Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
back to the Deep Dive. We are glad to have you
with us. Today we are wading into waters that,
let's be honest, they can terrify. even the most
seasoned nurses, let alone students who are getting
ready for their boards. Oh, absolutely. We are
talking about pediatric pain, specifically the
assessment and management of it. And I was looking
through the stack of articles and the textbook
chapters, all the clinical guidelines we're covering,
especially chapter 14. And it just it hit me.
This is arguably the most subjective high stakes
game of poker you can play in medicine. It absolutely
is. I mean, the stakes are just incredibly high
because you're dealing with a population that
often can't advocate for itself. You're looking
at a patient demographic that ranges from what,
a 24 week preemie and an incubator who literally
lacks the anatomy to speak, all the way up to
a 17 year old linebacker who is just refusing
to speak because he thinks admitting pain makes
him look weak. And if you, as the clinician,
if you get this wrong, if you miss the signs,
The consequences aren't just oh the kid has a
bad afternoon. We're talking about real physiological
damage long -term neural sensitization and frankly
Massive ethical failures right and looking at
the sheer volume of material here. I mean it
is dense You've got developmental theories a
dozen different pain scales pharmacology profiles
legal frameworks. It's It's overwhelming. And
too much to memorize. Exactly. So for this deep
dive, we are going to apply the Pareto Principle.
The 80 -20 rule. I love this approach for complex
clinical topics. It just cuts through the noise.
It really does. The whole premise is that 80
% of your results, or in this case, 80 % of the
safety questions on the NCLEX and 80 % of the
lifesaving decisions you make at the bedside,
they come from just 20 % of the information.
So our mission today is to filter the stack.
We want to clearly distinguish the need to know,
the stuff that keeps you out of court and keeps
your patients safe from the nice to know, which
is, you know, the deeper context that helps you
understand the why, but it isn't necessarily
the make or break data point for a tiered exam.
Which is so crucial because exam writers love
pediatric pain. Oh, they do. It's a favorite
target. It really is. It forces you to synthesize.
You can't just memorize a drug dose. You have
to look at a whole scenario, interpret a behavior,
navigate a complex family dynamic, and spot the
trap. And believe me, there are so many traps
in this topic. OK, so let's map this out. We're
going to structure this logically, essentially
following the nursing process. We'll start with
section one, the mindset shift. This is where
we have to dismantle the myths that cause students
to fail. Then section two is the framework. That's
the quest new to mnemonic. Section three is the
tools, specifically the rules on which scale
applies to which age. The rules are everything
there. Section four is the detective work reading
the body when the mouth is silent. Section five
is pharma. safety protocols for drugs. And finally,
section six, the art of nursing, all the non
-pharmacologic interventions. It's a really solid
roadmap. And I think starting with the mindset
shift is it's non -negotiable. Because historically,
the medical community has gotten this wrong for
a long, long time. If you walk into a pediatric
room with the wrong assumptions, you will undertreat
pain every single time. OK, let's unpack that.
Section one, the mindset shift. The source material
highlights several myths or misconceptions. And
looking at the need -to -know bucket or 80 -20
core, there is one trap that just seems to catch
everyone, the sleeping track. This is the number
one red flag on exams and in clinical practice.
Let's paint a picture here. Let's say you have
a patient. Let's call him Lucas. Lucas is four
years old. He had an appendectomy this morning.
You walk in at 2 p .m. to do your rounds. Lucas
is curled up in bed, eyes closed, fast asleep.
Or maybe he's awake and he's playing Mario Kart
on an iPad. The instinct, the trap, is to chart
010 -0 pain and walk away. Which feels intuitive,
right? I mean, if I'm in agony, I am not sleeping
and I'm certainly not playing video games. I'm
writhing. That is adult logic. You're applying
adult logic to a pediatric brain. And that is
where you fail. The source material is just...
