Age Appropriate Care & Pain Management

Self Learning Module – Developed by Staff & Community Education Revised 10/98; 7/01; 5/03; 11/07 Reviewed 9/10; 9/11; 9/12

Normal Vital Signs Adult vital signs Pulse 60 to 100 beats per minute 90 to 140 mmHg (systolic) Blood Pressure 60 to 90 mmHg (diastolic) Respirations 12 to 20 breaths per minute Child vital signs (age 1 to 8 years) Pulse 80 to 100 beats per minute Blood Pressure 80 to 110 mmHg systolic Respirations 15 to 30 breaths per minute Infant vital signs (age 1 to 12 months) Pulse 100 to 140 beats per minute Blood Pressure 70 to 95 mmHg systolic Respirations 25 to 50 breaths per minute Neonatal vital signs (full-term < 28 days) Pulse 120 to 160 beats per minutes Blood Pressure >60 mmHg systolic Respirations 40 to 60 breaths per minute

0-1 Month Neonate 0-1 Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Adaptations Care  Eyes are closed much of the  Able to fixate on  Prefers the  Sleep is  Involve parents in care time even when awake. an object visually human face major activity  Teach about feeding, hygiene, safety and other  Aversion to bright lights  Prefers ways to promote healthy development complex  Begins to  Tear ducts do not function patterns to develop  Support head simple sense of  Cannot support own head patterns touch  Observe fontanelles for tenderness, bulging or depression  Umbilical site heals to form  Prefers  Begins to navel medium recognize  Have bulb syringe available in case of need for lighted parents suctioning  Reflexes present: moro, objects stepping, smiling, grasping,  Keep crib siderails up at all times rooting, sucking, protective head turning, and tonic neck  Encourage parents to assist with care

 Neonates are especially  Smile at the neonate sensitive to electrolyte imbalance and to their  Provide basic needs, while maintaining a safe environment in terms of body environment heat regulation  Teach parents the importance of car seat safety  Anterior Frontal Fontanelle is and the danger of the child ingesting objects soft and will be until around 4 (baby-proof the environment) months of age.  Provide support to head and neck  Rapid Growth  Position on back to go to sleep to prevent SIDS  Average head circumference (Sudden Infant Death Syndrome) 13.5"  If giving IV fluids, use a volume control unit

 Pain is indicated by irritability, restlessness, brow bulge, or vigorous cry

1-12 Month Infant

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care Adaptations  Rapid growth  Raises head, turns  Recognizes  Establish trust  Involve parents or primary caregivers in care over, rolls over, parents,  Weight doubles sits up, scoots, primary  Smiles  Encourage parents to assist with care by 5 months and creeps, crawls, caregivers (0-3 spontaneously at triples by 1st year pulls themselves months) human faces (2  Keep siderails up on crib at all times. up and walks. months)  Posterior  Cries when  Keep parents in baby's line of vision fontanelle closes  Reaches and mother, father  Plays social - 2 months grasps objects or primary games (peek-a-  Utilize distraction techniques as appropriate bringing to mouth caregiver boo and patty  Begins teething leaves (7-9 cake)  Respond to baby's bid for help  Begins to feed months)  Bladder and themselves  Monitor toys for removable parts and safety bowel patterns  Begins to approval develop  Reactions speak and advance from mimic sounds  Provide familiar objects  Primitive reflexes reflexes to diminish toward intentional  Learns by  Provide opportunity for return demonstration of end of 1st year imitation new procedures by parents or primary caregivers

 Active learning  Provide basic needs while maintaining a safe environment  Shows range of emotions (ex:  Offer age appropriate toys anger, frustration,  Cuddle an upset child and talk in soothing tones affection, fear with  Pain in an infant is demonstrated by irritability, separation, and restlessness, brow bulge, or vigorous cry. anxiety with strange  Teach parents the importance of car seat safety situations and and the danger of the child ingesting objects people, etc.) (baby-proof the environment) (10-12 months)

