Discuss Abdominal Pain Management in Children

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Discuss Abdominal Pain Management in Children

Discuss Abdominal Pain Management in Children
Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues.Abdominal Pain Management in Children Essay

Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome.[2] About 10% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy.[2] In a third of cases the exact cause is unclear.[2]

Given that a variety of diseases can cause some form of abdominal pain, a systematic approach to examination of a person and the formulation of a differential diagnosis remains important.Abdominal Pain Management in Children Essay


Acute abdominal pain is a common presentation in the outpatient setting and can represent conditions ranging from benign to life-threatening. If the patient history, physical examination, and laboratory testing do not identify an underlying cause of pain and if serious pathology remains a clinical concern, diagnostic imaging is indicated. The American College of Radiology has developed clinical guidelines, the Appropriateness Criteria, based on the location of abdominal pain to help physicians choose the most appropriate imaging study. Ultrasonography is the initial imaging test of choice for patients presenting with right upper quadrant pain. Computed tomography (CT) is recommended for evaluating right or left lower quadrant pain. Conventional radiography has limited diagnostic value in the assessment of most patients with abdominal pain. The widespread use of CT raises concerns about patient exposure to ionizing radiation. Strategies to reduce exposure are currently being studied, such as using ultrasonography as an initial study for suspected appendicitis before obtaining CT and using low-dose CT rather than standard-dose CT. Magnetic resonance imaging is another emerging technique for the evaluation of abdominal pain that avoids ionizing radiation.Abdominal Pain Management in Children Essay

Abdominal pain is a common presentation in the ambulatory setting, accounting for 1.5% of all office-based visits and 8% of all emergency department visits in the United States in 2010.1 Acute abdominal pain has many potential underlying causes, ranging from benign, self-limited conditions to life-threatening surgical emergencies. Although the patient history, physical examination, and laboratory test results can narrow the differential diagnosis, imaging is often required for definitive diagnosis and treatment.

Acute abdominal pain in children presents a diagnostic dilemma. Although many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. The most common medical cause is gastroenteritis, and the most common surgical cause is appendicitis. In most instances, abdominal pain can be diagnosed through the history and physical examination. Age is a key factor in evaluating the cause; the incidence and symptoms of different conditions vary greatly over the pediatric age spectrum. In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions. Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant. Signs that suggest an acute surgical abdomen include involuntary guarding or rigidity, marked abdominal distention, marked abdominal tenderness, and rebound abdominal tenderness. If the diagnosis is not clear after the initial evaluation, repeated physical examination by the same physician often is useful. Selected imaging studies also might be helpful. Surgical consultation is necessary if a surgical cause is suspected or the cause is not obvious after a thorough evaluation.Abdominal Pain Management in Children Essay

Abdominal pain is a common problem in children. Although most children with acute abdominal pain have self-limited conditions, the pain may herald a surgical or medical emergency. The most difficult challenge is making a timely diagnosis so that treatment can be initiated and morbidity prevented. This article provides a comprehensive clinical guideline for the evaluation of the child with acute abdominal pain.

Clinically, abdominal pain falls into three categories: visceral (splanchnic) pain, parietal (somatic) pain, and referred pain.

Visceral pain occurs when noxious stimuli affect a viscus, such as the stomach or intestines. Tension, stretching, and ischemia stimulate visceral pain fibers. Tissue congestion and inflammation tend to sensitize nerve endings and lower the threshold for stimuli. Because visceral pain fibers are bilateral and unmyelinated and enter the spinal cord at multiple levels, visceral pain usually is dull, poorly localized, and felt in the mid line. Pain from foregut structures (e.g., lower esophagus, stomach) generally is felt in the epigastrium. Midgut structures (e.g., small intestine) cause periumbilical pain, and hind gut structures (e.g., large intestine) cause lower abdominal pain.Abdominal Pain Management in Children Essay

Parietal pain arises from noxious stimulation of the parietal peritoneum. Pain resulting from ischemia, inflammation, or stretching of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatology level as the origin of the pain. Parietal pain usually is sharp, intense, discrete, and localized, and coughing or movement can aggravate it.

Referred pain has many of the characteristics of parietal pain but is felt in remote areas supplied by the same dermatome as the diseased organ. It results from shared central pathways for afferent neurons from different sites. A classic example is a patient with pneumonia who presents with abdominal pain because the T9 dermatome distribution is shared by the lung and the abdomen.1

Abdominal pain in children is a common problem. About 1 out of 3 children is seen by a doctor for abdominal pain by the time they are age 15, but only a small number of these children have a serious problem.Abdominal Pain Management in Children Essay

Complaints of abdominal pain are more common in children younger than 11 years and are often caused by changes in eating and bowel habits. Most cases of abdominal pain are not serious, and home treatment is often all that is needed to help relieve the discomfort.

Abdominal pain in children is often frightening and frustrating for parents. Many times it is hard to find the exact cause of a child’s abdominal pain. Pain without other symptoms that goes away completely in less than 3 hours is usually not serious.

