Pain Management Concept Analysis Daryl Blackman Tennessee State University

Abstract Working in a burn unit, I recover patients after surgery. I care for patients of all ages, including children. Acute pain following a surgical procedure is one of the most common experiences by pediatric patients. Pediatric postoperative pain management has long been overlooked and treated differently than adult pain management. There tend to many misconceptions when it comes to pediatric pain management stemming from the belief that children do not experience pain the same way as adults. Since the pediatric population is not legally allowed to make medical decisions, guardians must make these decisions for them. Postoperative pain in the pediatric patient may be hard to assess and therefore healthcare professionals have begun to involve family members and caregivers in the pain management process. Pain can stem from many sources and thus must be holistic, involve multiple disciplines, provide education and apply to each individual patient. In practice, advocacy for these young children is important in helping them and their families understand about the situation and make education decisions on how to proceed with care. The concept of postoperative pediatric pain management must be analyzed to help resolve these misconceptions and not ignore the population who at times cannot speak for themselves.

Pain Management Concept Analysis Review of Literature After a surgical procedure, the pediatric patient will come into contact with many healthcare professionals including nurses, doctors, and psychologists. Each of these disciplines plays a key role in aiding the pediatric patient in the management of their pain. Nursing Discipline Sutters et al. (2007) examined pediatric patients following a tonsillectomy procedure in order to assess their perceptions and expectations of pain. They utilized a questionnaire and asked patients aged 6-15 how they perceived their pain to be after surgery in relation to the actual amount of pain. It was found that even though a tonsillectomy is considered to be a minor outpatient procedure, it is still a major event for the pediatric patient and is almost always associated with a certain amount of pain. The role of the nurse in postoperative pediatric pain management is to support both the patient and family, educate them on interventions, advocate for the child, and assess the cognitive abilities of the patient in order to accurately assess pain in the young patient (Sutters et al., 2007). Antecedents listed in this study are distress, tonsillectomy procedure, loss of control, and fear. Criteria are listed as education, advocate, age appropriate and cognition appropriate. Consequences are regaining control, decision-making, and increased coping. Shrethsa-Ranjit and Manias (2010) examined children ages 5-15 who underwent surgery for a fractured lower limb. A pre-formed assessment tool was unable to be found that adequately suited the proposed population so the study formulated another questionnaire that encompassed demographics, nursing care, pain assessment and use of pharmacologic or non-pharmacologic interventions. The study showed that ultimately there was a lack of knowledge in pediatric

postoperative pain management across the nursing discipline. There was also found to be a gap between initial assessment of pain and management over time following a pediatric surgery. The study concluded that nurses needed to assess pain at more frequent intervals and report their findings to physicians as well as educate families and patients on how to realize pain is occurring. Antecedents to this particular study are lower limb surgery, demographics of the patient, and distress. Criteria are listed as advocate, frequent assessment, population appropriate assessment and education. Consequences would be increased coping, trust, increased knowledge, and family involvement. Medical Discipline Kituyi, Imbaya, Wambani, Sisenda, and Kuremu (2011) conducted a study of clinicians knowledge of pediatric postoperative pain management. The study concluded that over half of the doctors surveyed stated they had inadequate knowledge regarding how to assess and treat pediatric pain in the postoperative patient, but did believe their patients experienced real pain. Furthermore many of the doctors also stated that they had never received any formal teaching in relation to pain evaluation and management. Results did show that doctors did believe it was important to continuously assess the pediatric postoperative patient and involve the family in decision making. The antecedent in this study is distress and the criterion is continuous assessment. A consequence would be family involvement. Green, Wheeler, Marchant, LaPorte, and Guerrero (2001) interviewed doctors whose primary area of expertise was pain relief. The overwhelming conclusion was that most physicians had never received formal training in how to treat postoperative pain, especially in a pediatric patient. Since adult patients are more apt to verbalize their pain, their pain requests are met more readily. Pediatric patients have the tendency to internalize their feelings in fear of

