No tiene

que doler
2003 Childrens Medical Center of Dallas
2003 Childrens Medical Center of Dallas

It doesnt
have to hurt

ain is useful when it

P warns you of danger,
injury or illness,
but is no longer useful once
the cause has been found.
Pain should then be treated.
What is pain? | Pain is an unpleasant feeling that
comes with bodily injury, damage or disease. If left
untreated, pain can cause many other problems and
can lead to lengthier hospital stays. Untreated physical pain can lead to emotional or psychological pain.
This booklet deals only with physical pain.
Only the person in pain can tell the amount,
location and quality of pain and relief from pain
medicines. It is important to take your childs
report of pain seriously. If we do not believe childrens reports of pain, they may lose trust in those
who are caring for them.
Children may have pain caused by an illness or
by things done while treating the illness, such as
blood draws, fingersticks, IV starts, spinal taps,
chemotherapy or chest physiotherapy (CPT).
How do we take away pain? | The best way to
treat pain is to prevent it. Once pain gets out of
control, it is hard to stop. The child, parents, nurses
and doctors collaborate to make a plan and to prevent or treat pain as soon as possible.
A pain relief plan is made based on your childs
needs, and as needs change, the plan is changed.
Our goal is to stop pain from procedures and treatments before it starts. If we are unable to prevent
pain, we quickly provide actions for pain relief.
We use a combination of medicine and psychological interventions. Each patient is asked regularly
about pain.
Parents should always tell the nurse or doctor if
your child is hurting, or if the medicine does not
treat the pain. Sometimes children will tell their
parents that they are hurting or uncomfortable, and
may be scared to tell a doctor or nurse.
Pain assessment | To relieve your childs pain, it
is important for the nurses and doctors to ask your

Pain assessment:
The FACES scale
Wong-Baker FACES Pain Rating Scale

1
HURTS
LITTLE BIT

0
NO HURT

2
HURTS
LITTLE MORE

3
HURTS
EVEN MORE

4
HURTS
WHOLE LOT

5
HURTS
WORST

Wong, D.L., Hockenberry-Eaton, M., Wilson, D. Winkelstein M.L., Schwartz, P.;

Wongs Essentials of Pediatric Nursing. ed. 6. St. Louis, 2001, p. 1301. Copyrighted
by Mosby, Inc. Reprinted by permission

Face
Face
Face
Face
Face
Face

0
1
2
3
4
5

has no hurt.
hurts just a little bit.
hurts a little more.
hurts even more.
hurts a whole lot.
hurts as much as you can
imagine (you don't have to be
crying to feel this bad)

he FACES scale is used for most

children over 3 years old. The
nurse will tell your child what each
face means, then ask her to choose the
face that best describes how she is feeling.
The nurse will tell your child that each
face is for a person who feels happy
because he has no pain, and hurt or sad
because he has some or a lot of pain. The
nurse will then ask your child to point to a
face that shows how much she is hurting at
that time.

child about the level of pain. We use one of three

pain scales, depending on the age and learning level
of your child; the numeric rating scale, the FACES
scale and the FLACC scale.
We ask our patients how much they hurt every
time we check their blood pressure and temperature
and even more often, if needed.
Tell the nurse if your child tells you he is hurting. Pain is an emergency and should be treated as
soon as possible.

Pain assessment:
The numeric
rating scale
he numeric rating scale is used for
children who can talk and express
how much they hurt by using a
number scale from 0 to 5. This scale is often
used with children who are 7 years old or
older. The pain scale is:

0 = No pain.
1 = Hurts just a little bit.
2 = Hurts a little more.
3 = Hurts a whole lot.
4 = Hurts even more.
5 = The worst possible pain.
If your child rates his pain at 3 or more,
the nurse should treat your childs pain
promptly.

