Pain assessment in pediatrics

ABSTRACT

Objectives:

to investigate how the pain assessment and management process in pediatric patients is performed and suggestions for its improvement.

Methods:

exploratory, qualitative study. Nine professionals from the nursing team of a pediatric hospital unit in Porto Alegre/RS participated in the study. A sociodemographic questionnaire and semi-structured interviews were used with content analysis.

Results:

the results reinforced the importance of pain assessment with family participation and the need to use tools and process improvements in the training and sensitization of professionals.

Final Considerations:

after the study was concluded, there was a clear need to address the issue, highlighting its relevance for pain resolution in pediatric patients.

Descriptors:
Pain Measurement; Pediatrics; Pediatric Nursing; Hospitals; Nursing Assessment

RESUMEN

Objetivos:

investigar cómo se lleva a cabo el proceso de evaluación y manejo del dolor en pacientes pediátricos y sugerencias para su mejora.

Métodos:

investigación exploratoria y cualitativa. Nueve profesionales del equipo de enfermería de una unidad de hospital pediátrico en Porto Alegre/RS participaron en la investigación. Se utilizaron los siguientes: cuestionario sociodemográfico y entrevista semiestructurada con análisis de contenido.

Resultados:

se reforzó la importancia de la evaluación del dolor con la participación conjunta de la familia; y la necesidad de utilizar herramientas y mejoras de procesos en la capacitación y conciencia de los profesionales.

Consideraciones Finales:

después de la conclusión de la investigación, se evidenció la necesidad de abordar el problema, destacando su relevancia para la resolución del dolor en pacientes pediátricos.

Descriptores:
Medición del Dolor; Pediatría; Enfermería Pediátrica; Hospitales; Evaluación en Enfermería

RESUMO

Objetivos:

investigar como é realizado o processo de avaliação e manejo da dor em pacientes pediátricos e sugestões para seu aprimoramento.

Métodos:

exploratório, qualitativo. Participaram do estudo nove profissionais da equipe de Enfermagem de unidade pediátrica hospitalar de Porto Alegre/RS. Foram utilizados questionário sociodemográfico, entrevista semiestruturada e análise de conteúdo.

Resultados:

reforçaram a importância da avaliação da dor com participação conjunta da família; e a necessidade do uso de instrumentos e aprimoramentos do processo na formação e sensibilização dos profissionais.

Considerações Finais:

concluído o estudo, foi evidenciada necessidade de abordar o tema, destacando sua relevância para resolução da dor em pacientes pediátrico.

Descritores:
Medição da Dor; Pediatria; Enfermagem Pediátrica; Hospitais; Avaliação em Enfermagem

INTRODUCTION

Pain is an important concern of human beings and plays a warning role by indicating biological dysfunctions⁽¹⁾. According to the International Association for the Study of Pain (IASP), this is an unpleasant sensory and emotional experience associated with actual or potential, subjective and individual injuries, reported according to individuals’ experiences⁽²⁾. Just as pain is subjective and individual, its assessment follows the same path and is a complex activity that requires guidance, monitoring and renewal.

Pain can be divided into three categories: a) Nociceptive: acute, caused by cutting, surgery, trauma. b) Neuropathic: chronic, generated by some damage to the nervous system, causing sensations of tingling, burning or electric discharge. c) Psychogenic: related to emotional state, such as migraines, epigastric pain and muscle contractures. The latter is harder to diagnose because there are no visible injuries or causes⁽³⁾.

Patients suffering from a painful process and treated by trained Nursing teams equipped with assistance tools for pain assessment and choice of the most appropriate analgesia for each individual have better pain relief compared to patients treated by untrained teams without assistance tools⁽⁴⁾. Hence, the use of scales as measurement tools to systematize this action facilitates and improves the pain assessment process at all ages. In order to achieve this goal, the Health team must be trained for the proper manipulation of pain assessment tools⁽⁵⁾.

Since pain management helps the recovery of patients, hospital institutions have been using care indicators. They are the numerical representation of the quality of care provided through tools that identify and monitor the processes and organizational results and support improvement actions⁽⁶⁾. Pain assessment and the methodical and periodic recording of its intensity are essential to follow patients’ evolution and make the necessary adjustments to treatment.

Constant quality improvement and humanized care are essential for any hospital wishing to achieve a minimum standard in line with current practices. The largest US accrediting agency - Joint Commission Accreditation Healthcare Organization (JCAHO) - uses pain assessment in the accreditation process and includes it as the fifth vital sign in hospitals going through the processes of assessment, accreditation and periodic reevaluations⁽²⁾.