 Obeys simple commands

1-3 years Toddler

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age- Adaptations specific Care  Decreased appetite and  Places foreign  Utilizes fantasy  Parents are  Involve parents in care food intake objects in and magical significant people orifices thinking and/or  Encourage parents/primary caregiver to  Abdomen protrudes mental play to  Discovers/develops stay with child, especially at night  Shakes, sniffs, adapt to fears and sense of will  Developing bowel and and visually anxieties  Allow to express feelings bladder control examines all  Separation/stranger new objects  Shares what they anxiety present  Explain what you'll be doing before  Improved balance want to be true, beginning  Feeds self believing what  Develops/asserts they are saying independence  Use play as a means of preparing and  Walks up and instead of stating explaining but be firm and direct down stairs facts  Everything is "mine"  Don't give anything small enough to fit  Stands on 1 foot  Play is a form of in a body orifice learning  Puts away toys  Throws a large experience  Utilize stories to explain what is ball  Plays simple happening and use their belief in magic  Understands games simple directions  Allow choices if possible and requests  Have little control over their emotions  Utilize distraction techniques  Verbal skills are improved  Provide opportunity for return demonstration of new procedures by  Short attention parents or primary caregivers span  Provide basic needs while maintaining  The toddler has a safe environment trouble  Explain procedures to parents and the understanding child in simple terms. Allow time for pain, and may questions think it is a  Educate parents on home safety, punishment outlets, windows, poisons, and using the car seat until child weighs 40 lbs

3-6 years Preschool

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age- Adaptations specific Care  Slow and  Bounces large ball with  Increased vocabulary  Parents, siblings and  Involve parent/primary caregiver in regular growth both hands progressing but uses words peers are significant care to one hand without  Becomes taller understanding  Learns to recognize  Use simple instructions and thinner  Skips, hops, jumps meaning and deal with rope, roller skates physical and  Prepare for procedures by  Toilet training  Ritualistic emotional separation pretending with actual equipment. completed  Prints own name (5 from parent Explain the procedure just before years)  Retains magical you perform it thinking  Others  Washes and dries hands  Hold their hand - bathes self  Expresses feelings  Aware of others’ through actions feelings  Tell stories to explain what is  Dresses self during play happening  May use aggression  Throws and catches  More fears than any  Utilize belief in magic ball other age group (ex:  Identifies behavior body mutilation, modification by  Provide opportunity for return death) rewards and demonstration of new procedures punishment by parents or primary caregiver  Frequently believes illness/injury is  Enjoys playing with  Provide basic needs maintaining a punishment for some other children and safe environment real or imagined making friends misdeed  Avoid words that might be scary  May have fears, for  Fears loss of body example about being  Provide reassurance that painful integrity separated from procedures are not punishment, parents or being explain any expected pain  Enthusiastic, asks injured questions and acts on  Safety- ensure protected impulse environment, bicycle helmet, seat belt, and car seat as appropriate  Imitates adults - role playing

6-12 years School Age

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Adaptations Care  Permanent  Refines motor  Ready and willing  Parents/primary  Involve parents or primary caregiver in care teeth erupt strength and to learn caregivers/ coordination: siblings/teachers  Explain/reinforce rules  Pubescent -gross: bike  Inquisitive - asks are significant changes riding, batting, many questions  Provide simple factual information dancing,  Interacts with  May become skateboarding  Learning to adults outside  Keep instructions short and simple. Avoid fatigued -fine: ties separate reality immediate family getting carried away with details and facts shoes, fastens from fantasy and  Proficient in clothes, give up magical  Develops concept  Use hands-on activities and play while games and writing, thinking of self demonstrating procedures. This approach sports musical aids in their understanding and gains instrument  Advancing from  Develops cooperation. simple logic to friendship skills  Cares for pets abstract thinking  Allow them to ask questions  Establishes  Increased ability to conscience  Distract as needed read, write, and do math  Recognizes rules  Provide opportunity for return demonstration for society of new procedures.  Able to understand cause and effect  Practices self-  Maintaining a safe environment discipline  Ask the child about friends, interests,  Concerned about accomplishments and concerns (for example, body changes body changes)

 Fear of body  Praise cooperative behavior mutilation, death and dying  Teach about healthy and safe habits, wearing a bicycle helmet, seat belt, not taking part in risky behaviors (including not using alcohol, tobacco, drugs)

