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Mar.04.2020

Pain Acute (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child experiencing an unpleasant sensation and emotional experience as a result of potential or actual tissue damage related to an injury or disease process.

Key Information

  • Pain is a symptom, not a diagnosis; it is what the person says it is (subjective, not objective).
  • Lack of physiologic response or absence of pain behavior (e.g., quiet, withdrawn, sleeping) should not be interpreted as absence of pain.
  • If the patient is unable to respond, assume pain is present during painful activity and procedures.
  • Autonomic responses will decrease with duration of pain and are a less reliable indicator over time; always consider the presence and impact of preexisting chronic pain.
  • Adequate pain control can increase functional ability, as well as reduce complications, recovery times and length of stay. Poorly managed or unrelieved acute pain can lead to the presence of chronic (persistent) pain.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Acceptable Pain Control and Functional Ability

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

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity, congenital anomaly
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • child and family/caregiver:
      • health literacy
      • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Pain Acute

Signs/Symptoms/Presentation

  • anxiety
  • body posture abnormal
  • concentration poor
  • crying
  • diaphoresis
  • eating pattern change
  • fatigue
  • fidgeting
  • flat affect
  • generalized weakness
  • grimacing
  • guarding
  • irritability
  • moaning
  • nausea
  • pacing
  • pleasure or interest in activity decreased
  • reluctance to move
  • reluctance to perform self-care
  • report of pain
  • restlessness
  • rocking
  • rubbing
  • sleep pattern altered
  • splinting
  • tense expression
  • undue quietness
  • vomiting
  • withdrawn appearance

Vital Signs

  • heart rate increased
  • respiratory rate increased

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.
  • Set pain management goals; determine acceptable level of discomfort to allow for maximal functioning.
  • Determine mutually-agreed-upon pain management plan, including both pharmacologic and nonpharmacologic measures; integrate management of chronic (persistent) pain.
  • Identify and integrate past successful treatment measures, if able.
  • Encourage patient and parent/caregiver involvement in pain assessment, interventions and safety measures.
  • Re-evaluate plan regularly.

Associated Documentation

  • Pain Management Interventions

Problem Intervention

Prevent or Manage Pain

  • Evaluate pain level, effect of treatment and patient response at regular intervals.
  • Minimize painful 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; premedicate for painful procedures.
  • 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).
  • Manage medication-induced effects, such as constipation, nausea, urinary retention, somnolence and dizziness.
  • Provide multimodal interventions, such as 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.

Associated Documentation

  • Bowel Elimination Promotion
  • Complementary Therapy
  • Medication Review/Management
  • Sensory Stimulation Regulation
  • 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 using techniques, such as distraction, mindfulness, guided imagery, meditation or music.
  • Assess for risk factors for developing chronic pain, such as depression, fear, pain avoidance and pain catastrophizing.
  • Consider referral for ongoing coping support, such as education, relaxation training and role of thoughts.

Associated Documentation

  • Diversional Activities
  • Supportive Measures

Education

CPG-Specific Education Topics

Overview

  • risk factors

  • signs/symptoms

Self Management

  • activity

  • coping strategies

  • medication management

  • nonpharmacologic pain management

  • sleep/rest

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

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

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

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 a pain assessment tool/scale appropriately.

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.
  • 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.

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.

References

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  • American Academy of Pediatrics Section on Integrative Medicine. Mind-body therapies for children and youth. Pediatrics. 2016;138(3) doi:10.1542/peds.2016-1896 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
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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.

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