This essay will explore a case study of the perioperative journey of a paediatric patient, Penny. Penny is a 10-year-old who suffers with acute and chronic pain and has undergone a complex emergency surgical procedure. The purpose of the essay is to investigate the barriers of pain assessment and management and the impact of stress and anxiety on the patients emotional and psychological health with focus on paediatric patients. Operating Department Practitioners, whom are predominantly involved in the perioperative process of a patient’s journey are in a critical position of the overall surgical journey. With more evidence emerging that highlight the challenges stress and anxiety pose to paediatric patients, are ODP’s able to leverage their position to influence the outcome of a child’s psychological and physiological wellbeing?
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The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 2017). This definition highlights the notion that pain is not a strictly biological or biological problem: the experience of pain includes complex emotional, behavioural and psychosocial dimensions as well. Pain is an acute or chronic phenomenon. Acute pain often is associated with an identifiable injury that resolves in predictable and expected time frame. Chronic pain is differentiated from acute pain when pain that has lasted for at least 3 or 6 months (Burns et al., 2012). While pain can either be acute or chronic, there are two types of pain, nociceptive and neuropathic. Neuropathic is associated with injury to the peripheral nerves, spinal cord, or brain (Burns et al., 2012). Nociceptive pain essentially described pain that occurs in healthy sensory nervous system, the brain and spinal cord, is detected by nerve receptors and transmitted.
At the age of 10 years old, Penny has been added to the emergency list for an exploratory laparotomy to investigate severe presentation of Crohn’s disease after describing being in continuous pain with cramping and knotting in her stomach and nausea. Penny has had three similar procedures in the past. The regular visit to hospital has made Penny extremely anxious and distrustful of healthcare staff, becoming extremely needle phobic. Her social life has also been extremely impacted as she misses schools due to her condition which has led to her to become introvert and distant from her parents and friends.
Crohn’s disease is a condition that causes inflammation on the digestive system also known as the gastrointestinal tract or gut. Inflammation is the body’s reaction to injury or irritation and cause redness, swelling and pain. It is estimated there are more than 300,000 patients of all ages diagnosed with Crohn’s disease across the UK and that of the newly diagnosed, 25% are under the age of 18 and 5% of those are under 5 years of age (CICRA, 2019).
In the last decade new evidence is emerging that indicate children, just like adult patients can be troubled by disturbing memories of their treatment or of the circumstances that brought them into the unit and by hallucinations, which can affect their long-term psychological recovery (Colville, 2012). Colville, (2012), continues to state parents also suffer significant levels of distress in relation to their child’s recollection of going through surgical procedures. Older studies indicate less distress within children, a study by Playfor et al. (2000) found two thirds of children remembered anything about their intensive care admission and their memories we mostly emotionally neutral in tone, however, this was a study that only included 38 children. In a larger set of study including 102 children, Colville et al. (2008) found a similar proportion of children reported factual memories of their stay, but a third of the sample also reported bizarre nightmares and strange perceptual experiences in the early stages of their recovery. Effective perioperative pain management requires the ODP to have a good understanding of range of issues including the physiology of pain, the potential psychosocial-emotional impact of pain on the child and family.
Stress is defined by NHS Health Scotland, (2019) as the feeling of being under too much mental or emotional pressure. Children’s inability to understand the reason for surgery as well as the limits of their cognitive functioning, limited experience and knowledge, lack of self-control as well as reliance on others makes them very vulnerable to stress and anxiety (Dionigi A, 2014). The preoperative period is stressful and anxiety provoking for the child and family; many parents express more concerns of the fear of anaesthesia than those of the surgery. The factors that influence the ability of the child and family to cope of the stress of the surgery includes, family dynamics, the child’s developmental and behavioural status and cultural biases, and our ability to explain away misperception and misinformation (Charles J. Cote, 2013). Rasti et al (2014) further support this notion by stating surgery is a potentially stressful and threatening experience not just for children but also for parents, regardless of whether at preoperative period or during an operation. Stress in children can contribute to anxiety, fright, anger and the feeling of helplessness (J. Mark G. Williams, 2007).
Anxiety is defined by NHS UK (2018) as a feeling of unease, such as worry or fear, that can be mild or severe. Anxiety in children undergoing anaesthesia and surgery is characterised by feeling of tension, apprehension and nervousness. The response is attributed to separating from parents, loss of control, uncertainty about anaesthesia and uncertainty about surgery and its outcome (Charles J. Cote, 2013). Parents just like children are also likely to experience anxiety and stress, it is possible for parents feeling of unease to be transferred to children indirectly. As such, it is imperative that prior to surgery, children and their family need to be well informed of what to expect and prepared to minimise their anxiety by enhancing their feeling of control and promoting postoperative recovery.
