Family Centered Care and Pain

Question 1

Family

Answer 1

A group of individuals who share a legal or genetic bond, but for many it means much more

Question 2

Legal bond

Answer 2

A family thats legally bound through marriage, adoption, guardians, and includes the rights, duties, obligations, and contracts that they entered in to
Can be changed, expanded or dissolved

Question 3

Blood bonds

Answer 3

individuals who are directly related through a common ancestor
Close and distant realtives

Question 4

Types of family

Answer 4

Nuclear or Conjugal
Extended
Complex
Step
Traditional
Adopted
Foster

Question 5

Nuclear or Conjugal family

Answer 5

Parents and their children living in the same residence or sharing the closest of bonds

Question 6

Extended

Answer 6

Includes all relatives being in close proximity (generations: X, Y, Z) where relatives live maybe not next door to each other, but in the same city
Household that is extended: these families can live together and share household duties, also called joint family or multigenerational family depending on which member are included

Question 7

Complex

Answer 7

Extended family which has 3 or more adults + their children
Formed through divorce and remarriage or may be formed through polygamy in societies where that practice is acceptable
Families may be complex without formal legal binds between adults

Question 8

Step

Answer 8

Families where adults have divorced and remarried bringing children from other unions together to form a new nuclear family
Called blended family
May come from several different parents or may be new to the family

Question 9

Traditional

Answer 9

Classical family
Father works outside of the household to support the members financially while the mom stays at home and raises the children and takes care of them
Roles may be reversed

Question 10

Adopted

Answer 10

Family shares legal bond but not genetics

Can be emotional or spiritual bond where no formal legal bonds are present

Question 11

Foster

Answer 11

Includes one or more adult parents who serve as temporary guardians for one or more children to whom they may or may not be biologically related to
More formal arrangements may be made
Foster children can be legally adopted

Question 12

Enabling

Answer 12

When we can enable a family through education and practice to acquire the competencies they require to take care of their child, they are able to meet the needs of their family

Question 13

Empowerment

Answer 13

Returns to the family a sense of control

This is something we can give to the family– a sense of control that they had lost when their child got sick

Question 14

Family Centered Care Basic concepts:

Answer 14

Enabling
Empowering
Control
Communication

Question 15

Communication

Answer 15

When we communicate, we offer education, we foster and honor the families sense of strength, abilities, and action
The family that will be taking care of the child upon discharge
Its imperative that we give them these skills, knowledge, and encouragement

Question 16

Promoting Healthy Families

Answer 16

Disease prevention
Health promotion
The family is the driver

Question 17

Family Centered Care: Best approaches

Answer 17

Education

Anticipatory Guidance

Question 18

Education

Answer 18

Important that we helpguide families through the stages of child growth and development and milestones of each age
If we identify problems early we can get better outcomes

Question 19

Anticipatory Guidance

Answer 19

Help the family understand the medical treatment and diagnosis
Encouraging the children to ask questions about their bodies and conditions, referring families appropriately to agencies or support groups
ABOVE ALL COMMUNICATE!

Question 20

Parenting Styles

Answer 20

Authoritarian
Authoritative
Permissive/Indulging
Uninvolved

Question 21

Parenting Styles: Authoritarian

Answer 21

Children are expected to follow very strict rules established by the parent and a failure to follow these rules will result in punishment
“Because I said so” parents
Often fails parents because they aren’t giving reasoning to. children about the action, so the children don’t understand why they are doing what they are doing
Parents have very high demands, children are not responsive
Children are obedient and proficient but often in test show lower confidence/self-esteem, happiness, and social competence than other children

Question 22

Parenting Styles: Authoritative

Answer 22

Like Authoritarian, having guidelines that they expect their children to follow, however they are more democratic
Responsive to their children and are willing to listen to their questions
More nurturing and when their children fail, they often are more forgiving and don’t give heavy/strict punishment
Assertive but not restrictive or intrusive
Disciplinary methods aren’t necessarily punitive
Desire their children to be assertive, socially responsible, and cooperative
Children are usually very happy, capable, and successful in their lives