It's explicit on this. A child who is sleeping
or playing is not necessarily pain -free. In
fact, they could be in severe pain. So what's
actually happening there physiologically? Why
would a child in pain be asleep? It's a coping
mechanism. And sometimes it's just pure unadulterated
exhaustion. I mean, think about Lucas. He's been
in a strange environment. He's been poked with
needles. He's had major surgery. His body's flooded
with cortisol. He might have spent the last three
hours fighting the pain, crying, tensing up all
his muscles. Eventually, the battery just runs
out. He crashes. He isn't sleeping because he's
comfortable. He's sleeping because he has nothing
left in the tank. If you wake him up... or if
you just check his vitals, you might find his
heart rate is still racing, his breathing is
still shallow. So sleep can be a form of shutting
down. It's not a sign of peace. Exactly. And
regarding the video games, distraction is an
incredibly powerful analgesic, but it's also
a wall. A child might focus so intensely on that
screen because the second they look away, the
pain rushes back in. It's a dissociation technique.
Got it. So for the exam writers, this is key.
If you see a question asking, the child is sleeping
post -op, do you wake them to assess? Or, do
you administer the scheduled pain med? The answer
is always yes. You assess. You never ever assume
sleep equals comfort. That is a critical distinction.
It's not just let sleeping dogs lie. It's check
if the dog is actually unconscious from exhaustion.
That's a perfect way to put it. Okay, the next
big one in the need to know category is the newborn
myth. And this one is hay. Well, it's horrifying
when you look at the history of it. It is. I
mean, we don't have to go back that far maybe
to the 80s to find a time when major surgeries
were performed on infants with minimal or sometimes
no anesthesia. That's unbelievable. The belief
was that their nervous systems weren't myelinated
enough to transmit pain signals, like the wires
just weren't hooked up yet. Which we now know
is completely false. 100 % factually incorrect.
The 80 -20 takeaway here is really simple. Newborns
do feel pain. Their neurologic system is absolutely
intact enough to perceive it. In fact, in some
ways, they feel it more intensely because they
lack the descending inhibitory pathways that
adults have to kind of dampen the signal. So
they just get the raw feed? They get the raw
feed, no filter. And this connects directly to
the next one, the memory myth. The old idea was,
well, even if it hurts them, they won't remember
it, so it doesn't matter. They're babies. They
don't have narrative memory. And that part is
true. Lucas won't remember the specific nurse
who poked his heel when he was two days old.
But his spinal cord remembers. This is the whole
concept of sensitization, or what we call windup.
I was reading about this in the source material.
It describes actual changes in the cellular structure,
like physical changes. Yes. Think of the spinal
cord like a volume knob. If you expose a newborn
to repeated painful stimuli -like heel sticks,
suctioning, intubation without adequate pain
management. The cells in the dorsal horn of the
spinal cord become hyper excitable. You are effectively
turning the volume knob all the way up and then
breaking it off. So fast forward five years.
What does that look like? Exactly. Five years
later, Lucas goes for a routine flu shot. A normal
kid might say ouch and be fine 30 seconds later.
But Lucas, whose system is sensitized, might
experience a level 10 trauma. His body overreacts
because that neural pathway was blazed wide open
when he was a neonate. Wow. So treating pain
in a newborn isn't just about kindness in the
moment, it's about protecting the entire architecture
of their developing nervous system. That adds
so much weight to the decision to use analgesia.
It's not just comfort, it's neurology. It's preventative
neurology. Okay, let's move up the age bracket,
the truthfulness trap. This seems to apply more
to the toddlers and preschoolers. It does. The
assumption here is... If it hurts, they will
tell me. Which, again, seems logical. If I step
on a Lego, I'm letting everyone in a five -mile
radius know about it. But you're an adult with
reasoning skills. Yeah. A child has completely
different motivations. Let's go back to Lucas,
our four -year -old. You walk in with a stethoscope
and you've got a syringe in your pocket. You
ask him, Lucas, does your tummy hurt? He looks
at the syringe. He knows that if he says yes,
you might come closer with that sharp thing.
So he says no. He's trading long -term relief
for short -term safety. Exactly. To him, the
shot is terrifying. It's an immediate known threat.
The pain in his belly is a constant dull threat.
He chooses the devil he knows. And it's not just
toddlers. What about a teenager? Oh, absolutely.
A teen might deny pain because they want to feel
in control or maybe they're an athlete and they've
been taught their whole life to walk it off or
play through the pain. Admitting pain feels like
a failure of character to them. So the idea that
self -report is the gold standard, it really
comes with a big asterisk. A massive asterisk.
