Full text of DOI:10.1177/104345420001700104

of
Pain
Children’s
Perceptions
3
ofBoneMarrow
Weeks
During
Transplant Experience
Leslie
Carol
Pederson, PhD, RN,
Parran, MS, RN, AOCN,
RN
andBonnie
PhD,
Harbaugh,
Most
bone marrow
severe
it
(BMT)
patients undergoing
transplant
experience
Because
is the mostreliable sourcewhen
pain.
is
self-reporting
assessingpain,
health care
understand howchildren
that
their
important
providers
perceive
of
this
and
factors. The
children’s
alleviating
purpose
descriptive, exploratory study
pain
of:
their BMTpain,
interven-
wasto understand
perceptions
(a)
(c)
(b)
in
and
in
their
role
tions effective
their
relieving
pain,
caregivers’
managing
The
consisted of 20 children
5 to 17
age
(50% male),
pain.
sample
BMT. All
received continuous-infusion
years, undergoing
study participants
with additional boluses as needed for
investigator-
pain. Using
therapy
opioid
on
structuredinterview
childrenwereinterviewedfourtimes:
Datawere
developed
guides,
thenatthree
weeklyintervals.
analyzed
of
a
the
day
transplant,
analysis approach.
using
that
In
the first
children
content
when
interview,
told someone. Several children used
reported
most
hurt,
they
they
commonly
to
all had been told
to relieve
nonpharmacologic techniques
pain. Although
some
one-third of the children described the
BMT.
BMT,
during
only
expect
pain
kinds of
that
pain
the
they anticipated having during
During subsequent
saidthatmedicationworkedbesttodecreasetheir
interviews,
In the final
majority
pain.
most children said
still hurt.
but mentionedsevenother
should be
interview,
they
They
reported pain
predominantlyin
pain
their mouthand
sites.
throat,
included that
on
Anecdotal comments
pain management
improved
BMTday
that
to teach
that it is
to use
the first
and
nurses need
children
okay
and research are
for
for clinical
education,
practice,
drugs
pain. Implications
discussed.
©
2000
Association
Nurses
by
of PediatricOncology
CHILDRENUNDERGObone mar-
for
is related to
and
may
ex-
recovery
healing
M
w
A
1
NY
row
conditions
ceed
3
children
weeks. Most
BMT
transplant (BMT)
experience pain
such as
bined
and severe com-
cancer, anemias,
in
and
report pain
during
recovery
Marrow
is
known about
various
little
immunodeficiency syndrome.
locations,
yet
of their
their
pain
perceptions
recovering
experience
while
from BMT. To
opti-
important
provide
mal care for these
that health care
it is
children,
From the School
Minnesota,
of
of
University
Nursing,
Fairview
Medical
Center,
MN;
MN;
how
understand
and
Minneapolis,
Minneapolis,
of Southern
Funded
University
providers
andthe
Collegeof Nursing, University
their
children
perceive
pain
alleviating
MS.
Mississippi, Hattiesburg,
BMT.
factors while
In
Zeta
and the
Clinical
Theta
Tau,
undergoing
by Sigma
Chapter,
and
Minnesota
of
former
Hospital
University
on
researchers
manystudies,
rely
paren-
Services.
Nursing
tal
orhealth care
assessment
Gavrin,
(Dunbar, Buckley,
report
provider
Address
to Carol
Pederson, PhD, RN,
reprint requests
of children’s
Associate
School
Professor,
of
of
University
pain
Nursing,
6-101
Weaver
308 Haruard
Hall,
Minnesota,
Densford
MN55455-0342.
children’s
Sanders, &
1995),
Chapman,
yet
St.,
Minneapolis,
source
is the mostreliable
(Acute
Panel,
self-report
Pain
@
2000
Association
Nurses
of Pediatric
7 043-4542/00/7 707 -0004$3.00/0
by
Oncology
Clinical Guidelines
Management
22
Downloaded from jpo.sagepub.com at The University of Melbourne Libraries on June 5, 2016

23
totheir
of Cancer Pain Guide-
Nurses need to ask chil-
because
of
related
treatmentcourse
1992;
lines
Management
types
and
pain
complications
Panel,
1994).
(Gaston-Johansson,
1992).
dren about
their
children may
Franco, & Zimmerman,
the
pain,
not
initiate
of
pain. This maylead
When
self-report
studying
peak pain
intensity
health
are
care
believe
to
that children
Gaston-Johansson
et al.