12-17 years Adolescents

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Adaptations Care

 Rapid growth  Improves fine  Utilizes logic and  Adolescents want to  Develop a relationship of trust and mutual motor skills abstract reasoning be in control respect  Onset of and applies formal menarch for  Capable of principles of logic to  Smiling and laughing  Be open, honest and straight forward females performing any situations they have mask frustrations and skill an adult never experienced fear  Read between lines  Onset of can perform nocturnal  Fear loss of self  Peer opinions are  Ask them what slang terms mean emission in  Easily fatigued concept and body important males image  Be tactful and thoughtful  May face peer  Attains  Developing an pressure  Do not take sudden mood swings personally physical identity maturity  Lives for the here and  Allow them to maintain as much control as  May not now safely possible  Vital signs acknowledge degree equal adults of pain  Maturing physically  Encourage involvement in care and decisions and compare their

 May have emotional own body growth and  Provide basic needs maintaining a safe  Eating swings development with environment disorders their peers may be a  May be self-  Allow to wear own clothing and have own concern conscious about body  Interested in the possessions when possible image opposite sex  Provide opportunity for return demonstration of new procedures  Dependence vs  Provide information on pain control methods,  Pain- have a good independence assessment scale, schedule for pain understanding of pain management, need to ask for pain medication and its causes.  Become interested in when pain begins, provide information on close relationships pain relief and reduction  Provide privacy for procedures and teaching  Privacy is extremely  Teach about healthy habits (nutrition, important exercise, hygiene and safety, STD & pregnancy prevention)  Encourage parents to stay involved in their child’s life

18-65 years Adult

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care Adaptations

 Men attain full adult  Abstract thought  Accepts  Be supportive - talk about stress Older adults: height in their 20's and responsibility for  Visual changes comprehensive themselves and  Organize teaching from simple to complex

 Peak muscular view of others utilizing a logical train of thought  Reflexes slow strength 25-30 years problems

 Productive,  Present information illustrating how it will affect  Loss of hearing  Skin begins to lose  Mental abilities creative and their lives and taste moisture peak during 20's achievement

oriented  Encourage him/her to talk about feelings and  Decreased concerns, and about how an illness or injury may balance and Older adults:  Begins to be affect plans, family and finances coordination  Menopause - female: concerned with

decreased energy health  Individualize teaching methods

level, strength and

endurance  Developing  Involve significant others and patient in plan of

relationships care

 Senses may be

diminished  Midlife crisis  Provide opportunity for return demonstration of

new procedures

 Adults ages 40-64  Measuring

begin to experience accomplishments  Provide basic needs, maintain a safe environment

physical changes, against goals

such as decreased  Provide culturally competent care in regard to endurance  Recognizes religion and norms limitations

 Onset of chronic  Prepare for Older Adults: health problems retirement  Safety- risk for falls, infection, pressure ulcers,

 When poor nutrition communicating,  Taking multiple medications “poly pharmacy” take into  Pain assessment scales need to be used and consideration the control of chronic pain if it is present patient’s culture and lifestyle 65+ years Geriatric

Physical Motor/Sensory Cognitive Psychosocial Interventions / Ways to Provide Age-specific Care Adaptations  Decreased  Decreased  Shares  Adjusts to  Encourage self care and independence/Assess skin tolerance to hot mobility wisdom with retirement and cold others  Use tape/bandaids sparingly and remove with care  Paresthesia  Adjusts/ accepts  Decreased  Drop in death of spouse/  Provide time for rest as needed bladder capacity/  Decreased performance friends control sense of  Provide opportunities for decision making relating to care balance, depth  Focuses on  Develops  Decline in all perception abilities dependence on  Provide opportunity for return demonstration of new sensory abilities others procedures involving caregivers as needed  Stronger  Keeps  Osteoporosis stimulation is mentally  Relocation to a  Provide mental stimulation / Provide more time to learn needed for all stimulated care facility  Skin becomes senses to  Provide for bowel and bladder needs thin and fragile experience  Decreased  Needs to feel sensation short-term useful,  Provide written instructions. Use larger-print materials  Decreased GI memory independent and absorption rate,  Ability to in control  Utilize short, specific instructions repeating as needed cardiac output respond  Reduced and airway quickly to attention span  Adults 80+ may  Provide instructions when rested and alert. Avoid rushing capacity stimuli feel isolated. decreases They may lose  Respect them / Concentrate on strengths  Loss of adipose self-confidence tissue  May develop as their abilities  Stress the need for immunizations, checkups and screenings. cataracts decline.  Many geriatric  Give chances to reminisce, to help promote a positive self adults have image chronic diseases  Possibly discuss option of an advance directive or Living and co- will. morbidities  Pain – Older adults may minimize their pain, be aware that  Wide variation there may be a communication barrier (nonverbal, dementia) across this Use appropriate pain scale population in  Safety- risk for falls, infection, pressure ulcers, poor physical and nutrition mental ability  Taking multiple medications “poly pharmacy” and health status