Question 23

Parenting Styles: Permissive/Indulging

Answer 23

Parents make very few demands of their children
Rarely discipline children
Have low expectations of maturity and self-control
Non-traditional parents and are very lenient
Will avoid confrontation
Can be nurturing and communicative, but they are more like a friend and not a parent
Almost like they are living through their children
Children rank low in happiness and self-regulation, have problems with authority and perform poorly in school

Question 24

Parenting Styles: Uninvolved

Answer 24

Parent place very few demands on children
Not alot of responsiveness and there is little communication
Fulfill the child’s basic needs, but are detached
Extreme cases: they may reject or neglect their child’s needs
Children lack self control, low self-esteem, and are less competent than their peers

Question 25

Parenting influences

Answer 25

Key characteristics parents should always exhibit when working with their children Engagement Consistency Validation

Question 26

Engagement

Answer 26

Need to be engaged Invested in childs activities Spending quality time with child

Question 27

Consistency

Answer 27

Must be consistent in what they do with children Cant deviate Children need consistency, so that they know what it is that they are expected to do and can do

Question 28

Validation

Answer 28

Builds self-esteem Validate: feelings (even if they seem inconsequential or idiotic), fears (its ok to be scared but you will work through the fear), and all other emotions Children see thing differently

Question 29

Parental Guildlines

Answer 29

Safety Realistic expectations Discipline Pediatric choices

Question 30

Safety

Answer 30

Most important to address with parents

Question 31

Realistic expectations

Answer 31

of their children and self

Question 32

Discipline

Answer 32

how to incorporate into family setting, knowing when its appropriate to use it Focus on the importance of consistency Focus on positive reinforcement and NOT negative reinforcement

Question 33

Pediatric choices

Answer 33

Parents need to be careful what they offer the child These influences can be tremendous Children that spend alot of time with their parents are directly influenced by their behaviors, choices, and beliefs

Question 34

Family Stressors

Answer 34

A sick child could be the first crisis that the family faces | Depended on: Severity of illness, Frequent flyer, Medical procedures, coping abilities, cultural/religious beliefs

Question 35

Frequent flyer

Answer 35

Do they have previous experience with illness/hospitalization? Sometimes they know what to expect, it can be a stressor because if something different happens, then they know disease has progressed

Question 36

Coping abilities

Answer 36

What are their personal strengths? Family support system? Other stressors are on the family system?

Question 37

Common themes in families with hospitalized children

Answer 37

Families become helpless, they question the skills of the staff, they don't understand/hear because they are stressed (you must reinforce teachings, use simple explanations They need their fears and uncertainty respected They need reassurance They need to see the staff being compassionate and concerned for their child, attending to every detail

Question 38

Sibling response

Answer 38

Lives are turned upside down Become scare, lonely, and angry Start noticing their parents pay more attention to the sick child and become jealous and resent their sick sibling, then they feel guilty for the jealousy Behavior often regresses to that of a previous developmental stage (its ok) These children need someone to talk to them about their siblings situation because they are emotionally stressed out

Question 39

Children and hospitalizations

Answer 39

Young children are vulnerable to stress and are so used to a routine and may not have the coping mechanisms necessary to deal with this new situation

Question 40

Children and hospitalizations: Children's Experience

Answer 40

Parental separation Loss of control They dont feel well and they dont understand why, and dont understand fear

Question 41

Children and hospitalizations: Parent Experience

Answer 41

Fear of whats happening to their child, guilt, confusion, loss of routine, loss of control