It is the gold standard only if the child is
capable and willing to be honest. If the child
says, no pain, but they are grimacing, their
body is rigid, and their heart rate is 140. You
trust the body, not the mouth. That's the detective
work we'll get to later. Before we leave the
myths, we have to touch on the elephant in the
room. Opioids. This comes up constantly with
parents. Don't give him morphine. I don't want
him to get addicted. This is a huge, huge barrier
to effective care. The need to know here is crystal
clear. Children are not more prone to addiction
than adults when they're being treated for acute
pain. And physically, they do not experience
more adverse effects than adults. So the fear
is largely unfounded, at least in the acute setting.
In the context of treating a broken femur or
post -surgical pain, yes, of course we are careful,
we monitor closely. But we do not withhold necessary
analgesia due to an irrational fear of creating
an addict in three days. In fact, the source
material emphasizes that untreated pain can actually
be a driver for chronic pain issues later on,
which is a far, far bigger risk factor for substance
use disorders down the road. Okay, so that really
covers the mindset shift. We know sleep is a
trap, newborns are wired for pain, memories are
physiological, kids might lie to avoid shots,
and opioids are safe when they're managed properly.
Let's look briefly at the nice -to -know context
here. The sources mention things like culture
and temperament. Right, and this is the... 80
% the supporting info. It's good to have in your
back pocket. Just be aware that pain is filtered
through culture. In some families, a boy crying
is seen as shameful, so it'll be stoic. In others,
expressive vocalization is encouraged and expected.
You have to read the room. And temperament, an
easy temperament child might just whimper quietly
when they're in agony, while a difficult or intense
child might scream bloody murder over a hangnail.
You have to calibrate your assessment to the
baseline personality of that specific. context
is everything okay let's move to section 2 the
framework we have a mnemonic here quest and that's
quest with two T's Q U E S T T this is your safety
net if you freeze up in an exam or in a real
clinical situation just walk through these letters
it'll guide you let's break it down Q question
the child this is always the first step but as
we just discussed how you question them matter
so much don't just ask do you have pain ask where
is the hurt or can you tell me how your tummy
feels You have to use their language, owie, boo
-boo, whatever works. Use a reliable pain scale.
And the emphasis there is on the word reliable.
This is a huge exam point. You absolutely cannot
use a scale designed for an adult on a toddler.
You can't use a self -report scale on a baby.
We're going to deep dive into the specific age
rules in just a minute, but you as your reminder
to pick the right tool for the job. Evaluate
behavior and physiologic changes. This is your
backup. This is what you do when the cue fails.
If they can't talk or they won't talk, you look.
You look at their face, their legs, their vitals.
This is absolutely crucial for the nonverbal
population. Secure parents' involvement. I feel
like this can be a double -edged sword for some
nurses. Sometimes the parent feels like an obstacle,
not a help. And that is such a dangerous attitude
to have. The need to know here is that the parent
is the expert on that child. You've known Lucas
for four hours. His mom has known him for four
years. Good point. If she says he isn't acting
right, or he looks like he's in pain, you believe
her. You believe her. Even the monitor says his
heart rate is within normal limits for his age.
She knows his subtle cues, the way he holds his
lip, the way he goes quiet before he cries. Securing
their involvement means using them as a primary
data source. That's a great clinical pearl. Never
bet against the mom. Okay, TNT. First T. Take
cause of pain into account. This is pathology.
If a child has sickle cell disease, that's ischemic
pain. It is excruciating. Even if they're sitting
quietly watching TV, you know the underlying
pathology warrants aggressive pain control. Don't
let a coping behavior override your knowledge
of the disease process. Got it. And the last
T. Take action. Assessment is completely useless
without intervention. If you find pain, you must
do something. Give medication, reposition them,
use distraction, and then critically reevaluate.
It's an action loop. Assess, act, reassess. Okay,
let's get into the weeds. Section three, assessment
tools. I feel like if there was a red alert section
for testing, this has to be it. Exam writers
just love to give you a scenario, a four -year
-old boy. and then ask you which scale to use.
