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Jan.10.2020

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 Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.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:
  • 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 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.
  • 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.

Associated Documentation

  • 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, 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.

Associated Documentation

  • 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 therapies and mindfulness-based stress reduction.

Associated Documentation

  • Diversional Activities
  • Family/Support System Care
  • Spiritual Activities Assistance
  • Supportive Measures

Education

CPG-Specific Education Topics

Overview

  • risk factors

  • signs/symptoms

Self Management

  • activity

  • coping strategies

  • medication management

  • nonpharmacologic pain management

  • pain self-advocacy

  • sleep/rest

When to Seek Medical Attention

  • signs of medication tolerance

  • 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 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.
  • 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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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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