Pain from procedures | Our goal is to keep your

child free from pain and fear during a procedure. If
a painful procedure is necessary, every effort will be
made to make your child comfortable.
For blood draws or IV starts, when it is not an
emergency, a topical anesthetic (such as EMLA)
will be applied to the skin before the procedure to
reduce the pain of the needlestick. EMLA is a
cream that is applied to your childs skin at least 60
minutes before a needlestick. Other topical anesthetics are available, if EMLA is not appropriate.
If a procedure such as a lumbar puncture or
bone marrow aspiration is done, your child may
need medicine to help him relax and strong pain
medicines in addition to topical anesthetics. Most
procedures will be done in the treatment room
rather than your childs room, keeping his room as a
safe place.
Pain after surgery | During a hospital stay, some
children have one or more surgeries. Surgery may
cause pain. The amount of pain depends on the type
of surgery. Since the amount of pain changes a lot
in the first hours and days after surgery, it is important for the doctors and nurses to ask about pain
scores frequently. They will adjust the amount of
medicine your child receives based on the pain level.
After surgery, most pain can be prevented or

FLACC: NONVERBAL PAIN SCALE

Pain assessment:
The FLACC scale
or children who cannot talk, behavior
is the best way to tell if they are
hurting. The FLACC Face/Legs/Activity/
Cry/Consolability) scale is used for patients
younger than 3 years old, or older children who
cannot talk or use the other scales.
Each of the five categories (F) Face; (L) Legs;
(A) Activity; (C) Cry; (C) Consolability is scored
from 0-2, which results in a total score between
zero and 10.

Appropriate for preverbal patients <3 years of age and older nonverbal patients.
Reprinted by permission 2001, Sandra Merkel.

SCORING
CATEGORIES

Face

No particular
expression or
smile

Occasional
grimace or frown,
withdrawn,
disinterested

Frequent
to constant
quivering chin,
clenched jaw

Legs

Normal
position or
relaxed

Uneasy, restless,
tense

Kicking or legs
drawn up

Activity

Lying quietly,
normal position,
moves easily

Squirming,
shifting back and
forth, tense

Arched, rigid
or jerking

Cry

No cry (awake or
asleep)

Moans
or whimpers;
occasional
complaint

Crying steadily,
screams or
sobs, frequent
complaints

Consolability

Content, relaxed

Reassured by
occasional
touching, hugging
or being talked
to, distractible

Difficult to
console
or comfort

decreased to a minimal level. Behavioral pain treatments can be used with medicine for pain relief.
After surgery, pain medicines should be given on
a regular basis. If your child complains of pain or
you suspect your child is in pain, tell your nurse or
doctor.

t Childrens Medical
A Center, we use a
combination of
medicine and psychological
interventions to treat pain.
Pain medicines | Many types of medicine control
pain. Acetaminophen (Tylenol) and Ibuprofen are
often given to children who have mild pain. These
medicines are generally given by mouth and do not
make your child sleepy. Ibuprofen (Motrin or
Advil) is an anti-inflammatory medicine and may
be given with or instead of Acetaminophen.
If your child is not able to eat or drink, pain
medication will be given through your childs IV.
Once your child can drink, most medicines will be
taken by mouth in a pill or liquid form. Tell your
nurse know which your child prefers.
Stronger medicines | If Acetaminophen or
Ibuprofen is not strong enough to take away the
pain, a very strong medicine (opioid) such as
codeine, oxycodone, hydrocodone or morphine will
be given. Sometimes the strong medicines are given
alone, but may be given with Acetaminophen or
Ibuprofen.
Some parents worry that their child may become
addicted to pain medicines or that the use of pain
medicines early on will reduce the effects later in
treatment. These concerns can lead to poor pain
relief or the use of less-effective medicines. Parents
should not let these concerns affect the pain management of their child.
Strong pain medicines are safe and useful for
children and will not lead to addiction. For severe
pain, a strong medicine must be used.
Children may develop a tolerance or physical
dependence to a pain medicine. This is not addic-

