Pain Assessment in Pediatric Settings

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Table of Contents

Introduction
Main Text
Conclusion
References

Introduction

Assessment of pain is one of the important issues in healthcare which helps to evaluate and analyze medical condition of a patient and his well being. In pediatric setting, pain management becomes a difficult point because of personal nature of this process and patients’ groups. The general approach of the pain is that pain behaviors are to be treated by systematic alterations in contingent reinforcement. Well behaviors are rewarded with praise, and even concrete reinforcers such as money, athletic shoes, and so on.

Pain centers also work to help them minimize reward for pain behavior. Even many highly resistant patients can show improvements in pain relief and can increase functional ability through an operant approach. Assessment of pain is complex due to the personal nature of the experience and other variables. It is particularly problematic in the pediatric setting

Main Text

The main layer of literature proposes a theoretical interpretation of pain and its assessment techniques. Warfield and Baiwa (2004) underline pain management techniques and possible ways to relief pain. Melzack and Wall (2003) Marie (2002) underline that any experience of protracted pain may lead to some of the same problems as have been found in back pain: excessive narcotic use, deconditioning syndrome, and inability to work, to name a few.

Further, patients’ personality dispositions and emotional states, and histories may affect their perception of, and response to, pain and injury. Turk and Gatchel (2002) analyses and evaluate the causes of pain and possible treatment methods in different settings. The researchers found that the power of cognitive therapy techniques in affecting improvements for chronic pain patients, as well as the intuitive appeal of a cognitive perspective, has led to a proliferation of assessment devices and cognitive treatment techniques.

Another layer of literature is represented by case studies and researches devoted to a particular problem of pain management in different medical settings. Ducharme et al (2002) analyze and evaluate treatment methods applied to Children of Parents with brain injury. The researchers found that as pain persists, such overt, respondent pain behaviors inevitably produce certain responses by the patient and the social environment. Calhoun (2001) found that family members may rush to give the patient medication, the employer may give the patient time off from work with pay, or the patient may receive narcotic medications. Lebovits (2002) investigates that responses to the patient’s pain displays can have the effect of turning the “respondent” acute pain behavior into “operant” pain behavior.

In general, pain is an unfortunate daily experience for many individuals. Chronic pain, lasting 6 or more months, is suffered by approximately 30% of the U.S. population. These individuals wake up, function during the day, and go to sleep trying to keep pain at a minimum while, at the same time, maintaining some quality of life. They may be frequent visitors to the doctor and the pharmacy (Ducharme et al 2002).

When they find relief it is usually short-lived and comes at a cost, such as dependence on narcotic medications or complete limitation of activity. Pain often becomes the central point of their existence. All pain is disturbing, irritating, and distracting, but when it is experienced on a constant basis, these noxious characteristics can become intolerable. Individuals who experience chronic pain can become increasingly physically disabled and emotionally distraught. Pain can be experienced in almost every organ system of the body. It is associated with a huge range of physical diagnoses. In many of these conditions, invasive treatment may be a plausible approach to removing the physical source of the pain, or at least reducing its impact on the patient (Calhoun 2001).

Assessment of pain is complex due to the unique nature and feelings of a patient, especially a child. The case study organized by Smith (2005) shows that a special case is patients with communication difficulties. “Lacking the ability to differentiate between various sensations and needs, the same type of behavior that signals the need to toilet may emerge when a person experiences discrete physical pain. Each is experienced as form of stress that may erupt in behavioral symptoms” (p. 99).

Similar situations are typical for pediatric settings when children cannot clearly express and identify their pain and its causes. Clinicians and researchers (Melzack and Wall 2003; Warfield and Baiwa 2004) have defined a wide variety of processes involved in the cognitive response to pain signals. Some of these processes, such as positive outcome expectancies and strong beliefs in one’s ability to control pain, are associated with better overall emotional adjustment and improved functional ability in chronic pain patients (Calhoun 2001).

Assessment of pain is a complex issue because it involves emotional, cognitive, and environmental factors (Lebovits, 2002).. This very explosion of the cognitive perspective presents a number of problems. Integrative theories do not have these limitations of the other theoretical perspectives. Integrative theories begin with an understanding of the physiological mechanisms by which tissue damage is monitored, and the neuronal signals indicating tissue damage are transmitted to the brain. Integrative theories go on to include consideration of psychological mechanisms, but within a physiologic framework (Lebovits, 2002).

Emotional, cognitive, and environmental factors are postulated to affect the physical transmission of pain signals. Some of these psychological events can have an inhibitory effect of the transmission of signals, whereas others may increase signal transmission. The value of integrative models is that they are able to incorporate a wide range of physical and psychological research on pain into a single and relatively simple model of pain (Turk and Gatchel 2002).

The model implies that the impact of an injury or tissue damage can grow as the process moves from nociception to pain behavior. Similarly, perception of the pain signals may be distorted so that the pain may seem to be magnified. The patient’s suffering may be disproportionate to nociceptive input and pain perception. Finally, the behavioral expression of the injury may be so excessive that it dominates the patient’ life. The interaction of physical and psychological factors influences the pain process, determining the extent to which the patient’s life is disrupted by the injury or disease process (Warfield and Baiwa 2004).

In the pediatric setting, the assessment of pain is difficult and complex because the possibility always exists that the nurse might be mistaken, either factually (clinically or technically) or morally in their initial assessment of a situation. For instance, what might at first appear to be a ‘moral problem’ may turn out not to be a moral problem at all, but merely a problem of poor communication, misunderstanding, misinterpretation of the facts, ignorance of legal law or institutional policy, inappropriate legal law, inadequate institutional policy, or cultural unawareness (Warfield and Baiwa 2004).