Pain management in pediatrics involves the evaluation of several factors because these patients have difficulty with defining pain location and intensity. The following should be considered: agitation, evaluation of facial expression in neonatology, and respiratory, physiological and heart rate changes. In addition, the evaluation of parents and caregivers provides important elements regarding the status of their loved ones. Given these issues, the use of scales favors the pain assessment process⁽⁷⁾.

The scales available for patients’ behavioral assessment are the Children’s and Infant’s Postoperative Pain Scale (CHIPPS) and the Neonatal Infant Pain Scale (NIPS)^(6,9). School-age children tend to express subjectivity more assertively by qualifying and quantifying their pain and providing more accurate information. Thus, in this age group, the face scale, numeric scale or visual analog scale can be used⁽⁵⁾.

In a study, pediatric intensive care nurses reported that pain was not routinely assessed in their units, they did not receive appropriate training to perform such a task neither in higher education nor in their work environment, and their patients did not have pain assessed in an appropriate and systematized way⁽⁷⁾. Testimonials from professionals also revealed that despite pain assessment and implementation of measures, procedures are often insufficient for effective care and require new strategies to improve the quality of care and, consequently, patients’ life and health conditions⁽⁸⁾.

A Brazilian study with nurses attending an international symposium on pediatric and neonatal intensive care conducted in São Paulo concluded that the presence of a multiprofessional team or pain team improved the quality of care⁽⁷⁾. The care provided to cancer patients by a multidisciplinary team favored the identification of patients’ physiological, psychological, social and spiritual needs. Still in this study, interviewees emphasized patients’ individuality as an important condition for the treatment of pain, based on personalized care according to patients’ needs in their social and family context, and demanding perception and sensitivity from professionals⁽⁹⁾.

In another study, was highlighted that nursing team professionals perceive the pain of cancer patients in various ways. In addition to physiological pain, they reported emotional pain - and both need to be considered, evaluated and treated. They mentioned the administration of analgesics, especially opioids, as the most frequently used action for minimizing pain. They also mentioned change of position, stimulation of ambulation and application of local heat or cold⁽⁹⁾.

The importance of professional training coupled with the use of support tools became evident in a study that analyzed the effect of training and the use of pain assessment procedures. In this study, patients were subdivided into three different groups with standard analgesia prescription. The first group was evaluated by nursing professionals who did not receive pain assessment training and followed the institution’s routines. Teams of the second and third groups received pain assessment training. The team that evaluated group two, received the training and used a systematized pain assessment form. Professionals that evaluated group two were based on the training received and routines of the institution. The results showed that the first and third groups achieved similar results, while the second group achieved better pain relief⁽⁴⁾.

In agreement with this perspective, the study revealed the importance of associating training and the use of appropriate tools such as pain assessment scales, thereby showing this analysis is composed of several variables and should be developed continuously⁽⁴⁾. Continuing Health Education (CHE) is an appropriate approach to the work context that stimulates such a development and uses everyday problems as the basis for strategic actions.

The aim of CHE is the knowledge production based on the reality experienced in daily work. It is based on the concept of “problematizing teaching” critically constructed in reality without the superiority of an educator, and on “meaningful learning” according to students’ previous personal experiences. Continuing Health Education enables learning based on questions pertaining to the universe of lived experiences⁽¹⁰⁾. This education model is a strategy for transformations in the work process. Critical reflections about the daily practice are used to produce changes in actions and thoughts of the health team, thereby strengthening and valuing teamwork⁽¹¹⁾. This study may contribute to the construction of knowledge about pain assessment and management in children in the hospital setting and help the proposition of CHE programs for improvement of care practices in the process of pain assessment and management in children in that environment.

OBJECTIVES

To investigate how the pain assessment and management process in pediatric patients is performed by nursing team professionals and the suggestions for its improvement.

METHODS

Ethical aspects

Since the study involved human beings, the guidelines approved by the Research Ethics Committee at the proposing institution (CAAE 6969333917.0.0000.5344) were followed, according to the National Health Council Resolution number 466/2012. As for possible discomfort in addressing work-related issues, data collection presented minimal risk to participants. No discomfort was reported during interviews. Anonymity was guaranteed because no personal data capable of identifying participants was disclosed. Other ethical aspects were preserved with use of the informed consent form signed by both parties.

Type of study

Exploratory qualitative study.

Study scenario

Conducted with Nursing professionals (nursing technicians and nurses) working in a pediatric inpatient unit of a private hospital in the state of Rio Grande do Sul. This institution is a hospital of excellence in health and a reference in medical practices, care and management in the state.