BMT,
that the
adult
providers
during
(1992)
comfortable when
are not. Health
of children’s
found
they
peak pain intensity reported
care
BMT
more
17
BMT
studied
wason
providers’
understanding
by
autologous patients
be even more
valuable as
+5. Pederson andParran
pain may
day
pain
(1999)
children make the transition from
the
in
20 adults
and
and 20 children
receiving
BMTinpatient
BMTrecovery to
where
more
in
earlier
BMT
their
courseof
BMT.
Children’s
setting
allogeneic
autologous
the
BMT
adults’
on BMT
on BMT
and
+8,
outpatient
setting,
is
pain peaked
day
day
contact with health care
+5.
Self-
providers
pain
peaked
The
time-limited.
ofthis
were similar in
adults
purpose
study
reported
pain patterns
was to
children’s
understand
while
of:
andchildren
3weeks
perceptions
BMT,
(b)
during
post-BMT.
their
Cebul-
Larson, Viele, Coleman,
Dibble, &
(a)
pain
undergoing
in
interventions effective
their
ski
relieving
pain,
(1993) compared perceived
symptoms
and
nurses’ role in their
in
BMT
30adult
and
of
(c)
pain manage-
recipients
perceptions
ment.
nurses
for themat four intervals in the
caring
post-BMT period.
nausea,
in-
Thirteen
symptoms,
and
Literature Review
Pain
cluding
pain, fatigue, appetite,
were recorded on
a
mucositis,
Likert-type
five-point
BMT-Related
Mucositis is the mostcommon
scale. At the first measurement
hours of
within 48
BMT,
patients
perceived
of
type
pain
distress than
and nurses
significantly greater symptom
during BMT(Wiley &
experiencedin
House,
often
children
nurses
rated
Both
perceived.
patients
Mucositis
is
continuous,
1988).
pain
the
second interval
and third interval
pain higher during
and is exacer-
and
requires opioid therapy,
+7 to
(BMT days
+10)
bated
mouthcare,
by
eating, swallowing,
+20 to
the
third
(BMT
28).
days
During
the mouth while
breathing through
sleeping
nurses
interval,
perceived patients’
symp-
et
Painfromoral muco-
al.,
(McGuire,
1993).
develops gradually
tomstobe
thanthe
indicated.
greater
Unrelieved
patients
has been identified
sitis
and is related to the
radiation
in
sev-
pain
effects of
transplant conditioning
eral studies. Gaston-Johansson et
found that out of 245
al.
(1992)
in 20
Theonset oforal mu-
and/or
cositis
chemotherapy.
pain
recordings
from BMTday -3 to BMTday
ranges
adult BMT
unmedicated on 71
these
were left
patients,
patients
with
0
the
The
of
+ 7,
et
(Dunbar,
day
day
peak
transplant
occasions and on 86
of mucositis
al.,
occurs
1995).
severity
occasions
was
relieved.
pain
incompletely
7
to 11
after the last chemother-
days
Ben
David and
found that
Musgrave (1996)
2
to
and
for
dose
apy
weeks
persists
et
approximately
morethan 50%of adult BMT
receiv-
patients
3
al., 1993;
(McGuire,
Chapko,
intravenous
boluses rated
severe.
ing
intensity
et
opioid
or
pain
Sullivan,
Schilter,
1989).
Syrjala,
Cummings, &
Hill
as severe
Also,
BMT
very
47
studied
al.
McGuire et
(1993)
pediatric
al.
tients
found that
(1990)
although
their
pa-
de-
12 to 54
and adult BMT
Mucositis was
patients age
experienced
years.
received
morphine,
pain
89% of the
86%
by
creasedto
50on
a
0to 100scale.
only
with
Ofthe
mucositis,
the
patients
patients.
experienced pain, demonstrating
signifi-
patient
was not
Pain
Children
Managementin
in
BMT
of
the
cance ofthis
pain
type
The
UndergoingBMT
incidence of
pain
population.
related to
of
or
often are
Opioids
to treat
in
type
and
transplant. Along
age
required
pain
of mucosi-
children
BMT. Dunbar
the
et al.
in
with
prevalence
intensity
undergoing
in
often
studied
tis
BMT,
patients
pain
or bone
experience
(1995)
opioid pain management
pain
multifocal
such as head-
4
12
to
years
39 children
age
low-grade,
ache,
undergoing
or other
pain,
BMT. The
received
children
or
abdominal,
morphine
Downloaded from jpo.sagepub.com at The University of Melbourne Libraries on June 5, 2016

24
to
994
of 19
over
a
mean duration
children’s
study
and
school-age
of
questions
hydromorphone
continu-
use
and 51 %
days,
The
to
com-
opioids by
Peak
knowledge
understanding
pain.
required
relieve
+ 11.
children demonstrated an
infusion to
ous
pain.
