1. Basic Needs and Comfort Measures

2. Objectives Define basic human needs
Define: self-actualization, self-esteem, love, security, belonging and physiologic needs according to Maslow’s Hierarchy of Needs
Explain and list physiologic needs
Define the terms associated with pain: agonist, analgesic, biofeedback, antagonist, relaxation, mediation, PCA endorphins
Understand pain measurement techniques
Describe techniques used to relieve pain
Evaluate effectiveness of pain control measures

3. Objectives List causes of discomfort for patients
List nursing measures to promote comfort and ease discomfort for patients

4. Comfort and Discomfort
List some attributes associated with comfort:
Examples:
Warmth, softness, rest, quiet, coolness, cleanliness, space, safety
Name some more that you associate with comfort

6. Comfort and Discomfort
List some attributes that you might associate with discomfort
Examples: pain, nausea, fear, hunger, thirst, dark, worry
List some other examples

7. Human Needs
Basic human needs: those which are common to all people and essential for survival
Some can be met independently; some are dependent on relationships with others
Food, water, shelter, warmth
Connection, love, security, spirituality

8. Abraham Maslow ( )

9. Maslow
Professor of psychology at Brandeis University who founded humanistic psychology
Created the Theory of Basic Human Needs
Useful for understanding the relationships of basic human needs and for establishing priorities of care
Theory of Basic Human Needs is a foundation for nursing care and interventions

10. Basic Human Needs have the following characteristics
The absence of a basic human need results in illness.
The presence of basic human needs helps prevent illness or signals health.
Meeting basic human needs restores health.
It is preferred over other satisfactions when unmet
One feels something missing when needs are unmet.
One feels satisfaction when needs are met.

11. Maslow’s Hierarchy of Needs
Certain needs are more basic than others
All people have the same needs all of the time, people generally strive to meet certain of their needs before attending to others
Level 1: Physiologic needs
Level 2: Safety and security needs
Level 3: Love and belonging needs
Level 4: self-esteem needs
Level 5: Self-actualization needs

13. Basic Human Needs
Level 1: Physiologic - oxygen, water, food, temperature, elimination, sexuality, physical activity and rest
Most basic needs and have the highest priority
Usually can be met through self-care, but many people who are ill require assistance
Level 2: Safety and security - safe environment, protection from violence, safe emotional environment
Level 3: Love and belonging needs - understanding and acceptance of others; belonging to a community

14. Basic Human Needs
Level 4: Self-Esteem needs - need to feel pride and a sense of accomplishment, respect, appreciation
Can be affected by body image, role changes
Level 5: Self-Actualization needs - need to reach one’s own full potential

15. Level 1: Physiologic Needs
A need which must be met at least minimally to maintain life; the most basic in the hierarchy and therefore with the highest priority
Most healthy children and adults can meet these needs through self-care
Very young, old, disabled and ill people requires assistance in meeting them
The lack of any of the following cause discomfort
Oxygen: respiratory diseases, cardiac disease
Water: dehydration, hypovolemia,
Food: starvation, NPO
Warmth

17. Level 2: Safety and security needs
Involves both physical and emotional components
Physical security:
Using hand hygiene and sterile techniques to prevent infection
Using electrical equipment properly
Administering medications knowledgeabley
Using skill when moving and ambulating patients
Assessing patients for potential risks, such as falling, bleeding, infection

19. Level 2: Safety and security needs
Emotional safety and security: being free from fear, anxiety and apprehension
Patients entering health care system face fear of the unknown, their prognosis, unfamiliar surroundings, unfamiliar personnel
All patients have anxiety
Comfort measures: explain procedures, friendly, unhurried approach, continuity of caregivers, relationship building.

20. Level 3: Love and Belonging Needs
All humans have this need
Called a higher-level need
Includes understanding, acceptance and a feeling of belonging to families, peers, friends, community
Nursing interventions to help meet this need:
Including family and friends in the care of the patient
Establishing a nurse-patient relationship based on mutual understanding and trust (by demonstrating caring, encouraging communication and respecting privacy)

22. Level 4: Self-Esteem Needs
Need for the person to feel good about him or her self, pride and a sense of accomplishment
Factors which impact self-esteem: role changes, body-image changes as a result of illness, surgery
Nursing interventions: respecting patients values and beliefs, encouraging patients to meet attainable goals

24. Level 5: Self-Actualization Needs
The need for individuals to reach their full potential through development of their unique capabilities
In general, the lower level needs must be met before this need can be satisfied.