In children, abdominal pain may be related to injury to the abdomen or an illness, such as an upset stomach, an ear infection, a urinary tract infection, or strep throat. Abdominal symptoms can also occur from an infection passed on by animals or while traveling to a foreign country. Constipation is a common cause of abdominal pain in children. Some more serious causes of abdominal pain in children include appendicitis, lead poisoning, or problems with the intestines, such as intussusception or malrotation. Girls who start having menstrual periods may have abdominal pain each month, and the pain may be more severe in some months than others.Abdominal Pain Management in Children Essay

Generalized pain occurs in half of the abdomen or more. Localized pain is located in one area of the abdomen. Babies and toddlers often react differently to pain than older children who can talk about their pain. A baby may become fussy, draw his or her legs up toward the belly, or eat poorly. Older children may be able to point to the area of the pain and describe how severe it is.

Abdominal pain is a common symptom in children, and can have a myriad of causes, ranging from problems that get better on their own to medical or surgical emergencies. Clues to the underlying cause of a child’s abdominal pain include the age of the child, the type of pain — sharp, dull or cramp y, and the duration of the pain. Additional clues include whether the pain has accompanying symptoms such as vomiting or fever, and the location of the pain. Left-sided abdominal pain is most often caused by problems in organs located on the left side, such as the spleen, the left ovary or testicle, and the left side of the large intestine.

Acute Left-Sided Pain That Can Occur Throughout Childhood
Several causes of left-sided abdominal pain cause sudden and often severe pain. For example, the spleen – an organ that makes and filters blood cells, and helps fight infection — is located in the upper left abdomen. Blunt trauma to this part of the abdomen, or even the mid back, can cause injury to the spleen resulting in pain (Ref 1, Etiology section). Moreover, trauma to the spleen can result in a tear of the surrounding capsule, causing severe blood loss from the spleen (Ref 4, p. 1526), a medical emergency. The spleen can also become infected or enlarged, by causes such as Epstein Barr virus infection or congestion from abnormal cells in sickle cell disease, causing left upper abdominal pain. Appendicitis is usually a cause of right-sided abdominal pain, but can actually cause left-sided pain in the rare case of a child born with the appendix located on the left-side of the abdomen (Ref 6, background section).

Acute Left-Sided Abdominal Pain in Older children
Twisting of the left ovary, which is called ovarian torsion, will usually cause intermittent sharp abdominal pain that also may radiate down the left leg (Ref 4, p 1668), usually in girls age 12 years and over (Ref 1, Table 2). Pain occurs because the nerves around the ovary are inflamed. Ovarian torsion is an emergency because of the possibility of loss of the ovary due to impaired blood supply. The same problem of twisting can occur in the left testicle—which most commonly occurs in boys age 12 and over. Since the testicle, unlike the ovary, is visible, a parent may notice the tell-tale signs of scrotal swelling, tenderness and discoloration (Ref 4, p. 1651-1652).Abdominal Pain Management in Children Essay

Chronic Left-Sided Abdominal Pain
Constipation, a common cause of left-sided abdominal pain, is characterized by stools that are infrequent or difficult to pass. The pain is often cramping, and relieved by a bowel movement. Other than abdominal pain, symptoms of constipation that a child may experience include pain during s tooling, blood on the stool or tissue paper after wiping, fecal soiling and wetting himself (Ref 2, p. 2). Risk for constipation is increased when a child’s diet is lacking adequate fiber sources, such as vegetables, fruit and whole grains (Ref 3). A left groin hernia can cause abdominal pain. A hernia occurs when abdominal organs, usually the intestine, enter the groin through an opening in the abdominal wall. Parents may notice a bulge in the child’s groin. Half of these cases occur in children under 1 year old. A groin hernia can cause acute pain and become an emergency if it gets trapped in the abdominal wall — called an incarcerated hernia — because it chokes off blood flow to the trapped organ.Abdominal Pain Management in Children Essay

Pain in this area of the body can be due to a variety of issues, some of which are more common than others, according to Shilpa Ravella, MD, assistant professor of medicine at Columbia University Medical Center in New York City.

“Some causes of lower left abdominal pain are benign, like gas or indigestion, while others are more serious,” says Dr. Ravella. “The left lower abdomen is home to the last part of the colon, so abnormalities in this area can be responsible for the pain.” However, she adds, left abdominal pain can also be caused by pain radiating from other areas of the body, such as the upper abdominal structures, kidneys, bladder or ovaries.Abdominal Pain Management in Children Essay

Signs You Should See a Doctor, Stat
So, when should you seek medical attention? According to David Cutler, MD, family medicine physician at Providence Saint John’s Health Center in Santa Monica, Calif., pain that falls into any of the following categories should be evaluated by a physician as soon as possible:

persists for more than a day
is severe or worsening
is accompanied by fever
has associated symptoms like vomiting or diarrhea
Common Causes
Below are the common causes of lower left abdominal pain. Read through to determine which condition might be ailing you.

1. Gas or Indigestion

Oftentimes the cause of sharp lower left abdominal pain that comes on suddenly, especially after eating a sizable meal, is nothing more than a little gas buildup. Treatment can involve the use of medications that alleviate gas, or dietary changes, says Dr. Ravella.

If, however, these symptoms do not fade within a few hours and/or are accompanied by additional concerning symptoms, like fever, constipation, diarrhea (with or without blood), nausea or vomiting, make an appointment with your doctor, as it may be something more serious. According to the Mayo Clinic, you should seek immediate medical attention if you’re also experiencing shortness of breath, sweating or chest pain radiating to the jaw, neck or arm.Abdominal Pain Management in Children Essay

2. Diverticulitis

One of the most common causes of left lower abdominal pain is diverticulitis. “Diverticula are small pouches that arise from weak spots in the colon that can become inflamed,” explains Dr. Ravella.