Although
opioid
ability
the children
70%
wason BMTday
municate
ex-
pain effectively;
provided
their
to record
were not asked
cellent
also
levels,
pain
pain descriptors. Ely (1992)
was evaluated
the Pain and
examined
children’s
daily by
pain
pain
eight school-age
pain
de-
The
evaluations were
Service.
The children could
Toxicity
descriptions.
clearly
not
scribe
pain
methods of
and
it.
reported.
alleviating
in 680 Irish
Pederson and Parran
studied
When
(1999)
to 17
5
pain
days.
studying pain
Gaffney (1987)
to 6 used
years
school-age
over22
in 20children
found that
children
and
years
age
children,
the children’s mean
5
daily morphine
Although
age
mainly sensory
to 1.88
mg/kg,
from0.09
mean levels of
evaluative worddescriptors.
ranged
equivalents
their
daily
Donaldson and
a
used
self-reported pain
Moinpour (1992)
from 19.0 to 34.6 on
a
0-100
scale,
visual
ports
children
The
scale to measure self-re-
ranged
showing
analogue
and
was not
that their
relieved. Nurses’ assessment
in 10
BMT.
of
pain
completely
parental reports
pain
of the chil-
6 to 16
years undergoing
age
was
than the
dren’s
assessed
pain
consistently higher
parents consistently
than the children
higher
the
The lack
children’s
of
of
nurses’ and
of children’s un-
pain.
self-reports
reported,
pain
negating
between the
that children
noted that
congruence
children’s
assumption
The authors
cult to obtain fromchildren
overreport pain.
are diffi-
perceptions
pain
obtain children’s self-
pain reports
derscores the need to
of
BMT.
undergoing
of
mea-
All of these studies indicate the
reports
Mackie, Coda,
20 adolescents
pain.
inability
and Hill
found that
(1990)
and
to
accurately
caregivers
parents
pain.
research on children’s
BMT
undergoing
the
reported
days
scores
sure children’s
first few
scores
during
also found that
highest pain
post-BMT. They
focused
and on
pain
Early
on whether children
pain
experience pain
assessment
on
a
0 to 100 scale after
remained below 50
(Donaldson &
qualitative experi-
quantitative pain
1992),
BMTday
+8.
as the
has been
and
Moinpour,
ence of children
reported only
PainAssessmentin Children
(1996)
hospitalized
Kristjanson
sparsely. Woodgate
11
of
of
to
studied
children
of
is the most reliable
perceptions
age
pain
Self-report
pain
assessing pain
and older who are
2-~
6-1/2
in
4
of
children
means
years. Findings
years
able to verbalize
Guidelines
revealedthat the children
of
experienced many
age
sur-
different
of
caused
(Acute PainManagementClinical
pain: pain
by
types
others
from
or
ob-
from
of Cancer Pain
by
doing something,
gery ;
jects
being
1992;
Panel,
Management
in the
suchaschest
et
tubes;
that the children
Guidelines
child,
pain
Panel, 1994;Mackie,
al.,
1991 ).
their
describe
can
most children
Because
sick,
with them to the
brought
to
related
or
care
should assessthe
to monitor the
health
hospital,
They
perceived
pain
providers
regularly
pain,
pain
as
defined all
in children
pain
parents leaving.
hurts
found
all of their
their &dquo;hurts&dquo; and
interventions
the individual
effectiveness of
(McGrath,
asbad.
In the
child can
has been
However,
1990).
only
whether his or her
determine
publishedqualitativestudy
McGuire et
only
pain
al.
of children
Theneedto obtain
relieved
BMT,
sample
BMT
undergoing
(McGrath, 1996).
that
a
of47 children
children’s
research
of
(1993) reported
self-reports
painis supported
by
that
and adults
assess-
that
perceived
undergoing
findings
caregivers’
their
to control their
was lowest
of children’s
are not
ments
ability
pain
congruent
1990;
pain
word
also
The
on BMTday +5. All
used the
most
with children’s
patients
self-reports (Eland,
&dquo;tender&dquo; to
&
&
describe their
Pederson
Parran, 1999;
pain;
Rodriguez, Kury,
used the
most
words
and
Schneider &
LoBiondo-
Hoffman, 1995;
Wood, 1992).
