Comfort Pain & Sleep PDF

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FUNDS Ch 35 - Comfort: Pain & Sleep Comfort: Pain ● What is pain? Subjective information, signifies something is wrong, pain is not good, it is unpleasant. Pain is an elusive and complex phenomenon. Despite its universality, its exact nature remains a mystery. It is one of the human body’s defense mechanisms that indicates the person is experiencing a problem. ● Categories of Pain ○ Duration ■ Acute versus Chronic - short vs long. Acute is short pain. Acute pain lasts 0 - 3 months. After 3 months it is considered chronic pain ex back injury, arthritis. ■ Acute pain is generally rapid in onset and varies in intensity from mild to severe. It is protective in nature. In other words, acute pain warns the person of tissue damage or organic disease and triggers autonomic responses such as increased heart rate, the fight-orflight response, and increased blood pressure. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs. Causes of acute pain include a pricked finger, sore throat, or surgery. ■ Chronic pain is pain that lasts beyond the normal healing period. In clinical practice, the time frame associated with defining pain as chronic varies based on the cause and may be anywhere between 1 and 6 months, with 3 months commonly used in practice and 6 months used in research. Chronic pain presentation varies greatly and can include pain that is unrelenting and severe, pain that is consistent with or without periods of remission (disease is present, but the person does not experience pain) and exacerbation (the symptoms reappear), or pain that is recurring and contains elements of both chronic and acute pain. Some providers are transitioning to use of the word persistent to describe this type of pain. ○ Location or source ○ Mode of transmission - No specific pain organs or cells exist in the body. Rather, an interlacing network of undifferentiated free nerve endings receives painful stimuli. ○ Etiology (cause) - Pain also is classified by its cause, which can be highly varied. ● Sources of Pain ○ Nociceptive - Nociceptive pain is initiated by nociceptors that are activated by actual or threatened damage to the peripheral tissue and is representative of the normal pain process ○ Cutaneous - Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. ○ Somatic - Deep somatic pain is diffuse or scattered and originates in

tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. ○ Visceral - Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed ○ Neuropathic - is pain caused by a lesion or disease of the peripheral or central nerves. The exact cause of neuropathic pain is unknown but it can originate either peripherally (e.g., phantom leg pain) or centrally (e.g., pain from spinal cord injury). Neuropathic pain can be of short duration but frequently is chronic. It is often described as burning, electric, tingling, or stabbing. ● Origin of Pain ○ Physical - Pain may originate from physical causes, that is, a physical cause for the pain can be identified. ○ Psychogenic - in your head. A physical cause for the pain cannot be identified. However, it has been observed that a pure origin is probably rare, and pain usually has both physical and psychogenic components. Furthermore, pain that results from a mental event can be just as intense as pain that results from a physical event. ○ Referred - feeling it anywhere, ex chest pain and also have pain in the jaw and left arm. Pain can originate in one part of the body but be perceived in an area distant from its point of origin. Pain: Perception ● Gate Control Theory

● Pain Sensation

Responses to Pain ● Physiologic - Effects on activities of daily living (ADLs). Ex - arthritis ● Behavioral ○ Past pain experiences - can also be responses to pain ○ Coping resources - people cope differently, pain is individualized, pain is wherever and whatever the patient says it is, cannot judge even if patient is smiling and talking and doesn’t look like they are in pain. Find out the tolerance to the pain. ● Affective ○ Feelings

Factors that Affect Pain ● Culture - some people feel that they will experience pain because example they are getting old, that they are not suppose to take medication because it's God's doing. Religious beliefs influence cultural beliefs. ● Ethnic variables ● Family, gender, age variables - men should not show pain because of society, but nurses should not treat women and men differently in terms of pain. ● Religious beliefs ● Environment and support ● Anxiety and other stressors ● Past pain experience How do nurses assess for pain? ● History & Physical ○ History ○ Direct observation of behaviors and physical manifestations ○ General assessments ● Vital Signs - all the v/s will be up if patient is in pain. ○ The Joint Commission (TJC) considers pain to be “the fifth vital sign” ● Assessment (Acute versus Chronic) ● Pain Assessment Tools

