Chapter 31 Pain Comfort and Sleep Copyright 2018

Lesson 31. 1 Overview of Pain and Comfort Theory 1) 2) 3) 4) Discuss

Lesson 31. 1 Overview of Pain and Comfort Clinical Practice 1) Assist the patient

Pain Pain is the feeling of distress and discomfort Affects or interferes with normal

Pain (cont’d) Surgical patients experience postoperative pain Many medical conditions cause pain Headache, myocardial

The Joint Commission: Pain Control Standards Patients have the right to appropriate assessment and

The Joint Commission: Clarification of Pain Control Standards • Revisions focused on including both

Theories of Pain defined as a feeling of distress or suffering caused by the

Figure 31 -1: Pain transmission Copyright © 2018, 2014, 2009 by Saunders, an imprint

Gate Control Theory Pain viewed as being controlled by a gate mechanism in the

Figure 31 -2: The gate control theory of pain Copyright © 2018, 2014, 2009

Endorphins Endorphins are endogenous, naturally occurring opiate-like peptides that modify the perception of pain

Pain Descriptions Type of pain Severity of pain based on a pain scale Quality

Types of Pain Acute: short-term Chronic: long-term Nociceptive: injury to tissues Neuropathic: sensitivity to

Type of Pain: Acute Pain Usually associated with injury, medical condition or surgical procedure

$Type of Pain: Acute Pain (cont’d) Causes include: Burns, bone fractures, muscle strains Ø$

Type of Pain: Chronic Pain that may continue for months or years Often associated

Type of Pain: Nociceptive Pain Involves injury to the tissue in which receptors called

Type of Pain: Nociceptive Pain (cont’d) Treatments are aimed at one or all four

Type of Pain: Neuropathic Pain Associated with dysfunction of the nervous system Pain receptors

Type of Pain: Phantom Pain Occurs with loss of a body part from amputation

Quality of Pain: Perception of Pain Assessment of pain: whatever the person says it

Location of Pain Area of pain Name of affected body part (e. g. ,

Severity of Pain: Pain Scales Pain scales Ø Number scale • Rate the level

Figure 31 -4: Pain number rating scale Copyright © 2018, 2014, 2009 by Saunders,

Figure 31 -5: Wong-Baker FACES Pain Rating Scale for children Copyright © 2018, 2014,

Pain Control: Nonmedicinal Methods Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS)

Figure 31 -6: TENS unit blocks pain signal transmission Copyright © 2018, 2014, 2009

Medicinal Pain Control: Medicinal Methods Analgesic medications Oral Ø Topical Ø Injected Ø Intravenous

Figure 31 -9: A portable PCA pump in use by patient Copyright © 2018,

Question 1 There are several different types of pain. Which type of pain occurs

Question 2 Kathy is working in a mother-baby unit. Which pain scale is used

Question 3 Karen’s patient is prescribed a COX-2 inhibitor for her pain. Which of

Lesson 31. 2 Overview of Sleep Theory 5) Analyze the need for normal sleep.

Lesson 31. 2 Overview of Sleep Clinical Practice 7) Gather data regarding a patient’s

Functions of Sleep Adequate rest and sleep important factors in general health and recovery

Stages of Sleep Rapid eye movement (REM) sleep Time in which you dream Ø

Stages of Sleep (cont’d) Non–rapid eye movement (NREM) sleep Believed to be the time

Normal Sleep Requirements Newborns: day Age 1: Preschool: School-Age: Adolescents: Adults: At least 16

Factors Affecting Sleep Working night or evening shifts, changing shifts Traveling (jet lag), exposure

Sleep Disorders: Insomnia Difficulty in getting to sleep or staying asleep at night Transient

Sleep Disorders: Sleep Apnea A condition in which the person will stop breathing for

Sleep Disorders: Snoring Harsh sounds caused by vibration and/or obstruction of the air passages

Sleep Disorders: Narcolepsy Sudden-onset, recurrent, uncontrollable, brief episodes of sleep during normal hours of

Question 4 Karen’s patient is experiencing sudden-onset, recurrent, and uncontrollable brief episodes of sleep

Question 5 Karen’s patient is going home with a prescription for a sleep aid.