Data source

Nine nursing team professionals who worked in a pediatric inpatient unit for over a year participated in the study. Participants were selected by the Snowball sampling method⁽¹²⁾. Professionals indicated colleagues who worked in the same workplace therefore, all participants were linked to the same private institution. The number of ten respondents was estimated. Data saturation was achieved in the eighth interview, and the ninth interview was conducted to confirm the theoretical saturation. When explanations and meanings attributed by subjects appeared regularly, was reached data saturation and reports of new ideas or concepts were no longer included⁽¹³⁾.

Data collection and organization

Data collection period was from November 2017 to January 2018. Semi-structured individual interviews were conducted, digitally recorded and transcribed. A guiding script was used with freedom to explore important points emerging throughout the interview. The script addressed aspects related to the perception of pain assessment, important points for its performance, the use of support tools and suggestions for improving training and sociodemographic information. Interviews were conducted in private rooms at the participants’ workplace.

Data analysis procedures

Content analysis was employed, comprising three phases: pre-analysis, analysis and treatment of results⁽¹⁴⁾. The transcription of interviews was classified into seven categories: 1) Importance of pain assessment in pediatrics; 2) Relevant factors for pain assessment in pediatric patients; 3) The family member’s role in pain assessment of the child; 4) Use of support instruments for pain assessment in pediatric patients; 5) Sensitization of nursing team professionals; 6) Difficulties found with pain assessment in pediatric patients; 7) Suggestions to improve the pain assessment process in pediatrics. This last category generated the subcategory “Training frequency”.

RESULTS

The study included nine nursing team professionals; seven women (77.8%) and two men (22.2%). Eight participants had children (88.9%), were aged between 26 and 60 years, had been working in Nursing between two and 27 years, in the Pediatric area between two and 26 years and in the same institution between two and 26 years. Out of these respondents, seven were nursing technicians (77.8%) and two were nurses (22.2%).

In the results, were highlighted data that can help identify professionals’ view of pain assessment and bring elements of their daily reality, which are essential factors in continuing health education. Chart 1 describes the categories and units of meaning that emerged from data analysis.

Chart 1
Categories

CATEGORY	UNIT OF MEANING
1 Importance of pain assessment in pediatrics	Subjectivity Treatment Recovery Wellbeing
2 Relevant factors for pain assessment in pediatric patients	Non-pharmacological needs Stress in the environment Family reference Orientation/Instruction
3 The family member's role in pain assessment of the child	Family/patient relationship Reports Assistance
4 Use of support instruments for pain assessment in pediatric patients so	Scales
5 Sensitization of nursing team professionals for pain assessment in pediatric patients	Empathy Importance Awareness
6 Difficulties found with pain assessment in pediatric patients	Type of patient Lack of continuing education Appropriate communication
7 Suggestions to improve the pain assessment process in pediatrics	Continuing education Training Creativity
7.1 Training need for pain assessment in pediatric patients	Scarcity Periodicity

Categories are presented as follows.

1. Importance of pain assessment in pediatrics

In this study, participants highlighted the importance of pain assessment for the development and recovery of pediatric patients and understood this action as part of treatment, according to the following reports:

[...] I find it extremely important, first of all, because pain is subjective, I don’t know what he is feeling, and because children will hardly lie about being in pain, if they are in pain, they really are, so I think it’s extremely important, because they won’t lie, they’ll really be in pain, you’re going to assess... (E 01)

I think if there is no pain, recovery is much faster. (E 08)

Participants’ statements indicated that nursing professionals realize the importance of pain assessment, the subjectivity involved in it, and the therapeutic function of analgesia and comfort (wellbeing) of hospitalized pediatric patients.

2. Relevant factors for pain assessment in pediatric patients

The environment or context of the patient, the expression of the stress level of family and children, the presence or absence of family references, as well as receiving previous guidelines on the actions to be taken, were items observed by study participants during pain assessment:

She put her feet in the water, she relaxed and was able to sleep, so that doesn’t mean “it’s a drug intervention that will make a difference”. (E 01)

So, besides assessment by the scale, we also, in a moment, he is saying that pain is 10 and you are assessing and seeing that morphine will not be necessary, it’s because the mother is not there, because someone else is, I guess the presence of a family member in the environment, depending on who is there, is a factor that influences, and the context the child is living within the pathology, the length of hospitalization too, hum ..., children’s mobility, if they leave the bed or not, this is also something very important for children because they feel bothered if they don’t move. (E 01)

I must consider ... the environment. If the environment is very hectic, a nervous mother also greatly influences the assessment of this patient in pain. I think that’s it. (E 08)

3. The family member’s role in pain assessment of the child

In the routine of pediatric inpatient units, the interaction between the health team and family members is continuous and indispensable. Although relying on family members’ evaluation may be difficult, if well conducted, it can facilitate the decision for the best conduct and outcome for the patient. This demonstrates the importance of considering the child’s knowledge, the parents’ report and the helping view of this joint action in interviewees’ statements:

[...] I think the mother’s opinion is also important, who knows her child more than we do. (E 02)

Parents can assess very well too, I think they know they are different, this also counts. (E 06)

4. Use of support instruments for pain assessment in pediatric patients

The following statements indicate the use of supportive instruments or lack thereof, such as pain assessment scales used by nursing team professionals. At the time of the study, in the institution where participants worked, were used three different scales for pain assessment in the pediatrics department, according to the best health practices studied by the team, namely the Neonatal Infant Pain Scale (NIPS), the Children’s and Infant’s Postoperative Pain Scale (CHIPPS) and the Visual Analog Scale (VAS).