Absolutely. This is probably the highest yield
section of our entire discussion. If you use
the wrong scale, your data is garbage. It's meaningless.
And on the NCLEX, using the wrong scale is a
safety violation. You fail the question. So let's
lay down the age rules. Let's start with the
most famous one, the Wong Baker Faces Scale.
We've all seen it. The little cartoon faces ranging
from a happy smiley face to a full -on crying
frowning face. Right. The target age for the
Faces Scale, the number to burn into your brain,
is three years and older. Three seems young.
I mean, can a three -year -old really understand
that concept? They can, but, and this is a huge
need to know, you have to explain it correctly.
You can't just point to the chart and say, pick
a face. What do you say? You have to anchor the
scale in pain, not emotion. You have to explain
this face pointing to the zero has no hurt at
all This face pointing to the two hurts a little
bit this face pointing to the ten hurts the most
Oh, so you use the word hurt? Yes, the word is
hurt or oh we not sad or happy Why is that distinction
so important? Because a three -year -old might
pick the crying face because they're sad that
mommy went to the cafeteria or because they dropped
their teddy bear on the floor, you have to clarify
that the faces represent hurt, not just sad.
If you skip that instruction, the tool is completely
invalid. Okay, so faces is three and up with
the right instructions. Now, what about the numeric
scale, the standard zero to ten that we use for
adults? The target age jumps up here. This is
generally for five years and older. Why the two
-year gap? Why can't Lucas, our four -year -old,
use the numbers? He can probably count to ten.
He can count, sure. but he doesn't understand
value or quantity in an abstract way. To a four
-year -old, numbers are just labels, like ABC.
He doesn't inherently understand that 8 is twice
as much as 4, or that 10 is a definitive limit.
A five -year -old, on the other hand, typically
has developed that cognitive numeracy. What would
a four -year -old do if you asked them? They'll
just guess a number they like. I'm a seven because
I'm seven years old. Right. Or they'll just say
ten every time. It's completely unreliable. That
is a classic exam trap. Don't give the number
line to the preschooler. Don't do it. Okay, so
what if the kid is too young for faces? or they're
non -verbal, or maybe they have a severe cognitive
delay like cerebral palsy, and they can't communicate
at a three -year -old level. When you abandon
self -report entirely, you can't use it. You
have to switch to an observational tool. And
the gold standard here is the FLACC scale. or
the revised version, our FLACC. FLACC. Break
that down for us. It's another mnemonic. It stands
for Face, Legs, Activity, Cry, Consolability.
You observe the child for about one to five minutes
and you score each of those five categories from
a zero to a two. So you're looking at their physical
presentation, their body language. Exactly. Face.
Are they dremising or clenching their jaw? That's
a two. A slight frown is a one. Legs. Are they
relaxed or are they kicking and drawn up tightly
to their chest? Activity. Are they lying quietly
or are they arching their back or jerking around?
Cry. Is it just a little whimper or a full -blown
scream? And consolability. This is a big one.
Can you distract them? If you pick them up or
rock them, do they stop crying? Or are they just
completely inconsolable? You tally all that up
to get a score out of 10. And this is the go
-to for infants and toddlers. Infants, toddlers,
and this is important, non -verbal children of
any age. If you have a 12 -year -old with a severe
developmental delay who cannot speak, you use
the FLACC. You don't try to force the FACES scale
on a child who doesn't understand the concept
of matching their feeling to a drawing. There's
one more mentioned in the 80 -20 list, the Outcher
Scale, which sounds kind of aggressive, but I
guess it's accurate. The outter is similar to
faces, but instead of cartoon drawings, it uses
actual photographs of children expressing different
levels of pain. It's also for three years and
older. The need to know nuance here is cultural.
The outter comes in different versions. There's
a Caucasian version, an African -American version,
a Hispanic version, so the child can identify
with the face they're seeing. It helps with reliability.
That makes perfect sense. Representation matters
even in pain assessment. What about the nice
-to -know stuff here? The source mentioned some
specific NICU scales. Yeah, unless you're planning
to go into the NICU, you probably don't need
to memorize the scoring grids for these, but
you should recognize the acronyms. NPS, that's
the neonatal infant pain scale, CRYSS, which
is specifically for post -op neonates, and PIPP,
the premature infant pain profile. If you see
these on an exam, just associate them with newborn.