While abdominal pain is certainly one common symptom, it’s not the only one. Other symptoms of diverticulitis may include constipation, cramping, fever, chills, vomiting and nausea.

Keep in mind that your risk for this condition increases with age. In fact, about half of all people over the age of 60 have it, according to Medline Plus, a site run by the U.S. National Library of Medicine. Dr. Ravella recommends seeing a doctor if you have acute pain in the left lower side that does not go away, especially with any of the associated symptoms.

3. Inflammatory Bowel Disease

According to the Centers for Disease Control and Prevention, inflammatory bowel disease (IBD) is a broader term for two conditions that cause chronic inflammation of the gastrointestinal tract: Crohn’s disease and ulcerative colitis.

While the presentation of IBD can vary, it can sometimes cause sharp pain in the lower left abdomen. If you’re experiencing this pain consistently along with diarrhea, with or without blood, IBD very well may be the culprit.

If the pain does not subside, and especially if you have frequent diarrhea and/or a family history of IBD, Dr. Ravella recommends seeing your physician for evaluation. If you do indeed have IBD, your doctor may prescribe an immunosuppressive medication.

4. Colo rectal Cancer

This serious condition is much more common in older patients over the age of 50, and symptoms can include abdominal pain coupled with a change in bowel habits or iron deficiency anemia.Abdominal Pain Management in Children Essay

“Cancer can block the bowel, causing sharp lower left abdominal pain and bleeding, as well as a potential rupture,” says Anton Bilchik, MD, PhD, professor of surgery and chief of gastrointestinal research at the John Wayne Cancer Institute at Providence Saint John’s Health Center in Santa Monica, Calif.

Colon cancer is the second-most common cause of cancer related deaths in the U.S., with a six-fold increase in millennial’s being diagnosed, according to a February 2017 study in the Journal of the National Cancer Institute. So it’s certainly worth it to schedule an evaluation with your doctor, no matter your age.

5. Hernia

If your left-hand-side abdominal pain is accompanied by a lump or bulge in your abdomen and/or groin, the cause may be a hernia. This common and treatable condition is marked by a weakness or hole in the peritoneum, the wall of muscle that holds your abdominal organs in place, according to the Cleveland Clinic.

“The pain may feel sharp or like a dull ache, and you may experience even more discomfort while lifting heavy objects,” says Dr. Ravella. “Treatment may involve surgery, depending on the severity of the case.”

6. Kidney Stones

Considered one of the most painful conditions, symptoms of kidney stones tend to come on abruptly and can be experienced in the lower left abdomen as well as the sides and back. You may also see changes in the color of your urine as well as experience nausea, vomiting, fever and chills, notes Dr. Ravella.

Although it’s not the most common condition, affecting approximately 11 percent of men and 6 percent of women in their lifetime, according to the National Institute of Diabetes and Digestive and Kidney Diseases, you should see your doctor right away if you suspect you have a kidney stone.

“Treatment usually involves pain control and hydration, but intervention by a urologist may be indicated for severe cases,” says Dr. Ravella.

For the purpose of the case study I intend to use Gibbs(1998) model of reflection as this model is clear, precise allowing for description, analysis and evaluation of the experience, then prompts the practitioner to formulate an action plan to improve their practice in future(Jasper, 2003).Abdominal Pain Management in Children Essay


Wilkinson (2007) identifies assessment as the first phase of the nursing process in which a nurse uses their knowledge and skills to express human caring. It is important to choose an organised and systematic approach when caring out an assessment that enhances your ability to discover all the information needed to fully understands someone’s heath status (Alfaro-Le Fevre,2004) .This can be achieved by obtaining your information form medical record and nursing charts by physical examination of the patient and also talking to patient and their families(Wilkinson,2007). The use of objective data is more helpful in collecting information when the patient is ventilated and sedated, as they are often in the critical care setting, and this can be done by examining the patients vital sign, blood pressure, heart rate, temperature and blood results (Bulman and Schutz 2004).

I have chosen pain assessment in post- operative ventilated patient. I have worked in ICU for 4 years during this time I have nursed many post- operative ventilator patients who were on continuous infusion of sedatives and analgesics. Many of them showed signs of inadequate pain relief and associated complications. Having undertaken this module I further educated myself in this field of nursing assessment I now know, or rather have an improved knowledge base and understanding of the different aspects of pain assessment tools and recognize the possibility that I have probably nursed many more patients who were demonstrating symptoms of inadequate analgesia and associated complications. Given an increased awareness and knowledge I have gained through teaching, research and current literature on this topic I now, also recognise the importance of this assessment practice in particular in relation to the ventilated, non- communicated patients in ICU.Abdominal Pain Management in Children Essay

