can't speak for themselves. 00:34:14.150 --> 00:34:17.429 Number three. Three. Respect the opioids. They 00:34:17.429 --> 00:34:19.530 are safe and effective if you monitor respiratory 00:34:19.530 --> 00:34:22.170 rate and sedation level. Watch for that slide 00:34:22.170 --> 00:34:24.090 into sleepiness before the breath stops. And 00:34:24.090 --> 00:34:26.800 the last one. And number four. Advocate. Be the 00:34:26.800 --> 00:34:29.780 advocate. Use the parents as a resource. Use 00:34:29.780 --> 00:34:32.079 the sugar water. Use the numbing cream. Use the 00:34:32.079 --> 00:34:34.840 bubbles. Don't just document the pain. Do everything 00:34:34.840 --> 00:34:37.059 in your power to treat it. And remind us of the 00:34:37.059 --> 00:34:39.119 why. Why do we care so much about this? It's 00:34:39.119 --> 00:34:41.940 not just about being nice. It's not. Because 00:34:41.940 --> 00:34:45.000 pain changes the wiring of the brain. Uncontrolled 00:34:45.000 --> 00:34:47.800 pain releases cortisol. It suppresses the immune 00:34:47.800 --> 00:34:51.840 system. It delays wound healing. A child in pain 00:34:51.840 --> 00:34:54.670 physically heals slower. And as we learned with 00:34:54.670 --> 00:34:57.610 the newborns, it can create long -term sensitization 00:34:57.610 --> 00:35:01.630 to pain. By managing pain well today, you're 00:35:01.630 --> 00:35:03.849 actually protecting that child's future interaction 00:35:03.849 --> 00:35:06.349 with the entire healthcare system. You are preventing 00:35:06.349 --> 00:35:08.369 medical trauma. I want to leave everyone with 00:35:08.369 --> 00:35:09.989 a thought that really stuck with me from our 00:35:09.989 --> 00:35:11.949 discussion on the sleeping trap. It just, it 00:35:11.949 --> 00:35:14.329 really challenges how we view our patients. It 00:35:14.329 --> 00:35:17.090 does. It's the question I want every nurse to 00:35:17.090 --> 00:35:19.289 ask themselves. When they walk into a room and 00:35:19.289 --> 00:35:21.590 see a quiet sleeping child in a hospital bed, 00:35:22.309 --> 00:35:25.269 are they peaceful or are they just exhausted? 00:35:25.809 --> 00:35:27.630 Explain that distinction one last time for us. 00:35:27.969 --> 00:35:31.849 Peaceful implies comfort, relief, resolution. 00:35:32.889 --> 00:35:35.289 Exhausted implies a battle has been fought. If 00:35:35.289 --> 00:35:37.429 that child has been fighting pain for hours and 00:35:37.429 --> 00:35:40.010 finally collapses into sleep, that is not a success 00:35:40.010 --> 00:35:43.050 for us. That is a physiologic shutdown. If you 00:35:43.050 --> 00:35:45.130 assume peace when the reality is exhaustion, 00:35:45.630 --> 00:35:47.670 you will miss the pain. and you will fail that 00:35:47.670 --> 00:35:49.969 patient. So look closer. Check the furrow in 00:35:49.969 --> 00:35:52.369 their brow. Check their palms. Check the history. 00:35:52.869 --> 00:35:55.190 Be the detective. Powerful stuff. Thank you so 00:35:55.190 --> 00:35:57.349 much for this deep dive. To all the nurses and 00:35:57.349 --> 00:35:59.250 students out there, good luck with your exams, 00:35:59.329 --> 00:36:01.090 but more importantly, good luck with your patients. 00:36:01.530 --> 00:36:03.670 Be the advocate they need you to be. See you 00:36:03.670 --> 00:36:04.030 next time.