Pain Management, Comfort, Rest, and Sleep Chapter 18

The Meaning of comfort
-One of the greatest challenges for the nurse is to provide comfort to the patient

-Promoting physical and psychological comfort is a vital part of the role of a nurse

-Comfort
+To give strength and hope, cheer, and ease the grief or trouble of another

Lack of Comfort Factors
Distention
Dry mouth
Dyspnea
Fatigue
Fear
Flatus
Grief
Headache
Hopelessness
Anxiety
Constipation
Constricting edema
Depression
Diaphoresis
Diarrhea
Lack of Comfort Factors
Powerlessness
Pruritus
Retention
Sadness
Singultus
Thirst
Vomiting
Hyperthermia
Hypothermia
Hypoxia
Incontinence
Muscle cramping
Nausea
Pain
Nature of pain
-A complex, abstract, personal experience

-An unpleasant sensation caused by noxious stimulation of the sensory nerve endings

-Serves as a warning to the body because it often occurs where there is actual or potential tissue damage

-May be a cardinal sign of inflammation

-Valuable in the diagnosis of many disorders and conditions

-Can occur when there is no tissue damage, such as the pain of grief or the pain of migraine headaches

Nature of pain Cont.
-Pain is subjective

-The interpretation and significance of the pain depend on the individual’s learned experiences and involve psychosocial and cultural factors

-Only the person who is bearing the pain is an expert about that pain

-A patient with pain does not always know how to report the pain to health professionals

-The nurse has a major role in helping the patient by conducting nursing pain assessments

Definition of Pain
-Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
Acute pain
-Intense and of short duration

-Usually lasts less than 6 months

-Generally provides a warning to the individual of actual or potential tissue damage

-Creates an autonomic response that originates within the sympathetic nervous system

-Floods the body with epinephrine—”fight or flight” response

Chronic pain
Pain lasting longer than 6 months

-Can be continuous or intermittent and may be as intense as acute

-Does not serve as a warning sign of tissue damage; may be due to damage that has already occurred

-Patient may develop chronic low self-esteem, change in social identity, changes in role and social interaction, fatigue, sleep disturbance, and depression

Types of Pain
Mild or severe-

Chronic or acute- chronic is long term(over 6 months), acute- sudden

Intermittent( comes and goes) or intractable

Burning, dull, or sharp

Precisely-knows specific pain point or poorly localized

Referred- pain in a different spot where it shows up

Gate Control Theory
Gate Control Theory
Theory suggests that pain impulses can be regulated or even blocked by gating mechanisms located along the central nervous system

The proposed location of gates are in the dorsal horn of the spinal cord

Pain and other sensations of skin and muscle travel the same pathways through the large nerves in the spinal cord

If cutaneous stimuli other than pain are transmitted, the “gate” through which the pain impulse must travel is temporarily blocked by the stimuli

Gate control theory CONT
-The brain cannot acknowledge the pain while it is interpreting the other stimuli

-A bombardment of sensory impulses, such as those from the pressure of a back rub, the heat of a warm compress, or the cold from ice applications will close the gates to painful stimuli

-Some patients can be distracted by removing the sensation of pain from the center of attention

-Auditory or visual stimuli can distract patients and help make pain more tolerable

-Gating mechanisms can also be altered by thoughts, feelings, and memories

Endorphins
-The body contains a natural supply of morphine-like substances called endorphins

-Stress and pain activate endorphins

-Analgesia results when certain endorphins attach to opioid receptor sites in the brain and prevent the release of neurotransmitters, thereby inhibiting the transmission of pain impulses

-People who have less pain than others from a similar injury have higher endorphin levels

-Pain relief measures, such as transcutaneous electric nerve stimulation, acupuncture, and placebos, are believed to cause the release of endorphins

Key concepts of controlling pain
-Patients have the right to appropriate assessment

-Patients will be treated for pain or referred for treatment

-Pain is to be assessed and regularly reassessed

-Patients will be taught the importance of effective pain management

-Patients will be taught that pain management is a part of treatment

-Patients will be involved in making care decisions

-Routine and PRN analgesics are to be administered as ordered

-Discharge planning and teaching will include continuing care based on the patient’s need at the time of discharge, including the need for pain management

Pain the 5th vital sign
-Making pain a vital sign—along with pulse, temperature, blood pressure, and respirations—would ensure that pain is monitored on a regular basis

-Use of a pain-rating scale allows patients to clearly articulate their pain and makes them more likely to receive proper treatment

-Scale of 0 to 10, in which 0 is no pain and 10 is the worst pain imaginable

-Appropriate pain management will typically bring about quicker recoveries, shorter hospital stays, fewer readmissions, and improved quality of life

-Unrelieved pain has harmful physical effects as well as psychological effects

Noninvasive pain relief techniques
-Transcutaneous electric nerve stimulation
+Provides a continuous, mild electric current to the skin via electrodes to block pain impulses

-Distraction
-Relaxation
-Guided imagery
-Hypnosis
-Biofeedback

Invasive approaches to pain
Nerve blocks

Epidural analgesics

Neurosurgical procedures

Acupuncture

Medication for pain management-Nonopioids
-Acetaminophen and nonsteroidal antiinflammatory drugs (aspirin, ibuprofen, and naproxen sodium)

-Most widely available and frequently used analgesic group

-Used primarily for mild to moderate pain

Medication for pain management- Opioids
-Morphine, meperidine (Demerol), and codeine

-Act on higher centers of the brain to modify perception and reaction to pain

-Manage moderate to severe acute pain

-Tolerance and physiologic dependence are unusual with short-term postoperative use, and psychological dependence and addiction are extremely unlikely after taking opiates for acute pain

Tolerance and addiction
-Opioids can delay gastric emptying, slow bowel motility, and decrease peristalsis

