Something For The Pain
By Julie Young
While a child may cry when experiencing pain from a scraped knee, broken bone or other one-time injury, the reaction of pediatric patients with chronic pain may be quite different. Some of the smallest patients can not communicate their pain and others often stare out a window or disassociate themselves from what they are feeling on the inside.
For nurses who must respond to a pediatric patient’s pain, reading the signs can be similar to deciphering a foreign language. Body language, parent’s assessments and targeted programs are all tools nurses use to help this patient population on the road to recovery.
Reading the Signs
Nurses on the floor use various assessment tools to read a patient’s pain level, especially when that patient is too young to communicate their own pain. An infant may draw in their arms and legs when they are uncomfortable or may act fussy when they experience a lot of discomfort.
Suzanne Porfyris, MSN, APN, PCCNP, anesthesia pain service at Children’s Memorial Hospital in Chicago, said she uses a standardized scoring system to help alleviate her patient’s pain.
“We teach our nurses and our patients’ families to look for the signs, and we have scales that can help us score babies,” she said. “We also understand that for the kids who can communicate, one person’s pain level is not the same as another’s.”
Porfyris instructs nurses to believe the patient when they communicate but not to ignore other possible signs of pain. She said just because a patient is not writhing in agony doesn’t mean they aren’t trying to escape the discomfort.
“When a child is sleeping a lot, it is a misconception that they aren’t feeling any pain,” she noted. “Kids who seem disinterested or who lose themselves in video games may look fine, but just because they are able to get their focus on something else doesn’t mean there is no pain.”
Listening to the family members can also alert nurses on the unit about the level of pain the patient is experiencing since the parent is around the child all of the time and can tell a nurse when he isn’t acting like himself. In many cases, when pain is managed properly, nurses get a chance to see a major difference in the child’s countenance.
“I may only see them twice a day so the parental input is important in what we can do for them and how we go about it,” Porfyris said.
Sometimes pain is an aftereffect of an illness or a surgical procedure; other times it is a symptom.
At the Mayo Family Pediatric Pain Rehabilitation Center (PPRC) at Children’s Hospital Boston at Waltham, MA, patients with Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), are admitted to a comprehensive multidisciplinary program for rehabilitation and treatment.
RSD is a rare neurological condition that affects skin, muscles, joints and bones, causing severe burning and aching pain, skin pigment changes and temperature changes, and excessive sweating and swelling of extremities.
A division of the Pain Treatment Service at Children’s Hospital Boston, the PRRC opened in June 2008 and takes a simple approach to treatment: intensive physical and occupational therapy, and cognitive behavioral therapy to retrain the brain’s pain response.
For many children, RSD can be successfully treated with outpatient physical therapy and cognitive behavioral therapy. The PRRC treats the small percentage of pediatric patients who are refractory to conventional treatment.
Judy Gaughan, MSN, RN, clinical coordinator of the PPRC, said the staff uses a multidisciplinary approach to help patients control their pain and improve their function.
“This is an incredibly painful condition and many of our patients have not ambulated or used the affected extremity for months, or even over a year, in some cases,” she said.
Gaughan added the program treats only four patients at a time, with the length of treatment varying from 3-5 weeks, depending on patient needs.
Retraining the Pain
Cognitive behavioral therapy is a key component of the program. Patients learn relaxation, guided self-imagery and deep breathing as tools to gain some control over their pain.
Gaughan said some of the patients admitted to the PPRC have been unable to tolerate textures of clothing or to tolerate wearing socks and shoes.
“They have withdrawn from their peers and have difficulty attending school,” she said. “The kids come from all over the U.S. and for many of them it is the first time they meet another person with the same disease.”
By working with a variety of disciplines, including physical therapy and occupational therapy specialists as well as medical staff, psychologists, nutrition specialists and even teachers, this program helps get pediatric pain under control. Since the inception of the Pain Treatment Service in 1986, more than 750 children with RSD have received treatment.
“This program is a comprehensive, multidisciplinary way of retraining kids to deal with their pain and regain their lives,” Gaughan said.
Julie Young is a regular contributor to ADVANCE.