25. Self-Actualization Characterized by:
acceptance of self and others as they are
focus of interest on problems outside oneself
ability to be objective
feelings of happiness and affection for others
Respect for all people
Ability to discriminate between good and evil
Creativity in solving problems and pursuing interests

26. Nursing Process
Assessment
Diagnosis
Planning
Intervention
Evaluation

27. Nursing Process Assessment: gathering information, data
Diagnosis: Name the problem
Planning: State an achievable goal
Interventions: Actions that work toward the stated goal
Evaluation: Did the plan/interventions meet the stated goal

28. Nursing Interventions to Meet Patient Needs
Physiologic needs usually take priority
Basic human needs are interrelated
Examples:
ER patient with an MI:
Level 1 needs?
Level 2 needs?
Level 3,4,and 5 needs?
Post-surgical patient in pain
Pt. NPO for surgery

29. Question
A nurse who focuses attention on the strengths and abilities of his patients rather than their problems is helping them to achieve which of Maslow’s basic human needs?
A. Self-actualization
B. Self-esteem
C. Love and belonging
D. Safety and security
E. Physiologic

30. Answer Answer: A. Self-actualization Rationale:
To meet patient self-actualization needs, nurses provide a sense of direction and hope and maximize patient potential.
Self-esteem needs are met by respecting patient values and beliefs and setting attainable goals for them.
Love and belonging needs are met by including family and friends and establishing caring relationships with patients.
Safety and security needs are met by encouraging spiritual practices and independent decision making.
Physiologic needs are needs that must be met to maintain life.

31. Comfort and Discomfort
Physiologic Discomfort can come from:
Pain
Nausea and Vomiting
Shortness of breath
Hunger
Thirst
Inactivity
Constipation

32. Comfort Measures - Pain

33. Pain
Def: an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
It is a red flag indicating that something is wrong: “Protective in nature”
Such an indicator of health that it is called the “5th Vital Sign”

34. Pain American Bar Association: Pain relief is a legal right
Therefore: Nurses are legally and ethically responsible for managing pain and suffering
McCaffrey: “Pain is whatever the experiencing person says it is, existing whenever he says it is.”

35. Common Responses to Pain
Physiologic: increased BP, RR and pulse; pupil dilation, muscle tension, pallor; increased adrenalin, increased blood sugar
Behavioral: moving away from painful stimuli, crying, moaning, restlessness
Affective: withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness

36. Categories of Pain Duration Location or source Mode of transmission
Etiology

37. Pain: Duration Acute pain: rapid in onset, varies in intensity from
mild to severe; warning signal that something
is wrong (cut finger, sore throat, headache)
Chronic pain: may be limited, intermittent or persistent, but lasts belong the normal healing
period. Can be periods of remission or exacerbation. (cancer pain, back pain). Interferes with normal functioning

38. Pain: Location or Source
Cutaneous Pain (superficial) usually involves the skin of subcutaneous tissue: paper cut
Somatic Pain originates in tendons, ligaments, bones, blood vessels and nerves: sprains, broken bones
Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen: stomach pain

39. Question
A patient who has bone cancer is most likely experiencing which of the following types of pain?
A. Cutaneous
B. Somatic
C. Visceral
D. Referred

40. Answer Answer: B. Somatic Rationale:
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves.
Cutaneous pain usually involves the skin or subcutaneous tissue.
Visceral pain is poorly localized and originates in body organs.
Referred pain is pain that originates in one part of the body and is perceived in an area distant to that part.

41. Origin of Pain Physical—cause of pain can be identified
Psychogenic—cause of pain cannot be identified
Referred—pain is perceived in an area distant from its point of origin

42. Pain: Mode of transmission
Referred Pain: pain which is perceived in an area of the body distant from its point of origin
Heart Attack or Myocardial Infarction: pain is felt in shoulder, jaw, or arms

43. Referred Pain

44. Pain: Etiology
Neuropathic pain: pain resulting from an injury of or abnormal functioning of peripheral or central nervous system (fibromyalgia, peripheral neuropathy)
Intractable: pain that is very resistant to treatment
Phantom Pain: pain in an amputated limb

45. Peripheral Neuropathy

46. Terms to know
Agonist: a drug that binds with a receptor to produce a therapeutic response
Analgesic: drug that relieves pain
Antagonist: a drug that binds to a receptor to prevent the action of an agonist
Placebo: “an inactive substance that gives satisfaction to the person using it”
Nociceptors: Peripheral nerve fibers that transmit pain