According to International Association for the Study of Pain (IASP,1979) pain is described as unpleasant sensory and emotional experience associated with actual or potential tissue damage. Clinically pain is whatever the person says he or she is experiencing whenever he or she says it does (Mc Caffery 1979) .Appropriate pain assessment is crucial to pain management. Patient’s self- report is the gold standard of pain assessment. However pain tools that rely on verbal self-report may not be appropriate for using non- verbal ventilated sedated patients in ICU. Pain assessment tool used in our critical care setting is based on a numerical pain rating score from 0-4, a score of 0 being no pain at all and 4 being the worst pain ever experienced. There is also a visual analogue scale for patients who have difficulty communicating, they can indicate by looking at the chart and pointing at either the happy face that has no pain or a series of faces showing different stages of pain (appendix three). These tools were chosen by the specialised pain care nurses working for the trust. The tools are favoured as they provide nurses with a quick, easy assessment. They are used widely throughout the trust to provide continuity of pain assessment.Both of these tools have proved successful in practice and are supported by the literature as being reliable and accurate in practice. However they depend greatly on the patient being able to express themselves or communicate verbally with the practitioner .Using these methods of pain assessment is not accurate on sedated patients with altered conscious level. In nonverbal patients the use of behavioural or physiological indicators are strongly recommended for detection of pain (Jacobi et al 2006).

The patient in critical care may experience pain from many sources. Along with physical pain, psychological factors such as fear, anxiety and sleep disturbances may play a significant role in patients’ overall pain experience (Macintyre and Ready 2002). Urden et al (2010) states, pain can be acute or chronic, sensations are different in relation to its origin. Acute pain-duration is short corresponds to the healing process, ranges between 30 days to 6 months. Chronic pain lasts more than 3 to 6 months and can either or not associated with an illness. Somatic pain is well localised sharp, acute pain arising from skin, muscle, joints. Visceral pain refers to the deep, ill localized arising from an organ. Nociceptive pain occurs when inflammation stimulates pain receptors ( Urden et al 2010). Pain experienced in critical care patients are mostly acute and has multiple origins.Abdominal Pain Management in Children Essay

Mr. Smith a 45 year old gentleman admitted to ICU following Laparotomy for small bowel perforation and faecal peritonitis. Mr Smith was cardiovascularly unstable and was unable to be extubated immediately after surgery due to secondary sepsis. He was receiving an infusion of Propofol and Fentanyl to keep him comfortable and provide analgesia. His medical notes revealed his past medical history of previous Cholecystectomy for gall bladder stones and biliary obstruction. I was assigned to nurse him on his second day in ICU. During handover the previous staff member reported that Mr. Smith became very agitated and hypertensive soon after he was repositioned to his side. Mr. Smith was given a bolus dose of Propofol infusion and the rate of Infusion increased. Whilst doing the Patient assessment I noticed Mr Smith is restless and not compliant with the ventilator. Arterial Blood Gas (ABG) performed which showed Mr. Smith is hypo ventilating. Meanwhile Mr. Smith became more agitated with escalating non-compliance with ventilator and significant increase in his Mean Arterial Pressure (MAP) which was being monitored continuously by the arterial line and transducer. He was showing facial grimaces and moving his extremities restlessly. I tried to reassure him by talking to him, reorientating him to time, place and person, explaining to him that he is safe. Adam and Osbourne (2005) identifies that critically ill patients frequently require help with coping with many of the stresses like physical discomfort, isolation, fear of pain and death. By using strategies like communicate caring and understanding and provide information repeatedly and in sufficient detail for the patient etc. helps the patient to cope with the stress. But repeated reassurance and reorienting has not made any improvements in his current status.

Pain is an important problem in critical care and its detection is a priority. Pain assessment is vital to detect pain (Urden 2010). Pooler-Lunse and Price(1992) emphasises that critically ill patients who are unable to communicate effectively are at high risk of suffering from pain. Poorly controlled pain can stress the sympathetic nervous system leaving vulnerable patients at risk of complication and can compromise recovery and negatively affect both morbidity and mortality(Puntillo et al 2004, Dracup and Bryan- Brown 1995).Mr Smith was ventilated and due to the effect of sedatives his level of consciousness was altered. In critical care factors alter verbal communication is mechanical ventilation, administration of sedative agents and the patients change in level of consciousness (Hamill-Ruth R J, Marohn L 1999 ,Kwekkeboom K L, Herr K 2001,Shannon K, Bucknall T 2003). The consequences of untreated acute pain in critically ill patients include increases in catecholamine and stress hormone levels which are potential causes of tachycardia, hypertension, increased oxygen requirements and decreased tissue perfusion (Blakely and Page 2001, Hamill-Ruth and Marohn 1991). Mr Smith was increasingly hypertensive and tachycardia. Despite giving increased oxygenation Mr.Smith was hypo ventilating due to non- compliance to the ventilator.Abdominal Pain Management in Children Essay

Marshall and Soucy(2003) identifies agitation is a common problem in critically ill patients and has been shown to be associated with inadequate pain management. Agitation can have serious consequences with patience removing access lines compromising their oxygen needs by self extubating (Cohen et al 2002).

Following discussion with the nurse in charge of the shift it was apparent that Mr. Smith was showing behavioural signs of pain. There were no other obvious reasons as to why he had become compromised with his ventilation.When I approached the medical team concerning Mr.Smith’s increasing agitation and non- compliance to ventilation I was instructed to give a bolus of propofol and fentanyl and to increase the rate of propofol and fentanyl until Mr Smith was deemed medically manageable. I was decided to increase Mr.Smith’s ventilatory support. Following the treatment Mr Smith became much more stable, he became less tachypoenic was synchronising with the ventilator; his blood pressure was within acceptable limits and monitoring in sinus rhythm.