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Lesson 31. 1 Overview of Pain and Comfort Theory 1) 2) 3) 4) Discuss the application of The Joint Commission pain standards in planning patient care, including the clarification of the standards. Give the rationale for why pain is considered the “fifth vital sign. ” Illustrate the physiology of pain using the gate control theory. Describe the use of a variety of nursing interventions for pain control, including biofeedback, distraction, guided imagery, massage, and relaxation. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 31. 1 Overview of Pain and Comfort Clinical Practice 1) Assist the patient in accurately describing sensations of pain and discomfort. 2) Accurately and appropriately, record the patient’s report of pain using clear, descriptive terms. 3) Assist the patient in using a transcutaneous electrical nerve stimulation (TENS) unit. 4) Evaluate the effects of various techniques used for pain control. 5) Care for patients receiving patient-controlled analgesia (PCA) or epidural analgesia. 6) Evaluate the effects of pain medication, and accurately report and record observations. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain Pain is the feeling of distress and discomfort Affects or interferes with normal activity No accurate objective measurement of pain Pain assessment is performed along with each assessment of vital signs and is considered the “fifth vital sign” Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain (cont’d) Surgical patients experience postoperative pain Many medical conditions cause pain Headache, myocardial infarction Ø Cancer, fractures Ø Cuts and abrasions Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Joint Commission: Pain Control Standards Patients have the right to appropriate assessment and management of pain Pain is assessed in all patients Patients are educated about pain and managing pain as part of the treatment, as appropriate The discharge process provides for continuing pain care based on the patient’s needs at the time of discharge Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Joint Commission: Clarification of Pain Control Standards • Revisions focused on including both pharmacologic and nonpharmacologic methods, in addition to the benefits and risks to patients, when deciding the most effective pain management strategy Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Theories of Pain defined as a feeling of distress or suffering caused by the stimulation of nerve endings Pain serves as a warning of tissue damage and allows sufferer to withdraw from the source of the pain Pain is transmitted through the nervous system Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Gate Control Theory Pain viewed as being controlled by a gate mechanism in the central nervous system Opening the gate allows transmission of pain Closing the gate blocks the transmission of pain The gate may be opened by activity in smalldiameter nerves, such as tissue damage Large-diameter nerve activity seems to close the gate Lack of input allows the gate to open Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endorphins Endorphins are endogenous, naturally occurring opiate-like peptides that modify the perception of pain They attach to opioid receptors and block pain Physiologic and psychological stressors can cause the release of endorphins Ø Long-distance runners often get an endorphin high Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain Descriptions Type of pain Severity of pain based on a pain scale Quality of pain Location of pain Duration of pain Degree of pain Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Pain Acute: short-term Chronic: long-term Nociceptive: injury to tissues Neuropathic: sensitivity to stimuli Phantom: after loss of body part Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Acute Pain Usually associated with injury, medical condition or surgical procedure Short duration, lasting a few hours to a few days May be described as aching or throbbing Patient may be restless or agitated Usually controlled with analgesics Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

$Type of Pain: Acute Pain (cont’d) Causes include: Burns, bone fractures, muscle strains Ø$