Here at the institution, we assess children’s and babies’pain according to the three types of scale available, which are our support instruments: for infants aged up to 29 days, the NIPS scale; from 30 days ofage to five years, the CHIPPS scale; and later, the VAS. (E 04)

Yes, they are very good. It’s really that. For children’s assessment, you have to use the scales, if not, there is no way, is there? (E 02)

5. Sensitization of nursing team professionals for pain assessment in pediatric patients

Pain assessment must involve the process of sensitization of professionals for minimizing failures in action, thus resulting in better patient care. The following statements highlighted the importance of professional awareness and empathy:

[...] it is something that needs to be fast, he is feeling it and for me, it is 100% empathy, so I think: no, this has to be done and done now, not later, now. Because I wouldn’t want to be in her shoes and the person would say “Soon I’ll come and put your feet to soak”. (E 01)

I believe this process is difficult, even for people’s awareness, but it must be addressed more and more in order to be effective and resolute in relation to hospitalized children. (E 04)

6. Difficulties found with pain assessment in pediatric patients

The difficulties found in the routine of study participants were related to the type of patient and lack of continuing education, according to the reports:

[...] how difficult is pain assessment in patients with cerebral palsy ... I don’t think we have any preparation to assess their pain. (E 08)

Just as I have this difficulty, I have not had this training, I do not know to what extent all nurses in my institution also have this training. (E 09)

If you say it, it seems like then, she is in pain, she says she’s in pain. If she is afraid, too. If she thinks you’re going to give her a shot, something like that, then I think it influences a lot, because you have to make it very clear that it’s not going to be a little sting, nothing, it won’t hurt, because they are in pain and they say they are not, because they are afraid... (E 07)

7. Suggestions to improve the pain assessment process in pediatrics

The statements demonstrated the need for developing Continuing Health Education programs aimed at pain assessment and management in Pediatrics. Among the characteristics highlighted by professionals, there is also the need for teaching the program in a playful, creative way and specifically focused on the sector:

[...] they are an extra support for your assessment of children’s pain, because I think pain in children is much more difficult to assess, so training is very important. (E 02)

That was in a more playful way, more, ... how can I say it?... (E 04)

Trainings. Trainings. More trainings. Focus more on that [...] (E 08)

Within this category, was found a subcategory in which were highlighted reports about the frequency of training, as described below.

7.1. Training need for pain assessment in pediatric patients

Participants mentioned that training frequency is scarce. In this aspect, we understand that the frequency with which the theme is addressed in continuing education can influence the outcome of patient care.

So, my suggestion, that I have, is that I learned a lot from this training, that it should be given at least twice a year, because it’s not only a training... (E 05)

I have not received much pain assessment training. I learned it from what my colleagues taught me, so I didn’t have specific pain assessment training. (E 09)

DISCUSSION

Assessing patients’ pain is not an easy task. Nursing professionals are not aware of this importance yet and continue to perform this task using only their personal beliefs empirically⁽¹⁵⁾. In line with other studies, the studied professionals are part of committed teams and identify the pain of their patients. However, there were weaknesses in knowledge related to management and control, showing their actions are limited to the pharmacological method and restricted approach to the problem⁽¹⁶⁾.

In the hospital where participating professionals work, pain is considered the fifth vital sign. Pain assessment is part of the institutional routine at every vital sign checking and whenever necessary (when the patient reports pain or after drug treatment), and by recording its assessment and reassessment in the specific sign form. Pain should be valued as the fifth vital sign, approached methodologically and treated through pre-established protocols⁽¹⁷⁾. The rate of drug absorption is directly linked to its route of administration. Intravenous route is the fastest way of absorption, followed by intramuscular, subcutaneous, sublingual and oral, and this aspect influences the minimum time for pain reassessment of patients treated with drug therapy⁽¹⁸⁾.

In pain assessment within pediatrics, important factors that influence the approach to pain should be considered. As reported in this study, some patients often need non-pharmacological interventions to relief their pain, which is reinforced by some authors who mention the importance of using these measures or behavioral measures for pain relief and management. Among them, are the change of position, massage, non-nutritive suckling, immersion bath, oral glucose and wrapping (swaddling)⁽¹⁹⁾.

