FREE ESSAY ON PAIN ASSESMENT

PAIN ASSESMENT

Running head: PAIN ASSESSMENT IN YOUNG CHILDREN
Experiences of Nurses Using 
The Wisconsin Children's Hospital Pain Scale 
for Preverbal Children: A Descriptive Study
Bradley University
Experiences of Nurses Using the University of Wisconsin Children's 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 patient's
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.
O'Conner-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, Maikler, & 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 parent's 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 patient's 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 Children's Hospital (UWCH) Pain Scale for Preverbal and
Nonverbal Children is a scale used to assess pain based on five categories: facial,
vocal/cry, behaviorial/consolability, 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 Children's Hospital Pain Scale for Preverbal and
Nonverbal Children on children between the ages of six and twelve months in the acute
clinical setting.
Review of Literature
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; Soud & Rogers, 1998, p.
689; Brown, 1997, p. 349). Recent studies have moved more toward the fetus having the
anatomic and neurochemical abilities to experience discomfort as early as the second
trimester (Soud & Rogers, 1998, p. 689.) The central nervous system is as mature as an
adult's 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
(Soud & 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
nasolabial 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 intubated infant (Jorgensen, 1999,
351; McCaffery & Pasero, 1999, p. 634). Researchers have found that infant's have a
distinct pain cry that may be perceptible by the infant's 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,
nonmelodious, 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 Children's Hospital Pain Scale for the Nonverbal and
Preverbal infant is a pain scale that assesses multiple behavioral categories: facial,
vocal/cry, behavior/consolability, 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).
Research Question
Research Question
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?
Identification of Variables
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.
Population
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.
Methods of Procedure
Setting
This study will be conducted on the pediatric unit of a regional medical center.
Design
A descriptive study design will be utilized. In a descriptive study, phenomena are
described or the relationship between variables is examined (Nieswiadomy, 1998, p. 127)
The experiences of nurses implementing the University of Wisconsin Children's Hospital
Pain Scale for Preverbal and Nonverbal Children are the phenomena being described in this
study.
The nurses involved in the study will attend an inservice describing and explaining how
to use the UWCH Pain Scale for Preverbal and Nonverbal Children. The scale will be
implemented for one month. At the end of the month, the nurses implementing the scale
will be interviewed and data will be collected.
Sample
The sample will be a convenience sample of all thirty registered nurses working on the
pediatric unit at a regional medical center.
Data Collection
Data for this study will be the self-report experiences of nurses participating in the
study and will be collected through a semi-structured interview. Set questions will be
asked, but the researcher also will be able to ask probe questions to further clarify the
responses. Both closed and open-ended questions will be used. The data will be collected
by the researcher one month after the implementation of the scale into practice in a
controlled environment, such as a conference room, obtained by the researcher. The
researcher will make appointments with each nurse involved in the study to allow for
adequate time for the interview and to ensure that all nurses are interviewed. The
interview schedule is located in Appendix A.
Analytic Procedures
Data collected will be compared across all participants of the study. Experiences will be
analyzed for major themes, similarities, for opinions as to whether or not this scale is
feasible to use in the clinical setting, and suggestions for improvement to the scale or
means of implementation.
Ethical Considerations
This proposal will be submitted to the Institutional Review Board of the medical center
for approval. Informed consent will be obtained from all participants by having the
participants sign a statement of informed consent (Appendix B). The nurses as employees
of the hospital are vulnerable subjects. They will be guaranteed that their participation
will in no way negatively affect their job. Participants will be guaranteed anonymity and
confidentiality. The researcher will be the only person who can connect any data
collected to the person it was collected from. All results will be generalized and in no
way linked to any one nurse. All subjects will participate of their own free will without
the use of coercion.
The benefits of this study appear to outweigh the risks. The benefits will be the
reflection of nurses on their means of pain assessment of the preverbal population. There
are no known significant risks in this study. All participants will be able to ask
questions about the study and were given a means of contacting the researcher if any
questions arose at any time before, during, and after the study is completed. Also, all
participants will be informed as to how to obtain the results of the study once
completed.
Plan for Communication of Results
The results of the completed study will be submitted to The Journal of Pediatric Nursing
for publication. Results will also be presented to the Pain Management Panel at the
regional medical center.
References
Baylor International Pediatric AIDS Initiative. (2000, June 8). Assessment and diagnosis
of pain in children. Houston. Retrieved July 11, 2000 from the World Wide Web:
http://bayloraids.org/resources/childpain/assess.shtml
Broome, M. E., Richtsmeier, A., Maikler, V., and Alexander, M. A. (1996, May). Pediatric
pain practices: A national survey of health professionals. Journal of Pain and Symptom
Management, 11, 312-320.
Brown, R. E., Jr. (1997). Care of children with pain. In M. Cahill (ed.), Expert pain
management (pp. 348-357). Springhouse, PA: Springhouse Corporation.
Fuller, B. F. and Conner, D. A. (1995, August). The effect of pain on infant behaviors.
