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The Pulse on Pain

For school nurses, assessing and managing students' pain levels is integral to secondary assessments of ill or injured students. From minor playground injuries to more serious conditions like chronic headaches and severe menstrual cramps, it is the school nurse's responsibility to help determine the nature and intensity of pain and choose appropriate interventions for pain management in the school setting. To ensure reliable and valid assessments, it is essential to consider pain a vital sign and follow standardized protocols for pain assessments.

To provide effective pain management, it is first necessary to acknowledge pain's unique and subjective nature. Upon assessment, this involves considering the student's age, cultural background, gender identity, cognitive ability, emotional state and reported past experiences. Self-report measures are clinically appropriate for students aged five years or older who are cognitively capable of providing verbal feedback. For students under four years of age and those who experience difficulties communicating, clinical use of pain assessment techniques that prioritize observation-based methods, such as pain behavior scales or checklists, is recommended.

Popular tools for pain assessments include the Wong-Baker FACES® Pain Scale, which consists of six cartoon faces with associated numbers ranging from a happy, smiley face illustrating no pain to a crying, hurt face representing worst pain. The FACES® scale is appropriate for students as young as three years old, and there are many fun adaptations of the scale, including this creative Lego version. Similarly, the Oucher is a pain assessment scale that can be used for students three years and older. It uses actual pictures of children to depict varying levels of pain, providing versions for different ethnicities that may allow students to more accurately self-report their level of pain. The Numeric Rating Scale (NRS) is another commonly used tool that ranks pain severity from 0 (no pain) to 10 (worst pain possible or imaginable). According to the American Academy of Pediatrics, NRS can be an effective self-report pain intensity measuring tool for students six and older.

For students unable to self-report, the Revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) scale is an observational pain measure. It is specifically designed to assess pain in children who are non-verbal or with cognitive impairment. The r-FLACC scale includes additional pain behaviors often exhibited by children with special needs and is customized to individual students by taking into account the unique pain behaviors reported by their parents or guardians within each category.

Irrespective of the tools used, providing a comfortable environment and establishing trust with students is critical to pain assessments in the school setting. Creating a protective space where students feel safe sharing their experiences is imperative to ensure accurate assessments and appropriate interventions in line with school policies. School nurses can ensure that students receive the best possible care for their pain by using standardized pain assessments and establishing trust with students. Proper pain management leads to better outcomes, benefiting a student's educational experience and overall quality of life.

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