Type of Pain: Acute Pain (cont’d) Causes include: Burns, bone fractures, muscle strains Ø Pneumonia, sickle cell crisis, angina Ø Herpes zoster, inflammations, infections Ø May worsen in the presence of anxiety or fear Usually relieved once the cause is removed Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Chronic Pain that may continue for months or years Often associated with conditions such as: Arthritis Ø Chronic back pain Ø May be dull, constant, shooting, tingling, or burning May be treated with both pharmacologic and nonpharmacologic interventions Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Nociceptive Pain Involves injury to the tissue in which receptors called nociceptors are located May be found in skin, joints, or organ viscera Four phases associated with nociceptive pain Transduction Ø Transmission Ø Perception Ø Modulation Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Nociceptive Pain (cont’d) Treatments are aimed at one or all four phases NSAIDs work at blocking transduction Opioids block transmission Distraction and guided imagery block perception Drugs that block neurotransmitter uptake work on modulation Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Neuropathic Pain Associated with dysfunction of the nervous system Pain receptors in the body become more sensitive to stimuli and send signals more easily Ø As nerve endings grow new branches, the signals become stronger Ø Often associated with Guillain-Barré syndrome, cancer, and HIV Treated with NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Phantom Pain Occurs with loss of a body part from amputation Ø Patient may feel pain in the amputated part for years after the amputation Not controlled by conventional methods May be treated with TENS units implanted in the thalamus Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Quality of Pain: Perception of Pain Assessment of pain: whatever the person says it is Observable indicators (may not always be present) Ø Ø Ø Moaning Crying Irritability Grimacing Frowning Rigid posture in bed Described as rushing, throbbing, pulsating, twisting, pulling, burning, searing, stabbing, tearing, biting, blinding, nauseating, debilitating Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Location of Pain Area of pain Name of affected body part (e. g. , foot, hand, leg, or upper/lower abdomen) Ø Localized, radiating, generalized Ø Frequency of pain Ø Constant, intermittent, occasional Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Severity of Pain: Pain Scales Pain scales Ø Number scale • Rate the level of pain: 0 is pain-free; 10 is worst pain imaginable Picture scale • Shows faces in varying degrees of pain Ø NIPS (Neonatal Infant Pain Scale) Ø CRIES (Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, and Sleeplessness) Ø PIPP (Premature Infant Pain Profile) Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain Control: Nonmedicinal Methods Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS) Binders Application of heat and cold Relaxation Biofeedback Distraction Guided imagery and meditation Music Hypnosis Massage Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Medicinal Pain Control: Medicinal Methods Analgesic medications Oral Ø Topical Ø Injected Ø Intravenous Ø Patient-controlled analgesia (PCA) Epidural analgesia Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 There are several different types of pain. Which type of pain occurs after the loss of a body part from an amputation? 1) 2) 3) 4) Acute pain Nociceptive pain Neuropathic pain Phantom pain Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Kathy is working in a mother-baby unit. Which pain scale is used to determine if the baby is in pain? 1) 2) 3) 4) FACES pain rating scale for children FLACC scale PIPP scale NIPS Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Karen’s patient is prescribed a COX-2 inhibitor for her pain. Which of the following is an example of a COX-2 inhibitor? 1) 2) 3) 4) Aspirin Morphine Antiinflammatory Antidepressant Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 31. 2 Overview of Sleep Theory 5) Analyze the need for normal sleep. 6) Recognize how the need for sleep changes over the life span. 7) Delineate factors that can interfere with sleep. 8) Define the sleep disorders insomnia, sleep apnea, and narcolepsy. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 31. 2 Overview of Sleep Clinical Practice 7) Gather data regarding a patient’s sleep difficulties. 8) Develop a plan designed to assist the patient in getting adequate sleep. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Functions of Sleep Adequate rest and sleep important factors in general health and recovery from illness Being rested increases pain tolerance and allows improved response to analgesia Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Stages of Sleep Rapid eye movement (REM) sleep Time in which you dream Ø A period of a high level of activity Ø Heart rate, blood pressure, and respirations are similar to that when awake Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Stages of Sleep (cont’d) Non–rapid eye movement (NREM) sleep Believed to be the time when the body receives the most rest Ø Heart rate, blood pressure, and respirations decline Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Normal Sleep Requirements Newborns: day Age 1: Preschool: School-Age: Adolescents: Adults: At least 16 hours of sleep per 12 -14 hours per day 11 -13 hours 10 -11 hours of sleep per night 9 -10 hours of sleep a night 8 hours sleep a night Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Factors Affecting Sleep Working night or evening shifts, changing shifts Traveling (jet lag), exposure to sunlight Snoring Caffeine, nicotine, or alcohol consumption Exercise, taking naps Stress, illness, fatigue Discomfort Environmental factors—heat, cold, light, noise Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Insomnia Difficulty in getting to sleep or staying asleep at night Transient insomnia may be caused by stress, depression Ø Chronic insomnia can have many causes; may require treatment from a health care provider specializing in sleep disorders Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Sleep Apnea A condition in which the person will stop breathing for brief periods during sleep Obstructive apnea—most common and severe; airway blocked at back of throat; snoring common; treatment is CPAP Ø Central apnea—diaphragm and chest stops working; person awakens to resume breathing Ø Mixed sleep apnea—combination of both Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Snoring Harsh sounds caused by vibration and/or obstruction of the air passages at the back of the mouth and nose May be caused by poor muscle tone, excessive tissue, or deformities such as a deviated septum Ø A partial blockage of the airway Ø Sleeping on the side or losing weight may help Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Narcolepsy Sudden-onset, recurrent, uncontrollable, brief episodes of sleep during normal hours of wakefulness May occur at any time and last from a few seconds to 30 minutes Ø Usually begins around age 25 Ø No known cure Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Karen’s patient is experiencing sudden-onset, recurrent, and uncontrollable brief episodes of sleep during hours of wakefulness. What condition does Karen’s patient have? 1) 2) 3) 4) Insomnia Sleep apnea Narcolepsy REM sleep Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 Karen’s patient is going home with a prescription for a sleep aid. When teaching the patient about the medication, Karen should be sure to include: 1) 2) 3) 4) medications should be used with alcohol. medications for sleep are for short-term relief. over-the-counter medications for sleep will keep you alert. hypnotics are not used for sleep. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.