Context

Nurses that care for children are required to keep up to date with current and best practice in regards to pain management. As the NMC Code (2015) states that all nurses must care to high standard, nurses must be able to assess the pain of children with cognitive impairment [CI] as effectively as children without CI. Evidence based guidelines should be utilized to deliver high-quality pain management through the appropriate use of prevention, assessment, and treatment methods (Department of Health [DH], Department for Education and Skills [DES], 2004). 

DH (2004) considers the self-reporting of pain to be gold-standard for the assessment of pain, however this presents a challenge for children with CI who are unable to self-report due to verbal communication difficulties as a result of their condition. Therefore, children with CI are obliged to rely on others, such as parents or caregivers, to identify their pain behaviours and appropriately intervene (Solodiuk et al 2010). However, Solodiuk (2012) identifies that a cause of the under treatment of pain in children with CI is as a result of pain in this population not being easily recognised. As a result, children with CI relying on others to identify their pain can prove to be difficult in practice as pain is a subjective and complex experience which is best understood through the use of self-reporting. Therefore, the need for reliable pain tools for children with CI is imperative to ensure that pain evaluation is consistent and that pain management is adequate (Chem-Lin et al 2012). 

Pain assessment is an integral aspect of the nursing assessment. The Royal College of Nursing [RCN] (2009) states that the objective of pain assessment is to ensure that successful processes and procedures are implemented to prevent or minimise pain, and that the pain management within paediatric nursing has been recognised as inadequate. In regards to children with CI, Oberlander and O’Donnell (2001) identified that although many healthcare professionals acknowledge that pain is a common experience amongst these children, it is believed that pain is not easily assessed or managed even when pain is recognised. 

Chem-Lin et al (2012) suggests that the communication of pain is individualized and can attributed to a behavioural change or change in behavioural pattern, which is best interpreted by primary caregivers. However, Ely et al (2012) indicates that behavioural idiosyncrasies such as moaning may conceal pain expression as well as play and sleep patterns which may be problematic to interpret due to physical problems associated with some children with CI. In addition, Dubois, Capdevila, Bringuier, and Pry (2010) state that some atypical behaviour mannerisms identified through studies can cause confusion in carers if their child does not display expected behaviours experienced by other carers of children with CI. Solodiuk et al (2010) found that 25% of no pain descriptors by primary caregivers were in fact reported as responses to pain in other children. As a result, pain assessment tools for children with CI need to be individualised and informed through parents and caregivers who are more accustomed to their child’s behaviour and pain expression than the healthcare professionals caring for them during inpatient stays.  

This chat will aim to explore the following:

• What tools do health professionals use to assess pain in children with cognitive impairment? 

• Is it important to have different tools?

• Do you use or know of any additional resources used in your trust to assist in pain assessment of this patient group?

• Is collaboration with parents/carers important? How do you facilitate this?

• What are the challenges of pain assessment of this patient group?

• How can we overcome these challenges?

• What are your top tips for pain assessment for this patient group?

Chen-Lim, M, L., Zarnowsky, C., Green, R., Shaffer, S., Holtzer, B., & Ely, E. (2012). Optimizing the Assessment of Pain in Children Who Are Cognitively Impaired Through the Quality Improvement Process. Journal of Pediatric Nursing, 27(6), 750-759. doi:10.1016/j.pedn.2012.03.023

Department of Health., & Department for Education and Skills. (2004). National service framework for children, young people, and maternity services: children and young people who are ill. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/199954/National_Service_Framework_for_Children_Young_People_and_Maternity_Services_-_Children_and_Young_People_who_are_Ill.pdf

Dubois, A., Capdevila, X., Bringuier, S., & Pry, R. (2009). Pain expression in children with an intellectual disability. European Journal of Pain, 14(6), 654-660. doi:10.1016/j.ejpain.2009.10.013

Ely, E., Chen-Lim, M, L., Zarnowsky, C., Green, R., Shaffer, S., Holtzer, B. (2012). Finding the Evidence to Change Practice for Assessing Pain in Children Who Are Cognitively Impaired. Journal of Pediatric Nursing, 27(6), 402-410. doi:10.1016/j.pedn.2011.05.009

Oberlander, T, F., & O’Donnell, M, E. (2001). Beliefs about pain among professionals working with children with significant neurologic impairment. Developmental Medicine & Child Neurology, 43(2), 138-140. doi: 10.1111/j.1469-8749.2001.tb00734.x

Solodiuk, J, C., Scott-Sutherland, J., Meyers, M., Myette, B., Shusterman, C., Karian, V, E., Harris, S, K., & Curley, M, A, Q. (2010). Validation of the Individualized Numeric Rating Scale (INRS): A pain assessment tool for nonverbal children with intellectual disability. PAIN, 150(2), 231-236. doi:10.1016/j.pain.2010.03.016

Solodiuk, J, C. (2012). Parent described pain responses in nonverbal children with intellectual disability. International Journal of Nursing Studies, 50(8), 1033-1044. doi:10.1016/j.ijnurstu.2012.11.015