Pain in New born and Nursing Management

Oznur Tosun; Yagmur Sezer Efe; Emine Erdem

doi:10.4172/2376-127X.1000229

ISSN: 2376-127X

Journal of Pregnancy and Child Health

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Pain in New born and Nursing Management

*Oznur Tosun^, Yagmur Sezer Efe and Emine Erdem**
Erciyes University, Health Sciences Faculty, Pediatric Nursing Department, Turkey
Corresponding Author :	Oznur Tosun Erciyes University, Health Sciences Faculty Pediatric Nursing Department, Turkey E-mail: obasdas@erciyes.edu.tr
Rec date: February 11, 2016; Acc date: March 4, 2016; Pub date: March 12, 2016
Citation: Tosun O, Efe YS, Erdem E (2016) Pain in New born and Nursing Management. J Preg Child Health 3:229. doi:10.4172/2376-127X.1000229
Copyright: © 2016 Tosun O, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

It is determined that first nociceptors (pain sensing receptors) occur in the perioral region at 7 weeks of intrauterine life, spread in the rest of face, the palms of the hands and feet at 11 weeks, with arms and legs at 15 weeks, all cutaneous and mucosal surfaces at 20 weeks. Distribution of nociceptive nerve endings in the skin of neonates was determined to be similar in density to an adult . In addition, pain in neonates is transmitted by unmyelinated C fibers. These fibers transmit impulses slowly. It starts second or seconds later than a painful stimuli and continues for minutes to increase in size. Pain transmitted by this fiber is perceived as dispersed, continuous, dull and burning. Therefore, anatomical, physiological and biochemical structures enabling the perception of pain are present in neonates and are sufficient for the transmission of painful stimuli. In this direction, the necessity of making researches on neonatal pain experience has been raised.

Review

Pain is unpleasant and undesirable biochemical and emotional or behavioral condition that resulting from certain part of the body, with or without depending on tissue damage, affected by the person’s past experience, to remove unwanted status [1-3]. It is a subjective data that affects individuals not only in terms of physiological but also psychological, social, cultural and cognitive aspects [4].

Pain and analgesia in neonates is discussed extensively in recent years. For many years, because of not being completed of myelination in neonates, ideas were common like the underdevelopment of the nervous system, the immaturation of memory for pain experiences, insufficient cortical functions that play a role in the interpretation or recall painful experiences. For these reasons, it was believed that neonates did not experience pain and did not require analgesia. However, prior to the embryonic period completion excluding myelination, all all the afferent pathways is developing [5].

It is determined that first nociceptors (pain sensing receptors) occur in the perioral region at 7 weeks of intrauterine life, spread in the rest of face, the palms of the hands and feet at 11 weeks, with arms and legs at 15 weeks, all cutaneous and mucosal surfaces at 20 weeks. Distribution of nociceptive nerve endings in the skin of neonates was determined to be similar in density to an adult [6-8]. In addition, pain in neonates is transmitted by unmyelinated C fibers. These fibers transmit impulses slowly. It starts second or seconds later than a painful stimuli and continues for minutes to increase in size. Pain transmitted by this fiber is perceived as dispersed, continuous, dull and burning. Therefore, anatomical, physiological and biochemical structures enabling the perception of pain are present in neonates and are sufficient for the transmission of painful stimuli [7]. In this direction, the necessity of making researches on neonatal pain experience has been raised.

Neonates are exposed to a variety of painful stimuli if required to receive care and treatment in the neonatal unit for various reasons. The interventions that lead to this painful stimulus are heel lance, intravenous practices, newborn examination, dressing changes, inserting a gavage tube, postural drainage, retinopathy examinations, mechanical ventilation,the removal of the patch in neonates [9]. In detection of painful stimuli and response is influenced by several factors [9]. These factors are gestational age, gender, general health status, severity of disease, past experiences, individual differences, coping skills and types, duration, intensity, frequency of exposure of painful stimuli [3,5,9]. Carbajal et al (2008) determined that these neonates exposed to a median of 115 processing and 75% of them is painful the first 14 days of 430 neonates stayed in neonatal intensive care unit (NICU) [10]. Johnston et al. found neonates are exposed to painful and stressful interventions more than 17,500 of 580 in a week period [11].