Barriers to pain assessment and management are considered to be an important first step towards improving pain management practices within paediatric patients (Michelle L. Czarnecki, 2019). The top five barriers were inadequate or insufficient physician medication orders, insufficient physician orders before procedures, insufficient time to premedicate patients before procedures, the perception of a low priority given to pain management by medical staff, and parents reluctance to have patients receive pain medication.
The consensus on the various research investigating pain assessment and management in children indicate awareness being instrumental to an improved paediatric patient outcome. While the majority of research in barrier of pain focused on practitioners’ awareness of psychological and physiological pain, some argued on the importance of primary care awareness on pain assessment and management playing a key role in paediatric patients. Paediatric pain assessment can be challenging given developmental and cultural considerations that influence pain expression. These include whether distressed behaviour manifested either verbal or nonverbal children of various ages indicate pain, or how other causative factors such as anxiety, fear, stress, or hunger in the infant and young child affect pain and its expression (Burns et al., 2012). In addition to these barriers, the management of pain in children is further complicated by how pain is identified or recognised. (HCPC, 2016; Carter & Simons, 2014) further support this notion and promote communication as being pivotal to the identification and recognition pain which will eventually lead to the right assessment and management of pain in children. Communication between the child, parents and health care professionals is therefore critical piece in identifying the root cause of pain and administering a therapeutic dose of analgesia.
The subjectivity of pain is another obstacle that makes it difficult for practitioners to understand the intensity, quality, location, duration, pattern and emotional impact of pain (F. Cox, 2009). This, coupled with children’s inability to clearly articulate and express their pain in a way caretakers can understand and treat accordingly in the most effective manner is a big challenge and a major area of concern for paediatric patients. Nevertheless, ODP’s have the ability to influence pain assessment and management. This is supported by multiple authors including (L. Shields, 2010), who stateseffective perioperative pain management requires the ODP to have a good understanding of range of issues including the physiology of pain, the potential psychosocial-emotional impact of pain on the child and family. With a sound knowledge of the wide range of attributes that contribute to a child’s pain such as psychological and physical issues, an OPD is able to navigate the extremely sensitive and emotional nature of paediatric treatment. The ongoing and proactive endeavour of ODP in keeping up-to-date with the latest developments of pain management research is essential and plays a significant role in aiding an improved pain assessment and management for paediatric patients.
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In Penny’s case, her distress is a sign of present physical and psychological trauma that is deeply rooted to her experience with past treatments. 10-year-old Penny’s repeated hospital visits due to complications with treatments she has undergone to treat her Crohn disease has had a very negative impact to her general well-being. Whilst any illness is bound to have a negative impact to ones’ well-being, the management of pain is critical to the patient’s experience. All authors from this research agree the assessment and management of pain leading to a successful treatment and consequently, better post-op outcome. While acknowledging the difficulty in accurately assessing and successfully treating chronic pain, (L. Shields, 2010), argues that the improvement in pain management have enabled children with pain related to chronic conditions to achieve a higher quality of life, stressing the important role of pain assessment and management.
The role of the parent and caregiver cannot be overstated when preparing the child for surgery. It’s imperative for ODP’s to have a collaborative approach during the preoperative preparation process. This will enable ODP’s to develop an important relationship leading to a collectively and well-coordinated pre and post operation. The parent’s involvement in pre and post operation process creates a normalised hospital environment for the child, providing comfort, support and reduce stress. Well informed and equipped parents are better enabled to support the child in both preparing the child mentally prior to surgery as well as post-surgery in helping carry out the required recovery routine as recommended by hospital professionals. For this, parents rely on the advice and support they receive from professionals, therefore ODP’s ability to understand the need to make sure parents are comfortable in what is required of them to support the child in successfully recovering is key part of the surgical process. This is further supported by (Panella, 2016) who has detailed preoperative anxiety response to help gage and determine the signs of pain expression in children.
Anxiety is considered to be a normal phenomenon that is part of preoperative experience and therefore something most children experience when facing an invasive or surgical procedure. Despite all the proper care being applied and the acknowledgement of the various factors such as separation from parents, discomfort and pain, lack of control, fear of unfamiliar staff and fear of induction anaesthesia that lead to stress and anxiety, (Bailey, 2010; Lee et al, 2013; Fernandes, Arriaga, Esteves, 2014) all agree on the notion that the root cause for stress and anxiety to potentially be mitigated, but not necessary avoidable. What is interesting is the lack of consistency in referring to and the terms used to describe what children experience when undergoing surgical procedures.