tion. Addiction is an overwhelming craving for the

feeling a drug gives, even if it is not needed for
pain relief. Children do not become addicted to pain
medicines when the medicine is used to treat pain.
Physical dependence and tolerance occur in anyone
who takes strong pain medicines for several days.
Your body gets used to some pain medicines, and
they must be decreased a little at a time to avoid
side effects.
Side effects | Some side effects caused by the
strong pain medicines (morphine or codeine) include
nausea and vomiting, itching, constipation, tiredness
or sleepiness, or confusion. If your child becomes
very sleepy, tell the nurse immediately. Nausea and
vomiting may stop without treatment, or your child
may need other medicines to help him feel better.
Other medicines may be needed to treat your childs
itching or constipation. If the side effects remain,
another type of pain medication may be needed.
Pain technologies | Your doctor may suggest the
use of patient-controlled analgesia (PCA) by using a
computer pump that gives a dose of pain medicine
through your childs IV. When your child is hurting,
she can push the button attached to the pump, and
receive a dose of
medicine. The
A PCA pump may
pump will delivbe used if your child: er only the
amount of medi Can understand how to
cine
the doctor
use the PCA.
has ordered.
Is able to push the button.
PCA is a safe
Can rate pain using the
way to give your
FACES or 0-5 scale.
child some control over her
Can tell the nurse if the
pain, but the
medicine does not take
away her pain.
button should
only be pushed
If your child has a PCA
by your child
and is still hurting, tell the
and not by other
nurse or doctor so
family members.
changes can be made.
An epidural
can be used in a
child of any age to relieve pain after surgery.
Epidurals are usually placed by an anesthesiologist
in the operating room and can provide continuous
pain relief for several days.
If your child has either a PCA or epidural, ask
your nurse or doctor for more information.

Behavioral pain treatments | Children experience

pain differently. Every child reports pain differently.
There are many different ways to relieve pain, such
as pain medicine. In addition to the medicine, relaxation, hot and cold applications, and massage can
help relieve pain.
We know that some things make pain worse.
Emotions like fear, anxiety and depression can cause
a child to have a higher level of pain. Controlling
these emotions can lower pain levels and allow your
child to feel better.
A painful experience at the beginning of a hospital stay, or a painful previous hospital stay, may
make a child more fearful during this hospital stay.
Poorly managed pain during a previous procedure or
test will cause more pain with the same procedure
in the future. If a child believes that a pain medicine has not worked in the past, that medicine will
provide little relief when used the next time, even if
the amount is increased.
Relaxation calms the nerves. Deep breathing,
progressive muscle relaxation and guided imagery
can calm emotions and fears, improve sleep and
increase energy. Relaxation also can lower blood
pressure and heart rate.

Behavioral pain
treatments
This table shows how children of different
ages can relax and decrease their pain.
For written instruction, please contact your
nurse or child life specialist.

Infants

Sensory

Cognitive or
Behavioral

Rocking

Holding a toy or
stuffed animal

Stroking
Sucking
(pacifier)
Cuddling
Positioning

Bubble blowing by
adults
Use objects that
change shapes
and colors

Music

Toddlers

All those
above and
Patting

Pop-up books

Story telling

Puppets

Speaking
to child
through doll
or puppet

Bubble blowing
Singing songs

Child life department | Child life specialists are

available to help your child prepare for surgery or a
procedure, or to help with distraction and coping
during a procedure. They can provide an explanation of the procedure and calm your childs fears.
Child life specialists can teach you and your
child techniques to help you make a plan for coping
with future procedures, based on what works best
for your child.
Pain management team | In some instances of
severe and uncontrolled pain, more help is needed.
These specialists may offer ideas and combinations
of medicines to relieve your childs pain. If you have
any questions about your childs pain management,
ask your nurse to contact a pain management
nurse.
Pain can be harmful if not treated. Parents
should take an active role in dealing with their
childs pain. As healthcare providers, it is our
responsibility to provide appropriate pain assessment and management. Together we can provide the
best pain management possible for your child.

