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An educational intervention to improve pain assessment in preverbal children.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now called The Joint Commission, implemented a policy calling for effective pain assessment and management in accredited health care institutions (Downey & Zin, 2011). Pain assessment is often referred to as the fifth vital sign (Downey & Zun, 2011). Pain assessment tools used for adults and older children involve asking the patient to describe their pain using a numerical or picture scale. Preverbal children younger than 36 months of age cannot verbally, fully describe their pain, leaving them at risk for prolonged and unrecognized pain.

The Wong Faces Scale is an established pediatric pain assessment tool (Noviello, 2006). Children and adults can easily point to the face that describes the way they are feeling at that moment. However, the Wong Faces pain assessment tool is only valid and reliable for assessing pain in children older than three years of age, or 36 months (Noviello, 2006). The FLACC (faces, legs, activity, cry, consolability) pain assessment tool has been shown to be an effective pain assessment tool in preverbal children (Blount & Loiselle, 2009) (see Figure 1). Practice standards dictate that pediatric nurses obtain vital signs every four hours in hospitalized children. Pediatric nurses should also assess pain in their young patients when assessing vital signs.

The overall purpose of this project was to improve nursing practice regarding pain assessment in preverbal children. Specifically, this project proposed to a) educate pediatric staff nurses as to the necessity of assessing pain in preverbal children, and b) introduce and promote the use of the FLACC pain assessment tool when assessing pain in preverbal children 36 months of age and younger. Changes in nursing practice before and after the educational intervention were evaluated via two approaches: a retrospective chart review and a survey. The chart review served to evaluate documentation of pain assessment in preverbal children pre-and post-educational intervention. The survey served to evaluate the nurses' pain assessment tool choice and frequency of assessment.

Literature Review

Health care professionals have an obligation to the patient to reduce the patient's pain. One challenge that health care professionals face is having the ability to detect the signs and symptoms of pain (Srouji, Ratnapalan, & Schneeweiss, 2010). Recognizing the signs and symptoms of pain in infants and children can be problematic, and recording correct pain measurements in infants and children is difficult. Because younger children are not able to fully express their pain, and health care professionals are not able to accurately determine their pain, less than optimal pain management is seen in the pediatric population (Gandhi, Thomson, Lord, & Enoch, 2010; Srouji et al., 2010). Clinical practice guidelines for pain management outline the importance of systematically and frequently assessing and documenting pain by using age-appropriate pain management scales (Voepel-Lewis, Zanotti, Dammeyer, & Merkel, 2010). Because pain assessment and management is not always optimized, age-specific pain management tools have been developed. Pain assessment tools include self-report for communicative patients and pain scales for non-communicative patients (Sessler, Grap, & Ramsey, 2008; Srouji et al., 2010). Frequent, systematic, and accurate pain assessment has been beneficial to pain management in children and is essential for optimal patient outcomes in children (Gandhi et al., 2010; Voepel-Lewis et al., 2008, 2010).

The patient's self-report of pain is the optimal pain assessment evaluation and is considered the gold standard for pain measurement (Bai, Hsu, Tang, & van Dijk, 2012; Baldridge & Andrasik, 2010; Gandhi et al., 2010; Nilsson, Finnstrom, & Kokinsky, 2008; Sessler et al., 2008; Srouji et al., 2010; Voepel-Lewis et al., 2010). As the most accurate measurement of pain, self-report should be used when available (Baldridge & Andrasik, 2010). In circumstances where self-reporting of pain is not available, a validated observational tool can offer the information needed to assess pain (Nilsson et al., 2008). Self-report is not feasible in preverbal patients; therefore, validated assessment tools may be used to identify pain-related behaviors in children (Bai et al., 2012). Gandhi and colleagues (2010) state that the FLACC pain assessment tool should be used in cases where it is not possible to obtain the patient's self-report due to expressive language limitations and developmental stage.