Question 42

Children and hospitalizations: Most common things seen

Answer 42

``` regression separation anxiety apathy fear sleep disturbances especially in children <7 ```

Question 43

Children and hospitalizations: Other factors that make hospitalization difficult

Answer 43

Children with difficult temperament (age? More temperamental between 6mo and 5yr) Gender Do they have a low IQ Frequent flyer syndrome

Question 44

Children and hospitalizations: Infants

Answer 44

Pain is not localized but generalized to them and they are totally in pain Make sure to relieve the pain Loss of routine Sleep deprivation Vulnerable immune system because they have not been able to have most of their vax

Question 45

Children and hospitalizations: Toddlers

Answer 45

Basic fear of loss of love, the unknown They wonder if they are being punished Immobilization and isolation will influence their physical and psychosocial development Can regress to earlier behaviors and will go through the stages of separation anxiety

Question 46

Children and hospitalizations: Separation anxiety

Answer 46

Protest Despair Detachment or denial of whats going on

Question 47

Children and hospitalizations: Protest

Answer 47

they will not be consoled by the parents they want to go home reject strangers or new nurses

Question 48

Children and hospitalizations: Despair

Answer 48

Sleep pattern will alter Lose weight because they wont eat Have diminished interest in play Sad and unresponsive to stimuli

Question 49

Children and hospitalizations: Detachment or Denial of whats going on

Answer 49

Wont acknowledge their parents | They'll be friendly to other people who come along

Question 50

Children and hospitalizations: Preschoolers

Answer 50

Have fears about their body image and bodily harm Have a limited understanding of what s going on Their fears are about intrusive things like IVs or shots or tubes Have the same perception of punishment and rejection Worry about pain and that they wont look the same Also regress View death as temporary Cry when parents leave but will calm down after they are gone May find physical exams threatening and so you may have to modify your procedures

Question 51

Children and hospitalizations: School age

Answer 51

Tolerate separation but really want their parents to be near Fear the unknown, bodily harm, and disfigurement Concept of death changes at this time (6-8yr/o: death is the boogieman, 9-10yr/o: death is more realistic) Very concerned about their self image and may even use avoidance to cope with physical discomfort Want to know whats going on, the rationale, and want to participate in self care

Question 52

Children and hospitalizations: Adolescents

Answer 52

Be honest They have concerns about their privacy, sense of control, and independence Very concerned about their body image and being different than their peer Developmental problems that might be going on are magnified by their illness Can be non-compliant Worry about the future We must empower them as much as possible and allow them choices as appropriate

Question 53

Preparing for hospitalization

Answer 53

Prevent separation from parents Make their room a home away from home MInimize everyone's loss of control Promote freedom of movement, particularly with adolescents Maintain child's routine as much as possible Encourage independence (self care) Help them understand whats going on using simple language Promote plat to teach the children and help the parents learn what's going on. Demonstrate things you are going to do Distract children, use treatment room appropriately so their room stays a safe place Prevent and minimize fear about pain and imagery

Question 54

Positive effect of Hospitalizations

Answer 54

Can strengthen family relationship Offer educational opportunities Help child become independent and self reliant and gain self mastery

Question 55

Cultural competency

Answer 55

Be sensitive to cultural differences (Culture: a particular group with its own set of values, beliefs, norms, patterns that are learned, shared, and transmitted from one generation to another) Be aware and appreciate cultural values of patient and family Have knowledge Collect data that is important in working with families of different culture Encounters can happen indirectly or directly Have desire to be engaged and sincere in wanting to learn more about other cultures May be rituals, diets, and alternative therapies that are important to family in care of the child Thought process must extend to spirituality, and the need to be aware and sensitive aof dealing with other religious beliefs and practices

Question 56

What is pain

Answer 56

Whatever the child says it is and exists whenever the child says it does Pay attention to the child: look at them objectively, listen to them subjectively in regard to their description of pain If a procedure is invasive it will hurt whether the child says it does or not, still requires the same treatment

Question 57

Pedi pain experiences

Answer 57