That's usually enough. Them for the older kids.
Any other tools? There is the APPT, the adolescent
pediatric pain tool. This is for ages about 8
to 15. It's much more sophisticated. It has a
body outline where they can actually color in
where the pain is. It asks about the quality
of the pain. Is it burning? Is it stabbing? Is
it throbbing? It treats the child more like a
mini adult, capable of a more detailed assessment.
OK, that's a great overview of the tools. So
moving on to section four. Developmental clues.
We've picked our tool, but now we have to actually
do the assessment. We need to play detective.
Let's walk through the age groups because the
presentation of pain just changes so drastically
as the brain develops. Let's start with the infants.
The babies. With them, you are entirely dependent
on spotting the physiologic changes. Think fight
or flight. So the sympathetic nervous system
just kicks right in. It goes into overdrive,
heart rate goes up, respiratory rate goes up.
But here is a critical exam detail that people
often miss. Oxygen saturation goes down. Why
does the O2 sat drop if they're breathing faster?
It's a great question. There are a few reasons.
They might be holding their breath while they're
crying, which is called Valsalva. Or their breathing
becomes really shallow and rapid to chipnia,
which isn't efficient for gas exchange at all.
So if you see a baby desaturating on the monitor,
pain should be high on your list of possible
causes. What else are we looking for? Palmar
or plantar? Sweating. just touch their little
hands and the soles of their feet. If they're
clammy, that's a stress response. Changes in
vagal tone. And behaviorally. The biggest thing
is to look for guarding. Guarding? What does
that look like in an infant? It's a refusal to
move a body part. If an infant has a sore arm
from an IV, they will hold it perfectly still,
flexed against their body. If you try to extend
it, they will scream. That rigidity is their
way of splinting the injury themselves. And the
cry? Oh, the cry. Listen to the cry. A pain cry
is distinct. It's high pitched. It's shrill.
It's harsh. It sounds completely different than
a hungry cry or a wet diaper cry. Experienced
NICU and PEDS nurses can hear the difference
from down the hall. OK, let's grow up a little
bit. The toddlers and preschoolers. The Lucas
age group. We already talked about how they might
lie to you, but what else is going on in their
little heads? This is where magical thinking
comes into play. Cognitively, toddlers often
view pain as punishment. Punishment for what?
For being bad. I hit my brother earlier, so now
my tummy hurts. Or I didn't clean my room, so
now the nurse is sticking me with a needle. they
really struggle to separate the physical cause
from their own behavior. That is absolutely heartbreaking.
It adds this whole layer of guilt and fear on
top of the physical pain. It does. And that's
why they might kick, bite, or try to run away.
In their mind, they're fighting off the punishment.
They also have very poor body boundaries. If
you put a band -aid on them, they might honestly
believe that band -aid is the only thing keeping
all their insides from falling out. So when you're
assessing them, you need to be very reassuring.
So reassuring. You didn't do anything wrong.
This medicine is just to help your tummy feel
better. That reassurance is absolutely key. Now,
the adolescents. The teenagers. They are cognitively
capable of understanding pain, but they come
with so much social baggage. Huge social baggage.
Their primary developmental drive is identity
and independence. And their biggest fears are
body image and loss of control. So how does that
manifest when they're hurting? It often looks
like stoicism. We mentioned the football player
earlier. A teen might sit there, stone -faced,
scrolling on their phone while their pain is
an 8 out of 10. They are terrified of losing
control of crying in front of you or their parents
or, God forbid, their friends who might visit.
They don't want to look like a baby. So with
a teenager, a calm exterior could just be a mask?
It's often a mask, yes. Yeah. You have to give
them permission to be vulnerable and you have
to give them choices. Do you want the pill now?
or in 15 minutes. Do you want your mom to stay
in the room or do you want her to step out for
this part? Giving them back just a tiny bit of
control can lower their anxiety, which we know
actually lowers their perception of pain. That
connects nicely to the nice to know notes here.