The nursing staff have concerns with measures used to minimize children’s pain during hospitalization. Pain relief actions may be adopted, but there is no standardization in reported behaviors. Issues related to knowledge acquisition and updating are very relevant, highlighting the importance of professionals’ participation in scientific events and the need for regular continuing education programs as forms to meet this demand⁽²⁰⁾.

During hospitalization, when children report pain, caregivers may be the first to realize their uneasiness and need for assessment. Often, family members are the first to search the nursing staff looking for pain relief for the child. Having the parents around or other reference people to the child already provides a sense of security and protection, which also contributes to pain relief⁽²¹⁾.

In the pediatric evaluation, must be considered that children’s manifestation of pain is often mediated by the caregiver. Thus, including the child’s parents or other family member in the entire process of assessment and conduct for pain relief relies on the assumption that they know their children and perceive behavioral changes better. However, some studies show that the communication between family and the nursing team is still weak or needs improvement⁽⁷⁾.

The use of some scales, such as the revision of the Face, Legs, Activity, Cry, Consolability (FLACC) scale, the FLACC-R, allows the assessment of patients’ consolability criteria and children’s behavioral pattern within their normal conditions outside the hospital setting, through information provided by parents and family members, which complements the visual and physiological evaluation performed by the professional⁽²²⁾. This resource can be an intersection point between the scientific knowledge of the health team, the knowledge about the child’s behavior informed by parents or caregivers at the time of hospitalization, and the child’s pain situation. However, the use of this specific scale was not mentioned by the study participants, because this is not a support instrument validated by the institution.

According to a study, teams trained for pain assessment without the use of adequate support instruments are equivalent to teams without specific training for such procedure⁽⁴⁾. That kind of research leads to an understanding on the importance of integrating actions of skill development and support to health teams by providing facilitating instruments, and about the relevance of scientific studies on this topic.

In the search for objectivity and accuracy in pain assessment in pediatrics, child-specific assessment instruments are continually developed and improved. In this sense, pain assessment scales for hospitalized patients are the most recommended for pain recognition, quantification and treatment. These instruments facilitate interaction and communication between team members, who begin to observe the same criteria for pain assessment, evolution and resolution⁽²³⁾.

Pain is individual and unique and each person experiences it differently given the influence of multiple factors, namely the biological variables - hormones, genetics, pain circuit pathways, and variations in the Central Nervous System - and psychosocial variables - depression, anxiety, culture, expectations, social experience and importance given to individual pain⁽²⁴⁾. It is understandable that the pain assessment performed by nursing professionals goes through the same path, i.e., their assessment will be guided by their painful experiences, the presence or absence of empathy, appreciation of the other’s report and its impact on their daily lives.

In another study conducted with nurses working in the intensive care unit (ICU), pain assessment was directly related to the interaction between the professional, the child and the family and subjective factors of these professionals may exert influence on the process. Another conclusion was that the nursing team’s sensitization in pain assessment can optimize ICU treatment⁽²⁵⁾.

It is important to sensitize nursing teams to the problem so that they assess and quantify pain appropriately, and to include the development of identification, measurement, recording and management skills in their continuing education⁽²⁵⁾. The awareness issue is highlighted in both older and current studies^(23-25). Hence the belief that pain assessment should be continually studied, perhaps because of its individual character, its constancy in health services, or its great impact in hospitalization periods.

Although pain assessment and quantification are not easy tasks, these actions should become routine for nurses and their teams⁽²³⁾. In a study from year 2006, in one of the categories evaluated, were analyzed the intervening factors that made the assessment and treatment of children’s pain difficult. The obstacles and difficulties faced by nursing professionals were associated with the relationship between the multidisciplinary team; the difficulty of communicating with the child; insufficient human resources; and the ambivalent feeling regarding the use of analgesics in children⁽²⁴⁾.

Nurses value the assessment and interventions for pain relief in children, but consider the following problems: collaboration between staff; infrastructure, lack of definition of processes; and insufficient formal and continuing education within institutions⁽⁷⁾.

The difficulties with the assessment involve cognitive and emotional areas of professionals and extend to the deficient therapeutic options that generate insecurity at the moment of analgesia⁽¹⁵⁾. The estimation challenge is higher when pain assessment is related to children with neurological impairment, especially of the cognitive system and speech⁽²⁰⁾.

When providing care to children, health professionals should be aware that each intervention will be done differently, and they should find the best strategy of action and the quickest and easiest access to achieve the safety of these patients and their caregivers. The reports show the need for further studies including areas such as the application of specific scales for patients with cognitive impairment in search for a better work process.

