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Onset Location Duration Character

Aggravating/associated factors Relieving factors Temporal factors Severity

Onset:

• Was it sudden or insidious?

• Was it a result of injury or trauma?

Location:

• Is the pain localized or generalized?

• Is the pain superficial or deep?

• Does the pain follow the distribution of one of more nerve paths?

• Does the pain radiate or is it referred to areas other than the point of origin?

• Can the child identify or point to the painful body part or area?

Duration:

• If the pain is recurrent, how frequent and prolonged were the previous painful episodes?

• What is the typical progression and course of pain?

Character/quality:

• What descriptors or adjectives are used to describe the pain?

• Muscle/fascia - dull, achy, sore, burning, and cramping

• Nerve - sharp, knifelike, shooting, pins and needles, tingling, prickling, burning, and numb

• Vascular - burning, stabbing, throbbing, tingling, and cold

• Visceral - deep, cramping, and stabbing

• Is the pain constant or intermittent, dormant or progressive?

Aggravating/associated factors:

• How is the pain exacerbated?

• How has the pain impacted activity, appetite, sleep, concentration, mental and emotional status?

• Are there other symptoms resulting from the pain, i.e., nausea/vomiting, sweating, tremors, rigidity?

Relieving factors:

• Have any mediating activities been identified, i.e., prescription and non-prescription medications, dietary, vitamins, herbal supplements, complementary and alternative therapies

• What coping strategies have been helpful?

Temporal factors:

• What has been the chronological sequence of events?

• Is there a correlation to time of day, environmental conditions, specific events, or activities?

• Does anticipation intensify the pain?

Severity:

• What is the current, the highest, and the lowest pain level that is experienced?

• What is the acceptable level of pain?

Past Medical History/Family History/Social History

The next component of a thorough pain history is the past medical, family, and social history. The clinician should inquire about previous pain experiences and management strategies including pharmacological, non-pharmacological, and complimentary treatments, the presence of chronic pain conditions and any pertinent familial details. A thorough social history should recognize if the child's pain experience has impacted activities of daily living (i.e., sleep, work/school, mood, interactions with family and friends) and physical functioning.

Physical Examination

The physical examination should begin with the overall appearance of the child and recent physical vitals (blood pressure, heart rate, respiratory rate). When performing the actual physical examination, the clinician should take into consideration the child's level of discomfort and proceed from the areas causing the least to most pain.

Behavioral Signs of Pain

• Irritable crying

• Shallow breathing

• Changing facial expressions when touched or moved

• Resisting movement

• Rigid posture

• Difficulty sleeping

• Depressed mood

Physiologic Signs of Acute Pain

• Skin temperature changes

• Tachycardia

• Hypertension

• Decreased O2 saturation

Physiologic Signs of Chronic Pain

• Involuntary muscle spasm

• Trigger points

• Decreased serotonin and endorphins

• Habituation of sympathetic response

Pain Measurement/Assessment Tools

The most accurate measure of pain is through patient self-report. The patient's description of the experience provides the clinician with the information needed to determine the location and severity of the pain. However, due to limitations in age or developmental level, the child may not be able to provide useful self-report. When a child is unable to provide self-report, clinicians must recognize certain physiological and or behavioral cues to determine treatment.

Observational assessment tools are indicated for children that are too young to understand the concept of self-report, too distressed to use self-report, or too restricted by cognitive or communicative impairments. Although pain assessment in this population can be achieved by using physiological and behavioral measures, the gathered information must be interpreted with caution. Physiological measures, such as heart rate, respiratory rate, and blood pressure, can provide clues to the presence of pain, but when viewed in isolation are not specific to pain.

Numerous pain assessment tools are available (Table 30.2) and the selection of the appropriate tool should be individualized to the child's age and developmental level.

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