&dquo;sharp.&dquo;
&dquo;aching&dquo;
commonlyselected
affective
descriptor
Morequali-
for
was
Ross and Ross
used
open-ended
pain
&dquo;tiring-exhausting.&dquo;
(1984)
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25
tative
229
91
methods of
children’s
BMTs,
including
the
and
pediatric
proximately
examining
are needed to better understand children’s
pain
were
done,
of
BMTs,
average pediatric
days.
47
was
of
and what
them
experiences
with
length
stay
pain
helps
patient
cope
pain
(Ely, 1992).
In
ence
most BMT
summary,
recipients experi-
Instruments
Three
that is not relieved
pain
completely.
but
their
Structured
investigator-developed
Children are
their
able to
of
report
pain,
Interview Guides were used to elicit data
often conflict with
self-reports
pain
from children:
the Initial Interview Guide
the Second
(a)
of
others’ assessments of their
searchers havestudied
children’s
re-
of
Few
pain.
usedon
the
(b)
transplant,
day
qualitative aspects
andThird
Guideusedforthe
WeekInterview
secondandthird
Children’s
of
pain.
perceptions
pain
and
the Final
interviews,
(c)
increase
can
of
caregivers’
experience
may
understanding
Interview
The first interview focused
with and
Guide.
children’s
while
pain
which
undergoing
on children’s
experiences
expecta-
BMT,
assessmentand
The research
promote
improved pain
tions of BMT
successive interviews
pain;
management.
questions
on
of their
focused
BMT
children’s
perceptions
of this
were:
study
de-
After
investigators
pain experience.
of their
what are children’s
perceptions
(a)
interview items to meet the
two
veloped
purposes,
search
study
while
factors
and
alleviating
undergoing
pain
re-
experienced pediatric
and
what are children’s
BMT?,
(b)
percep-
in
not involved
the
study
experts
the items for content
sions were made based on their comments.
Thenumberofitems asked
role related to their
tions of
pain?
caregivers’
Revi-
checked
validity.
Method
from9 to
ranged
in
15
eachinterview.
StudyDesign
Adescriptive,
wasused.
of
exploratorydesign
of
Procedure
The
BMT
was
a
investigation
larger
study
part
TheBMTclinical nurse
identified
in
researchers examined
which
specialist
pain
children who met
subject
selection
criteria,
to the children and
their
andadults’
and distress while
children’s
pain
the
and
both
BMT,
explained
study
using
quantitative
Parran,
undergoing
qualitative
andobtained
on
consent
of
methods
parents,
assent).
parental
(and
(Pederson &
the
Researchers also examined nurses’
day
transplant
Beginning
1999).
and then
a
at
research
related to
Parran,
and attitude
intervals,
beliefs,
management
weekly
knowledge,
assistant trained
the
BMTpain
(Pederson &
by
investigators (a pedi-
atric
nurse not
on that
oncology
employed
1997).
conducted
a
structured interview with
total of four interviews of
unit)
each
for
a
child,
andSetting
was
Sample
The
15 minutes
BMTnurses
interviews but
which was re-
each.
approximately
20 children
of
sample
composed
were
not
the
present
during
undergoing BMTat one center.
ranged
3.46).
Ages
often were
on the interview
Research Council
parents
corded
present,
All
BMTwas
17
to
SD
from
were
5
9.9,
years (M
form. The
hospital
50% were male.
Caucasian;
the Institu-
and
Nursing
for
tumor cancer
leukemia
done as
(10 patients),
therapy
tional Review Board:
HumanSubjects Com-
anemia or
solid
(4), aplastic
mittee
the
(IRB) approved
study.
disease
severe combined
and
immunodeficiency
To
(3).
non-Hodgkins lymphoma
(3),
Data
Analysis
pain, all subjects
receivedcontinuous-
relieve
bo-
Data were
a
content
with additional
infusion
luses as
opioid
analyzedusing
described
analy-
therapy
to managepain.
approach
by Krippendorff
recommended
and McCain
sis
needed
BMT
in
within
a
was
a
32-bed
unit
Thesetting
(1980)
by
(1988).
three-step
process
a
mid-
This
includes a
care center
567-bed
western
approach
large
tertiary
In
on this BMT
of:
the unit of
1996
unit,
(a)
ap-
identifying
analysis, (b)
city.