The FLACC pain assessment tool is a behavioral assessment tool that was developed to measure pain intensity in children from birth to 36 months (Gandhi et al., 2010; Kabes, Graves, & Norris, 2009; Sessler et al., 2008). The tool was designed in an effort to offer a simple and reliable system for health care professionals to assess pain in children. The FLACC pain assessment tool evaluates pain by observing the child's behavioral signs of face, legs, activity, cry, and consolability (Blount & Loiselle, 2009; Sessler et al., 2008; Srouji et al., 2010). Each of the five categories is scored on a scale of 0 to 2 that results in a total score with a range of 0 to 10. The patient's face, legs, activity, and cry are all observed for two to five minutes. Another score is given on the health care professional's ability to console the patient (Blount & Loiselle, 2009; Gandhi et al., 2010; Srouji et al., 2010). A total score ranging from 0 to 3 is defined as mild or no pain, a score ranging from 4 to 7 is considered moderate pain, and a score ranging from 8 to 10 is categorized as severe pain (Bai et al., 2012). The FLACC pain assessment tool has been extensively accepted and used, and researchers have labeled the FLACC pain assessment tool as a simple, effective, rapid, and useful way to assess pain in children (Gandhi et al., 2010; Srouji et al., 2010; Voepel-Lewis et al., 2010). One benefit of the FLACC pain assessment tool is that it can be used across populations of patients and in many different situations, such as in the acute care setting, the intensive care setting, the postoperative setting, and also for procedural pain (Blount & Loiselle, 2009; Voepel-Lewis et al., 2010). The pain scale has been recommended for extended usage in clinical trials in preverbal children (Nilsson et al., 2008).

The FLACC pain assessment tool has been sufficiently validated in a variety of pediatric settings (Gandhi et al., 2010. It has great clinical efficacy showing admirable construct validity through different populations of pediatric patients (Voepel-Lewis et al., 2010).

The FLACC pain assessment tool has also been validated for use in acutely ill pediatric patients. The content validity of the tool has been reinforced by the behavioral signs and an assortment of descriptors that have been connected with pain in children. In a study by Voepel-Lewis and colleagues (2010), the interrater reliability of the FLACC pain assessment tool for judging pain was supported by the fact that agreement was exceptional between observers for each cat egory along with the total score. The tool was reviewed and presented as having superb internal consistency, interrater reliability, criterion validity, and construct validity. All measurements defend the utility of the FLACC pain assessment tool in gauging pain.

A repeated-observation study was performed to calculate the associated validity, sensitivity, and specificity of the FLACC pain assessment tool for the post-operative assessment of pain in children. The tool was again publicized as having respectable interrater reliability and validity in the evaluation of pain for preverbal children. The tool displayed both high sensitivity and high specificity for pain indicators, with a suggested ideal limit of a score of 2 on the pain scale. The FLACC pain assessment tool was proclaimed as a valuable means of evaluating pain in non-communicative children (Bai et al., 2012).

Nilsson et al. (2008) performed another study that also confirmed concurrent and construct validity of the FLACC pain assessment tool, not only in the post-operative setting, but also during the procedural setting. The conclusions of the research support interrater reliability and the clinical practice of using the FLACC scale for preverbal children.

The FLACC pain assessment tool has been recognized as the best behavioral assessment tool for pain in preverbal children because it has exceptional psychometric properties (Voepel-Lewis et al., 2008). The tool has been validated for pain assessment in preverbal children because of the good interrater reliability and validity for pain assessment (Nilsson et al., 2008; Sessler et al., 2008).

Needs Assessment

According to Noviello (2006), preverbal children were being assessed for pain by nurses at a mid-sized hospital using a scale that was not indicated for use in children less than three years of age. In that study, the Wong Faces pain assessment scale was included on the standardized nursing note for use on most units in the hospital, and was used to assess pain in all children, both verbal and preverbal. Noviello (2006) used a grounded theory approach to explore the processes and factors that affect nurses' behaviors in managing preverbal children's pain. The researcher interviewed 11 nurses from three hospitals, two acute care hospitals, and one pediatric hospital, all of whom care for preverbal children. Demographic information was obtained, as well as responses to a series of questions regarding pain management in preverbal children. Noviello (2006) found that despite all three hospitals having an assessment tool available, only the nurses from the pediatric hospital used an age-appropriate tool to assess pain. The nurses working on the mid-sized acute care hospital were using an inappropriate tool for preverbal children and stated that it was a waste of time to assess pain with the wrong tool. This project was implemented in the mid-sized acute care hospital used in Noviello's (2006) study.