Pain Management

1. Jameson Health System is committed to maintaining a patient’s pain level at less than a “4” when possible or maintaining the pain level at the patient’s established comfort goal. Keeping the patient as comfortable as possible is the true goal of pain management.

2. The patient knows better than anyone else what his or her pain feels like. It is important to treat pain based on what the patient says, not one’s own opinion. The most reliable indicator of pain is the patient’s self report.

3. Age has nothing to do with the level of pain a person feels.

4. Some people cope with pain by staying calm and quiet.

5. Many people in pain are unwilling to admit it because of cultural, social, and personal reasons.

6. Physical dependence means the body has learned to tolerate a certain drug; and must adjust when the drug is no longer needed to relieve pain.

7. Addiction is a psychological need for a drug that leads to physical, emotional, and social harm. When properly monitored and balanced, pain medications may be safely taken on a long-term basis.

8. Pain negatively affects patients both physically and mentally. Untreated pain can lead to: poor wound healing, weakness, muscle breakdown, decreased physical movement, sodium and water retention, elevated blood pressure and heart rate, anxiety, depression, decreased immune response. (www.medscape.com)

Pain Management

Older Adults:

Often have chronic and acute pain at the same time May use words such as ache or sore instead of pain Feel pain just as intensely as younger adults Are more likely not to ask for additional or stronger medication

Cognitively impaired patients:

Assess the need to treat pain that is typically experienced by patients undergoing a certain procedure Consult the physician regarding an around-the-clock analgesic regimen. Observe the patient for: facial expressions, unusual movements such as guarding or bracing, change in behavior Listen for vocalizations such as sighing, moaning, groaning Use the FLACC SCALE

Children: Children exhibit and cope with pain differently than adults. They may be less verbal or may exhibit a wide range of responses To determine an infant’s level of pain, staff must rely on diagnosis, the infant’s response to routine comfort measures, assessment of facial expressions, body movements, crying, groaning, or changes in vital signs. Use the UWCH Pain scale or the Wong-Baker scale according to age

Jameson Hospital New Castle, Pennsylvania

0 – 10 Numeric Rating Scale

Indications: Adults and children (greater than 9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain

Wong–Baker Faces Pain Rating Scale

Indications: For children 3 – 12 and adults who are unable to verbalize self report. Jameson Hospital New Castle, Pennsylvania

UWCH Pain Scale for Preverbal and Nonverbal Children

0 2 – 4 6 – 8 10 Consistent cry that Moaning, gentle cry or Vocal/Cry No cry Occasional whimpers increases in volume and whimpering duration Occasional tense Marked distress. Brow expression, slightly Neutral expression, bulge, eyes squeezed negative expression Facial Smiling, calm, relaxed frowning, occasional shut, open mouth, taut (e.g. grimace) brow grimace tongue, deepening of bulge, shallow nasolabial furrow nasolabial furrow Neutral, moves easily, Easy to console with Consoles with moderate Inconsolable; absent or interacts with people or holding, position difficulty; sucks for very disorganized sucking; Behavioral environment, strong change, or sucking; short periods, followed high pitched cry or rhythmic suck on winces when touched/ by crying; cries out scream when touched or pacifier moved when moved/touched moved Thrashing, flailing, Moderate agitation or incessant agitation or Fidgeting, mild moderate immobility, strong voluntary Body Movement/ Normal motor activity, hypertonicity above intermittent flexion; immobility; pronounced baseline muscle tone Posture baseline moderate hyper-tonicity flexion; strong above baseline hypertonicity above baseline Unable to sleep or Sleep periods shorter Sleeping quietly with sleeping for prolonged than normal, awakes Sleep easy respiration; normal Restless while asleep periods of time easily, sleeps sleep/rest interrupted by jerky intermittently movements Overall rating (circle): 0 2 – 4 6 – 8 10 Cultural Considerations: Cultures vary in when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desired. Explore generic beliefs about pain/discomfort with the client. (Clinical Nursing Skills & Techniques, Perry and Potter, Mosby 6th Ed. Page 132, 2006) Revised 12/06; 11/07