-Opioids may also reduce secretions from the colonic mucosa; result is slow-moving, hard stool that is difficult to pass

-Gastrointestinal dysfunction can result in ileus, fecal impaction, and obstruction

-A preventive approach, regular assessment, and aggressive management are required

Administration routes for analgesics- IV
+Intravenous (IV)
-Route of choice for opioid analgesics after major surgery
-Bolus and continuous infusion
Administration routes for analgesics -Oral
+Oral
-Optimal route, especially for chronic pain

-Convenient, flexible, and relatively steady blood levels

-Appropriate to use as soon as the patient can tolerate oral intake

-Mainstay of pain management for ambulatory surgical patients

Administration routes for analgesics- IM
+Intramuscular (IM)
-Unreliably absorbed
-Painful and traumatic
-May cause fibrosis of muscle and soft tissue
Administration route for analgesics -Epidural analgesia
+Epidural analgesia
-Insertion of an epidural catheter and the infusion of opiates into the epidural space

-Medication diffuses slowly from the epidural space across the dura and arachnoid membranes into the cerebrospinal fluid

-May be 10 times as much as a dose that would be injected directly into the cerebrospinal fluid

-Side effects: urinary retention, postural hypotension, pruritus, nausea/vomiting, respiratory depression

Responsibility of nurse in pain control
-Pain management is a challenge that every nurse must face, regardless of the practice setting

-The nurse’s role in pain management is probably more important than that of any other member of the health care team

-The nurse should advocate for the patient by clarifying concerns, answering questions, supplying all the information the patient needs to make decisions about care, and supporting the patient’s decisions

Nursing assessment of pain Collection of subjective data
-Characteristics and description

-Assess site, severity, duration, and location of pain

-Ask the patient what relieves the pain, what causes the pain to be worse, and what does not relieve the pain

-Identify usual coping mechanisms and the patient’s, family’s, and friends’ expectations of appropriate behavior when in pain

Nursing assessment of pain collection of objective data
-Tachycardia

-Increased rate and depth of respirations

-Diaphoresis

-Increase systolic or diastolic blood pressure

-Pallor

-Dilated pupils

-Increased muscle tension
-Possibly nausea or weakness

Nursing assessment of pain collection of objective data Cont.
-Changes in facial expressions—frowning or gritting teeth
-Clenched fists
-Withdrawal
-Crying, moaning, or tossing in bed
-Fetal position
-Clutching at the affected body part
-Pacing
PQRST – pain assessment
Provoke- what started it
Quality- is it sharp or dull
Region- where does it hurt
Severity scale 0-10
Timing- does it come and go
Guidelines for individualizing pain therapy
-Use different types of pain relief measures

-Provide pain relief measures before pain becomes severe

-Use measures the patient believes are effective

-Consider the patient’s ability or willingness to participate in pain relief measures

-Choose pain relief measures appropriate for the severity of the pain as reflected by the patient’s behavior

-If a therapy is ineffective at first, encourage the patient to try it again before abandoning it

-Keep an open mind about what may relieve pain
-Keep trying
-Protect the patient

Nursing interventions
-The following measures can be performed by the nurse to assist in pain control.

-Tighten wrinkled bed linens

-Reposition drainage tubes or other objects on which patient is lying

-Place warm blankets for coldness

-Loosen constricting bandages
Change moist dressings
Check tape to prevent pulling on skin
Position patient in anatomic alignment
Check temperature of hot or cold applications, including bath water

Nursing Interventions Cont.
-Lift, not pull, patient up in bed; handle gently

-Position patient correctly on bedpan

-Avoid exposing skin or mucous membranes to irritants

-Prevent urinary retention by ensuring patency of Foley catheter

-Prevent constipation by encouraging appropriate fluid intake, diet, and exercise and by administering prescribed stool softeners

Sleep and Rest
-A patient at rest feels mentally relaxed, free from worry, and physically calm, free from physical or mental exertion

-Sleep is a state of rest that occurs for a sustained period

-The reduced consciousness during sleep provides time for repair and recovery of body systems for the next period of wakefulness

-Sleep restores a person’s energy and feeling of well-being

REM sleep
-Stage of vivid, full-color dreaming

-First occurs approximately 90 minutes after sleep has begun; thereafter occurs at end of each NREM cycle

-Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased fluctuating blood pressure

-Loss of skeletal muscle tone

-Responsible for mental restoration

-Stage in which sleeper is most difficult to arouse

Sleep deprivation
-Deprivation involves decreases in the amount, quality, and consistency of sleep

-When sleep is interrupted or fragmented, changes in the normal sequence of sleep stages occur, and cycles cannot be completed

Physiologic signs and symptoms of sleep deprivation
Hand tremors

Decreased reflexes

Slowed response time

Reduction in word memory

Decrease in reasoning and judgment

Cardiac dysrhythmias

Psychologic signs and symptoms of sleep deprivation
-Mood swings
-Disorientation
-Irritability
-Decreased motivation
-Fatigue
-Sleepiness
-Hyperexcitability
Promoting rest and sleep
-Determine the patient’s usual rest and sleep patterns, decide whether they are sufficient, and note why the patient is not getting sufficient rest

-A plan should be developed to provide for more rest
+Limit interruptions during the night
+Provide a quiet environment with a comfortable room temperature
+Limit the number of visitors and duration of visits
+Carry out all procedures within a given time frame

Promoting rest and sleep Cont.
-Preparing the patient for sleep
-Wash the patient’s back
-Gently massage the back
-Change the linens
-Make certain the patient is warm enough
-Offer a caffeine-free beverage such as milk
-Change soiled dressings
-Have the patient void
-Environmental stimuli should be decreased by dimming the lights and decreasing the noise level