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 Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.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

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