Continuing education should be understood as a teaching/learning practice and a health education policy, similar to school education but with a view to work⁽¹⁰⁾. In this area, the development of health education actions and policies within hospital institutions is essential and reported as a need by workers themselves. Research shows that overcoming obstacles is linked to collective intervention projects, in which professionals critically reflect on their own difficulties, build protocols and collaborate in the training of all involved⁽²⁶⁾.

Continuing health education does not involve a being with knowledge who teaches another without knowledge. It involves knowledge exchange that generates critical and transformative education. By no means this implies that what we already know or do is wrong, but that questioning and the discomfort with reality generates what is yet to be known⁽¹⁰⁾.

It is also important that nursing team professionals’ needs are periodically updated in order to keep the training attractive to them with discussions on relevant content to their routines. Interviewees’ statements demonstrated the need for improvements in the pain assessment process, and some suggestions of contents to be addressed in the development of training and support materials with guidelines for pain assessment in pediatrics.

Study limitations

Studies seeking information from the reality of hospital institutions can generate content that will be better applied in the routine of nursing professionals. However, they may generate misleading information because of a possible discomfort of employees in suggesting flaws in the process created by the employer.

Contributions to the Nursing area

The aim of this study was to investigate the pain assessment and management process in pediatric patients and suggestions for its improvement, based on the testimony of nursing professionals working in this area.

In the bibliographic review and interviewees’ statements, was observed the complexity of the pain assessment process and the need for the continuous search for new and better ways to perform it. The study also pointed out that the need for new support instruments or improvements to existing ones should be routine, since resorting to new ways of performing such actions is always possible, especially in the pediatric area, where the use of support instruments is essential because of children’s particularities in expressing and communicating their pain. The multidisciplinary health team has vital importance in the performance of appropriate pain assessment and treatment according to pediatric patients’ needs. Family support is of similar importance, because they provide information on the pediatric patient history, which offers guidance to professionals’ actions.

The difficulty to standardize non-pharmacological behaviors is noteworthy and patients’ medical records had no records of these actions performed by the Nursing team⁽²⁷⁾. Some standardizations can unify the evaluation and conduct process, such as the use of pain assessment tools as the FLACC (Face, Legs, Activity, Cry, Consolability) scale, which includes the consolability level of pediatric patients (actions performed empirically by nursing professionals)⁽²⁰⁾. In a review conducted in 2011, Maia and Coutinho found authors indicating that non-pharmacological pain relief measures are the responsibility of the nursing team, while the medical team is responsible for recommending medication actions. The review included studies highlighting that the lack of multiprofessional communication and protocol standardization hinder the care of patients in pain⁽¹⁵⁾.

Realizing that pain is individual and can be composed of previous or current experiences lived by the human being in care facilitates the decision process and the action plan in order to find a problem solution. Understanding the factors that may influence the assessment of patients’ pain, how they affect the management of this condition and the best paths to follow requires continuous studies and updating.

Several scales have been developed in search for objectivity in pain assessment, although they have not been implemented in the clinical practice of most institutions yet⁽¹⁵⁾. Researchers are concerned that health teams do not use pain assessment scales in hospital service routines. For an accurate assessment, the ideal situation would be to use a single pain assessment scale in each service. However, there may be a need to use more than one instrument - according to the age of patients treated at the unit and the child’s profile⁽²¹⁾.

A study conducted with nurses working in neonatal ICUs revealed that only a quarter of these professionals reported having knowledge of some scale for pain assessment of these patients. Some of the reasons for difficulties with using the scales were the lack of professional training and lack of a scale considered gold standard for pain measurement⁽²⁸⁾. Another difficulty found in the use of scales is that assessment may have altered sensitivity according to the evaluator, since their experiences may interfere with the assessment⁽²¹⁾.

The concern with a reliable pain assessment has received a great deal of commitment from health institutions and researchers in the area. However, knowing that pain assessment is an important point in the treatment of our patients is not enough. This exercise must become part of a routine and seek the appropriate configuration in order that the action is performed in a practical, fast and safe manner, with little room for doubt or individual interpretations of evaluators.

FINAL CONSIDERATIONS

For decades, pain assessment has been gaining prominence and is valued in patient management. If well performed, it qualifies the service and allows observing the evolution of clients’ health condition. The adequate recording of pain assessment by the Health team generates statistical data and creates an indicator of quality of care in institutions that wish to improve care and evaluate their performance.

The results demonstrated the need to address the theme, the relevance of the assessment, the importance of the nursing team role to resolve pain in pediatric patients, as well as the need to stimulate the search for knowledge and value professionals’ actions in the face of this situation.

