Presentation on theme: "Pain Management, Comfort, Rest, and Sleep. The Meaning of Comfort Comfort – To give strength and hope, to cheer, and to ease the grief or trouble of another."— Presentation transcript:
Pain Management, Comfort, Rest, and Sleep
The Meaning of Comfort Comfort – To give strength and hope, to cheer, and to ease the grief or trouble of another One of the greatest challenges for the nurse is to provide comfort to the patient Promoting physical comfort is a vital part of the role of a nurse.
Comfort and well-being can be promoted with eye contact and gentle touch.
Providing Comfort Lack of comfort can be the result of many factors and can take many forms such as: – AnxietyNausea – DepressionPain – DiarrheaPowerlessness – DyspneaUrinary Retention – FatigueIncontinence – FearHypoxia – Headache
Providing Comfort The nurse should pursue methods to assist the patient in achieving relief from discomfort. – Actively listen – Recognize non-verbal discomfort signals – Be diligent in your efforts – If interventions are not successful, pursue alternative interventions
Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in the US.
Nature of Pain A complex, abstract, personal subjective experience
Nature of Pain Per the American Pain Society and the International Association for the Study of Pain: – An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Nature of Pain -unpleasant sensation -noxious stimulation of the sensory nerve endings -warning system to the body -actual or potential tissue damage -sign of inflammation and/or infection -diagnosis of many disorders and conditions -no tissue damage, such as the pain of grief
Interpretation and significance of the pain Individuals learned experiences Psychosocial and cultural factors. Expert is the person who is bearing the pain: -location -intensity -quality -pattern Degree of pain relief obtained from therapy. Pain is Multifaceted
Psychological factors that influence the perception of pain Increased Pain – Sadness, Depression – Fatigue – Anger – Discomfort – Insomnia – Anxiety – Fear Decreased Pain – Happiness – Rest – Diversion – Relief of symptoms – Sleep – Sympathy – Understanding
Nature of Pain Nursing goal – empower the patient to be an active partner in reporting information about the pain Pain history – patients description – optimal pain management.
Nursing Assessment of Pt. Pain Obtain a baseline perspective In the past, failed efforts to control the pain plan future therapy. Complete a physical examination Persistent pain consider: -physiologic cause is not always obvious or identifiable
Types of Pain Acute Pain Intense and of short duration -comes on quickly -very definite symptoms -can be quite intense -heal in a relatively brief period of time. Autonomic response -Sympathetic Nervous System Floods the body with epinephrine mediator for fight or flight response
Chronic Pain Generally characterized a pain lasting longer than 6 months Continuous or intermittent Can be intense Chronic pain does not serve as a warning of tissue damage in process but rather signals the fact of its having occurred. Changes in the behavior of the patient Development of fear-avoidance strategies Precursor of chronic disability
Chronic Pain Fundamental mechanisms sustaining the pain has become independent of the initial injury or damage -difficult to treat -very frustrating for patient and health providers. -chronic low self-esteem -change in social identity -changes in role and social interaction -fatigue -sleep disturbance -depression/suicidal ideation Syndrome of Chronic Pain
Chronic Pain Treating chronic pain – identify source [although it may be unknown] – referral to Pain Management Specialist as soon as possible – requires a multidisciplinary approach
Referred Pain: Felt at a site other than the injured organ or part of the body
Nociceptor A peripheral nerve organ or mechanism for the reception and transmission of painful or injurious stimuli
Peripheral Nociceptors Unspecialized cell endings -free endings -detect chemical substances released from damaged tissue. -skin, muscle, joints, and some visceral tissues
Theories of Pain Transmission Gate Control Theory – Small diameter nerve fibers carry pain stimuli through a gate mechanism – Larger diameter nerve fibers go through the same gate – If other cutaneous stimuli besides pain are transmitted, the gate through which the pain impulse must travel is temporarily blocked by the other stimuli. – The brain does not have the capacity to acknowledge the pain impulse when it is interpreting the other stimuli. – When gates are open, pain impulses flow freely.
Gate Control Theory Pain – Gate Theory cont. - The gate is shut by stimulating nerves responsible for carrying the touch signal bombardment of sensory impulses -Enables the relief of pain through massage techniques, rubbing, and application of hot and cold packs - The gate mechanism is shut by stimulating the release of endorphins – Chemicals released by the body in response to pain stimuli
Endorphins Natural supply of morphine-like substances – neurotransmitters that activate opiate receptors – Stress and pain activate endorphins analgesia Certain endorphins attach to opioid receptors in the brain preventing release of neurotransmitters inhibition of the transmission of pain impulse
Endorphins People who have less pain than others from a similar injury have been found to have higher endorphin levels. Acupuncture, TENS unit and placebos are believed to cause the release of endorphins.
