Module 3 PSYCHOLOGICAL ASPECTS OF BASIC NURSING PRACTICE

Sleep 1920

Physiology of Sleep Circadian rhythms Sleep regulation Cyclical rhythms Biological clock Regulated by a sequence of physiological states integrated by CNS activity Stages of sleep Sleep cycle Nonrapid Eye Movement (NREM) -Stages 1, 2, 3, 4, And REM (Rapid Eye Movement Once asleep a person passes through 4 to 5 sleep cycles

Sleep Cycle Stages Stage 1: NREM Includes lightest level of sleep. Stage lasts a few minutes. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Sensory stimuli such as noise easily arouses person. Awakened, person feels as though daydreaming has occurred.

Stage 2 NREM Period of sound sleep. Relaxation progresses. Arousal remains relatively easy. Stage lasts 10 to 20 minutes. Body functions continue to slow.

Stage 3 NREM Involves initial stages of deep sleep. Sleeper is difficult to arouse and rarely moves. Muscles are completely relaxed. Vital signs decline but remain regular. Stage lasts 15 to 30 minutes.

Stage 4 NREM Deepest stage of sleep. Very difficult to arouse sleeper. If sleep loss has occurred, sleeper will spend considerable portion of night in this stage. Vital signs are significantly lower than during waking hours. Stage lasts approximately 15 to 30 minutes. Sleepwalking and enuresis (bed-wetting) sometimes occur

REM Sleep � Vivid, full-color dreaming occurs. � Less vivid dreaming occurs in other stages. � Stage usually begins about 90 minutes after sleep has begun. � Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. � Loss of skeletal muscle tone occurs. � Gastric secretions increase. � Very difficult to arouse sleeper. � Duration of REM sleep increases with each cycle and averages 20 minutes. � NREM, Nonrapid eye movement; REM, rapid eye movement.

Functions of Sleep Purpose of sleep ◦ Remains unclear ◦ Contributes to Physiological and psychological restoration ◦ Maintenance of biological functions Dreams ◦ Occur in NREM and REM sleep ◦ Important for learning, memory, and adaptation to stress Physical Illness

Sleep disorders-Box 42 -2 �Insomnia- difficulty falling a sleep �Sleep Apnea- lack of airflow through the nose ( excessive snoring) and mouth for periods of 10 sec or longer ( OSA obstructive sleep apnea) �Excessive daytime sleepiness (EDS) S/S fatigue, they take daytime naps and OSA. �Narcolepsy- dysfunction that regulates the sleep and wake cycle ◦ Cataplexy- sudden muscle weakness during intense emotions Sleep Deprivation – not getting enough sleep ( confusion, and irritability)

Normal Sleep Requirements Loss of sleep decreases healing process Neonates to 3 months ◦ need 16 hrs sleep Infant 3 months and up ◦ need 8 -10 hrs sleep Toddlers – 2 years ◦ Maintain consistency in the same bedtime rituals and 12 hrs sleep Pre-school ◦ 12 hrs sleep School age: ◦ 6 years old 10 -12 hrs, ◦ 12 years and up 9 -10 hrs

Normal Sleep Requirements Adolescents ◦ need 7. 5 hrs sleep Young adults ◦ need 6 -8 hrs sleep Middle adults and older ◦ ◦ start having problems with sleep stage 3 and 4 NREM older have no stage 4 NREM) Older adults have a decline in stage 4 sleep Causes of sleep problems may be anxiety, depression, caffeine, menopause, and chronic illness

Factors Affecting Sleep Physical illness Drugs and substances Cardiac, respiratory, skeletal, chronic illness, GI, nausea Hypnotics, diuretics, antidepressants, alcohol, caffeine, narcotics, betablockers, anticonvulsants Box 42 -4 Lifestyle Work schedule, social activities, routines Usual sleep pattern Emotional stress Environment May be disrupted by social activity or work schedule. Worries, physical health, death, losses Noise, routines Good ventilation is essential Exercise and fatigue Food and calorie intake Moderate exercise and fatigue causes Time of day, caffeine, nicotine, alcohol a restful sleep Foods that promote sleep – L-trytophan ( found in milk, cheese, and turkey, whole grains)