47. The Pain Process Transduction—activation of pain receptors
Transmission—conduction along pathways (A-delta and C- delta fibers)
Perception of pain—awareness of the characteristics of pain
Modulation—inhibition or modification of pain

48. Pain Process: Transduction, Transmission, Perception, Modulation

49. Stimulator of Nociceptors or Pain Receptors
Bradykinin: powerful vasodilator, trigger release of histamine (redness, swelling, inflammation)
Prostaglandins: hormone-like substances that send additional pain stimuli to the CNS
Substance P: sensitized receptors on nerves to feel pain
These are Neurotransmitters: substances that excite or inhibit target nerve cells

50. Pain Reception

51. Pain Receptor Stimulators
Mechanical - friction
Thermal - heat or cold
Chemical - acid
Electrical- static electricity

53. Perception of Pain
Pain threshold: lowest intensity of a stimulus that is recognized as pain
Adaptation: “getting used to the stimulus”
Modulation of pain: sensation of pain is modified or lessened by naturally produced chemical substances
Neuromodulators
Endorphins, dynorphins, enkephalins

54. Gate Control Theory of Pain
States that certain small nerve fibers conduct pain impulses toward the brain
Certain large nerve fibers appear to block pain impulses toward the brain
A “gating mechanism” occurs when too much information is sent to the brain and the pain signal is interrupted
The brain can influence its own gating mechanism through past experiences and learned behaviors

55. Gate Control Theory

56. Factors Affecting Pain Experience
Culture
Ethnic variables
Family, gender, and age variables
Religious beliefs
Environment and support people
Anxiety and other stressors
Past pain experience

57. General Assessments of Pain
Patient’s verbalization and description of pain
Duration of pain
Location of pain
Quantity and intensity of pain
Quality of pain
Chronology of pain

59. Pain Scale

60. Symptom Analysis P, Q, R, S, T
P = Place: where is the pain (or other symptom)?
Q= Quality: what does it feel like?
R = Radiation: does it go anywhere else?
S = Severity:how bad is it? Rate it on a 1-10 scale
T = Time: how long have you had this?

61. Nursing Interventions for Pain
Establishing trusting nurse–patient relationship
Manipulating factors affecting pain experience
Reviewing additional pain control measures
Initiating nonpharmacologic and pharmacologic pain relief measures
Considering ethical and legal responsibility to relieve pain
Teaching patient about pain

62. Establishing a Relationship

63. Manipulating Factors Affecting Pain
Remove or alter the cause of pain: change body positions, empty distended bladder, loosen tight bindings
Alter factors affecting pain tolerance: promote rest, sleep; encourage use of pain medication
Initiate non-pharmacologic relief measures: distraction, humor, music, imagery, relaxation techniques, cutaneous stimulation (TENS unit), hypnosis, biofeedback, therapeutic touch

64. Transcutaneous electrical nerve stimulation (TENS unit)

65. Pharmacologic Pain Relief Measures Selecting analgesics
Pharmacological – Analgesics
Non-opiods – act on peripheral nerve ending at the injury site (Tylenol, NSAIDS)
Opiods – Act on the CNS (Morphine, Codeine, Demerol; also synthetic opiods like Dilaudid)
Adjuvants/Co-analgesics – Used in combination with opiods (benzodiazapines: Valium, Ativian)

66. Selecting analgesics - WHO Ladder

67. Additional Methods for Administering Analgesics
Patient-controlled analgesia
Epidural analgesia
Local anesthesia

68. PCA pump: Patient Controlled Analgesia

69. PCA: Patient Controlled Analgesia

70. Placement of an Epidural Catheter

71. Scheduling Analgesic Doses
Preventive approach to pain management is crucial
Nurses should be able to anticipate procedures and activities which will cause pain and pre-medicate the patient
Pain should be controlled “ATC” or around the clock with long-acting medications and/or prn with “break-through” medications
When pain is out of control, larger doses are required

72. Comfort Measures Provide quiet, clean, uncluttered environment
Provide warmth or coolness as indicated
Provide personal hygiene: keep patient clean and dry, linen changes, oral care
Provide activity as indicated: TV, radio, reading material
Explain all procedures, tests, hospital routines
Facilitate family visits and support
Check with patient at regular intervals about his comfort/discomfort
Keep call light within reach and encourage patient to call you if needed

73. Focus on the Patient