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Running head: PAIN ASSESSMENT IN YOUNG CHILDREN The Wisconsin Childrens Hospital Pain Scale for Preverbal Children: A Descriptive Study Experiences of Nurses Using the University of Wisconsin Childrens Hospital Pain Scale for Preverbal Children: A Descriptive Study Most patients in the hospital setting experience pain. Pain is a subjective phenomenon that varies from person to person. The most relied upon indicator of pain is a patients verbal report of the pain, but what happens when the patient cannot verbalize his pain? This is the case with infants and other nonverbal patients.
They experience pain but are unable to tell a nurse where it hurts, how it hurts, and the intensity to which it hurts. OConner-Von (2000) stated "if self-report is not available, physiologic or behavioral measures must be used" (p. 1), and "nurses are the key health care personnel responsible for continuous assessment in children in the health care setting" (p. 1). Nurses need a reliable and continuous means of pain assessment for the preverbal population. A study of the pediatric pain practices of national health professionals showed that only twenty percent of the sample used a behavioral assessment scale (Broome, Richtsmeier, Miller, & Alexander, 1996, p. 314). Investigation of the tools used to assess pain in the nonverbal population of the pediatric floors in hospitals located in a small Midwestern city revealed that no one method was being used in any of the hospitals. According to several pediatric nurses from various hospitals in the area, nurses were assessing the pain of the nonverbal population based on their own opinions as to whether or not the patient was in pain, how consolable the patient was, and the parents report as to whether or not the patient was in pain.
While this method of pain assessment can be accurate, it can also vary widely between nurses as no two nurses have the same perception or assessment of any one patients pain. In order to ensure that pain of a nonverbal child is being assessed every time by every nurse in a consistent manner, a pain assessment scale is necessary. The University of Wisconsin Childrens Hospital (UWCH) Pain Scale for Preverbal and Nonverbal Children is a scale used to assess pain based on five categories: "facial, vocal / cry , behavioral / consol ability , body movements / posture , and sleep" (Soetenga, Frank, & Pellino, 1999, p. 3). This scale is in a column format due to previous reports that this form is easier to use in the clinical setting than scales that require the user to add up scores in each category to get an end result (p. 3). The purpose of this study is to describe the experiences of pediatric nurses at a regional medical center as they implement The University of Wisconsin Childrens Hospital Pain Scale for Preverbal and Nonverbal Children on children between the ages of six and twelve months in the acute clinical setting.
Infant pain has for the most part been inadequately assessed and poorly managed. This is largely due to myths that children cannot feel pain or if they do feel pain, are unable to remember the occurrence (Mccaffery & Pasero, 1999, pp. 629 - 630; Sound & Rogers, 1998, p. 689; Brown, 1997, p. 349). Recent studies have moved more toward the fetus having the "anatomic and neuro chemical abilities to experience discomfort" as early as the second trimester (Sound & Rogers, 1998, p. 689. ) The central nervous system is as mature as an adults by 36 weeks gestation (Brown, 1997, p. 349), and at birth, an infant has comparable, if not more, numbers of nociceptive nerve endings on their skin surface as an adult (Mccaffery & Pasero, 1999, p. 629). This suggests that infants are as capable as adults of experiences painful impulses. Studies have also shown that infants can in fact remember painful stimuli. Continual behavioral changes in infants after painful procedures indicate that the infants have some ability to remember the painful event (Sound & Rogers, 1998, p. 689).
Infants also can develop behaviors, such as stiffening and withdrawal, in response to the anticipation of repeated painful stimuli such as a heel lance (Mccaffery & Pasero, 1999, p. 630). As these myths have been discredited, more importance has been placed on assessing the pain of the nonverbal child. The assessment, in itself, is challenging. How does a nurse assess the pain when verbal self-report is non-existent? Researchers Jacob and Puntillo (1999) surveyed the practice of childhood pain assessment and management and found that "nurses indicated that physiological changes, facial expression, and body language are determinants of pain" (p. 283). Because similar physiological changes can occur due to either the actual illness or the pain the infant is experiencing (Jorgensen, 1999, p. 351) and due to the fact that the body adjusts itself in times of stress, returning to normal parameters when the pain still exists (Baylor International, 2000, p. 3), other indicators of pain must be used when assessing the preverbal child.