Responses to stress and anxiety that are frequently referred to as “psychological upset” and “emotional distress” vary in intensity and characteristics (Rasti, Jahanpour, & Motamed, 2014). This is further exacerbated when the child is not able to adequately express the pain they are feeling. To facilitate with this, pain scale such as faces scale which consists of a series of six cartoon type faces that express a range of emotions from happy to sad. The faces scales explained to the child by telling them that the happy face means no pain at all while the sad or distressed face means the worst pain ever. The child then points to the face that best describes how much pain they are feeling (Imelda Coyne, 2010).
pain scales present the child with drawings or photographs of facial expressions representing increasing levels of pain intensity, the child is asked to select the picture of a face that best represents their pain intensity and their score is the number of the expression chosen. Faces scales have been well validated for use in children aged 5-12 years. Faces pain scales with a happy and smiling no pain face or faces with tears for most pain possible have been found to affect the pain scores recorded.
This essay has explored Penny Brooke along her preoperative journey; it has investigated what pain is, how we mange pain and assess pain in children, the various strategies in treating pain particularly chronic neuropathic pain and the effects that pain has on associate individuals and their family. This essay used a different book together with journal articles and relevant websites to support information provided. This essay helps to tell ODP the problem with pain assessment and management and this could show the ODP how to carry out pain assessment and management with children and communicate with family also reduce the anxiety and stress throughout the hospital journey.
- Stories of Children's Pain: Linking Evidence to Practice. (2014). SAGE Publications Ltd.
- Burns, C., Barber Starr, N., Dunn, A., Blosser, C., Brady, M. and Garzon, D. (2012). Pediatric primary care. 5th ed. Philadelphia: Elsevier Health Sciences, p.403.
- Trigg, E., Mohammed, T., Ford, L., Montgomery, H. and Vidler, V. (2010). Practices in Children's Nursing E-Book. 3rd ed. Elsevier Health Sciences, p.454.
- Narayan, D., Kaye, A. and Vadivelu, N. (2018). Perioperative pain management for general and plastic surgery. 1st ed. New York: Oxford University Press, p.1.
- Tanner, A, & Shields, L (eds) 2009, Perioperative Care of the Child: A Nursing Manual, John Wiley & Sons, Incorporated, Hoboken. Available from: ProQuest Ebook Central. [9 November 2019].
- Panella, J.J. 2016, "Preoperative Care of Children: Strategies from a Child Life Perspective: The Official Voice of Perioperative Nursing The Official Voice of Perioperative Nursing", AORN Journal, vol. 104, no. 1, pp. 11-22.
- Bailey, L. (2010). Strategies for Decreasing Patient Anxiety in the Perioperative Setting. AORN Journal, 92(4), pp.445-460.
- Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. and Garzon, D. (2012). Pediatric Primary Care - E-Book. 5th ed. Philadelphia: Elsevier Health Sciences, p.416.
- Charles J. Cote, J. L. (2013). A Practive of Anaesthesia for Infants and Children. Philadelphia: Elsevier Health Sciences.
- Colville, G. (2008, June). The Psychological Impact on Children of Admission to Intensive Care. Pediatric Clinics of North America, pp. 605 - 616.
- Colville, G. (2012, March). Paediatric intensive care. Paediatric psychology, pp. 206 - 209.
- Dionigi A, S. D. (2014). Clown intervention to reduce preoperative anxiety in children and parents: a randomized controlled trial. Health Psychology, 369 - 380.
- IASP. (2017, December 14). IASP Terminology. Retrieved from International Association for the Study of Pain: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
- J. Mark G. Williams, T. B. (2007). Autobiographical Memory Specificity and Emotional Disorder. Psychological Bulletin, 122 - 148.
- Michelle L. Czarnecki, A. G. (2019). Barriers to Pediatric Pain Management: A Brief Report of Result from a Multisite Study. Pain Management Nursing , 305 - 308.
- NHS Health Scotland. (2019, September 27). Struggling with stress? Retrieved from NHS Scotland Inform: https://www.nhsinform.scot/healthy-living/mental-wellbeing/stress/struggling-with-stress
- Rasti-Emad-Abadi, A. N. (2017). The Effects of Preanesthetic Parental Presence on Preoperative Anxiety of Children and their Parents: A Randomised Clinical Trial Study in Iran. Iranian Journal of Nursing and Midwifery Research, 72 - 77.
- S Playfor, D. T. (2000, November). Recollection of children following intensive care. Diseas in Childhood, pp. 445 - 447.
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