Downloaded from jpo.sagepub.com at The University of Melbourne Libraries on June 5, 2016

26
and their
of each
about
BMT
the main
the
BMT,
pain
phrase,
perceptions
topics
identifying
from similar
that
and
categories
theymayexperience (Table 1 ).
developing
(c)
Most of the children were able to
Data were
on
clusters of ideas.
explain
analyzed
The
of
unit
that
is a hurt or discomfort and
describe
data collection.
of
pain
completion
answers to
Most described
the
was
participant’s
specific pain episodes.
pre-
fol-
analysis
such as
Commentsfromeachpartici-
vious
each
pain experiences,
injuries
or
question.
from the field notes.
off
a
were transcribed
sur-
bike, headaches,
had no
lowing
falling
pant
Transcript
data were
four said
interview,
Oneresearcher
organized
gery ;
previous pain
by
they
each
All
that when
reported they
separately by
question.
experiences.
set twice.
During
told
and several
read
the entire data
answers
hurt,
that
others,
they
they
reported
through
for each
question
let
know with somatic
or
re-
the third
wereidentified
people
reading,
which
suchas
main
sponses,
crying
reported
&dquo;stiffening up.&dquo;
by
topics/themes,
in the
were
The children
that
used non-
werewritten
of answers
pagemargins. Categories
they
such
as dis-
from
similarly
pharmacological techniques
developed
After
relaxation
traction,
aside the
clustered themes.
breathing
play,
tapes,
setting
andmusic to
them
for
1
two research
exercises,
month,
reviewed the data
massage,
help
process
analysis
feel more comfortable when
hurt.
team members
for
they
They
together
for
andthe namesof
categories
accuracy
this
data from
each
the
TABLE 1.
step,
question. Following
original questionnaires
1: SelectedBaseline InterviewQuestions
Interview
were reviewed
BMT
and
AboutPreviousPain
Experience
to
interpreted
of
the data
had been
and
with
analysis,
compared
Preparation
validate that
meanings
Within
are
numbers
categories,
accurately.
responses
with the content
reported
to illustrate how
chil-
of
data,
responded
Data were
many
particular
to
analysis
dren
in
to an item
a
with
sensitivity
way.
analyzed
no
differences, however,
related differences were identified
developmental
age-
in
chil-
dren’s
to the four interviews.
responses
Results
The first interview was conducted with 20
on the
or
their
to,
children
BMT.
of,
day
just prior
The second interview was conducted
about
1 weekafter the
with 16 children
BMT;
the third interview was conducted with 17
2
children about
weeks
and the
post-BMT;
interview was conducted with 19 chil-
final
ofinter-
Lack
dren about
3
weeks
post-BMT.
because
views with some children occurred
the child was from the BMT
the
unit,
away
in
child refused to
the
interview,
participate
or
to
the child’s
nonresponsiveness
ques-
tions.
Interview 1: BaselineData
of
The
was to
the first interview
purpose
examine the
children’s
of
pain,
to
perceptions
with
oneanswer.
morethan
their
for
aSomechildren
gave
strategies
coping
pain prior
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27
believed that
was
A
what
medications.
most to take
or
few
that
moreand
helped
pain
reported
analgesic
forgetful.
medications allowedthemto do
moreactive.
be
away
All of
the
children said that
mouthsores. In
had been
they
told to
some
addition,
were warned about
and &dquo;butt&dquo;
expect
Interview 4: FinalInterview
that
reported
they
belly
head
pain,
anal)
pain, leg
pain,
(peri-
In
the final
researchers assessed
interview,
children’s overall
seven children
However,
they
pain.
only
and
the
included one
pain experience
that
wouldhave
predicted
pain. Notably,
described
from
of
inter-
question
previous
responses
fewerthan
one-thirdofthechildren
for
over
views,
comparison
the
that
pain
they might experience
despite
given.
had
still
time. Most of the children said
they
the information that
hadbeen
they
in various
six
that
locations;
(Table 3).
reported
pain
they
Most of the
had no
pain
Interviews
2and3:
Continued
Follow-Up
children also
that their
was
reported
pain
few
The
in
re-
items included
the second andthird
over the 3-week
continuous
period;
Children’s
interviews were
sons over time
identical,
comments,
allowing compari-
ported episodic pain.
were
in-
the second
During
each made
creased
mouth care.
that mouth
once,
when
(Table 2).