Project Plan

A two-month retrospective chart review was conducted to evaluate documentation of pain assessment prior to project implementation. All charts of children 36 months of age and younger admitted during two months prior to the in-service were reviewed. An in-service was held for the nursing staff of each shift to introduce the FLACC pain assessment tool and give directions for its use. A survey was given to the nurses upon entering the in-service, and the nurses were asked to fill out the questionnaire and place it in a self-addressed stamped envelope to be mailed to the primary investigator. The survey included demographics, questions regarding pain assessment, and barriers to pain assessment. The nurses were introduced to the FLACC pain assessment tool during the in-service and were asked to use it for assessing pain on all preverbal children admitted to the pediatric unit during the next two months. The FLACC pain assessment tool was placed in each room on the bulletin board. The nurses were given a laminated, pocket-sized scale to use. In addition, a copy of the scale was placed in the front of each patient's chart. The nurse was asked to fill in the scale when assessing pain on a preverbal child and report it in the child's chart. The same pre-implementation survey was given post-implementation to evaluate pain assessment. A chart review was conducted two months after the in-service to identify the actual use of the scale during the implementation phase. All charts of children 36 months of age and younger admitted two months subsequently were reviewed.
Figure 2.
Survey for Pediatric Nurses

Please mark (circle or list) as appropriate:

1. Age--

2. Gender [] Male [] Female

3. Level of Education [] BSN [] ASN/ADN [] LPN [] Master Other --

4. Years of nursing experience --

5. Years of pediatric nursing experience --

6. Do you have children of your own? [] Yes [] No

7. Do you use a tool/scale when assessing for pain in children three
   years of age or younger? [] Yes [] No

   If yes, what tool/scale do you use? Wong Faces FLACC Other --

8. What percent of the time do you use a pain assessment scale for
   assessing children three years of age and younger? --

9. Do you find the scale easy to use? [] Yes [] No

10. What are the barriers that keep you from using a pain tool/scale?

    Time -- Workload --

    Too hard to understand -- Other --


Target Population

The population consisted of all registered nurses and licensed practical nurses (N = 38) employed on the pediatrics unit during the two months of the study. Verbally and with displayed flyers, the nurse manager encouraged all nurses to attend the in-service and return the surveys.

Setting

The setting for this study was the pediatrics unit of a 400-bed acute care hospital in Georgia. The pediatrics unit consisted of 28 beds with a projected census of 50 preverbal children per month during January through March per the clinical coordinator of the unit.

Data Collection

The researchers obtained Institutional Review Board (IRB) approval from the hospital. Consent from the staff nurses participating in the study was implied by completing and returning the survey. A cover letter was attached to the survey detailing the risks, benefits, and project detail. Confidentiality was ensured by locking all documents in a file cabinet in the primary investigator's office. The FLACC pain assessment tool was obtained with permission from Sandra Merkel, the author of the scale (11/2/2006). The scale was placed on the bulletin board in all patient rooms on the unit. The nurses were given a laminated pocket size scale and a scale was placed in the front of each patient's chart.

The primary investigator instructed the staff nurses how to use the FLACC scale. The audience consisted of nurses on both the day and night shifts. The lesson was given by an oral presentation with laminated FLACC pain assessment tools. The class lasted less than 30 minutes, including a time for questions and answers to determine comprehension of the scale. The nurses demonstrated the use of the FLACC pain assessment tool during the in-service by scoring an example of a patient. A designated nurse, involved in an evidence-based nursing program at the hospital and employed on the pediatrics unit encouraged the nurses to use the FLACC pain assessment tool throughout the two-month study period verbally and by attaching the tool to the charts.

A survey (see Figure 2) was given at the in-service and two months following the in-service to all nurses to determine the use, ease of use, barriers to use, and demographics. Post-implementation surveys were distributed to all the nurses who attended the in-service. No personal identifiers were on the survey. Both surveys had a stamped self-addressed envelope to return to the primary investigator. Completed surveys were kept in a locked file cabinet in the primary investigator's office.

A chart review tool was used to retrospectively review charts from two months prior to the in-service and two months concurrently following the in-service on the charts of all preverbal children, those 36 months of age and younger. The chart review determined the age of the patient, admission diagnosis, if pain assessment was documented, and if as needed, (PRN) pain medication was given. No identifiers were used. Assessing pain is a standard of care for each patient in the hospital and should be documented on all charts. The chart reviews were locked in a file cabinet in the primary investigator's office.