The clinician did not assess Mr Smith for signs of inadequate pain management. Unfortunately due to hypoventilation and non-compliance to mechanical ventilation, Mr Smith had to be remained on high levels of ventilation and increased levels of sedatives for the next few hours emphasising evidence by Pooler-Lunse and Price(1992), the physiological complications associated with pain including Pulmonary complications and increased cardiac workload as well as depression and anxiety and increased days of hospital stay(Desbians et al 1996).Upon further reflection I should have noted Mr Smith’s agitation associated with inadequate pain relief. Had I been knowledgeable in this field Mr.Smith’s agitation and physiological signs of restlessness and facial grimaces would have prompted me to carry out a detailed pain assessment. Had there been a behavioural pain assessment scale on the unit where I work that may have prompted me carry out the assessment and linked these signs as indicators of inadequate pain relief.Abdominal Pain Management in Children Essay

During my further assessment of Mr.Smith I had various thoughts and feelings which included feeling apprehensive and self-doubt regarding the decision to increase sedation and ventilator support. Whilst reviewing his past medication history I noticed that Mr Smith had been on regular analgesics which are co-codomol and paracetamol and there was no indication for their use in his notes. Fink R (2000) recognises that reviewing patient’s past pain experiences and how did he or she usually react to it can be of good value when assessing pain and can help to decide treatment options ,by questioning patients’ family or significant other can provide us the information about patient’s pain history. Later during the visiting hours Mrs Smith came to visit Mr Smith. I have given her a brief update of his condition including the changes made to his sedation and ventilation. Then I enquired to Mrs Smith about the indication of those analgesics he was on .She revealed that Mr.Smith developed back pain when he discharged to home after undergone cholecystectomy six months ago and he was prescribed those analgesics by his G.P(General Practitioner). She also mentioned that he had problems getting optimal pain relief post operatively even when he had cholecystectomy, and he would not tolerate lying on his sides. This co-related his agitation and restlessness happened when the night staff turned him to his side.

I notified these things to the ICU doctors and raised my concern that lack of adequate pain management could be the reason for Mr Smith’s earlier agitation. They also agreed on this possibility and advised to change fentanyl infusion to remifentanyl and to adjust the rate of the infusion to keep Mr Smith’s pain relief optimal. Remifentanyl is potent analgesics, so ensure the patient is pain free but prevents over sedating the patient, allows rapid arousal and recovery from sedation thus facilitates daily sedation holds and neurological assessment( Dhaba et al 2004). He was also prescribed regular paracetamol and Tramadol when required. It was then decided to reduce Mr.Smith’s sedation as he was haemodynamically stable, he was then able to respond and started following commands. Mr. Smith was now able to communicate if he had pain or not by squeezing my hand to command.Abdominal Pain Management in Children Essay

Invasive technology can restrict the reliance on many behavioural indicators of pain (Bucknall and Shannon 2003) on the other hand it is argued that invasive lines enables constant monitoring of blood pressure (B.P) and heart rate (H.R), two commonly utilised indicators of pain and thus help to assess pain (Bucknall and Shannon 2003) .Even though Mr Smith was hypertensive and tachycardic this was presumed to be due to agitation. In a contradicting statement Bucknall and Shannon(2003) points out that the sympathetic symptoms i.e. Increasing B.P and H.R are also been found to be unreliable. Pooler-Lunse and Price (1992) emphasises that the Para sympathetic stimulation can result in less observable signs with prolonged pain, but pain intensity remains unchanged. The American Society for Pain Management Nursing (ASPMN) recommendations cited in Herr k et al ( 2002) emphasises that vital signs can be affected by other distress conditions, homeostatic changes and medications there for they should not be considered as primary indicators of pain.With conflicting evidence it is difficult to make decisions that best support this assessment practice.

Anand K J S,Craig K (1996), Herr K et al (2006) states that behavioural indicators are strongly recommended for pain assessment in non- verbal patients , few tools have been developed and tested in critically ill patients. The Behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) are suggested and supported by experts for using uncommunicative critically ill patients (Li-D, Puntillo, Sessler 2008). BPS was tested and validated exclusively in ventilated, unconscious patients (Payen et al 2001,Young G 2006, Aissaoui Y et al 2005).The Behavioural Pain Scale (BPS) includes three behaviour’s 1) facial expression 2)movements of upper limbs3)compliance with the ventilator. Each behaviour is rated on a scale from 1 to 4 for a possible total score from 3 to 12. The BPS can be used quickly (2 to 5 minutes), most clinicians were satisfied with its ease of use (Payen et al 2001). The Critical Care Pain Observation Tool (CPOT) was tested in verbal and non- verbal critically ill adults (Gelinas C 2006,2007) its content validity supported by ICU experts including nurses and physicians (Gelinas C 2009). CPOT includes four behaviours 1) facial expression 2) body movements 3) compliance with the ventilator 4) muscle tension. Each behaviour is rated from 0 to 2 for a possible score of 0 to 8.Gelinas C and Hammond reports that feasibility and clinical utility of CPOT were positively evaluated by ICU nurses and agree it is easy to complete, simplicity to understand the usefulness for nursing practice.Abdominal Pain Management in Children Essay

My experience of using a behavioural pain scale tool is limited, however I feel that if practitioners were able to assess pain more accurately then they would be able to manage there patients pain more effectively.