Procedure related pain: dressing changes, IV line placement, PT session Operative pain Trauma associated pain Acute and Chronic pain from illness or injury All influence the child's future response to pain Fear and anxiety have such a large effect in pedi pt. especially procedural pain. Provide adequate analgesia, especially for the first procedure as this will highly influence future pain perception for child

Question 58

Assessment of Pedi pain

Answer 58

Report of pain is the most reliable diagnostic measurement of pain Behavior and physiologic measures are also used to evaluate pain in infants, non-verbal children Pain assessment is individualized and not one patient is the same Know your options: if the medication doesn't work, then know your backup, tailor according to the patients response Evaluate to know their response

Question 59

Influential factors in assessing Pedi pain: take into consideration

Answer 59

Age: how pain is communicated Developmental level Past experiences with pain: can affect their future perception of pain, control it the first time Socio-cultural difference in attitudes toward pain and how child expresses pain Anxiety and fear and fatigue: all increased sensitivity to pain Cognitive impairment: may affect child's ability to report pain Family and friends may decreased sensitivity to pain by staying with the child Personal genetic wiring for pain

Question 60

Pain free me

Answer 60

Multidisciplinary approach Nurse must utilize proper assessment techniques and tools Work closely with: Physicians, Pain specialist (pedi team), Anesthesia, Child life specialists

Question 61

Ranges of pain

Answer 61

Pain level ranges from a scale of 0-10 Pain score will determine the appropriate intervention Mild: 1-3 (non-pharmacological methods) Moderate: 4-6 (meds) Severe: 7-10 (meds) Combined pharmacological and non-pharmacological methods for best pain relief

Question 62

Neonate characteristic facial responses to pain

Answer 62

Bulged brows, eyes squeezed shut, furrowed nasolabial creases, open lips, pursed lips, stretched mouth, taut tongue, quivering chin

Question 63

Neonatal physiological response to pain

Answer 63

Increased BP | Decreased arterial saturation

Question 64

Older children and pain

Answer 64

Important to note their body posture matches what they are telling you Sometimes they won't tell you they have pain because they don't want to stay in the hospital longer and other times they will tell you they are in severe pain but are not showing it. It is our job to assess and start with non-pharmacological methods and determine what can be used to treat stated pain

Question 65

Various pain scales available

Answer 65

Be familiar with your hospital's policies | Pain scales are different depending on the child's age, verbal/nonverbal

Question 66

Various neonatal behavioral pain scales

Answer 66

PIPP CRIES NIPS aka N-PASS NFCS

Question 67

PIPP

Answer 67

behavioral measure of pain for premature infants

Question 68

CRIES

Answer 68

Neonatal postoperative pain scale Pain is rated on a scale of 0-10 and the behavior indicators include: crying, changes in VS, expression, and altered sleeping patterns Used for 32 weeks of gestation to 20 weeks of like

Question 69

NIPS aka N-PASS

Answer 69

Used to measure pain in preterm and full term neonates

Question 70

NFCS

Answer 70

Used for assessing post-op pain in infants

Question 71

Other behavioral pain scales

Answer 71

FLACC | COMFORT

Question 72

FLACC

Answer 72

Measurement used to assess pain for children between the ages 2 mo - 7yr or individuals that are unable to communicate their pain from post-op pain

Question 73

COMFORT

Answer 73

ICU setting | Also used for infants

Question 74

Pain rating scales for children

Answer 74

Children from 3-7 may comprehend how to use these | Visual scales should be used for children > 3 (FACES, VAS, OUCHER, WONG-BAKER)

Question 75

FACES

Answer 75

Drawings of happy or sad faces to depict levels of pain

Question 76

VAS

Answer 76

Visual analog scale Used for 7 years and older May be effective in children as young as 5 Rate pain on a scale of 0-10, the child points to the number that best describes their pain

Question 77

OUCHER

Answer 77

Ages 3-12yr Ethnically based self reporting tool 3 versions: Caucasian, AA, Hispanic Used to help child identify with something that looks like them Ask them to state exactly where the pain is Don't use words like happy or sad to describe pain 0: no hurt at all 2: little bit of hurt 4: little more hurt 5: pretty much hurt 6: biggest hurt you can ever have Ask the child to point to the picture that corresponds with what they are feeling and document accordingly

Question 78

WONG-BAKER

Answer 78

0-10 with faces

Question 79

Objective data for assessment and evaluation of pain

Answer 79

Facial expression (grimace, wrinkled forehead, eyes closed shut) Body movement (restlessness, pacing, guarding) Moaning and crying Decreased attention span Vital signs: objective part of the whole picture

Question 80

Subjective data for assessment and evaluation of pain

Answer 80