Imagery

Nursery rhymes
Pat-a-cake

Preschoolers

School-age
children

Patting

Pop-up books

Story telling

Stroking

Puppets

Music

Bubble blowing

Pretend
situations

Handholding

Counting

Pretend
roles

Magic Wand

Fantasy

Squeezing
playdough

Singing songs

Cold/heat

Videos

Music

Bubble blowing

Taking a trip

Cold/heat

Counting

Massage

Magic Wand

Pretend
roles

Handholding

Pop-up books

Squeezing
playdough

Kaleidoscope
Nintendo/videos
Breathing exercise

Adolescents Music

Bubble blowing

Cold/heat

Counting

Massage

Breathing exercise

Squeezing
playdough

Nintendo/videos
Conversation

Pain switch
Visual
fixation
Pretend
story
Guided
imagery
Pain Switch
Self
Relaxation
Visual
Fixation

Nuestro compromiso
al tratamiento
del dolor peditrico
Prometemos administrar el mejor alivio posible al
dolor de todos los pacientes de Childrens Medical
Center Dallas. Nos comprometemos a:
 Proporcionar un tratamiento del dolor apropiado para la edad.

 Examinar peridicamente al nio para determinar si siente dolor.

Evaluamos el dolor en intervalos de 2 a 4 horas. Cada vez que
evaluamos los signos vitales, evaluamos el dolor como quinto
signo vital.
 Escuchar toda queja de dolor que tenga el nio. Haremos lo
necesario para aliviar su dolor antes de que pase una hora de su
comienzo.

 Evitar el dolor de los procedimientos. Utilizaremos una medicina

para el dolor en todos los procedimientos que no sean de
emergencia y que requieran agujas.

 Crear un plan individual para evitar y tratar el dolor del nio, y

actualizar dicho plan constantemente para proporcionar el mejor
tratamiento del dolor.
 Utilizar toda opcin disponible para tratar o prevenir el dolor.

 Tratar el dolor de manera que el nio pueda reanudar sus actividades normales, como caminar, baarse o jugar.

 Proporcionar el mejor entorno posible para disminuir o eliminar

el dolor.

Qu puede esperar como padre:

 Recibir informacin sobre el dolor y el alivio del mismo.

 Personal dedicado a prevenir y tratar el dolor.

 Profesionales de la salud que responden rpidamente a toda

seal de dolor.
 Terapia de avanzada contra el dolor.

Como padre de un nio internado en Childrens,

usted debe:

 Preguntar al mdico o enfermera del nio qu debe esperar en

lo que se refiere al dolor y a su tratamiento y hablar de las
opciones para aliviarlo.
 Colaborar con el mdico y enfermera del nio para disear un
plan de tratamiento del dolor.
 Pedir un analgsico apenas el nio sienta dolor.

 Ayudar al mdico y enfermera a evaluar el dolor del nio.

 Informar al mdico o enfermera si el dolor no se alivia.

 Help your childs doctor or nurse assess your childs pain.

 Manifestar cualquier inquietud que tenga sobre los analgsicos

que toma el nio.

 Express any worries you have about the pain medicines your
child may be taking.
0903

 Tell your childs doctor or nurse if pain is not relieved.

 Ask for pain relief when your child first experiences pain.

 Work with your childs doctor and nurse to develop a pain

management plan.

 Ask your childs doctor or nurse what to expect regarding pain

and pain management, and discuss pain relief options.

As a parent with a child at Childrens, you should:

 State-of-the-art pain management.

 Health professionals who respond quickly to reports of pain.

 A concerned staff committed to pain prevention and
management.
 To receive information about pain and pain relief.

As a parent you can expect:

 Providing the best environment possible to decrease

or eliminate pain.

 Treating pain so each child can return to normal activities such as

walking, bathing and playing.
 Using every available option to treat or prevent pain.

 Creating an individual plan to prevent and treat pain for

each child, and to continually update the plan to provide the
best pain management.

 Preventing pain from procedures. We will use a pharmacologic

option for procedural pain for all non-emergent needle
procedures.
 Listening to each childs complaint of pain. We will take action
to relieve a childs pain within one hour of onset.

 Checking every child for pain on a regular basis. We assess for

pain every 2-4 hours. Every time we check vital signs, we assess
for pain as the fifth vital sign.
 Providing age-appropriate pain management.

We promise to provide the best pain relief possible

for all patients at Childrens Medical Center Dallas.
We are committed to:

Our commitment
to pediatric pain
management