pain
the
a
and
children
vari-
interview,
reported using
eating, drinking,
doing
of interventions when
most told
had &dquo;little
asked for
the
antacid medications
made
was worse
ety
hurts&dquo;;
they
Switching
exacerbated stomach
and/or
the third
pain, walking
parents
medication.
knee
the
and
worse,
interview,
pain
night.
pain
during
During
children
their
to
reported
parents
per-
asking
form
a
of comfort interven-
Most of the children
medications worked best to
themfeel morecomfortable.
that
reported
greater variety
again
such as
for more
tions,
medication,
help
antacids,
andsuc-
with
asking
analgesic
Useof
their back or
and
a
feet,
massaging
applying
with or
mouthcare, ointments and
creams,
heating pad,
playing
holding
in
them.
of oral secretions
conjunction
tioning
medicationsalsowere
Most of the children
that nurses
in decreas-
reported
pain
ing pain.
Most of the children
helpful
asked
a
or
a
if
them
few
several times
day
and
low
hurt. Most said that when the nurses
reported
they
asked about
asked
whether
medium levels of
most of the time
pain, they
the children felt
only
some nurses also
pain
Mostalso believed that nurses did
any pain;
the children needed or wanted
post-BMT.
if
asked
a
of
themfeel morecomfort-
any
goodjob
helping
medication.
four children
able when
had
and most did not
pain,
pain
Only
reported
they
that nurses
such as its
think
morethatnurses could
asked further about their
and
therewasmuch
pain,
Most
havedone.
some
were
location,
However,
offered. One child said that
type,
intensity.
suggestions
ofthe children said that
nurses when
they felt comfortable
pain manage-
the
that
and
mentshould
betteronthe first
havebeen
and one said that
hurt.
they
During
day
telling
his
third
fewer children
antacid
interview,
post-BMT,
reported
any pain
nurses asked them if
had
shouldhavebeen
worked
better.
soonerto onethat
they
changed
far
children said that medications
fewer
their
more
Parents
anecdotal data. One fa-
worked best to decrease
children said that nurses
pain, yet
provided
ther said that to
for his
them medica-
management
improve pain
10-year-old
gave
All
nurses
son,
them more comfortable.
children said that what nurses had done to
tions to make
quiet
probe
very
neededto
morein their assessmentsof
was
he hide
tried to
with
to
a
his son’s
because
relieve their
few children
as a
it,
medication;
pain give
mentioned other
pain
result that his
the
outofcontrol. The
methods such
mouth care.
pain got
14-year-old
ice
or
that nurses do
said
comfort care and that nurses
father of
not
a
heating pad,
pack,
reported
children
that
had
no
three
they
provide
Only
should not assume that because
a
is
parent
pain.
that
a
is
The mother of
a
Most of the children
child
reported
analge-
sleepy, dizzy,
present,
10-year-old
okay.
madethemfeel
said that nurses need
to empha-
sic medications
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28
TABLE
2.
Interviews
2
and3: Children’s
of
BMT
Their
Pain
Perceptions
Experience
aSomechildren
morethanoneanswer.
gave
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29
TABLE4.
size
that
medicationsfor
use of
is differ-
She stated
taking
the
pain
drugs.
Patient
AcrossThreeInterviews
Responses
ent from
illegal
that children
whohadbeen
would refuse
that
taught
drugs
were bad
medications
child
legitimate analgesic
was
until
bad. One
pain
a
really
that
to the
reported
quicker response
nurses’ call
light wouldhave
helped.
Pain With
Prior
of BMT
Comparisons
Expectations
with the second
interview
re-
children
was
Compared
sponses,
said
worse than
in the third interview fewer
that the
experienced
expected.
pain they
had
In
the final
they
whenchildren were askedto reas-
interview,
BMT
their
most
whether
sess
pain
they thought
had
was what
expected,
reported
they
that
had different
that the
with
they
expectations,
than
most
was worse
saying
pain
(Table 4).
NOTE: Children were asked the
&dquo;Before
question:
did think
you
had
bone marrow
would
you
they
expected
your
transplant,
in
the
hurt aboutthis muchwhen
werehere
you
hospital
for
yourtransplant?&dquo;
TABLE
3.