School age kids, that middle group, they're usually
the easiest to assess, right? Generally, yes.
The six to 12 year olds. Yeah. They have the
language to describe the pain. It feels like
a knife versus it just aches. And they understand
cause and effect. I fell off my bike, so my knee
hurts. They're usually your most reliable historians
in the pediatric world. All right. We've assessed
the pain. We've found it. Now we have to treat
it. Section five, pharmacologic management. This
is the heavy lifter. This is where safety is
absolutely paramount. This is the section where
the 80 -20 rule really saves lives. We need to
talk about the drugs, the side effects, and what
I call the assessment loop. Let's start with
the big three categories mentioned in the text.
How should we organize these in our minds? It's
a simple framework. Number one, analgesics. This
is your main pain fighting category. It includes
non -opioids like acetaminophen, Tylenol, and
NSI. It's like ibuprofen. And then it includes
the opioids morphine, fentanyl, hydromorphone.
Number two, adjuvants. These are drugs that aren't
primarily painkillers, but they help with specific
types of pain or with the anxiety that comes
with pain. Think benzodiazepines, like Valium,
for muscle spasms, or anticonvulsants, like gabapentin,
for neuropathic or nerve pain. And number three,
anesthetics. These are the numbing agents, lidocaine
that you inject or EMLA cream that you put on
top of the skin. Let's focus on the analgesics
first. The text mentions something called a sealing
effect. This feels like a classic nuance that
exam writers would test on. It is. It's a key
distinction. Non -opioids, like ibuprofen, have
a sealing effect. That means there is a maximum
dose where you get maximum pain relief. If you
give more than that dose, you don't get any more
pain relief. You just get more side effects like
liver or kidney toxicity. The curve basically
flattens out at the top. Exactly. But opioids,
specifically the pure agonists like morphine,
do not have a sealing effect. Theoretically,
the more you give, the more pain relief you get.
So why don't we just give massive doses and wipe
out all the pain? Because the side effects also
have no sealing. The limiting factor with opioids
isn't efficacy. It is respiratory depression.
You stop increasing the dose because the patient
stops breathing. And that brings us to the number
one need -to -know adverse event, respiratory
depression. This is the ABCs of nursing. Airway,
breathing, circulation. It is. But in practice,
we need to be very specific about what that looks
like. It's not just, he's not breathing. It's
a progression. It's a slide. What's the first
sign? First, the patient gets sedated. They get
drowsy. Then the respiratory rate starts to slow
down. Then the depth of their breathing becomes
shallow. And only then does the oxygen saturation
drop. So if you wait for the O2 sat alarm to
start beeping, you are late to the party. You
are very late. The O2 sat is a lagging indicator.
The need to know assessment parameters are sedation
level and respiratory rate. If Lucas is on a
morphine drip and he is unarousable, you can't
wake him up by shaking his shoulder. That is
an emergency. Even if his O2 sat is still 95
percent, he is on the verge of respiratory failure.
And the intervention in that moment? Stop the
infusion immediately. Stimulate the patients.
Shake them. call their name and have naloxone
or Narcan ready. But remember Narcan reverses
the pain control too. Lucas will wake up screaming
in agony. So you use it very carefully titrating
it if possible to just bring his respiratory
rate up without completely eliminating his pain
relief. Let's talk about the other side effects.
The ones that won't kill them but will make them
miserable. Constipation. This is basically guaranteed.
Opioids slow down bowel motility to a crawl.
If a child is on opioids for more than 48 hours,
they must be on a bowel regimen. Stool softeners,
laxatives. You do not wait for them to get impacted.
Prevention is key. And pruritus. Itching. Ah,
yes. This is the classic sake allergy trap on
exams. You give a dose of IV morphine. Five minutes
later, the parent hits the call bell and says,
he's scratching his nose. He's allergic. The
new nurse panics and thinks, oh my god, anaphylaxis.
Is he allergic? Probably not. Opiaries can cause
histamine release, which causes itching, especially
around the face and nose. It is a very common
side effect, not necessarily a true allergy.