Hudson (1997) reported in response to a question regarding the current recommendations for providing comfort for infants hospitalized in the acute care setting that "behavioral observation has been recommended as the primary pain assessment method for the nonverbal child" (p. 1). Behavioral indicators of pain include grimacing (facial expression), crying, holding the breath (Brown, 1997, p. 354), "gross motor movement, and changes in behavioral state and functions (e. g. , sleeping and eating patterns" (Mccaffery & Pasero, 1999, p. 633). Facial expression is the most typical behavioral indicator of pain and is characterized by the "brows and forehead bulging, eyes squeezed tightly closed, cheeks raised to form a naso labial furrow, and the mouth opened and stretched both horizontally and vertically" (Mccaffery & Pasero, 1999, p. 633).
These facial expressions are usually accompanied by a cry and are even present during the "silent cry" of an incubated infant (Jorgensen, 1999, 351; Mccaffery & Pasero, 1999, p. 634). Researchers have found that infants have a distinct pain cry that may be perceptible by the infants mother and other trained individuals (Jacob & Puntillo, 1999, p. 282). Other studies show the cry of an infant in pain has an increased pitch, "intensity of higher frequency components, and mean cry energy of a vocalization" (Fuller & Conner, 1995, p. 255), and is "tense, harsh, non melodious, short, sharp, and loud (Mccaffery & Pasero, 1999, p. 633). Body movement is another behavioral indicator of pain.
An infant in pain can have increased body movements such as "kicking, thrashing, and limb / trunk rigidity" (as cited by Hudson, 1997, p. 1) and increased muscle tension as the infant "moves vigorously, extends and flexes arms and legs, and squirms on the bed (Jorgensen, 1999, p. 351). While some infants in pain exhibit increased activity, the opposite may occur as a child, who has learned that moving or being picked up increases his pain, lies very still in bed (Baylor International, 2000, pp. 2 - 3). Sleep and wake patterns can also be affected by pain. A child who is in pain "is typically fussy", but a sleeping child or one who is seemingly unaffected can still be experiencing pain as they may have decreased resources to expend the energy needed to move or even cry (Jorgensen, 1999, p. 351). Because of this, no one behavioral indicator can be relied upon to assess the pain level in a nonverbal child. In order for a pain assessment scale to be accurate, multiple behavioral categories need to be integrated (Soetenga et al. , 1999, p. 3).
The University of Wisconsin Childrens Hospital Pain Scale for the Nonverbal and Preverbal infant is a pain scale that assesses multiple behavioral categories: "facial, vocal / cry , behavior / consol ability , body movements / posture , and sleep" (Soetenga et al. , 1999, p. 3). This scale, in column format, gives a description of behaviors that a nurse can compare to the behaviors of the patient and obtain a pain rating on a scale of 0 - 5 (pp. 3 - 6). The validity and reliability of this scale was tested and the scale was found to be both valid and reliable (Soetenga et al. , 1999). The construct validity, inter-rater correlation, and internal consistency were all found to be acceptable (p. 9). "The criterion validity may be low due to comparison of nurse ratings with parents ratings and the use of a more subjective scale, rather than another behavioral scale" (p. 10). What are the experiences of pediatric nurses at a regional medical center as they implement The UWCH Pain Scale for Preverbal and Nonverbal Children between the ages of six and twelve months in the acute clinical setting? The variable in this study is the experiences of nurses implementing The UWCH Pain Scale for Preverbal and Nonverbal Children.
The operational definition of this variable is the results gathered by the researcher from interviews (see Appendix A) with pediatric nurses who have implemented the scale in the acute clinical setting at a regional medical center. The target population of this study is pediatric registered nurses in the acute clinical setting. The accessible population is pediatric nurses at a regional medical center. This study will be conducted on the pediatric unit of a regional medical center. A descriptive study design will be...
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