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Oct.26.2020

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 Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.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

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, 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.

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 therapy 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.

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.

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