Older Adult Considerations Changes in drug absorption, distribution, metabolism and elimination – affect the plasma levels/analgesic drug levels – drug absorption may be altered – increased gastric pH and decreased gastric motility – distribution of drugs may change – decrease in lean body mass or plasma proteins and albumin level secondary to chronic illness and poor nutrition.
Older Adult Considerations Hepatic blood flow, renal blood flow and glomerular filtration rate are decreased Elimination of drugs may change as renal and hepatic clearance decreases. Management of acute pain in the elderly involves: - careful titration of analgesic doses -assessing patients frequently for inadequate pain control and for adverse side effects
Age and Pain Control Psycho-social issues in the elderly r/t pain: – Misconceptions pain perception decreases with age elderly cannot tolerate opioids – Inadequate assessment difficult in patients with cognitive impairment, dementia, aphasia
Age and Pain Control Psycho-social issues in the elderly r/t pain: (cont.) – Lack of education fear of addiction (patient, health care giver) patient expects to have pain patient unfamiliar/unwilling to use equipment: e.g. PCA may be as simple as HOH or needs repetitive instructions
Analgesic options in the elderly Pharmacologic options – use around the clock dosing – start with low dose (25% to 50% of usual adult dose), titrate up slowly – use adjuncts (acetaminophen or NSAID) for opioid sparing effect – patient monitoring for sedation, respiratory depression
Analgesic Options in the Elderly Nonpharmacologic Options -heat or cold -massage -exercise -transcutaneous electrical nerve stimulation (TENS). -Cognitive-behavioral techniques -education/instruction -relaxation -imagery -music -biofeedback
Pediatric Pain Just because you cant talk, doesnt mean you dont have pain – Crying – Restlessness or agitation – Thrashing – Stiffened arms and legs – Increases in heart rate and blood pressure – Ask the mother !!!!!
Pediatric Pain Developmental Effects of Unrelieved Pain – Increased behavioral/physiologic responses – Altered temperaments – Somatization –psychological needs are expressed in physical symptoms – More distress behaviors – Altered development of the pain conduction system – Stress disorders, addictive behavior and anxiety states – Lowered pain threshold
Pain The Fifth Vital Sign American Pain Society recommendations goal is to ensure pain is treated with the same zeal as any changes in pulse, temperature, blood pressure, and respirations would receive. A strategy to increase accountability for pain control
Pain The Fifth Vital Sign Pain Assessment – Ask patients about their pain – Accept and respect what they say – Use Nursing Process Assess Diagnose and Plan Implement Evaluate 50% of people who suffer moderate to severe pain will continue to suffer because nurses fail to assess pain.
Pain The Fifth Vital Sign Unrelieved pain has harmful physical effects Increased oxygen demand Respiratory and cardiac function stressed Decreased gastrointestinal motility Confusion Depressed immune response Anxiety, depression and irritability Inability to enjoy life Delaying analgesia until pain is severe has no benefits
JCAHO Standards for Pain Control Joint Commission on Accreditation of Healthcare Organization – – Our Mission: To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.
JCAHO Standards for Pain Control Under the new JCAHO standards – Health care providers -knowledgeable about pain assessment and management – Facilities -develop policies and procedures -appropriate use of analgesics and other pain control therapies.
Key Concepts – Patients have the right to: -appropriate assessment. -be treated for pain or referred for treatment. -be assessed and regularly reassessed. -be taught effective pain management. -be taught that pain management is a part of treatment. JACHO Standard of Care
Patients have the right to: (cont.) -be involved in making care decisions. -routine and PRN analgesics are to be administered as ordered. -continuing care based on the patients need at the time of discharge, including the need for pain management
Nursing Assessment of Pain Subjective Data collection: – Obtain accurate information from the patient pt. c/o pain provides no useful data Assess all characteristics of pain Obtain socio-cultural information – Encourage patients to use their own words Quote the patient as needed
Nursing Assessment of Pain Subjective Data Collection ( cont. ) – Validated pain scale. -use the same pain scale = the one the patient chooses. – Document so that all involved in the patients care have a clear understanding of the pain problem.
Pain History Critical Elements of the Pain History – How the pain developed – Description of the pain – Location of the pain and any spread – The pattern of the pain over time – The patients pre-morbid and current levels of function and impairment (how does the pain interfere with activity?) – What aggravates or relieves pain – Previously attempted treatments
Nursing Assessment of Pain Objective Data Carefully observe the patient for: Tachycardia rate and depth of breathing Diaphoresis BP Pallor; dilated pupils Increased muscle tension
Nursing Assessment of Pain If the pain is chronic or less severe, observe for: – Changes in facial expression – Frowning, gritting teeth – Clenched fists – Withdrawal or c/o – Pacing – Wanting constant attention or to be left alone
Nursing Interventions Comfort measures/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.