So how do you tell the difference between a side
effect and a life -threatening allergy? You look
for the other signs of anaphylaxis. Are their
hives urticaria all over the body? Is their child
wheezing? Do you hear stride or is their blood
pressure dropping? If it's just an itchy nose,
it's a side effect. You can treat it with an
antihistamine like Benadryl or you can talk to
the provider about switching to a different opioid.
But don't immediately label that kid allergic
to morphine without a full assessment. You might
block them from getting necessary pain control.
for the rest of their life. That is a crucial
distinction. Now the assessment loop, the source
text is very, very firm on this. The assessment
loop is your legal and ethical requirement. It
is not enough to give the pill or push the IV
med. You must reassess. The standard of care
is typically 15 to 30 minutes after an IV medication
and 45 to 60 minutes after an oral medication.
You have to go back to the bedside. And what
are you checking for specifically in that reassessment?
Three things. Number one, did it work? What's
the new pain score? Number two, are they safe?
What are their vitals? What is their respiratory
status and sedation level? And number three,
are there any side effects? Are they itching?
Are they nauseous? If you document the administration,
but you don't document the reassessment legally,
you abandon that patient. Abandon the patient.
That's a phrase that just chills the blood. It
should. Okay. Let's wrap up pharma with a need
to know regarding dosing. PADES is different
from adults because... Weed -based gosing. Everything
is per kilogram. Milligrams per kilogram per
dose. Which means math. Which means errors. The
single most common cause of medication error
in pediatrics is a calculation error. Moving
the decimal point one spot to the right is a
tenfold overdose. If Lucas is supposed to get
two milligrams of morphine and you accidentally
give him 20 milligrams, that is likely fatal.
So the rule is? Double check. Triple check. Many
hospitals require a two nurse check for high
alert medications like opioids and insulin. But
even if they don't, you do your own math twice.
Verify the weight, never ever guess. Alright,
section six. We are in the home stretch. Non
-pharmacologic and procedural management. This
is what I call the art of PEDS nursing. It's
not just pushing meds, it's managing the environment
and using your creativity. And honestly, for
a lot of minor procedures, needle sticks, IV
starts, these are your primary interventions.
or at least should be used in combination with
meds. Let's talk about sucrose, the sweeties.
This sounds like an old wives' tale. It sounds
like it, but it's pure evidence -based magic
for infants. It's a 24 % sucrose solution, basically
concentrated sugar water. You dip a pacifier
in it, or you can put a few drops directly on
the tongue. And how on earth does sugar stop
pain? It stimulates the release of endogenous
opioids and endorphins in the infant's brain.
It effectively drugs them with their own natural
pain killer. That's wild. It works best for infants
up to 12 months, although it's most effective
under six months. You use it about two minutes
prior to a procedure like a heel stick or an
ID start. Combined with non -nutritive sucking,
the pacifier, it significantly reduces pain scores.
So sugar plus a pacifier equals a much happier
baby. It's a proven formula. Next up. Therapeutic
hugging. I love this term because the word restraint
just sounds so barbaric. And it felt barbaric.
We used to do that. Yeah. Papoose boards, holding
kids down, spread eagle on a table. It was incredibly
traumatizing for everyone involved. Therapeutic
hugging is a secure holding position. Usually
the parent sits on the bed or chair and holds
the child on their lap, securing the child's
arms and legs with their own body in what feels
like a big tight hug. So the child feels held,
not trapped or attacked. Correct. It provides
comfort and immobility so the nurse can get the
IV or the shot in safely. And it turns the parent
into a protector and a helper rather than just
a terrified spectator. What about topical anesthetics?
Things like EMLA cream or LMX. These are creams
that numb the skin. The absolute need to know
here is timing. EMLA cream takes a full 60 minutes
to work effectively. LMX is a bit faster. It
takes about 30 minutes. So you have to plan ahead.
You can't just decide to use it in the moment.
You have to anticipate. If you know Lucas needs
a blood draw at 10 a .m., you put the cream on
at 9 a .m. If you walk in at 10 a .m. and say,
oops, I forgot, it's too late, you're going to
have to stick them without it. Anticipatory guidance
is a huge part of good pediatric pain management.