Pediatric scale is the baker scale

On adults use the numerical scale. 1-10 scale ● Ask the mnemonic to gather info on pain. How does the pain feel like ? do not describe the pain for the patient, let the patient tell you how it feels like. Use the mnemonic. Nursing Interventions for Pain ● Establishing trusting nurse–patient relationship - keep your word to get the patient to trust you, if you don’t keep your word, you seem dishonest. Most patients with pain feel better, suffer less, and experience less anxiety when they believe that a competent nurse cares about their experience of pain and is available for help and support. ● Manipulating factors affecting pain experience ○ Remove or alter cause of pain - pharmacological and nonpharmacological interventions. Possible measures that promote comfort and help in pain relief include removing or loosening a tight binder, if permissible; seeing to it that a distended bladder is emptied; taking steps to relieve constipation and flatus; changing body positions and ensuring correct body alignment; and changing soiled linens and dressings that may be irritating the skin. A hungry or thirsty patient may need a snack or a drink to feel more comfortable. Certain drugs are useful for removing or altering the intensity of painful stimuli. For example, drugs that decrease smooth-muscle spasms in the GI tract and those that decrease contractions of skeletal muscles reduce discomfort. ○ Alter factors affecting pain tolerance - Pain tolerance level is the maximum intensity of a stimulus that produces pain a person is willing to accept in a given situation (IASP, 2014b). Alleviate these factors whenever possible. For example, patients whose families have never acknowledged their pain and who have repeatedly been told that their pain is all in their head may experience a greater ability to deal with their pain when someone finally takes the pain seriously. Nursing measures include communicating to the patient that responses to pain are acceptable and providing education to the patient’s family. A discussion of goals and expectations regarding pain

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also increases the amount of control the person feels and can impact on his or her ability to tolerate a certain level of pain at a given moment in time. Fatigue tends to increase pain, so promoting rest is helpful. The patient in pain usually feels more comfortable when the environment is quiet and restful. Although sensory restrictions—such as eliminating unnecessary noise and bright lights—are usually indicated, it is rarely helpful to leave the patient alone in an environment with little sensory input. The patient is then more likely to focus on self and the discomfort. Lack of knowledge, finding no meaning in the pain, being pessimistic about its relief, and fear may also interfere with the patient’s ability to deal with pain. Reviewing additional pain control measures Initiating nonpharmacologic and pharmacologic pain relief measures - Although analgesics are usually the primary treatment measure for pain, a growing trend is seen involving integration of complementary health approaches (CHA) and integrative health care (IH) concepts. Considering ethical and legal responsibility to relieve pain - have to tell patient what medication what they are giving them for their pain, correct medication, check that medication won’t cause harm to the pain. Know all the rights of medication administration, ethical - always doing the right thing. It is not legal to give placebo to patient who says they are in pain. Teaching patient about pain - teach them things they can do to relieve the pain

Pain Relief: Non-Pharmacologic ● Distraction - Conscious attention often appears to be necessary to experience pain, whereas preoccupation with other things has been observed to distract the patient from pain. Distraction requires the patient to focus attention on something other than the pain. ● Humor - Humor can be an effective distraction, can help a person cope with pain, and may even have a positive effect on the immune system. It has been proven beneficial in relieving acute painful procedural pain in children. Many pain, cancer, and ambulatory care centers encourage patients to view humorous videos before a painful, tedious procedure ● Music - Listening to music can relax, soothe, decrease pain, and provide distraction. Music affects various neurotransmitters (such as epinephrine and norepinephrine), hormones (particularly cortisol), components of the immune system (especially with the cytokine interleukin-6), the autonomic nervous system (sympathetic and parasympathetic components), and psychological responses ● Imagery - Patients who use imagery (an example of mind–body interaction) to decrease pain sensation imagine something that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain. ● Relaxation - Relaxation techniques reduce skeletal muscle tension and lessen anxiety. ● Cutaneous stimulation - The success of cutaneous stimulation (techniques that stimulate the skin’s surface) in relieving pain is often explained using the gate control theory. The gate control theory of pain involves cutaneous nerve fibers,

