Pain Management

Assessment

Effective pain management begins with an accurate assessment of pain. This can be problematic, as many pain episodes are infrequent or occur only under specific circumstances. However, the clinician should consider at least five areas for assessment of pain—location, frequency, intensity, duration, and quality—and painfree periods. Pain location can be assessed by asking where on the child's body the pain occurs. The child should be asked to point to the pain, and the accompanying adult should be asked to verify this location. Pain frequency should be assessed on both the micro and macro level: Is the pain constant or transient? How often has it occurred during the past hour, day, and week? and When does it occur more often? Pain intensity is usually gauged with a visual analog scale for younger children or a verbal analog scale for older children. The Whaley-Wong visual analog scale can range from 0 to 4 and have frowning and smiling faces as anchors. For older children, the analog scale usually ranges from 0 (no pain) to 10 (worst pain ever). Pain duration is assessed by inquiring how long pain occurs, once it begins, and what is associated with pain remittance. Pain quality is subjective, but certain descriptive terms are commonly employed, such as burning, stabbing, or squeezing. Children should be asked to describe the pain themselves first, and then prompted with these terms if necessary. Finally, how often and under what environmental and behavioral circumstances painfree periods occur should be assessed.

It is important to obtain multiple assessments in multiple settings in order to increase the likelihood of detecting patterns of pain as well as to assess for interand intrasubject variability. For instance, it is helpful to know if the child reports more pain than usual for his or her developmental age, if this pain is reported more at home than at school, and if this pain is reported more in the presence of Mom as opposed to Dad. Moreover, a good assessment will elucidate what type of pain the child is experiencing and will enable the clinician to target pain behaviors and symptoms effectively. It is apparent that multiple variables affect what type of intervention is chosen for pain; these multiple variables are not necessarily mutually exclusive, often operating in conjunction with each other. Therefore, an accurate assessment will consider these variables as overlapping and covariate.

For example, time of pain should be assessed. The clinician must know whether the pain is acute or chronic. While both acute and chronic pain can be [Page 934]treated with standard behavioral interventions such as distraction, as pain moves more into the chronic phase, more cognitive coping skills can be utilized. For example, a child with sickle-cell disease may experience pain crises only one or two times per year, but a child with chronic back pain resulting from an automobile accident may experience daily pain. An assessment of frequency and duration of pain will provide this information.

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