Page 708 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 685

the preschooler for defined short periods. Hospitalisation critical care nurses need to also consider the developmen-
remains difficult, but preschoolers respond to anticipa- tal level of the child when providing care.
tory preparation and concrete explanations. 38
COMFORT MEASURES
SCHOOL-AGE CHILDREN (STAGE 4)
Children between 6 and 11 years are usually referred to Critically ill infants and children are particularly vulner-
as being of school age. This period represents a widening able to pain. If pain remains unrelieved it may cause
of the sphere of influence from parents/family to include short- and long-term physiological and psychological
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the school environment and peers. A transition complications, such as increased risk of mortality and
51-53
from egocentric thinking to concrete operations morbidity. The assessment of pain in children is par-
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occurs, 38,39 with children becoming more independent ticularly challenging, but the use of valid pain and seda-
and achievement-oriented for their sense of self-worth. In tion assessment tools may be useful for the management
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the ICU, school-age children may have a distorted or of pain in critically ill children. Prevention of proce-
fantasy-laden view, and will need concrete explanations. dural pain is important not only to avoid pain-related
Sicker children are less able to cope with the ICU envi- complications and emotional trauma, but also to facili-
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ronment and are more likely to regress, which can have tate the procedure. Target sedation level according to the
a significant impact on their sense of self-worth. Modesty child’s clinical status may help maintain comfort without
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and privacy is imperative at this age. Preadolescence compromising haemodynamic and respiratory status,
occurs between 10 and 11 years, and represents a time of as well as minimising other undesirable effects of analge-
turmoil and emotional upheaval. 39 sics and sedatives.
ADOLESCENTS (STAGE 5) PAIN AND SEDATION ASSESSMENT
Adolescence is considered a time of transition from child- Recent advances in pain and sedation assessment show
hood to adulthood. It is a developmental stage rather that they remain problematic in paediatric critical care
than an age group, but is typically represented by children and highlight the need for routine assessment, documen-
aged 12–18 years, or teenagers. Internal changes relate to tation and effective communication of the pain and seda-
emotional upheaval, search for autonomy, and transition tion scores. Numerous pain assessment instruments have
of thought process from concrete to abstract. External been developed, but few have been validated for the pae-
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changes relate to physical changes, such as the emergence diatric critical care population. These latter include the
of secondary sex characteristics with a related preoccupa- PICU-MAPS and the COMFORT behaviour scale. The
tion on bodily functions and image. 38 PICU-MAPS is a multidimensional scale developed for
critically ill children, including five categories of physio-
A goal in adolescence is to develop an integrated sense of logical and behavioural items, providing a possible pain
self, achieved through managing the conflicting demands score between 0 (no pain) and 10 (maximum pain). 58,59
of family and peers. Peer identity is essential to psycho- The COMFORT scale has been validated in several studies
logical growth and development, as is the gradual shift in PICU 60,61 and comprises seven behavioural items,
from family to peer orientation. The peer group provides where only six are rated (alertness, calmness/agitation,
a way for the adolescent to self-evaluate and to bolster respiratory response or crying, physical movement,
self-esteem. Adolescents also target authority figures with muscle tone, and facial tension), generating a possible
retaliation and defiance. Conversely, adolescents will seek score between 6 and 30. In combination with pain,
out non-parental adults, such as a teacher or relative, to assessment of sedation is paramount and the State
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obtain approval and acceptance. Slote has described a Behavioral Scale (SBS) is particularly relevant to evaluate
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process associated with adolescent illness. The first is the level of sedation in infants and children in ICU. It
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hopelessness and helplessness provoked by the equip- consists of a six-level responsiveness continuum, ranging
ment and environment. Adolescents often think they will from −3 (unresponsive) to +2 (agitated), with a neutral
not get better, and need to be given clear information state ‘awake and able to calm’ of 0.
about the expected course of the illness. They also need
to be included as much as possible in decision making PAIN AND SEDATION MANAGEMENT
and encouraged to participate in their own care. Feeling Painful procedures should be minimised when possible.
helpless and defenceless is contrary to their normal feel- Some nonpharmacological therapies have been shown to
ings of invincibility and may result in antisocial behav- be beneficial alone in managing mild pain or in combi-
iours. The adolescent must learn to accept that the quest nation with drug therapy in infants and young children.
for autonomy has been temporarily interrupted. Acknowl- These therapies may include non-nutritive sucking (e.g.
edging his/her feelings and setting clear behavioural finger or pacifier) with or without sucrose (for infants up
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limits can help an adolescent cope. Adolescents will also to 4 months), swaddling, music therapy, and distraction
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experience fear and anxiety. This can be offset by clear with or without parental presence. 64
explanations and acknowledgement of feeling through
articulation and reflection. Concerns for body image is Pharmacological treatment of pain and sedation in
also paramount, particularly fear of mutilation and scar- infants and children should be tailored to the child’s
ring. Physical appearance is important for acceptance into need and condition. Continuous opioid (morphine)
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the peer group and for self-esteem. In summary, in addi- infusions are used at the lowest effective dose and
tion to considering age-related physical characteristics, minimum duration based on regular pain assessment.