Results

The nurse demographics revealed that 95% were female, and 57% had children of their own. The mean age of the respondents was 28.79 [+ or -] 6.95 years. Fifty percent of the participants reported their highest educational level as a bachelor's degree. The mean years of nursing experience was 6.18 [+ or -] 7.09 years. The mean years of pediatric nursing experience was 5.18 [+ or -] 7.06 years.

Survey

A total of 22 pre- and 20 post-nurse surveys were returned from the nurses employed on the pediatrics unit. The nurses gave their informed consent by returning the survey via postal mail. Four in-services were conducted, and pre-surveys were distributed to all nursing staff. Twenty-two nurses returned the survey prior to implementation of the FLACC scale. After a two-month implementation phase, post-surveys were distributed to all pediatric nurses employed on the unit, 20 returned the post-survey, for a return rate of 52%. The surveys were not matched; therefore, it is not assumed that all pre-survey nurses participated in the post-survey.

Differences pre- and post-intervention were significant. Whether or not the nurses used a pain assessment tool when assessing preverbal children was significant (1.12 [+ or -] 0.328, p < 0.025), (see Table 1). The tool used to assess for pain in preverbal children was significant (1.41 [+ or -] 0.551, p = 0.000). Prior to implementation of the FLACC pain assessment tool nurses reported using the Wong scale 77% and the FLACC scale 22% of the time. After the educational in services and FLACC pain assessment tool implementation, the nurses reported using the Wong scale 25% of the time and the FLACC pain assessment tool 85% of the time. Whether the nurses found the scale easy to use was significant (1.18 [+ or -] 0.385, p = 0.004). The barriers to use were not statistically significant (2.33 [+ or -] 0.777, p = 0.166).

Chart Review

Table 2 shows the demographics of the chart review. The chart reviews included all preverbal children admitted to the unit during the designated time periods. A chart review was conducted on a total of 288 charts, 137 pre-implementation of the FLACC pain assessment tool and 151 charts of patients admitted post-implementation. The mean age of the children whose charts were reviewed was 13.39 [+ or -] 11.55 months. The mean length of stay in the hospital was 3.86 [+ or -] 1.64 days. The mean number of times pain was assessed and documented each day was 2.95 [+ or -] 5.45.

An independent-samples f-test was used to analyze potential differences between the use of pain assessments prior to implementation of the FLACC pain assessment tool and following the FLACC scale implementation. The only significant difference was found in total number of times pain was assessed pre- and post-implementation of the FLACC pain assessment tool (t = -5.415, p < 0.001).

Discussion

After implementation of the FLACC pain assessment tool, there were desired outcomes found in both the nurse survey and chart reviews, including that the nurses increased pain assessment in preverbal children on the pediatrics unit. An increase in pain assessment may help improve health outcomes in preverbal children. Both pre- and post-survey returns were greater than 50% of the nursing population on that unit. The years of pediatric nursing experience reported was 5.18 [+ or -] 7.1 years. The nurses reported that they used a pain assessment tool when assessing for pain in preverbal children (M 1.12 [+ or -] .33), with one being yes and 2 being no. In the pre-survey, the nurses reported use of a tool as (81%) and post-survey (95%). The nurses in this project indicated using a tool to assess for pain but used the Wong scale the majority of the time (72.7%). The pre-survey reported 77% of nurses using the Wong scale; 22% using the FLACC pre-implementation, while 25% reported using the Wong scale; and 85% reported using the FLACC scale post-survey. The nurses decreased the use of the age inappropriate Wong scale and increased the use of the age appropriate and used the FLACC pain assessment tool after the in-service. Some nurses reported using both scales, indicating there is a need for further education.

The nurses reported the scales as easy to use (78%); however, the question did not specify which scale was used in the stated question. By not specifying which scale was easy to use, the researchers cannot accurately state that the FLACC scale was reported as easy to use. The barriers to use were not statistically significant; however, barriers were similar in both surveys. Comparatively, barriers were identified as perceived workload (63% pre and 85% post), time it took to assess for pain (36% pre and 15% post), and too hard to understand (27% pre and 0% post). By identifying the barriers to assessing pain the researcher can provide valuable feedback in order to make changes in current practice.