Tools for Assessment of Sleep � Subjective Report (O-10) � Sleep History � Usual Sleep Pattern � Nature of sleep disorder � Onset & Duration � Severity � Predisposing Factors � Effect on Patient � Emotional & Mental Status � Bedtime Routines � Behaviors of Sleep Deprivation

Nursing Process Assessment ◦ Box 42 -7: Assessment : Insomnia Diagnosis Planning Implementation ◦ Box 42 -8 Focus on Older Adults ◦ Box 42 - 9 Client Teaching Evaluation Review Nursing Care Plan for Insomnia Review Concept Map – Figure 42 -5

PAIN

Pain • Most common reason people seek health care • Defined as “unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage or describe in terms of such damage. International Association for the Study of Pain. • “pain is whatever the experience person says it is, existing whenever he says it does” ( Mc. Caffery)

Nature of Pain � � Involves physical, emotional, and cognitive components Pain is Subjective, individualized � Stimulus for pain is Physical and/or mental in nature � Is exhausting and demands energy � Interferes with relationships � Nurse’s Role & Responsibility � Pain: ◦ occurs in all clinical settings ◦ Not a normal part of aging � Pain s/s could include: depression, sleep difficulties, change in gait and mobility and decreased socialization.

Physiology of Pain Transduction- energy conversion Transmission- how pain impulses begin Perception- point at which patient is aware of pain Modulation – inhibition of pain impulses

• Created by Melzack and Wall ( 1965) Gate Control Theory of Pain • Suggest that pain impulses pass through when a gate is open and are blocked with the gate is closed • Consist of emotional & cognitive components with a physical sensation • Ex: back massage: nursing intervention • The gate can be physiological, emotional or cognitive processes. • Pain threshold-point when a pt feels pain. • Physiological Responses to Pain

Behavioral Response Varies Pain threatens a patients physiological & psychological well being Observe for non –verbal expressions of pain (especially in cognitive impaired) Lack of expression does not mean no pain Pain tolerance –level of pain a pt can accept Pain is easier to prevent than to stop pain.

Pain • Teach to report pain rather than endure pain • Pain is easier to prevent than treat • Encourage patients to accept pain relieving measures • Offer pain medication before painful procedures • Observe behavior ( body movements, facial expressions, clenching teeth, guarding, grimace, restlessness, moans) • The patient has the best perception of pain.

Types of Pain Acute/transient pain Chronic/persistent Protective, identifiable, short duration Is not productive and has no purpose or may not have identifiable cause Chronic episodic Cancer Occurs sporadically over an extended duration Can be acute or chronic Inferred physiological Idiopathic Musculoskeletal, visceral, or neuropathic Chronic pain without an identifiable physical or psychological cause

• Attitude of health care providers • Malingerer or complainer Nursing Knowledge Base • Assumptions about patients in pain • Biases based on culture, education, experiences. • Objective signs not present-does not mean pt is not experiencing pain • Remember, the patient reports pain and you apply skills & techniques to provide pain relief • See Misconception about pain ( Box 43 -2) • Misconceptions about pain in older adult (Table 43 -4) -pain is not a part of growing old -pain perception does not decrease with age -Opiods are safe when patient assessed & monitored frequently for response/side effects. Monitor for respiratory depression

Factors Influencing Pain Physiological ◦ Age: Table 43 -3 & Box 43 -3 ◦ fatigue, genes, neurological function Social • attention – increase in pain( distraction helps to diminish pain relaxation, guided imagery, massage) • Previous experience • Family and support groups –presence usually makes the pain less stressful Spiritual ◦ “why has this happened to me? ”

• Psychological Factors Influencing Pain • Anxiety- • increases perception of pain & pain causes feelings of anxiety • Coping style • internal vs external control • Cultural ( Box 43 -4) • Meaning of pain • Ethnicity – cultural beliefs & values • What is expected & accepted by their culture

Pain management needs to by systematic Nursing Process & Pain management needs to include the patients quality of life Use appropriate scale to determine pain level ( 0 -10) Clinical guidelines are available to manage pain ◦ American Pain Society ◦ National Guideline Clearing House ◦ National Guideline Clearinghouse | Home

Assessment Client’s expression of pain Box 43 -6: ABC’s of Pain Management ABCDE ( ask, believe, choose, deliver, empower) ◦ A- Ask about pain regularly ◦ B- Believe what the client and family tells you in the report of pain and how it is relieved ◦ C-Choose the pain control option that best fits the patient ◦ D- Deliver intervention in a timely manner ◦ E- Empower the clients and their family. Enable them to control their course to the greatest extent.