being considered a bad child and will often tell healthcare providers they feel okay when in truth they are hurting. Physicians realize that there is a difference in treating pediatric patients and adult patients because of body size, composition and continuous development, but that is where the training ends. They are well versed in treating pain at the pharmacologic level but agree there is more that needs to be done in the holistic aspect of care. However, they do tend to verbalize that the holistic practices are more efficiently done by the nurses as they spend more time with the patients and their families. In conclusion, physicians are more apt to manage pediatric postoperative patients with pharmacologic interventions than holistic ones. They also arent readily aware of when their patients are in pain and rely heavily on the nursing discipline to form relationships with the families and patients and report back to them. Antecedents of this study are distress and internalized feelings. Criteria for pediatric pain management are holistic, education and pharmacologic. Consequences of postoperative pain management are verbalization, family involvement, and comfort. Psychology Discipline Psychology is an important part of postoperative pain management in the pediatric patient. A study performed by Caldwell-Andrews and Kain (2006) found that a significant number of children experiencing postoperative pain displayed sleep related problems, behavioral problems, and anxiety. Psychologists understand that pediatric patients fear the unfamiliar and when they are scared, they tend to internalize their feelings. Children who will require multiple surgeries and suffer chronic pain should see psychologists regularly to talk about their feelings of pain and learn how to express these feelings to nurses, healthcare providers and their families. The study found that children whose pain is not managed efficiently tend to have behavioral problems in the future and will not cope well with future painful experiences. In addition, pediatric patients can attribute their own feelings with those of the people surrounding them. Psychologists play a

major role in helping parents cope with their childs pain, and state that parents who display a calm and warm affect around their children will encourage healing. Conversely, those parents who were very anxious and worrisome in front of their children caused the children to become anxious and thus experience a greater consistency of pain. The study lists the antecedents of pain management as fear, anxiety, behavior problems, and sleep disturbance. Criteria of pain management are education and family involvement. Consequences of pediatric pain management in the psychology discipline are independence, increased coping, regaining control, and behavior modification. Antecedents The antecedents discussed throughout this paper are numerous. The main ones focused upon are tonsillectomy surgery, lower limb surgery, fear, distress, loss of control, demographics of patient or family, internalized feelings, abandonment, anxiety, behavioral problems, sleep disturbance, chronic illness, and previous surgery. Types of surgery and previous surgery were grouped together under the term surgical intervention. Surgical intervention has a tendency to cause pain in a patient regardless the type or extensiveness of that intervention (Sutters et al., 2007). Patients in pain can behave outside the norm whether it is behavioral problems, sleep disturbance, or anxiety. The terms listed are all descriptors of types of distress, so distress was chosen as an all-encompassing antecedent (Penner et al., 2008). All articles touched heavily on the prominence of fear in the pediatric patient when it came to postoperative pain as well as fear of the family that they will not be able to provide enough support for their child. Pediatric patients also have the tendency to internalize their feelings when there is a pain experience occurring or about to occur. They tend to shut down as a coping mechanism and can often put off that they are okay instead of internally suffering. The psychology and nursing disciplines both

feel that young children either keep their feelings to themselves or do not know how to verbalize them correctly, thus internalization of feelings was included in the antecedent list. Lastly, the element of loss of control was included because pain in any population is something that is outside the norm and foreign to a body. Experiencing something unfamiliar can lead to a loss of control both in the pediatric patient and their family. The other elements were only touched on by a few of the articles and were excluded from the final antecedent list. Consequences Lastly, the consequences that best describe pediatric pain management are: coping, trust, regaining control, family involvement, decision-making, pain relief, verbalization, comfort, independence, behavioral modification and increased knowledge. Family involvement in the care of the pediatric patient was a theme continuously discussed in the literature and was included as a main consequence for this analysis. The pediatric patient is not legally an adult and cannot ultimately make their own decisions. Through education of the family and patient together, pain can be more readily assessed and acted upon in a timely manner. Decision making was also termed a consequence once the family was involved in care. Effective pain management promotes faith in the healthcare system, thus allowing the patient and family to make decisions regarding future care and to become more independent in doing so. Rotenberg et al. (2008) finds that children have a hard time trusting healthcare providers if pain is not controlled or is ignored. Thus, a consequence of trust was included in this analysis because it is important to the patient to believe the healthcare provider is doing whatever possible to help them. Trusting in the healthcare provider also leads to better coping with pain from a patient standpoint and coping of the family with the difficulty of having a child in pain. For these reasons, trust and increased

coping were chosen as consequences. Verbalization, behavioral modification, and control were used as antecedents in this analysis and were discarded from the list of consequences. Conclusion In conclusion, a thorough analysis of the literature from the nursing, medical and psychology disciplines has yielded a comprehensive list of antecedents, criteria, and consequences that address the concept of postoperative pediatric pain management. Pain management in the pediatric patient is holistic, demographic appropriate, advocates for patients, and includes multiple disciplines in the healthcare profession. The education of the patients, their families, and the healthcare professionals about pediatric pain management can ensure the young patient is treated in the most evidence based and comprehensive way possible. It is the duty of the healthcare professional to be as up to date as possible on how to effectively provide pain care for their discipline.

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Sutters, K.A., Savedra, M.C., Miaskowski, C., Holdridge-Zeuner, D., Waite, S., Paul, S.M., & Lanier, B. (2007). Childrens expectations of pain, perception of analgesic efficacy, and experiences with nonpharmacologic pain management strategies at home following