The chart review found a statistically significant increase in the documentation of pain assessment in the charts. Patients were assessed for pain more often after the in-services and implementation of the FLACC pain assessment tool (M = 4.48 times per day, SD = 6.86, n = 151) than before the scale was implemented (M = 1.28, SD = 2.28, n = 137). Although there was an increase in documentation of pain, according to mandates, pain should be assessed at least six times per day. The mean time per day post-implementation was 4.48, which was still less than the mandate.

Limitations

Limitations to this study involved how the nurses were sampled. The nurses who returned the surveys were not matched per nurse and may have been the same participants or different participants. By matching the nurses the post-survey findings may have revealed different results.

The size of the sample was a limitation due to the small number of nurses. The results of the nurse survey and chart reviews cannot be generalized due to the type of hospital and small size of the sample. In the survey, the question regarding whether the pain scale was easy to use did not specify which scale, thus limiting the data.

The documentation in the charts had a limited amount of information on whether the FLACC pain assessment tool was used to assess for pain. The nursing notes at this institution had a small area for pain assessment and lacked the space for specific scale use. In the future, if the institution chooses to use the FLACC pain assessment tool, nursing notes should be changed to provide a place for a scale name or provide both scales on the notes.

The tool for the chart reviews should be revised to include pain scale specified as well as reassessment after nursing intervention. The charts did not specify the use of the FLACC pain assessment tool specifically, and future studies need to focus on the use and documentation of the FLACC scale.

The nurses documented that the patient was "not in distress," "no signs or symptoms of distress noted," or "denies complaints" in the majority of nursing notes. The nurse may have used these statements to address pain. Only specific statements including "no pain" or the numbers on a pain scale counted as pain assessments in this study. Nurses need further education on the documentation of pain assessments. If nurses were referring to pain in these previous statements, the number of pain assessments would have been higher than reported.

Implications for Nursing Practice

This study demonstrated an increase in the awareness of pain assessment and documentation. The nurses recognized that they were using an inappropriate pain scale and lacked documentation in the chart. The outcome of this project increased nurses' pain assessment as evidenced by an increase in documentation in the charts, but still less than practice standards dictate.

The majority of the nurses were reporting pain assessment (62%) as evidenced by chart review documentation (68%). The information obtained by this project can be used by the hospital to implement the FLACC pain assessment tool in areas of the hospital where preverbal children are being treated. By providing education in-services, the nurses related the importance of pain assessment in preverbal children and demonstrated this understanding by increasing pain assessment and documentation. These results provided a positive change in documentation during the project period.

During the project implementation, The Joint Commission evaluated the hospital. The hospital received an RFI (recommendation for improvement) for pain assessment and documentation. This project was used to show the improvement needed for increased pain assessment documentation as required by The Joint Commission.

Pediatric nurses (N = 38) at a Georgia acute care pediatric unit demonstrated improvement on the appropriate use of the FLACC pain assessment tool and documentation of pain assessment in preverbal children admitted during a two-month pilot study period. Implementation of similar projects at acute care facilities that care for preverbal children could improve pain management and outcomes on a broader scale. Clinical practice guidelines and in-service education for pediatric nurses can improve utilization of appropriate pain assessment scales and decrease adverse outcomes in preverbal children.

References

Bai, J., Hsu, L., Tang, Y., & van Dijk, M. (2012). Validation of the COMFORT Behavior Scale and the FLACC Scale for Pain Assessment in Chinese children after cardiac surgery. Pain Management Nursing, 13(1), 18-26.

Baldridge, K.H., & Andrasik, A. (2010). Pain assessment in people with intellectual or developmental disabilities. American Journal of Nursing, 110(12), 29-35.

Blount, R.L, & Loiselle, K.A. (2009). Behavioural assessment of pediatric pain. Pain Research and Management, 14(1), 47-52.

Downey, L.A. & Zun, L.S. (2011). Pain management in the emergency department and its relationship to patient satisfaction. Journal of Emergencies, Trauma, and Shock, 3(4) 326-340. doi:10. 4103/0974-2700.70749

Gandhi, M., Thomson, C., Lord, D., & Enoch, S. (2010). Management of pain in children with burns. International Journal of Pediatrics, 2010. doi:10.1155/2010/825657

Kabes, A.M., Graves, J.K., & Norris, J. (2009). Further validation of the nonverbal pain scale in intensive care patients. Critical Care Nurse, 29, 59-66. doi:10.4037/ccn2009992

Merkel, S. Voepel-Lewis, T., Shayevitz, J., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293-297.