More research on the subject can help to make the action an application of science, which is still poorly understood by professionals who perform it. They still understand pain assessment as an action performed empirically without theoretical basis. A theme that addresses such individuality, subjectivity and vulnerability deserves to be valued and developed continuously, bringing improvements to both the professional practice and the recovery process of pediatric patients.

REFERENCES

• ¹
  Ruviaro LF, Filippin LI. Prevalence of chronic pain in a Basic Health Unit of a middle-sized city. Rev Dor. 2012;13(2):128-31. doi: 10.1590/S1806-00132012000200006
  » https://doi.org/10.1590/S1806-00132012000200006
• ²
  SBED-Sociedade Brasileira de Estudos da Dor [Internet]. 2016 [cited 2016 Oct 15]. Available from: http://www.sbed.org.br
  » http://www.sbed.org.br
• ³
  SBED - Sociedade Brasileira para o Estudo da Dor. Brasil sem dor - Campanha nacional pelo tratamento e controle da dor aguda e crônica [Internet]. 2018 [cited 2018 Mar 19]. Available from: http://www.sbed.org.br/sites/arquivos/downloads/brasilsemdorfolderweb.pdf
  » http://www.sbed.org.br/sites/arquivos/downloads/brasilsemdorfolderweb.pdf
• ⁴
  Silva MADS, Pimenta CAM, Cruz DALM. Treinamento e avaliação sistematizada da dor: impacto no controle da dor do pós-operatório de cirurgia cardíaca. Rev Esc Enferm USP. 2013;47(1):84-92. doi: 10.1590/S0080-62342013000100011
  » https://doi.org/10.1590/S0080-62342013000100011
• ⁵
  Silva YP e, Silva JF da. Dor em Pediatria. Rio de Janeiro: Guanabara Koogan; 2006. 279 p.
• ⁶
  Agência Nacional de Vigilância Sanitária (BR). Assistência Segura: uma reflexão teórica aplicada à prática[Internet]. 2017;2 ed:1-170. Available from: http://portal.anvisa.gov.br/documents/33852/3507912/Caderno+1+-+Assistência+Segura+-+Uma+Reflexão+Teórica+Aplicada+à+Prática/97881798-cea0-4974-9d9b-077528ea1573
  » http://portal.anvisa.gov.br/documents/33852/3507912/Caderno+1+-+Assistência+Segura+-+Uma+Reflexão+Teórica+Aplicada+à+Prática/97881798-cea0-4974-9d9b-077528ea1573
• ⁷
  Santos MZ, Kusahara DM, Pedreira MLG. Vivências de enfermeiros intensivistas na avaliação e intervenção para alívio da dor na criança. Rev Esc Enferm USP. 2012;46(5):1074-81. doi: 10.1590/S0080-62342012000500006
  » https://doi.org/10.1590/S0080-62342012000500006
• ⁸
  Stübe M, Cruz CT, Benetti ERR, Gomes JS, Stumm EMF. Perceptions of nurses and pain management of cancer patients. Rev Min Enferm. 2015;19(3):696-703. doi: 10.5935/1415-2762.20150053
  » https://doi.org/10.5935/1415-2762.20150053
• ⁹
  Oliveira RM, Silva LMS da, Pereira MLD, Moura MAV. Manejo da dor de pacientes com aids: análise da estrutura gerencial em hospital de referência. Rev da Esc Enferm da USP. 2013 Apr;47(2):456-63. doi: 10.1590/S0080-62342013000200026
  » https://doi.org/10.1590/S0080-62342013000200026
• ¹⁰
  Ceccim RB, Ferla AA. Educação permanente em saúde [Internet]. 2017 [cited 2017 Dec 10]. Available from: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/edupersau.html
  » http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/edupersau.html
• ¹¹
  Medeiros AC, Pereira QLC, Siqueira HCH, Cecagno D, Moraes CL. Gestão participativa na educação permanente em saúde : olhar das enfermeiras. Rev Bras Enferm. 2010;38-42. doi: 10.1590/S0034-71672010000100007
  » https://doi.org/10.1590/S0034-71672010000100007
• ¹²
  Biernacki P, Waldorf D. Snowball Sampling: Problems and techniques of Chain Referral Sampling. Sociol Method Res. 1981;2:141-63.
• ¹³
  Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saúde Pública. 2008;24(1):17-27. doi: 10.1590/S0102-311X2008000100003
  » https://doi.org/10.1590/S0102-311X2008000100003
• ¹⁴
  Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2011. 279 p.
• ¹⁵