Use of a behavioural pain score (BPS) evaluating facial expressions, limb movement and compliance with the ventilator has proved to be a valid reliable tool in practice. A recent study evaluating the reliability and use of the BPS consistently identified increases in pain scores after repositioning patients in the ICU. There were only small non- specific changes in the BPS after non painful intervention of eye care (Gelinas etal 2006).

I nursed Mr Smith again 5 days later. He had since been extubated and was alert and oriented. Even though he could not remember the events when he was ventilated and sedated, he learned from his wife what had happened. He was very thankful to me for investigating the possible reason for his agitated behaviour and prompting the doctors about this and thus provide him adequate pain relief.Abdominal Pain Management in Children Essay

Upon further reflection and evaluation of my assessment of Mr.Smith I feel there have been positive and negative aspects of the assessment. The positive aspects include- I have been able to gain further knowledge in various aspects and tools of pain assessment .By reviewing patients medical notes and gaining history from his wife I have linked his agitated behaviour and taken the possibility that these are signs of inadequate pain relief and I have managed to convince the medical team regarding this in order to act on it. Current research identifies multidisciplinary collaboration provides optimum care for the patient (Bucknall T, Shannon K 2003), this emphasises the need to perform regular, accurate pain assessment and care full documentation (Bucknall T, Shannon K 2003).

When considering the negative aspects of my assessment I feel I did not use a holistic approach instead I considered Mr.Smiths agitated behaviour as a physical problem, I was concentrated to treat the symptoms and not the patient. As described in Roper Tinney L(1989) assessment tools achieving patient centred nursing is important. I could not identify Mr.Smith’s behavioural indicators of pain primarily due to my lack of knowledge about this assessment tool as well as there was no unit assessment protocol which includes the behavioural assessment scale, Unfortunately this is not isolated, it is in fact a universal problem .Camp (1998) points out that like many speciality nurse critical care nurses and physicians recognises that there basics education was insufficient for caring for patients in pain.Abdominal Pain Management in Children Essay

Accurate detection of the critically ill patient’s pain is not an easy task for ICU nurses especially when the patient is unable to self-report because of mechanical ventilation or due to the effects of sedatives. Stanton (1991) argues that pain assessment and management may be significantly improved by enhancing nurses knowledge combined with improved communication of the problem. NMC(2008)emphasises that having appropriate knowledge, skills and attitude towards pain, pain assessment and its management is essential to provide optimum patient care.

Use of pain assessment tools is highly recommended by Kaiser(1992), identifies that an effective pain assessment tool as part of the documentation improves communication between patients and nurses as well as nurses and medical staff. Even though we had a pain assessment tool (0 to 4 numeric pain assessment scale) due its limitations on the use in non-communicative patients it was not contributing much in patient’s pain management. The previous practitioner documented the patient’s pain score is “Unable to assess “as the patient is sedated and ventilated. This highlights the inappropriate use of our pain tool currently being used in practice as a patient is unable to verbalise or communicate their pain if they are sedated and ventilated. Although todays guidelines strongly suggest that the use of a standardised behavioural pain scale to nurses who care for uncommunicative patients, further research is still needed to fully understand the behavioural and physiological responses of critically ill patients who are experiencing pain (Herr K et al 2008).Abdominal Pain Management in Children Essay

On reflection my underpinning knowledge and confidence in this area of assessment has developed tremendously. I feel that I have gained knowledge and insight into an important patient assessment, from an initial lack of sufficient knowledge I am now able to bring evidence based practice in the clinical area which will benefit the patient and my colleagues. By understanding the physiology, pain assessment tools and the complications of poorly managed pain, I will have the knowledge and skills to manage these patients. The use of sedatives and analgesics places a great deal of responsibility on critical care nurses and they must understand how the drugs work , complications of their use and how to monitor effectiveness staff must understand sedation does not equate analgesia (Ashley and Given 2003). The use of an appropriate pain assessment tool and management algorithm is essential for adequate pain management. Since undertaking this study, it is of interest to note that our practice development nurse and the specialist pain nurse for ICU ,have jointly developed a behavioural pain assessment scale similar to the BPS and CPOT scale, and staffs are encouraged to use it routinely.

I feel that my action plan and recommendations are to promote the use of the pain assessment tool by educating the nurses and emphasising the importance of this assessment to improve patient outcome. The need for education to train staff on how to use the tool would take both time and money. The NHS is already under extreme financial pressures and money for training is not readily available. However if an improvement in pain management was successful then patients stay may be shorter, thus having a beneficial effect. I am also aware of the importance of not relying solely on the assessment tools but the use of both good nursing assessment and assessment tools to improve optimal patient management, shortening the recovery time and reducing the likely hood of complications (Ashley and Given 2003). A sedated, ventilated, non-communicative patient is vulnerable and relies completely on those providing care for them but as to their family at this anxious time. Education and training will improve patient care and ultimately patient safety which is paramount. Therefore I will take the knowledge and information I have acquired back to my clinical area as I have a duty to provide a high standard of practise and care at all times (NMC 2008)Abdominal Pain Management in Children Essay

Fetal abdominal cystic lesions are a common finding during routine antenatal ultrasonography. They may arise virtually from any abdominal organ; however, the urogenital and gastrointestinal systems are the ones most commonly involved.