4: Final
Interview
Interview
Discussion
in
The children
the
of
described
study group
their
perceptions
past pain, expectations
BMT
BMT
of
number of
of
and
pain,
pain.
pain
pain.
experiences
named
the children
a
Also,
locations andfactors that relieved their
Their
to describe
oftheir
ability
aspects
supports seeking self-reports directly
children. The of
pain
from
over time
variability
within each individual child indicates the
needfor assessment. It
pain
frequentpain
is impor-
tant that nurses
mannerof
about each child’s
inquire
to
so that nurses
such as stiffen-
children to verbalize
pain,
responding
can
cues,
correctly interpret
up. Encouraging
pain may
ing
their
increase their
to
willingness
This
tell nurses about their
consistent
a
pain.
requires
nurses to
ask,
dis-
approach among
and believe children when
listen,
close their
they
pain.
Some children’s
that nurses
perceptions
and ask
assess
pain infrequently
that
only gen-
need
nurses may
eral
questions suggest
sedative
to assess
effects of
However,
pain
differently.
have affected
medications
may
some children’s recall when
to
responding
one
a
morethan
answer.
Nurses’
of
consistent use
stan-
aCertain children
gave
questions.
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30
This
increases the
about
would allow
to and
of
scale
com-
dardized
parison
difficulty
unpredictable.
pain-rating
of levels
teaching
pain
effectively
accurately
prior
produce
following
pain
both the need for
indicates
an overall
and
and
interventions
pattern
ongoing
BMT
the
than ask
Rather
of
recovery period
during
teaching
only general
pain.
to
chil-
andindividualizing
such as &dquo;how are
teachingaccording
you feeling?,&dquo;
questions,
needs.
related
dren’s
nurses needto ask
to
specific
questions
specific
Children’s
on medications as
andfactors that
of
location,
emphasis
quality, pain
pain
in
them
the most
com-
cause or relieve
help
making
Examples
specific
or
being
pain.
fortable reinforces the
comment
&dquo;where is
are
parental
your pain?&dquo;
questions
to teach children
that nurses need
taking
that
and
where
and
&dquo;does
&dquo;show me
come
is,&dquo;
your
your pain
or do
medications for
is
have it all the
pain
okay,
pain
time?,&dquo;
go
you
should
doto
a
that children
them. This
not
no&dquo; to
like meto
&dquo;what would
and
&dquo;say
taking
you
needs to
to
feel more comfortable?&dquo;
teaching
begin prior
Using
help you
and needs to include
flowsheet
bedside
pain experiences
management
measuring patterns
pain
information about the
the
of
oc-
of children’s
facilitates
pain
possibility
and
interven-
of
effectiveness
physiologic
negative
psycho-
curring,
logical
self-reported pain,
effects of
and
enduring pain, pharmaco-
tions,
pain management
improved
1990;
interventions
and
&
Pouliot,
Paice,
nonpharmacologic
logic
(Stevens,
1995).
Voigt,
and
in
those
for
relief,
support
using
to ask
feel more
them
pain
in
interventions.
nurses need
evident
when
the
were
Individual differences
children’s
Also,
usually helps
what
children
felt
strategies
they
coping
and
feel
comfortable when
the children’s
to individualize
inter-
Nurses need
pain
support
they
pain
pain.
use of those inter-
evaluation
for each child.
ventions
continuing
Ongoing
number of
a
Children
ventions.
alerts
of interventions
of the effectiveness
reported
that their
interventions
Nurses need
in
to
interven-
when it is time
nurses
nonpharmacologic
provided.
parents
parental participation
change
to
feasible
children about
tions.
support
op-
Informing
for interventions and
children
tions
pain;
they recog-
relieving
including
for
about interventions for
in decision
telling parents
example,
making
them with
value of
nize the
a
sense of
To
interventions,
parental
pro-
having
pain empower
and
distraction
some control over their
materials,
allowingpar-
time
necessary
effectively
viding
pain.
ents and children the
to be well
nurses need
children,
empower
informed about
interven-
for
of both
thera-
com-
and
the effectiveness
nonpharmacologic
privacy
tions.
and
nonpharmacologic
pharmacologic
the children
their first
andwithdrawal
for
interview,
During
pain
symptoms
pies
namedseveral
children
techniques
nonpharmacologic
undergoing
monly experienced by
need
tech-
them
con-
used
with
Nurses
that
to
BMT.
they
to cope
pain.
aboutthe
did not
experi-
most of the children
Prior to
BMT,
inquire
nonpharmacologic
that children have found
to
that
name
help
niques
expected
they
any pain
their
not
when
feel
then
did
indicate that
ence. This
internalize the
that
support
they
pain,
they
may
when
can
nurses
use of those
to
information
them,
they
help
by
techniques
tinuing
given
experience BMT
orthat
haveBMTpain,
not
hopedto
Also,
pain.