Pain and stress experienced because of invasive procedures and the stressful intensive care environment affect negatively behavior, family neonate interaction, the adaption to extrauterine life, development of the senses and growth [1-5,9]. Short and long term effects of pain are given in Table 1.

Because newborn cannot express their pain verbally, they develop physiological, behavioral and hormonal responses to pain.

1. Physiologic response: Term and preterm neonates give physiological responses to painful stimuli such as increased heart rate, blood pressure and respiration rate, decreased O2 saturation, paleness or redness, sweating/sweating palms and pupil dilation [12,13].

2. Behavioral response: These are assessed face and body movements.

Face movements: The movement of the face as a result of autonomous (spinal cord and brain stem) control is the most reliable and consistent behavioral indicators in pain assessment. Typicall facial movements in neonates experienced pain are seen as face and forehead wrinkling, jaw trembling, his eyes squeezing,being newborn's mouth open and tense [1,12,13].

Body movements: Body responses such as opening hands, squeezing his fists, protecting a part of the body, restlessness, moving the head from side to side , back rubbing or jumping, kicking, open fold the finger are evaluated [14].

3. Hormonal and katabolic stress response: While plasma renin activity, catecholamine levels (epinephrine, norepinephrine), cortisol levels, nitrogen excretion, growth hormone, glucagon, aldosterone secretion, glucose, lactate, prüvat, ketone, serum levels of esterified fatty acids increase, insulin secretion decreases [15].

Pain Assessment in Neonates and Management

Description of pain, determination of severity and quality make it difficult because neonates can not express pain verbally. In describing pain in the neonates a variety of scales are developed such as Neonatal Infant Pain Scale (NIPS), Neonatal Postoperative Pain Scale (CRIES), Premature Infant Pain Profile (PIPP) [1-3,5,9]. By using these scales pain can be defined and pain management can be achieved through appropriate nursing interventions.

Many pharmacologic and nonpharmacologic methods are used in order to reduce the pain felt by neonates. Pharmacological methods that can be used for this purpose include opioid and non-opioid analgesics, antagonists, local anesthetics and sedatives [1-4]. Nurses are responsible for apply these pharmacological methods. Moreover they can also be used to cognitive, behavioral and physical nonpharmacologic methods to increased the effectiveness of pharmacological methods [3,16]. Nowadays, interest in nonpharmacological methods is increasing. Mainly, nonpharmacologic methods used for this purpose are position change, kangaroo care, massage, nonnutritive sucking, sweet substances, breastfeeding, reducing environmental stimuli, music, individualized developmental care etc. [1-3,9,16-20].

Purpose in neonatal pain management is to minimize pain felt by newborns and to help to cope with pain. After a pain evaluation is done correctly, neonatal pain can be managed with active individual based care by health care professionals. Nurses' active role in the neonatal pain management starts with evaluation of pain, treatment, selection of appropriate interventions and planning the care. For achievement in neonatal pain treatment and management is required multidisciplinary team approach [1]. For this purpose, the nurse:

Should provide family-centered individualized developmental care,

Parents should be able to get a role as early as possible in the multidisciplinary care plan of the neonates,

To reduce stress, pain and anxiety symptoms in the neonates the adaptation between primary care and medical practices should be maintained,

Should evaluate changes that occur during pain continuously and comparatively,

Should be observed hormonal and behavioral responses in addition physiological changes,

Should be able to distinguish pain symptoms from signs of agitation and irritation,

Nurse should assess continuously the care plan by implementing timely and effective pharmacologic and nonpharmacologic pain management strategies.

Nurses are an indispensable member of the health professional that care providers neonates. So, it is significant that nurses know and practice properties, assessment of pain in newborns infants, and providing pharmacological and nonpharmacological pain control methods.