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which are large-diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. Acupuncture - Acupuncture is a technique that uses thin needles of various lengths inserted through the skin at specific locations to produce insensitivity to pain. Hypnosis - a technique that produces a subconscious state accomplished by suggestions made by a hypnotist, The person’s state of consciousness is altered by suggestions so that pain is not perceived as it normally would be. According to many hypnotists, it also alters the physical signs of pain. Biofeedback - a technique that uses a machine to monitor physiologic responses through electrode sensors on the patient’s skin. The feedback signal or unit transforms the physiologic data into a visual display of their rate and depth of respirations, muscle tension, sweat response, and/or heart rate. Therapeutic Touch - Therapeutic Touch (TT) historically is focused more on the universal field and directing life energy to patients. Patients who have received TT state that it helps with feelings of comfort, calmness, and well-being. Healing Touch, requires no equipment, uses light touch, and is appropriate for every level of care.

Pain Relief: Pharmacologic ● Analgesic administration - a pharmaceutical agent that relieves pain. Analgesics function to reduce the person’s perception of pain and to alter the person’s responses to discomfort. There are three general classes of drugs used for pain relief: ○ Nonopioid analgesics - (acetaminophen and nonsteroidal antiinflammatory drugs [NSAIDs]). ○ Opioids or narcotic analgesics - (all controlled substances; e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) ○ Adjuvant drugs - (anticonvulsants, antidepressants, multipurpose drugs). ● The WHO 3-Step Analgesic Ladder: recommends the appropriate progression of drugs and dosages that should be used to manage chronic pain effectively. Emphasis is on individualizing treatment and using the analgesic ladder to provide attentive, aggressive pain relief.

● What is the rationale for using multiple medications in pain management? Numeric Sedation Scale Respiratory depression is a commonly feared adverse effect of opioid use. In reality, it is an uncommon occurrence in long-term therapy because patients have usually developed a tolerance to the drug and its respiratory depressant effects. However, with these CNS depressants, respiratory depression is often the root cause of opioid-related death and is typically related to an overdose. Nursing assessment using the numeric sedation scale can determine those patients at risk for respiratory depression more so than assessing the respiratory rate. If respiratory depression is suspected and the opioid dose is withheld, the patient may be physically stimulated by shaking or using a loud sound, along with reminders every few minutes to breathe deeply. If this is ineffective, naloxone, an opioid antagonist that reverses the respiratory depressant effect of an opioid, can be used. Naloxone is administered intravenously in the hospital setting, but a new nasal form may be used in other settings. Narcotic for pain - don't overdoes the patient. v/s respiration is important must check R first before giving a narcotic, if it is below 9/8 don't give it to them, must check after narcotic was given, if it is decreased must call HP to get an antidote. Must continuously monitor patient. 1—awake and alert; no action necessary 2—occasionally drowsy, but easy to arouse; no action necessary - this is what a narcotic does. 3—frequently drowsy, drifts off to sleep during conversation; reduce dosage - ask HP to give reduced dose. 4—somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

Chronic/Cancer Pain Management ● ● ● ● ● ●

Make sure the analgesic is given on a regular schedule Give medications orally if possible Administer medication around the clock rather than prn Administer breakthrough medication prn Assess for effectiveness Educate patient and allow autonomy over regimen

