The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical SymptomsSymptom Assessment with Pediatric PatientsSymptom assessment in children requires particular skill. Pediatric AIDS is a specializedarea and26discussedpicaselsewhere . 36 (See Chapter 12: The Care of Children and Adolescents.) Briefly,the age of the child and his or her ability to provide a report will influence the symptom assessment.Older children who can provide answers to questions can be assessed with greater easethan younger children.Careful attention to verbal cues and parental input is crucial in the pediatric population. Validatedmeasures for many symptoms in this population are lacking, but a variety of measures have beendeveloped for the assessment of pain including visual analogue scales, “faces” scales, 37-42 andobservational scales such as the Observational Scale of Behavioral Distress 43 and the ProcedureBehavior Checklist. 39The Memorial Symptom Assessment Scale (MSAS) has been adapted for use in children aged 10to 18 years of age (see Figure 3-1). The MSAS can provide multidimensional information aboutsymptoms experienced by children. Its pediatric use to date, however, has been in the populationwith cancer and in the research setting rather than in clinical care. 44Additional tools specifically for measuring pain in pediatric patients are presented at the end ofthis chapter in Figures 3-4 (a-d).IIICultural and Language BarriersSymptom assessment and measurement can also present challenges in patients who differ inculture and language from the professionals providing their care. In cases where language barriersexist, meticulous attention should, where possible, be given to skilled translation. When measuringsymptoms, only a few instruments have been shown to be reliable and valid across cultures andlanguages. 45, 46 Translation and appropriate symptom measures must be used.In the clinical setting, health care professionals can use simple, face-valid symptom measures toovercome language barriers. At the initial assessment the clinician can spend time with thepatient and an interpreter to develop a simple, two-language verbal rating scale for symptoms,which can be kept by the patient’s bedside. To monitor the level of distress and impact of interventions,such scales should address both symptom intensity and relief. This approach will helpto ensure that symptom distress is minimized even when interpreters are not available. In addition,historytaking should explore cultural barriers to symptom assessment and management.Substance Abuse History or ProblemsClinicians frequently report that symptom assessment is especially challenging when thepatient has a previous or current problem with substance abuse or addiction. In addition, difficultywith symptom assessment also is common in situations in which the clinician is concernedthat a substance abuse problem may be present. In these situations, the assessment and managementof pain presents many difficult clinical issues. 47 However, as highlighted by Passik, etal., “virtually any drug that acts on the central nervous system and any route of drug administration,can be abused.” 48, 49 The implication is that assessment of substance abuse is importantwhen assessing a wide variety of symptoms including pain, anxiety, depression, insomnia andmany others. In cases where substance abuse is defined as a problem, experience and skill incaring for such patients can be invaluable as the issues involved in care can be very complex. 47U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 57