Nilsson, S., Finnstrom, B., & Kokinsky, E. (2008). The FLACC Behavioral Scale for procedural pain assessment in children aged 5-16 years. Pediatric Anesthesia, 18, 767-774. doi:10.111/j.1460-9592.2008.02655.x

Noviello, S.R. (2006). A grounded theory study of pain management behaviors of nurses who care for preverbal children. Unpublished doctoral dissertation. Medical College of Georgia.

Sessler, C.N., Grap, M.J., & Ramsay, M.A.E. (2008). Evaluating and monitoring analgesia and sedation in the intensive care unit. Critical Care, 12. Retrieved from http://ccforum.com/content/12/S3/S2

Srouji, R., Ratnapalan, S., & Schneeweiss, S. (2010). Pain in children: Assessment and nonpharmacological management. International Journal of Pediatrics. Retrieved from http://www.hindawi.com/journals/ijpedi/2010/474838/ doi:10.1155/2010/474838

Voepel-Lewis, T., Malviya, S., Tait, A.R., Merkel, S., Foster, R., & Krane, E.J. (2008). A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Pediatric Anesthesiology, 106(1), 72-78. doi:10.1213/01.ane.0000287680. 21212.d0

Voepel-Lewis, T., Zanotti, J., Dammeyer, J.A., & Merkel, S. (2010). Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. American Journal of Critical Care, 19, 55-56. doi:10.4037/ajcc201624

Aimee Vael, DNP, RN, FNP-BC, is an FNP Program Director, Assistant Director Graduate Nursing, and an Associate Professor, Columbus State University School of Nursing, Columbus GA.

Kelli Whitted, DNP, FNP-BC, APRN-BC, is an Assistant Professor, Troy University School of Nursing, Troy, AL.
Table 1.
Nurse Survey Results: Mann Whitney U Test

                             Nurse Survey
                      (Questions Referring to Use
                        in Pre-Verbal Children)

                   Pre-Mean   Post-Mean
Variable             Rank       Rank       Sig.

Do you use a        23.77       19.00     0.025 *
pain assessment
tool? Yes = 37;
No = 5

What pain           10.89       24.94     0.000 *
assessment tool
do you use?
Wong = 18;
FLACC = 15

Do you find the     24.00       17.00     0.004 *
tool easy to
use? Yes = 33;
No = 7

* Significant finding p [less than or equal to] 0.05.

Table 2.
Independent Samples t-Test Pre- and Post-FLACC Implementation

                                Pre-Test              Post-Test
Variable                          M SD                   M SD

Age of child in months    13.27 [+ or -] 11.37   13.49 [+ or -] 11.76
Total days hospitalized    3.70 [+ or -] 1.58     4.00 [+ or -] 1.69
Number of times pain       1.28 [+ or -] 2.28     4.48 [+ or -] 6.87
  documented daily

Variable                           t

Age of child in months    -0.164
Total days hospitalized   -1.548
Number of times pain      -5.415 *
  documented daily

* p < 0.001

Figure 1.
FLACC Pain Assessment Tool

Categories      Score 0           Score 1           Score 2

Face            No particular     Occasional        Frequent to
                expression or     grimace or        constant frown,
                smile             frown,            clenched jaw,
                                  withdrawn,        quivering chin
                                  disinterested

Legs            Normal position   Uneasy,           Kicking or legs
                or relaxed        restless, tense   drawn up

Activity        Lying quietly,    Squirming,        Arched, rigid,
                normal            shifting back     or jerking
                position, moves   and forth,
                easily            tense

Cry             No cry (awake     Moans or          Crying
                or asleep)        whimpers,         steadily,
                                  occasional        screams or
                                  complaint         sobs, frequent
                                                    complaints

Consolability   Content,          Reassured by      Difficult to
                relaxed           occasional        console or
                                  touching,         comfort
                                  hugging, or
                                  being talked
                                  to;
                                  distractable

Source: Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997.
[c] 2002 The Regents of the University of Michigan. All
rights reserved. Used with permission.
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Author:Vael, Aimee; Whitted, Kelli
Publication:Pediatric Nursing
Article Type:Report
Date:Nov 1, 2014
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