Additional Methods for Administering Analgesics ● Patient-controlled analgesia: ○ This device is most commonly used to deliver analgesics intravenously, subcutaneously, or via the epidural route. The most frequently prescribed drugs for PCA administration are morphine, fentanyl, and hydromorphone. ○ The PCA system consists of a computerized, portable infusion pump containing a chamber for a syringe that is prefilled with the prescribed opioid analgesic. Initially, a loading dose is administered to raise blood levels to a therapeutic level and control the pain. Although a PCA pump can be set to deliver at a set rate (automatic dose or basal rate), these pumps are more typically used to deliver a dose when initiated by the patient. When the sensation of pain reoccurs, the patient pushes a button that activates the PCA device to deliver a small preset bolus dose of the analgesic. A dose interval that is programmed into the PCA unit (usually 6 to 8 minutes) prevents reactivation of the pump and administration of another dose during that period of time. The pump mechanism can also be programmed to deliver only a specified amount of analgesic within a given time interval (the lock-out interval). This is most commonly every hour or, occasionally, every 4 hours. The 1-hour lock-out is viewed more favorably in opioid-naïve patients. These safeguards limit the possibility of possible overmedication. In addition, time is provided for the patient to evaluate the effect of the previous dose. PCA pumps also have a locked safety system that prohibits any tampering with the device ○ PCA - pt is giving himself a dose, by pressing a button. Medication is put into a pump, dr gives orders, and key to pump is kept in the pixus. Narcotics kept under lock and key, nurses must count in the morning and in the afternoon. Input dr orders into the pump, ex medication every 2 min, then the patient can press every 2 min and receive medication through pump. Pts like it because they feel a sense of control. Need to educate them that they can press but wont get med until the set time. ○ When pt is on a PCA pump, nurse will Check the orders right next to the pump, get the keys, check line by line to see if it is exactly what the dr ordered. ○ People can die. If vial concentration mg/ml is wrong. Must check. ○ Legal implications- must double check everything. ○ IV and PO medications Pain Overview

Comfort: Sleep and Rest ● Goal as a nurse is to make sure pt is comfortable. “Do you have any pain” , “are you comfortable” . if your in pain, it keeps you up. ● One of the greatest impacts on sleep and rest is pain! Sleep ● Stages of Sleep ○ Non-rapid eye movement (NREM) - Consists of four stages: ■ Stage I and II—5% to 50 % of sleep, light sleep ■ Stage III and IV—10% of sleep, deep-sleep states (delta sleep) ○ Rapid eye movement (REM) - more difficult to arouse a person during REM sleep. During REM sleep, the pulse, respiratory rate, blood pressure,metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed. REM sleep is believed to be essential to mental and emotional equilibrium and to play a role in learning, memory, and adaptation. Single Normal Sleep Cycle

Factors Affecting Sleep ● ● ● ● ● ● ● ● ● ●

Developmental considerations - across the lifespan Motivation Culture Lifestyle and habits Physical activity and exercise Dietary habits Environmental factors Psychological stress - will keep you up all night Illness Medications - side effects may affect sleep

Illnesses Associated with Sleep Disturbances ● Peptic ulcers

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Coronary artery diseases Epilepsy Liver failure and encephalitis Hypothyroidism

Sleep Disturbance Assessment ● ● ● ● ● ● ●

Nature and cause of problem Accompanying signs and symptoms Date of occurrence and effect on everyday living Severity of the problem Treatment of problem How the patient is coping with the problem Characteristics ○ Restlessness ○ Sleep postures ○ Sleep activities ○ Snoring ○ Leg jerking

Some Common Sleep Disorders: ● Dyssomnias ○ Insomnia - characterized by difficulty falling asleep, intermittent sleep, or difficulty maintaining sleep, despite adequate opportunity and circumstances to sleep. ○ Restless leg syndrome

○ Hypersomnia - characterized by excessive sleep, particularly during the day. ○ Sleep apnea - a potentially serious sleep disorder in which the throat muscles intermittently relax and block the airway during sleep, causing breathing to repeatedly stop and start. ○ Narcolepsy - a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. ● Parasomnias - Parasomnias are patterns of waking behavior that appear during REM or NREM stages of sleep. They are more commonly seen in children. Although parasomnias are commonly outgrown before adulthood, safety and prevention of injury are paramount concerns. These sleep disorders can occur rarely or on a regular basis ○ Somnambulism - Somnambulism or sleepwalking may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of his environment. ○ Sleep talking ○ Bruxism - is a condition in which you...