Clinical Nursing Research, 4, 253-273.
Hudson, D. C. (1997). Pain management in the hospitalized infant. Journal of the Society
of Pediatric Nurses, 2, 93+. Retrieved July 11, 2000 from Firstsearch database on the
World Wide Web: http://firstsearch.oclc.org
Jacob, E. and Puntillo, K. A. (1999, May-June). A survey of nursing practice in the
assessment and management of pain in children. Pediatric Nursing, 25, 278-286.
Jorgensen, K. M. (1999, December). Pain assessment and management in the newborn infant.
Journal of PeriAnesthesia Nursing, 14, 349-256.
McCaffery, M., and Pasero, C. (1999). Pain: Clinical manual. St. Louis: Mosby.
Nieswiadomy, R. E. (1998). Foundations of nursing research. Stamford, CT: Appleton &
Lange.
O' Conner-Von, S. (2000, July 11). Pediatric pain assessment. Iowa City: University of
Iowa. Retrieved July 11, 2000 from the World Wide Web:
http://coninfo.nursing.uiowa.edu/sites/PedsPain/Assess?chiast.html 
Soetenga, D., Frank, J., and Pellino, T.E. (1999). Assessment of the validity and
reliability of the University of Wisconsin Children's Hospital pain scale for preverbal
and nonverbal children. Pediatric Nursing, 25, pp. 670+. Retrieved July 11, 2000 from
Firstsearch database on the World Wide Web: http://www.firstsearch.oclc.org
Soud, T. E. and Rogers, J. S. (1998). Manual of pediatric emergency nursing. St. Louis:
Mosby.
Appendix A
Interview Schedule
Educational background (diploma, associate's degree, B.S.N, advanced degree)? Number of
years in nursing?
Years in pediatric nursing? 
What shift normally worked?
Does unit have written standards for pain assessment?
How did you assess the pain of the nonverbal child prior to implementation of the UWCH
pain scale?
Did you ever take into consideration the behavioral actions of the child to be
indications of pain? If so, what behavioral characteristics?
Do you feel that adequate explanation and/or instruction were given in regards of using
the UWCH pain scale?
Was the scale easy to use? Explain, how.
What were your experiences in using the UWCH pain scale for preverbal and nonverbal
children?
What were the advantages/disadvantages of using the scale?
Are there any areas where you feel the scale could be modified to ease use or improve the
assessment of pain in this population? 
How would you compare the level of pain assessed using the UWCH pain scale to how you
would have previously assessed the pain? 
Would you have assessed a higher or lower level of pain than what was assessed using the
scale? 
Appendix B
Statement of Informed Consent
BRADLEY UNIVERSITY
Committee on the Use of Human Subjects in Research
I, _______________________________, am being asked to participate in a research project
entitled Experiences of Nurses Using the University of Wisconsin Children's Hospital Pain
Scale for Preverbal and Nonverbal Children: A Descriptive Study. This project is being
conducted under the supervision of Brandee Witbracht and was approved by Bradley
University's Committee on the Use of Human Subjects in Research on ________________.
From this project the investigators hope to learn the experiences of nursing implementing
the UWCH pain scale. An interview will be conducted after the scale is implemented and
responses will be analyzed for themes, similarities, and opinions as to whether or not
the scale is feasible for practice.
As a participant in this project I shall be asked to attend an inservice explaining the
scale and describing how to implement the scale. After the inservice, I will be asked to
use the scale in my everyday assessment of pain in the nonverbal population for a period
of one month. At the end of the month I will be interviewed by the researcher in a
controlled setting obtained by the researcher.
The nature of this study has been explained to me by Brandee Witbracht. I understand that
the anticipated benefits of my participation in this study are my reflections on my own
practice and the protocols of my unit on the assessment of pain in the nonverbal
population. There are no known significant risks in this study.
The investigators will make every effort to safeguard the confidentiality of the
information I provide. Any information obtained from this study that can be identified
with me will remain confidential and will not be given to anyone without my permission.
If at any time I would like additional information about this project, I can contact
Brandee Witbracht at Bradley University's Nursing Department.
I understand that I have the right to refuse to participate in this study. I also
understand that if I do agree to participate I have the right to change my mind at any
time and stop my participation. I understand that grades and services I receive from
Bradley University or my employment at__________________ will not be negatively affected
by my refusal to participate or by my withdrawal from this project.
My signature below indicates that I have given my informed consent to participate in the
above-described project. My signature also indicates that:
I have been given the opportunity to ask any and all questions about the described
project and my participation and that all of my questions have been answered to my
satisfaction.
I have been permitted to read this document and I have been given a signed copy of it.
I am at least 18 years old.
I am legally able to provide consent.
To the best of my knowledge and belief I have no physical or mental illness or weakness
that would be adversely affected by my participation in the described project.
_______________________________________ __________
Signature of Participant Date
_______________________________________ __________
Signature of Witness Date