Cystic masses in the fetus are reliably identified with US but it may not be possible to make a precise prenatal diagnosis. The shape, size, character and position of the lesions usually suggest the most likely diagnosis. The relationship to the adjacent organs and normality of the other organs also help in arriving at a diagnosis. Detection of associated anomalies, assessment of the liquor amnii, visualization of the genitalia, prokaryotic and family history further help in the diagnosis.

Isolated lethal cystic lesions or the lesions associated with other serious structural defects and/or abnormal karyotype need no further US surveillance. In such cases, termination of pregnancy is a reasonable approach. However, isolated, non-lethal lesions should be monitored with repeated ultrasound examinations because the evolution of these lesions in utero is extremely variable. They may increase in size, decrease or even disappear or may undergo complications which carry life-threatening risks to the fetus. Serial scans not only help in the management of the pregnancy but are also valuable in therapeutic management.Abdominal Pain Management in Children Essay

This pictorial essay originates from the department of ultrasound of a 35-bedded maternity hospital and includes fetal abdominal cystic malformations recorded during routine antenatal US (about 15,000 cases) between January 1992 and December 1998. Various congenital malformations detected at this center have been followed by serial US scans. The prenatal findings have been correlated with autopsy reports after termination of pregnancy or postnatal investigations/or surgical findings after delivery. This approach has helped in defining the natural history of congenital anomalies, determining the psychophysiology features that affect clinical outcome and formulating management based on prognosis.

How does exercise reduce stress, and can exercise really be relaxing?

Rest and relaxation. It’s such a common expression that it has become a cliche. And although rest really can be relaxing, the pat phrase causes many men to overlook the fact that exercise can also be relaxing. It’s true for most forms of physical activity as well as for specific relaxation exercises.

Exercise is a form of physical stress. Can physical stress relieve mental stress? Alexander Pope thought so: “Strength of mind is exercise, not rest.” Plato agreed: “Exercise would cure a guilty conscience.” You’ll think so, too — if you learn to apply the physical stress of exercise in a controlled, graded fashion.Abdominal Pain Management in Children Essay

How exercise reduces stress
Aerobic exercise is key for your head, just as it is for your heart. You may not agree at first; indeed, the first steps are the hardest, and in the beginning, exercise will be more work than fun. But as you get into shape, you’ll begin to tolerate exercise, then enjoy it, and finally depend on it.

Regular aerobic exercise will bring remarkable changes to your body, your metabolism, your heart, and your spirits. It has a unique capacity to exhilarate and relax, to provide stimulation and calm, to counter depression and dissipate stress. It’s a common experience among endurance athletes and has been verified in clinical trials that have successfully used exercise to treat anxiety disorders and clinical depression. If athletes and patients can derive psychological benefits from exercise, so can you.

How can exercise contend with problems as difficult as anxiety and depression? There are several explanations, some chemical, others behavioral.Abdominal Pain Management in Children Essay

The mental benefits of aerobic exercise have a neurochemical basis. Exercise reduces levels of the body’s stress hormones, such as adrenaline and cortisol. It also stimulates the production of endorphins, chemicals in the brain that are the body’s natural painkillers and mood elevators. Endorphins are responsible for the “runner’s high” and for the feelings of relaxation and optimism that accompany many hard workouts — or, at least, the hot shower after your exercise is over.


Behavioral factors also contribute to the emotional benefits of exercise. As your waistline shrinks and your strength and stamina increase, your self-image will improve. You’ll earn a sense of mastery and control, of pride and self-confidence. Your renewed vigor and energy will help you succeed in many tasks, and the discipline of regular exercise will help you achieve other important lifestyle goals.Abdominal Pain Management in Children Essay

Exercise and sports also provide opportunities to get away from it all and to either enjoy some solitude or to make friends and build networks. “All men,” wrote St. Thomas Aquinas, “need leisure.” Exercise is play and recreation; when your body is busy, your mind will be distracted from the worries of daily life and will be free to think creatively.

Almost any type of exercise will help. Many people find that using large muscle groups in a rhythmic, repetitive fashion works best; call it “muscular meditation,” and you’ll begin to understand how it works. Walking and jogging are prime examples. Even a simple 20-minute stroll can clear the mind and reduce stress. But some people prefer vigorous workouts that burn stress along with calories. That’s one reason ellipticals are so popular. And the same stretching exercises that help relax your muscles after a hard workout will help relax your mind as well.

Auto regulation exercise and stress relief
Regular physical activity keeps you healthy as it reduces stress. But another special sort of exercise known as auto regulation exercises can also reduce stress.

Stress comes in many forms and produces many symptoms. Mental symptoms range from worry and irritability to restlessness and insomnia, anger and hostility, or sensations of dread, foreboding, and even panic.

