1. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pain, Comfort, and Sleep

2. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lesson 31.1

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

4. 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) Assist with the care of patients receiving patient-controlled analgesia (PCA) or epidural analgesia. 6) Evaluate the effects of pain medication, and report and record observations appropriately. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 4

5.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 5

6.  Surgical patients experience postoperative pain  Many medical conditions cause pain  Headache, myocardial infarction  Cancer, fractures  Cuts and abrasions Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 6

7.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 7

8.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 8

9. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 9

10.  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 small- diameter nerves, such as tissue damage  Large-diameter nerve activity seems to close the gate  Lack of input allows the gate to open Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 10

11. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 11

12.  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  Long-distance runners often get an endorphin high Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 12

13.  Type of pain  Severity of pain based on a pain scale  Quality of pain  Location of pain  Duration of pain  Degree of pain Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 13

14.  Acute: short-term  Chronic: long-term  Nociceptive: injury to tissues  Neuropathic: sensitivity to stimuli  Phantom: after loss of body part Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 14

15.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 15

16.  Causes include:  Burns, bone fractures, muscle strains  Pneumonia, sickle cell crisis, angina  Herpes zoster, inflammations, infections  May worsen in the presence of anxiety or fear  Usually relieved once the cause is removed Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 16

17.  Pain that may continue for months or years  Often associated with conditions such as:  Arthritis  Chronic back pain  May be dull, constant, shooting, tingling, or burning  May be treated with both pharmacologic and nonpharmacologic interventions Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 17

18.  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  Transmission  Perception  Modulation Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 18

19.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 19

20.  Associated with dysfunction of the nervous system  Pain receptors in the body become more sensitive to stimuli and send signals more easily  As nerve endings grow new branches, the signals become stronger  Often associated with Guillain-Barré syndrome, cancer, and HIV  Treated with NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 20

21.  Occurs with loss of a body part from amputation  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 21

22.  Pain scales  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  NIPS (Neonatal Infant Pain Scale)  CRIES (Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, and Sleeplessness)  PIPP (Premature Infant Pain Profile) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 22

23. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 23

24. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 24

25.  Assessment of pain: whatever the person says it is  Observable indicators (may not always be present)  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 25

26.  Area of pain  Name of affected body part (e.g., foot, hand, leg, or upper/lower abdomen)  Localized, radiating, generalized  Frequency of pain  Constant, intermittent, occasional Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 26

27.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 27

28. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 28

29.  Analgesic medications  Oral  Topical  Injected  Intravenous  Patient-controlled analgesia  Epidural analgesia Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 29

30. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 30

31. There are several different types of pain. Which type of pain occurs after the loss of a body part from an amputation? 1) Acute pain 2) Nociceptive pain 3) Neuropathic pain 4) Phantom pain Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 31

32. Kathy is working in a mother-baby unit. Which pain scale is used to determine if the baby is in pain? 1) FACES pain rating scale for children 2) FLACC scale 3) PIPP scale 4) NIPS Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 32

33. 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) Aspirin 2) Morphine 3) Antiinflammatory 4) Antidepressant Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 33

34. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lesson 31.2

35. Theory 5) Analyzethe 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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 35

36. 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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 36

37.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 37

38.  Rapid eye movement (REM) sleep  Time in which you dream  A period of a high level of activity  Heart rate, blood pressure, and respirations are similar to that when awake Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 38

39.  Non–rapid eye movement (NREM) sleep  Believed to be the time when the body receives the most rest  Heart rate, blood pressure, and respirations decline Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 39

40.  Newborns: At least 16 hours of sleep per day  Age 1: 12-14 hours per day  Preschool: 11-13 hours  School-Age: 10-11 hours of sleep per night  Adolescents: 9-10 hours of sleep a night  Adults: 8 hours sleep a night Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 40

41.  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 © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 41

42.  Difficulty in getting to sleep or staying asleep at night  Transient insomnia may be caused by stress, depression  Chronic insomnia can have many causes; may require treatment from a health care provider specializing in sleep disorders Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 42

43.  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  Central apnea—diaphragm and chest stops working; person awakens to resume breathing  Mixed sleep apnea—combination of both Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 43

44.  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  A partial blockage of the airway  Sleeping on the side or losing weight may help Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 44

45.  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  Usually begins around age 25  No known cure Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 45

46. 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) Insomnia 2) Sleep apnea 3) Narcolepsy 4) REM sleep Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 46

47. 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) medications should be used with alcohol. 2) medications for sleep are for short-term relief. 3) over-the-counter medications for sleep will keep you alert. 4) hypnotics are not used for sleep. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 47