they
their
would
children
improve
described
pain
that the
believed
strategies
coping
they
not
additional
them
This
to them.
that whenever nurses
nonpharmacologic
teaching
finding suggests
happen
feel
when
such as
teach
children,
they
techniques,
imagery,
they
discomfort.
about
children’s
need to ask
the
perception
BMT,
numberof children who said that
said
more
fewer children
In
third
interview,
nurses asked about their
the
their
the
information
ofthe
small
Following
taught.
pain, yet
medica-
have
said that nurses
them
children
BMTpain was what
had
gave
sug-
expected
they
This
weeks
tions to decrease their
assimilate
to trans-
the children did not
that
information
may
post-BMT,
pain.
gests
2
because at
occurred
were
nurses
about BMT
that the
pain prior
pattern
in to children’s
tuned
of BMTpain is
pain
and/or
plant
very
Downloaded from jpo.sagepub.com at The University of Melbourne Libraries on June 5, 2016

31
and
ofthe
assessment
onthe
nurses need to
be children’s
medications
basis
Also,
advocates
gave
analgesic
pain.
children’s behaviors and
byseeking changesin
physiological
physician’s
such as mucositis. Al-
orders and
findings,
teaching parents
nonpharmaco-
behaviors and
assess-
to
children’s com-
though
ment
physiological
logic techniques
promote
nurses also need
data,
yield important
fort.
to
of
obtain children’s
consistently
education needs to
self-reports
include basic
Nursing
information about
based on
well-documented
pain,
discrep-
assessment in chil-
pain
ancies between
and
children’s
caregivers’
dren and
to
and alleviate
their
ways
prevent
assessmentsofchildren’s
1990;
pain (Eland,
studentsneedtobe
pain.
Nursing
knowledge-
thera-
et
Pederson &
al., 1995;
Parran,
Rodriguez,
1999).
able about
other
and
opioid
as well as various
analgesic
pies,
nonpharmacologic
In the final
most children
in
and
various loca-
said
interview,
pain
reported
so
can individualize these
techniques,
therapies
they
that
still had
they
most also
for BMT
patients.
researchers need
that their
had
tions ;
pain
reinforces the
to
further
Nursing
study
been continuous. This
of
finding
children’s
while
pain experience
undergoing
in
children
loca-
importance
addressing pain
and interventions
BMT,
factors,
alleviating
BMT. The
of
undergoing
diversity
pain
effective for
discomforts. Pain
re-
specific
tions
a
for nurses when
provides
challenge
search utilization and
of Agency
application
and
children’s
Phar-
BMTnurses
assessing
relieving
pain.
for Health
Care
and Research
Policy
(AH-
BMT
macists
to
units,
assigned
in clinical
need to
CPR)
guidelines
practice
in
andBMTphysi-
pain management,
expert
be examined. Research is needed on
effec-
cians can be resources to BMT
nurses who
diverse and
tive means of
when chil-
tapering opioids
care for children with
provide
dren’s
to
decreases.
pain
the
researchersneed
of children
Also,
BMT
Nurses can
changing
pain.
and consistent
promote
study
pain experience
assessment
thorough
pain
incorporating
intotheirclinical
from BMT
to
discharged
inpatient
settings
and
a
clini-
managementby
pain
BMT
ceive
In
clinic
while
to re-
settings
therapy.
continuing
calpathway
algorithm
prac-
or
opioid
tice.
children
BMT
conclusion,
undergoing
Nurses
carefor children
providing
undergo-
are
able to verbalize their
pain experiences.
BMTneed to assess children’s
at
con-
pain
sufficiently
ing
To
need
nurses
provide
optimalpain
management,
sistently through self-reports
to askchildren abouttheir
pain history,
intervals.
bedside
frequent
management
pain
Maintaining
pain
and
flowsheets and
coping strategies, present pain,
pre-
computer
improve
management. Learning
ferred interventionsto relieve
pain.
assessment screens
can
chil-
dren’s
pain
about
various
and
pharmacologic
nonpharmaco-
nurses with the
to inform children and
Acknowledgment
interventions
logic
provides
The
authors thank
Deb
necessary knowledge
RN,
Rasmussen, BS,
families abouttheir choiceswhen
for
data collection
for this
OCN,
addressing
study.
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