Pain Chronic (Persistent) (Pediatric Inpatient)
Clinical Description
- Care of the hospitalized child experiencing persistent pain of sufficient duration and intensity to adversely affect wellbeing, level of function, developmental health and quality of life.
Key Information
- Pain is a symptom, not a diagnosis. It is real to the patient and it is what he/she says it is (subjective, not objective).
- Lack of physiologic response or absence of pain behavior does not equate with “no pain”. Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.
- Vital signs tend to “normalize” over time as the body adapts to the presence of chronic pain.
- Chronic pain can occur in single or multiple body regions.
- Long-term, untreated or under-treated pain in children can lead to continued pain into adulthood.
Clinical Goals
By transition of care
A. The patient will achieve the following goals:
B. Patient, family or significant other will teach back or demonstrate education topics and points:
- Education: Overview
- Education: Self Management
- Education: When to Seek Medical Attention
Pain Chronic (Persistent)
Signs/Symptoms/Presentation
- altered time perception
- anxiety
- body posture abnormal
- concentration impaired
- constant pain
- crying
- eating pattern change
- fatigue
- fidgeting
- flat affect
- focused on medication timing
- guarding
- irritability
- pacing
- pain present at rest
- pain worsens with activity
- pleasure or interest in activity decreased
- reluctance to move
- reluctance to perform self-care
- reports pain over time
- restlessness
- rocking
- rubbing
- self-focused
- sleep pattern altered
- social withdrawal
- splinting
- tense expression
- weakness
Problem Intervention
Develop Pain Management Plan
- Acknowledge child and parent/caregiver as the experts in pain self-management.
- Use a consistent, validated tool for pain assessment; include function and quality of life.
- Evaluate risk for opioid use and dependence.
- Set pain management goals; determine acceptable level of discomfort to allow for maximal functioning and quality of life.
- Determine mutually-agreed-upon pain management plan, including both pharmacologic and nonpharmacologic measures.
- Identify and integrate past successful treatment measures, if able.
- Encourage patient and caregiver involvement in pain assessment, interventions and safety measures.
- Re-evaluate plan regularly.
- Pain Management Interventions
Problem Intervention
Manage Persistent Pain
- Evaluate pain level, effect of treatment and patient response at regular intervals.
- Minimize pain stimuli; coordinate care and adjust environment (e.g., light, noise, unnecessary movement); promote sleep/rest.
- Match pharmacologic analgesia to severity and type of pain mechanism (e.g., neuropathic, muscle, inflammatory); consider multimodal approach (e.g., nonopioid, opioid, adjuvant).
- Provide medication at regular intervals; titrate to patient response.
- Manage breakthrough pain with additional doses; consider rotation or switching medication.
- Monitor for signs of substance tolerance (increased dose to reach desired effect, decreased effect with same dose).
- Avoid abrupt withdrawal of medication, especially agents capable of causing physical dependence.
- Manage medication-induced effects, such as constipation, nausea, pruritus, urinary retention, somnolence and dizziness.
- Provide multimodal treatment interventions, such as physical activity, therapeutic exercise, yoga, TENS (transcutaneous electrical nerve stimulation) and manual therapy.
- Train in functional activity modifications, such as body mechanics, posture, ergonomics, energy conservation and activity pacing.
- Consider addition of complementary or alternative therapy, such as acupuncture, hypnosis or therapeutic touch.
- Bowel Elimination Management
- Complementary Therapy
- Medication Review/Management
- Sleep/Rest Enhancement
Problem Intervention
Optimize Psychosocial Wellbeing
- Facilitate patient’s self-control over pain by providing pain information and allowing choices in treatment.
- Consider and address emotional response to pain.
- Explore and promote use of child and parent/caregiver coping strategies; address barriers to successful coping.
- Evaluate and assist with psychosocial, cultural and spiritual factors impacting pain.
- Modify pain perception by using techniques, such as distraction, mindfulness, guided imagery, meditation or music.
- Assess and monitor for signs and symptoms of behavioral health concerns, such as unhealthy substance use, depression and suicidal ideation.
- Consider referral for ongoing coping support, such as cognitive behavioral therapy and mindfulness-based stress reduction.
- Diversional Activities
- Family/Support System Care
- Spiritual Activities Assistance
- Supportive Measures
Education
Overview
risk factors
signs/symptoms
When to Seek Medical Attention
General Education
admission, transition of care
orientation to care setting, routine
advance care planning
diagnostic tests/procedures
diet modification
opioid medication management
oral health
medication management
pain assessment process
safe medication disposal
tobacco use, smoke exposure
treatment plan
Population-Specific Considerations
Toddler/Preschooler
- At about 18 months of age, children are able to verbally express pain.
- A toddler may require parent/caregiver report to assess pain.
- At about 3 to 4 years of age, children are able to report pain.
- At this age, there is a heightened sense of fear that may influence pain.
- Indicators of pain include guarding, protecting site of pain, tugging at pain site and refusal of usual activities.
Younger School-Aged
- At this age, children are beginning to develop a sense of cause and effect.
- There is an ability to use pain assessment tool/scale appropriately.
- Common primary complaints of ongoing pain in children include headache or migraines, abdominal pain, limb or joint pain, muscle pain and back pain.
Older School-Aged
- At this age, there is a deepened understanding of pain and an improved ability to self-report.
- This age group understands the basic mechanisms of pain and are able to express feelings (boys are often less expressive than girls).
- A change in eating or activity level may be seen.
- Pain may not be expressed in order to be “brave”.
Adolescent
- Most adolescents have had a previous experience with pain and will self-report.
- There is an awareness of emotions and the impact on pain.
- Adolescents may choose not to express pain, especially in front of family and friends; a private evaluation of pain level may be required.
- Opioid agents should be avoided if possible; if prescribed, close supervision by a parent/caregiver is important.
Child with Disabilities, Sedated or Mechanically Ventilated
- Consider the child's level of impairment and understanding; adjust the assessment and self-report accordingly.
- Involvement of parents/caregivers should be encouraged.
- Focus on the physiologic and behavioral indicators of pain.
- Clinical judgment should be utilized.
Pregnancy
- Young women of childbearing age and those who are currently pregnant or lactating should have the specific risks of opioid use reviewed prior to administration.
References
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Disclaimer
Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.