And for the tiniest patients, the preemies there
is kangaroo care. Skin to skin contact. You just
place the diaper -clad infant directly on the
parent's bare chest. The research on this is
so robust. It stabilizes their heart rate and
improves their O2 saturation, and it significantly
reduces pain scores during and after procedures.
It's free, it's safe, and it promotes bonding.
There's no reason not to do it. Let's talk about
the procedure itself. Sometimes we have a choice
in how we hurt them, right? We do. Procedural
choice. This is especially true for newborns.
If you need a significant amount of blood, the
evidence clearly shows that a venipuncture drawing
from a vein with a small butterfly needle is
actually less painful than a heel stick. Really?
The heel stick seems so routine, so much less
invasive. But it involves squeezing the foot
over and over to milk the blood out. That causes
breathing and prolonged pain. A skilled phlebotomist
doing a venipuncture is one quick poke, you get
the blood flow, and you're done. So we should
always advocate for the method that hurts less.
And finally, cognitive strategies. Destruction.
Bubbles. I always carry bubbles in my pocket.
Do you know why they are the perfect tool? Because
everyone loves bubbles. That's part of it. But
there's a physiological reason. To blow a bubble,
you have to take a deep breath in and then exhale
slowly and controlled. It forces the child to
do deep breathing exercises without even knowing
they're doing it. Oh, that's brilliant. It lowers
their heart rate, relaxes their muscles, plus
watching the bubble float away is a powerful
visual distraction. It helps gate the pain signal.
The brain is so busy processing the bubble, it
has less capacity to process the pain. It's a
breathing exercise disguised as a toy. I love
it. Guided imagery is another great one for older
kids. Lucas, tell me about your favorite place.
Is it the beach? What does the sand feel like?
Can you hear the seagulls? Is the water cold?
If you can get his brain to process all the sensory
details of the beach. It has less bandwidth to
process the pain signal coming from his abdomen.
The brain can only focus on so much at once.
We have covered a massive amount of ground here.
Let's bring this in for a landing with the summary.
If the listener is driving to their exam right
now or walking onto the unit for their shift,
what are the gold standard takeaways? Let's hit
the top four. The absolute must -knows. Go for
it. Number one, trust the assessment, but know
the traps. Sleep does not equal comfort. Newborns
feel pain. Kids will lie to you to avoid a shot.
Believe the body. Okay, number two. Two. Use
the right tool. Faith Ease is for three and up,
but only if they understand the instructions.
Numeric Scale is for five and up. And FLA CC
is for everyone who can't speak for themselves.
Number three. Three. Respect the opioids. They
are safe and effective if you monitor respiratory
rate and sedation level. Watch for that slide
into sleepiness before the breath stops. And
the last one. And number four. Advocate. Be the
advocate. Use the parents as a resource. Use
the sugar water. Use the numbing cream. Use the
bubbles. Don't just document the pain. Do everything
in your power to treat it. And remind us of the
why. Why do we care so much about this? It's
not just about being nice. It's not. Because
pain changes the wiring of the brain. Uncontrolled
pain releases cortisol. It suppresses the immune
system. It delays wound healing. A child in pain
physically heals slower. And as we learned with
the newborns, it can create long -term sensitization
to pain. By managing pain well today, you're
actually protecting that child's future interaction
with the entire healthcare system. You are preventing
medical trauma. I want to leave everyone with
a thought that really stuck with me from our
discussion on the sleeping trap. It just, it
really challenges how we view our patients. It
does. It's the question I want every nurse to
ask themselves. When they walk into a room and
see a quiet sleeping child in a hospital bed,
are they peaceful or are they just exhausted?
Explain that distinction one last time for us.
Peaceful implies comfort, relief, resolution.
Exhausted implies a battle has been fought. If
that child has been fighting pain for hours and
finally collapses into sleep, that is not a success
for us. That is a physiologic shutdown. If you
assume peace when the reality is exhaustion,
you will miss the pain. and you will fail that
patient. So look closer. Check the furrow in
their brow. Check their palms. Check the history.
Be the detective. Powerful stuff. Thank you so
much for this deep dive. To all the nurses and
students out there, good luck with your exams,
but more importantly, good luck with your patients.
Be the advocate they need you to be. See you
next time.