Mental stress can also produce physical symptoms. Muscles are tense, resulting in fetidness, taut facial expressions, headaches, or neck and back pain. The mouth is dry, producing unquenchable thirst or perhaps the sensation of a lump in the throat that makes swallowing difficult. Clenched jaw muscles can produce jaw pain and headaches. The skin can be pale, sweaty, and clammy. Intestinal symptoms range from “butterflies” to heartburn, cramps, or diarrhea. Frequent urination may be a bother. A pounding pulse is common, as is chest tightness. Rapid breathing is also typical, and may be accompanied by sighing or repetitive coughing. In extreme cases, hyperventilation can lead to tingling of the face and fingers, muscle cramps, lightheartedness, and even fainting.Abdominal Pain Management in Children Essay

The physical symptoms of stress are themselves distressing. In fact, the body’s response to stress can feel so bad that it produces additional mental stress. During the stress response, then, mind and body can amplify each other’s distress signals, creating a vicious cycle of tension and anxiety.

Because the root cause of stress is emotional, it is best controlled by gaining insight, reducing life problems that trigger stress, and modifying behavior. But stress control can — and should — also involve the body. Aerobic exercise is one approach; physical fitness will help promote mental fitness. But there is another approach: you can learn to use your mind to relax your body. The relaxed body will, in turn, send signals of calm and control that help reduce mental tension.Abdominal Pain Management in Children Essay

Auto regulation exercises are a group of techniques designed to replace the spiral of stress with a cycle of repose. Several approaches are available.

Breathing exercise reduces stress
Even without formal meditation and controlled breathing, the gentle muscle stretching of yoga can reduce stress. “Full service” yoga is even better. But if that’s not your thing, simple breathing exercises can help by themselves. Rapid, shallow, erratic breathing is a common response to stress. Slow, deep, regular breathing is a sign of relaxation. You can learn to control your respiration’s so they mimic relaxation; the effect, in fact, will be relaxing.

Here’s how deep breathing exercises work:

1. Breathe in slowly and deeply, pushing your stomach out so that your diaphragm is put to maximal use.

2. Hold your breath briefly.

3. Exhale slowly, thinking “relax.”

4. Repeat the entire sequence five to 10 times, concentrating on breathing deeply and slowly.

Deep breathing is easy to learn. You can do it at any time, in any place. You can use deep breathing to help dissipate stress as it occurs. Practice the routine in advance; then use it when you need it most. If you find it helpful, consider repeating the exercise four to six times a day — even on good days.Abdominal Pain Management in Children Essay

Mental exercises reduce stress, too
Bodily exercise can help relax the mind, and mental maneuvers can, too. Most often, that means talking out problems with a supportive listener, who can be a friend, a chaplain, or a trained counselor or psychotherapist. But you can also do it yourself, harnessing the power of your own mind to reduce stress. Simply writing down your thoughts and feelings can be very beneficial, and formal meditation exercises have helped many people reduce stress and gain perspective.Abdominal Pain Management in Children Essay

Meditation is a prime example of the unity of mind and body. Mental stress can speed the heart and raise the blood pressure; meditation can actually reverse the physiological signs of stress. Scientific studies of Indian yoga masters demonstrate that meditation can, in fact, slow the heart rate, lower the blood pressure, reduce the breathing rate, diminish the body’s oxygen consumption, reduce blood adrenaline levels, and change skin temperature.

Although meditation is an ancient Eastern religious technique, you don’t have to become a pilgrim or convert to put it to work for you. In fact, your best guide to meditation is not an Indian spiritualist but a Harvard physician, Dr. Herbert Benson. Here’s an outline of what Dr. Benson has termed as the relaxation response:

1. Select a time and place that will be free of distractions and interruption. A semi-darkened room is often best; it should be quiet and private. If possible, wait two hours after you eat before you meditate and empty your bladder before you get started.

2. Get comfortable. Find a body position that will allow your body to relax so that physical signals of discomfort will not intrude on your mental processes. Breathe slowly and deeply, allowing your mind to become aware of your rhythmic respiration’s.

3. Achieve a relaxed, passive mental attitude. Close your eyes to block out visual stimuli. Try to let your mind go blank, blocking out thoughts and worries.

4. Concentrate on a mental device. Most people use a mantra, a simple word or syllable that is repeated over and over again in a rhythmic, chant-like fashion. You can repeat your mantra silently or say it aloud. It’s the act of repetition that counts, not the content of the phrase; even the word “one” will do nicely. Some meditates prefer to stare at a fixed object instead of repeating a mantra. In either case, the goal is to focus your attention on a neutral object, thus blocking out ordinary thoughts and sensations.

Meditation is the most demanding of the auto regulation techniques, but it’s also the most beneficial and rewarding. Once you’ve mastered meditation, you’ll probably look forward to devoting 20 minutes to it once or twice a day.

Progressive muscular relaxation
Stressed muscles are tight, tense muscles. By learning to relax your muscles, you will be able to use your body to dissipate stress.

Muscle relaxation takes a bit longer to learn than deep breathing. It also takes more time. But even if this form of relaxation takes a little effort, it can be a useful part of your stress control program. Here’s how it works:Abdominal Pain Management in Children Essay

Progressive muscle relaxation is best performed in a quiet, secluded place. You should be comfortably seated or stretched out on a firm mattress or mat. Until you learn the routine, have a friend recite the directions or listen to them on a tape, which you can prerecord yourself.

Progressive muscle relaxation focuses sequentially on the major muscle groups. Tighten each muscle and maintain the contraction 20 seconds before slowly releasing it. As the muscle relaxes, concentrate on the release of tension and the sensation of relaxation. Start with your facial muscles, then work down the body.Abdominal Pain Management in Children Essay