``` Use the specific words that the child used to describe the pain When did your pain start? Where is your pain? Can you rate your pain? What makes your pain better/worse? Does anything else hurt? What does the pain feel like? ```

Question 81

Physiological signs of pain

Answer 81

Acute phase: increased HR, BP, diaphoresis The body's normal response when revved up is to calm down Chronic pain will not have a physiological difference Look at the whole picture: objective data, subjective data, physiological measurements

Question 82

Pain management

Answer 82

Unrelieved pain can lead to potential long term physiological, psychological and behavioral consequences Use both pharmacological and non-pharmacological measures Non-pharmacological measures can help reduce perception of pain, decrease anxiety and provide a sense of control

Question 83

Non-pharmacological measures used in pedi pain

Answer 83

Positioning: comfortable, not laying on side where they had surgery, use pillows to guard area Reinforcing breathing and relaxation techniques Providing Ice or heat to swollen or injured area Maintaining calm environment Music therapy Pet therapy: shown to decrease patients pain, anxiety, and increased their healing Splinting: stiffening of a body part to avoid pain caused by movement of the part, as from a fracture or other injury, use pillows for positioning Cluster your care Offering warm blankets Assisting with guided imagery Offer distractions Provide comfort with physical contact Administer sucrose pacifiers for infants during procedure

Question 84

Various Routes for pain management

Answer 84

``` PO IV PCA/PNCA Epidural Refrigerant sprays Transmucosal Transdermal Topical ```

Question 85

Pain management: PO

Answer 85

First choice when available Tylenol: mild to moderate pain Ibuprofen: mild to moderate pain Tylenol #3: (combo of tylenol and codeine): moderate to severe pain

Question 86

Pain management: IV

Answer 86

Morphine: severe pain Fentanyl: severe pain Dilaudid: severe pain

Question 87

Pain management: PCA/PNCA

Answer 87

Patient controlled, parent controlled, nurse controlled analgesia Morphine: moderate to severe pain Hydromorphone: moderate to severe pain Fentanyl: moderate to severe pain

Question 88

Pain management: Epidural

Answer 88

Ropivacaine | Levobupivacaine

Question 89

Pain management: Refrigerant sprays

Answer 89

Ethyl chloride | Fluoromethane

Question 90

Pain management: Transmucosal

Answer 90

Oralet (fentanyl)

Question 91

Pain management: Transdermal

Answer 91

Fentanyl or Morphine patch: know where its located on your patient and how often it needs to be changed

Question 92

Pain management: Topical

Answer 92

EMLA | LMX

Question 93

Pharmacological Management of Pain: Non opioids

Answer 93

Mild to moderate pain or in addition to opioids for severe pain Acetaminophen is very common IV, PO, PR

Question 94

Pharmacological Management of Pain: NSAIDS

Answer 94

``` Mild to moderate pain Puts the patient at risk for bleeding: must get baseline CBC and monitor for bleeding Ibuprofen Ketorolac Naproxen ```

Question 95

Pharmacological Management of Pain: Opioids

Answer 95

For moderate to severe pain Combo: Acetaminophen and codeine: Tylenol #3 (remember theres a limit to amount of tylenol) Combining an opioid and non opioid medication treats pain peripherally and centrally, offers greater analgesia with less A/E like respiratory depression, constipation and nausea Morphine is the gold standard and most commonly Rx Hydromorphone Fentanyl Methadone Tramadol Meperidine

Question 96

Pharmacological Management of Pain: PCA

Answer 96

Used to manage post-op pain, pain from injury, and chronic conditions 2 nurse check Know how the dr orders it: patient controlled, parent controlled, nurse controlled MD must order: Medication, Program settings, Rate/dose, Bolus volume (if the patient is allowed to have for breakthrough pain), Maximum allowed hourly dose, Lock out time (the time the patient has to wait before being able to push the administration button again)

Question 97

Narcotic Side effects

Answer 97

Respiratory depression #1 Constipation (order stool softener, monitor bowels, hydration) N/V (can take antiemetics before) Dizziness (educate about getting up slowly and resting both feet on ground before standing) Itching (might need to give benadryl before) Increased sleepiness (can be from too much benadryl: adjust dose)

Question 98

Have these at the patient's bedside when on narcotics

Answer 98

15L O2 flow regulator Various O2 delivery systems Ambu bag with appropriate size face mask (need at least 15L to fill up Ambu bag that will be attached to O2 flow regulator Code sheet (patient could go into respiratory and cardiopulmonary failure) PRN order for Naloxone if respiratory depression occurs

Question 99

Continuous monitoring for patients on narcotics

Answer 99

Cardiopulmonary and pulse ox to monitor for respiratory depression

Question 100

Evaluation of effectiveness of pain therapy

Answer 100

Need to evaluate 30 minutes to an hour after administration for effectiveness If not effective then it needs to be changed If it works on one patient it doesn't mean it will work on the next Know all options available to you and the safe dosages