Protect the children
Comfort cart a welcome addition to pain management tools
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By Stefanie Dell’Aringa
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EDITOR'S NOTE: Stefanie Dell’Aringa is a freelance writer.
Nurses on the pediatric floor of WakeMed Health & Hospitals in Raleigh, N.C., are using evidence-based practice to improve pain scores, working collaboratively with parents of their patients.
Wanda Bowman, BSN, NE-BC, RN, nurse manager, pediatrics/Peds ICU, and clinical nurse Karen Tsang, BSN, CPN, RN, a nurse for 36 years, put into practice what they call a comfort cart to distract patients from their pain. In addition, they’ve developed a pain management care plan tailored to the patient. “We’ve always dealt with how best to handle pain with children,” Bowman, who has been a nurse for 40 years, said. “In 2013, our pain [management] rates were in the range of 62% to 63%, so we formed a committee.” The committee's goal is to raise the pain management rate to 100%. The comfort cart has six age-specific drawers stocked with items such as mirrors for infants, a karaoke machine for preschool children and iPads for teens. Tsang applied for and received a $5,000 grant from Friends of WakeMed Foundation to purchase the comfort cart and stock it. Drawers contain everything from cards, board games, toys and magnets to doctor kits and capes. Tsang said the dress-up items are fun and effective. “They feel like they are superheroes and princesses, so they can handle the pain better,” Tsang said. “It works really well.”
A committee chaired by Tsang and overseen by Bowman asked 100 parents of children undergoing acute pain procedures to fill out pain surveys between October 2013 and March 2015. The information helped staff to identify what items would work best in the comfort cart. “We now know what kind of comfort toy would be good for each child,” Tsang said, adding that the patient’s pain management care plan — which includes what diversions work and what pain meds the patient is taking — is posted in each patient’s room. Of the 100 parents, 61 completed the surveys. Parents were asked, “How does your child act when they’re in pain?” The top three behaviors reported were to verbalize, to cry and to sleep. Another key question was, “What interventions help to relieve their pain?” Of the 61 parents:
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They feel like they are superheroes and princesses, so they can handle the pain better,” Tsang said. “It works really well.”
— Karen Tsang, RN
Added to the unit in January of 2016, the cart and pain management care plan have been beneficial tools. The team is working better now that the pain management care plan is in patients' rooms. Each nurse is clear on what to do with each patient without having to ask. While the cart is mostly used on the pediatric floor, staffed by nine nurses during the day and eight at night, it’s available to the five nurses working in the PICU. “Generally, the ICU patients are too sick to use the cart because some are sedated or intubated, but some are awake,” Tsang said. Feedback from parents has been extremely positive, and the current pain score for pediatrics is improving with an increase of about 15%, according to Bowman.

“We’re heading up,” Bowman said. “What we have learned is that some of the strategies and the use of the comfort cart help with all of our patients, whether it’s those with chronic pain or an autistic or behavioral child or children with autism or behavioral issues. You don’t always need medication to take care of kids who are uncomfortable.”
Parents give their input
Encouraging results
Standard practice on the pediatric floor now includes collecting data from parents at admission and discharge to better address pain, which is key to creating the individualized pain management care plan. “What we know is that we have to ask the parents what works,” Tsang said. The cart and plan can be used as a model for other pediatric units, and Tsang and Bowman plan to share their evidence-based practice at the 2017 ANCC National Magnet Conference in October. Their presentation is called “Making Magic: Translating Knowledge About Pediatric Pain Into Clinical Knowledge.” “A lot of research shows that pain medication and a nondrug approach work together,” Tsang said. “This is a pharmacological and nonpharmacological approach.” The most important thing is that the nursing staff and the clinical staff should use a consistent approach, she said. “There are two reasons why we have the care plan,” Tsang said. “One is for consistency and the second is that it’s individualized. We have the plan and everybody, including the patient and the family, knows what that is.”
Lessons learned
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Comfort cart stock
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Mirrors for infants
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A karaoke machine for preschool children
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iPads for teens
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Cards
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Board games
Toys and magnets
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Doctor kits
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Capes
Dress-up items
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6 - 10 of them said a pacifier, swaddling, books, looking away from the procedure, or looking at the procedure helped relieve their child’s pain;
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21 - 25 parents said soothing touch helped;
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more than 26 parents said scheduled medications, television, movies, or internet were effective; and
Nurses were surprised by two statistics from the research data. “Amazingly, almost a quarter of the parents expected their children to not have any pain,” Tsang said.
The second statistic – 82% of parents said their child never had a pain experience – was astounding. Pain scales that use faces and numbers may be ineffective on patients new to pain.
“You can’t just base pain on a scale, but you have to base it on the perception of pain,” Tsang said.
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about 20 parents said skin-to-skin contact, holding hands, a quiet room, visitors or video games helped.
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In addition to the comfort cart and the pain management care plan, Tsang decided to follow appendectomy patients from admission to discharge to improve the timing and type of medication they received. She is proud to report that pediatric patients with appendectomies no longer have to be admitted for an overnight stay due to a new, streamlined EBP process. Prior to surgery, patients are given an acetaminophen suppository. When they awaken, they’ve already been transferred to a pediatric bed. They’re given something to drink and pain medication by mouth instead of IV opioids. “We have a lot more evidence-based practice to support that premedicating them with a simple acetaminophen suppository prior to surgery means they’ll need less pain medication after surgery,” Tsang said.
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