Assessment �Characteristics of pain ◦ Onset and duration ◦ Location �Table 43 -5 ◦ Superficial or Cutaneous ◦ Deep or Visceral ◦ Referred ◦ Radiating ◦ Intensity �Adult Pain Scales (NRS); Fig 43 -6 �Children ◦ Wong-Bakes FACES: Fig 43 -8 ◦ Facial Expressions: Fig 43 -7 �Non-Verbal ◦ Box 43 -9

Assessment �Characteristics of pain ◦ ◦ Quality Pattern Contributing symptoms Behavioral effect �Box 43 -9 Disruption of ADLs

Diagnosis and Planning Focuses on the specific nature of pain Mandates a thorough assessment Selected from NANDA – approved list Intervention selected after patient goals & outcomes are identified ◦ Fig 43 -9 ◦ Fig 43 -10 - Concept Map What can one do to assist in pain management – Control Painful Stimuli (Box 43 -12)**

Implementation �Nonpharmacological interventions ◦ Relaxation and guided imagery ◦ Distraction ◦ Music �Music- treats both acute and chronic pain, stress, anxiety, and depression ◦ Cutaneous stimulation �Requires a physician’s order �Massage, heat, cold, acupressure �TENS – cutaneous stimulation of skin with a mild electrical current using electrodes externally. Use when pain is perceived ◦ Herbals ◦ Reducing Pain Perception ◦ Remove stimuli; Anticipatory Response

• Analgesics ( 3 types) Pharmacological Pain Relief • Non-opiods • Acetaminophen, • NSAIDS ( non-steroidal Anti-inflammatory drugs ( ask about GI bleed or renal issues) • Opiods( narcotics) • check respirations and ask about sleep apnea) Percocet, Vicodin, Lortab • Acetaminophen is often a component of opiods • “Tell me about your medication allergies”

Pharmacological Pain ( cont) • Adjuvants/co-analgesics • Tri-cyclic antidepressants ( nortriptyline) & anticonvulsants (neurontin), & Lidocaine can be used to treat neuropathic pain • Corticosteroids' –may be used for inflammation & bone metastasis • Sedatives, anti-anxiety meds & muscle relaxants have no effects on pain.

PCA Patient Controlled Analgesia • PCA – • Used to self administer opiods ( morphine, hydromorphone, fentanyl) always check respirations, minimal risk of over dose • Patient Teaching – Box 43 -14 • Topical Agents • EMLA • Lidoderm patch • Epidurals – special care to vital signs every 15 minutes, especially respiratory rates, rhythm, and skin color. • Hypotension is common complication of epidurals.

Things to consider • Vital signs • Diagnosis • Allergies • Previous doses of same med and effectiveness • Use or non-opiod used and effectiveness • Age of patient • Route of medication ( and other meds already received) • Start with lowest available( po, then advanced to IV)

Chronic Noncancer and Cancer Pain Management Cancer pain either chronic or acute Breakthrough pain ◦ Box 43 -15 Transdermal and transmucosal fentanyl

Barriers to Effective Pain Management Barriers: Patient, Health care provider, and the health care system ( 4316) Physical dependence, addiction, drug tolerance: Box 43 -17 pseudo-addiction ( client behavior- drug seeking when pain is under controlled) Placebo’s – Are they ethical? Professional organization discourages use of placebo for pain Do they jeopardize trust?

Pain Clinics, Palliative Care, & Hospice Pain centers treat patients on an inpatient or outpatient basis The goal of palliative care is to learn how to live life fully Hospice are programs for end of life care

Pain Evaluation of pain is considered a major responsibility of nurses The patient responses to pain may not be obvious Evaluating the appropriateness of pain medication will require nurses to evaluate patients 15 -30 minutes after administration & document response.

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