  Caetano EA, Lemos NR, Cordeiro S, Pereira FM, Moreira DS, Buchham SMM. O recém-nascido com dor: atuação da equipe de enfermagem. Esc Anna Nery. 2013;17(3):439-45. doi: 10.1590/S1414-81452013000300006
  » https://doi.org/10.1590/S1414-81452013000300006
• ¹⁶
  Silva MS, Pinto MA, Gomes LMX, Barbosa TLDA. Dor na criança internada: a percepção da equipe de enfermagem. Rev Dor. 2011;12(4):314-20. doi: 10.1590/S1806-00132011000400006
  » https://doi.org/10.1590/S1806-00132011000400006
• ¹⁷
  Maia ACA, Coutinho SB. Fatores que influenciam a prática do profissional de saúde no manejo da dor do recém-nascido. Rev Paul Pediatr. 2011. doi: 10.1590/S0103-05822011000200020
  » https://doi.org/10.1590/S0103-05822011000200020
• ¹⁸
  Lüllmann H, Mohr K, Hein L. Farmacologia. 7o. Porto Alegre: Artmed; 2017.
• ¹⁹
  Amaral JB, Resende TA, Contim D, Barichello E, Amaral JB, Resende TA, et al. The nursing staff in the face of pain among preterm newborns. Esc Anna Nery. 2014;18(2):241-6. doi: 10.5935/1414-8145.20140035
  » https://doi.org/10.5935/1414-8145.20140035
• ²⁰
  Aquino FM, Christoffel MM. Dor neonatal : medidas não-farmacológicas utilizadas pela equipe de enfermagem. Rev Rene [Internet]. 2010;11:169-77. Available from: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/483
  » http://www.revistarene.ufc.br/revista/index.php/revista/article/view/483
• ²¹
  Silva LDG, Tacla MTGM, Rossetto EG. Manejo da dor pós-operatória na visão dos pais da criança hospitalizada. Esc Anna Nery. 2010;14(3):519-26. doi: 10.1590/S1414-81452010000300013
  » https://doi.org/10.1590/S1414-81452010000300013
• ²²
  Bussotti EA, Guinsburg R, Pedreira MLG. Cultural adaptation to Brazilian Portuguese of the Face, Legs, Activity, Cry, Consolability revised (FLACCr) scale of pain assessment. Rev Latino-Am Enfermagem. 2015;23(4):651-9. doi: 10.1590/0104-1169.0001.2600
  » https://doi.org/10.1590/0104-1169.0001.2600
• ²³
  Viana DL, Dupas G, Pedreira MLG. A avaliação da dor da criança pelas enfermeiras na Unidade de Terapia Intensiva. Pediatr. 2006:251-61.
• ²⁴
  Palmeira CCA, Ashmawi HA, Posso IP. Sex and pain perception and analgesia. Rev Bras Anestesiol [Internet]. 2011[cited 2019 Jan 20];61(6):814-28. Available from: http://www.sciencedirect.com/science/article/pii/S0034709411700915
  » http://www.sciencedirect.com/science/article/pii/S0034709411700915
• ²⁵
  Santos JP, Maranhão DG. Cuidado de Enfermagem e manejo da dor em crianças hospitalizadas: pesquisa bibliográfica. Rev Soc Bras Enferm Pediatr. 2016;16:44-50. Available from: https://sobep.org.br/revista/images/stories/pdf-revista/vol16-n1/vol_16_n_1-artigo-de-revisao-2.pdf
  » https://sobep.org.br/revista/images/stories/pdf-revista/vol16-n1/vol_16_n_1-artigo-de-revisao-2.pdf
• ²⁶
  Capellini VK, Daré MF, Castral TC, Christoffel MM, Leite AM, Scochi CGS. Conhecimento e atitudes de profissionais de saúde sobre avaliação e manejo da dor neonatal. Rev Eletrônica Enferm. 2014;16(2):361-9. doi: 10.5216/ree.v16i2.23611
  » https://doi.org/10.5216/ree.v16i2.23611
• ²⁷
  Sposito NPB, Rossato LM, Bueno M, Kimura AF, Costa T, Guedes DMB. Assessment and management of pain in newborns hospitalized in a Neonatal Intensive Care Unit: a cross-sectional study. Rev Latino-Am Enfermagem. 2017;25(0). doi: 10.1590/1518-8345.1665.2931
  » https://doi.org/10.1590/1518-8345.1665.2931
• ²⁸
  Sousa BBB, Santos MH, Sousa FGM, Gonçalves APF, Paiva SS. Avaliação da dor como instrumento para o cuidar de recém-nascidos pré-termo. Texto Contexto Enferm. 2006;15(spe):88-96. doi: 10.1590/S0104-07072006000500010
  » https://doi.org/10.1590/S0104-07072006000500010

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Priscilla Valladares Broca

Publication Dates

• Publication in this collection
  31 July 2020
• Date of issue
  2020

History

• Received
  26 July 2019
• Accepted
  28 Oct 2019