One should observe how pain behaviors such as shifting weight, rubbing affected areas, and facial pain expressions vary through the course of the session. Particularly, observe differences in pain behavior when the patient’s attention is called to this behavior, versus when the patient is distracted.

In most pain syndromes “normal” pain behaviors have been described. Pain has a normal distribution throughout the body in each syndrome. Certain activities and diagnostic techniques, such as palpation, should elicit particular types of pain responses. This risk factor is identified to the extent that the patient’s pain reports are not consistent with the level of pain behavior displayed, or are inconsistent with “normal” complaints in the particular pain syndrome (Warfield and Baiwa 2004).

Clinical judgment can be exercised when the client’s number of risk factors is near threshold level. Such judgment can be used when the patient displays three to five of the medical risk factors just listed, or when the patient displays three to five of the psychological risk factors just listed (Smith, 2005). When using clinical judgment, the patient is moved from one side of the high-risk threshold to the other. Thus, the decision about surgical prognosis can be altered, based on factors observed, but not specifically listed previously. However, because clinical judgment can only be applied when patients fall into a narrow range of risk factors, the use of this technique basically ties the decision on surgical prognosis to specific criteria, while permitting the practitioner some clinical latitude (Melzack and Wall 2003).

Nurses need to be open-minded about the precise nature of the problem at hand when diagnosing or identifying a supposed moral problem. Credibility is strongest when one not only documents carefully the basis for decisions in specific cases, but also when each patient becomes a part of ongoing research on pain assessment. After all, this form can be completed quite rapidly and provides the scientific basis of all the practitioner’s decisions (Warfield and Baiwa 2004).

The following example shows that it is difficult for a nurse to assess a child condition and determine the causes of pain and physical state. The case (personal communication) involves a girl of 10 suffering moderately chest pain and shortness of breath. The electrocardiograph (ECG) showed a number of cardiac arrhythmias, all of which were suggestive of an acute condition warranting immediate specialised medical and nursing care (Smith, 2005). Upon further questioning, it was revealed that the girl was also suffering a mild pain in her left arm (a pain she had ‘never had before’). The pain improved, however, while she rested in the casualty department.

Her past medical history indicated no known heart disease or any previous incidence of chest pain. This was the first time she had ever experienced such symptoms — symptoms which were indicative of significant underlying cardiac disease (Smith, 2005). The case shows that for a child it is difficult to describe and analyze her physical conditions, and it’s a task of nurse to foresee possible consequences and ask a child about the nature of pain (Calhoun 2001).

In some situations even the most competent and compassionate of clinical assessments will not necessarily result in the identification of a satisfactory solution to the problem of the patient’s pain since the obvious ‘clinical solution’ is precluded by the moral demand to respect the patient’s autonomous wishes (Lebovits, 2002). For instance, if a patient is left psychogenically distressed (for example, emotionally distressed, anxious, depressed and even suicidal) or in a state of needless physical pain and/or disability as a result of his/her experiences (as a patient in a given health care setting) reflective commonsense tells us that this person’s interests have been violated and the person him/herself ‘harmed’. The patient uses “emotional” or “psychological” vocabulary, such as “I feel,” “stress,” or “pissed off.”

The client makes “vague references” to intense emotional states, such as, “let’s not go into that,” “you don’t want to know,” or “it took me a long time to understand that” (Calhoun 2001). The client’s body language or facial expression indicate intense emotions even though the client does not verbalize these. For nurses in pediatric setting, the interview provides an opportunity, not only to gather verbalized information, but also to assess how the patient’s functioning and behavior are affected by pain and by interpersonal situations. One should observe how pain behaviors such as shifting weight, rubbing affected areas, and facial pain expressions vary through the course of the session (Smith, 2005).

Conclusion

In sum, assessment of pain is complex due to the personal nature of the experience. Because the patient’s presenting problem is medical in nature, it is advisable to begin the interview by asking the patient about the injury and current symptoms. This allows one to explore the patient’s knowledge about the medical basis of the injury. By empathically listening to the story of the pain and injury, one establishes a level of rapport that will later allow the patient to discuss more emotional and personal issues. Even the most defensive patient will often provide hints at emotional issues while discussing the medical aspects of the pain. The astute practitioner is alert for these hints and takes the opportunity to explore them.

References

Ducharme, J. M., Davidson, A., Rushford, N. (2002). Treatment of Oppositional Behavior in Children of Parents with Brain Injury and Chronic Pain. Journal of Emotional and Behavioral Disorders, 10 (4), pp. 241-245.
Calhoun, J. A. Pain Must Not Be Wasted. Reclaiming Children and Youth, 10 (1), pp. 15-18.
Lebovits, A. (2002). Psychological Issues in the Assessment and Management of Chronic Pain. Annals of the American Psychotherapy Association 5 (3), pp. 19-23.
Turk, D. C., Gatchel, R. J. (2002). Psychological Approaches to Pain Management, Second Edition: A Practitioner’s Handbook. The Guilford Press; 2 edition.
Warfield, C. A., Baiwa, Z. H. (2004). Principles & Practice of Pain Management. McGraw-Hill Professional; 1 edition.
Melzack, R., Wall, P. D. Handbook of Pain Management: A Clinical Companion to Textbook of Pain. Churchill Livingstone; 1 edition. 2003.
Marie, B., S. (2002). Core Curriculum for Pain Management Nursing. Saunders; 1 edition.

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Pain Assessment in Pediatric Settings

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