FLACC SCALE

Face 0 1 2 No particular expression or Occasional grimace or Frequent to constant frown, smile frown, withdrawn, clenched jaw, quivering chin. disinterested. Legs 0 1 2 Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up

Activity 0 1 2 Lying quietly, normal Squirming, shifting back and Arched, rigid or jerking position, moves easily forth, tense

Cry 0 1 2 No cry (awake or asleep) Moans or whimpers, Crying steadily, screams or occasional complaint sobs, frequent complaints

Consolability 0 1 2 Content or relaxed Reassured by occasional Difficult to console or touching, hugging, or comfort “talking to”. Distractible.

Overall Rating (0 – 10)

Indications: (For patients who are unable to communicate)

Cultural Aspects of Pain Management

Culture is the framework that directs human behavior in a given situation. The meaning and expression of pain are influenced by people’s cultural background. Pain is not just a physiologic response to tissue damage, but also includes emotional and behavioral responses based on a person's past experiences and perceptions of pain. Not everyone in every culture conforms to a set of expected behaviors or beliefs; so cultural stereotyping (assuming a person will be stoic or very expressive about pain) can lead to inadequate assessment and treatment of pain. Many studies have shown that patients from minority groups and cultures different from that of health care professionals treating them receive inadequate pain management.

Heath care professionals need to be aware of their own values and perceptions, as they affect how they evaluate the patient’s response to pain and ultimately how pain is treated. Even subtle cultural and individual differences, particularly in nonverbal, spoken, and written language between health care providers and patients will impact care.

To be culturally competent, you must: Be aware of your own cultural and family values Be aware of your personal biases and assumptions about people with different values than yours Be aware and accept cultural differences between yourself and individual patients Understand the dynamics of the difference Adapt to, and respect, diversity

You must listen with empathy to the patient’s perception of their pain, explain your perception of the pain, acknowledge the differences and similarities in perceptions, recommend treatment, and negotiate agreement.

Questions that staff can use to help assess cultural differences in order to better assess and work out an appropriate pain management plan with a patient and family include:

What do you call your pain? What do you think caused your pain? Why do you think it started when it did? How severe is your pain? http://www.cityofhope.org/prc;pdf/Cultural Bibliography

Age-specific competency. Med Source website. Available at: www.medsrc.com/Age-Specific.htm. Accessed October, 2007.

Joint Commission of Accreditation of Healthcare Organizations website. http://www.jointcommission.org/. Accessed October, 2007.

Bombard, C. RN, MHA, CPHQ FACHE. One Size Doesn’t Fit All with Age-Specific Competencies. Accessed October 2007. https://www.nurseweekce.net/edr_course_print.asp

Pain Management Fast Facts, Cultural Aspects of Pain Management. http://www.cityofhope.org/prc/pdf/Cultural%20Aspects%20of%20Pain%20Management.pdf, Accessed October, 2007.

Perry, A.G., RN, MSN, EdD, FAAN., Potter, P.A. RN, PhD, CMAC, FAAN.(2006). Clinical Nursing Skills & Techniques (6th ed.). Mosby, Inc.

Kozier, B., Erb, G. et al. Fundamentals of Nursing Concepts, Process, and Practice.(2004). Fundamentals of Nursing Concepts, Process and Practice (7th ed.). Prentice Hall.

Pain Management Made Incredibly Easy. 2003. Lippincott Williams & Wilkins. Philadelphia

Parse, R. PhD, RN, FAAN, Illuminations: The Human Becoming Theory in Practice and Research. National League for Nursing Press, New York, March 1999.

Nursing 2001, Volume 31, Number 7: Controlling Pain

Channing L. Bete Co, Inc., Age-Specific and Cultural Competencies.2000

McCaffey, M. RN, MS, FAAN, Pasero. C. RN, MSN, Pain Clinical Manual. Second Edition. Mosby 1999.