Nursing Interventions Comfort Measures cont. – Check tape to prevent pulling on skin. – Position patient in anatomic alignment. – Check temperature of hot or cold applications, including bath water. – Lift, not pull, patient up in bed; handle gently. – Position patient correctly on bedpan. – Avoid exposing skin or mucous membranes to irritants.
Nursing Interventions Other Comfort Meas ures: – 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. – Just saying I believe that you are in pain and I will assist you in whatever way I can to relieve your pain
Its as easy as ABCDE ! Ask about pain regularly. Assess pain systematically. Believe the patient and family in their reports of pain and what relieves it. Choose pain control options appropriate for the patient, family and setting. Deliver intervention in timely, logical and coordinated fashion. Empower patients and their family. Enable them to control their course to the greatest extent possible
Unrelieved Pain Erodes the patients quality of life. About 50 million Americans (1 in 5) report persistent or intermittent pain annually.
Unrelieved Pain: -Public Health Problem Estimated to cost billions of dollars in direct and indirect expenses. Improved knowledge and practice of principles of pain assessment and management.
Nursing Interventions Treated aggressively Nurses role in pain management is important Advocate for the patient -clarifying concerns -answering questions -supplying information the patient needs to make decisions about care -supporting the patients decisions.
Analgesics Goal: effective pain relief without causing loss of consciousness Selection of proper analgesic – Effectiveness of the agent – Duration of action – Desired duration of therapy – Ability to cause drug interactions – Hypersensitivity of the client – Available routes of drug administration
Placebo Effect Occurs when a person responds to the medication (or other treatment) because of an expectation that the medication (or treatment) will work rather than because it actually does so. American Pain Association recommends that facilities have policies in place prohibiting the use of placebos – Educational programs should be conducted for nurses and other healthcare providers about effective pain management – Ethics committee should assist in developing and disseminating these policies
Placebo Effect Factors that influence the placebo effect include: -characteristics of the placebo -pill looks genuine -believe that it contains medicine -larger sized pills suggest a stronger dose than smaller pills -two pills appears more potent than swallowing just one -injections have a more powerful effect than pills.
Noninvasive Pain Relief Techniques Advantages – - some self control over the treatment of pain – - inexpensive and easy to perform – - low risk and few side effects
Noninvasive Pain Relief Techniques Transcutaneous Electrical Nerve Stimulation (TENS) A special device transmits low-voltage electrical impulses through electrodes on the skin to an area of the body that is in pain Considered safe Electrical current that is too intense or use incorrectly can burn or irritate the skin.
Noninvasive Pain Relief Techniques – Distraction Turns attention to something other than the pain. -"take their minds off" the pain. – Relaxation Reduces tension in the muscles. – Other: guided imagery, biofeedback, meditation, and hypnosis – See P. 399 FON Table 16-1
Invasive Approach to Pain Management Invasive = Anything that enters the body Risks are high Examples invasive procedures/risks: – Nerve blocks Complications Pneumothorax, hemorrhage, infection, paresis, paralysis, bowel or bladder dysfunction – Epidural analgesics unexpected and unusual side effects, pedal edema and excessive perspiration.
Medication for Pain Management Nonopioids – NSAIDS and Acetaminophen – frequently used, widely available – headache, mild to moderate pain – over the counter (OTC), inexpensive – ceiling effect – doses higher than the recommended dose will not produce greater pain relief, but can cause toxicity. – no physical dependence
NSAIDS Aspirin: – Most widely used – Oldest and cheapest – Reduce inflammation and pain – inhibits the synthesis of prostaglandin – Reduce fever stimulating the hypothalamus peripheral blood vessel dilation increase sweating/promotes heat loss.
NSAIDS Aspirin (cont.) Adverse Reactions Irritation of the GI tract -gastric ulceration/hemorrhage Nausea /vomiting, thirst Interfere with blood clotting Interferes with Ibuprofen if taken concurrently Could cause Respiratory Alkalosis from respiratory center stimulation (hyperventilation)
NSAIDS Aspirin (cont.) – High doses -CNS over-stimulation -tinnitus and/or hearing loss -confusion, impaired vision – Children with viral infections (cold or chicken pox) -Risk for Reyes Syndrome if take aspirin
NSAIDS Acetaminophen OTC -over 200 types of pain relievers and cold remedies maximal therapeutic dose is 4 Gram per day. -inhibiting prostaglandin synthesis in the central and peripheral nervous system -inhibition of the synthesis or actions of other substances that sensitize pain receptors to stimulation.
NSAIDS Acetaminophen (cont.) Reduces fever -acts on the heat-regulating center of the hypothalamus. -drug of choice to treat fever and flu-like symptoms in children.
NSAIDS Acetaminophen (cont.) – Adverse Reaction Skin rash, hypoglycemia, neutropenia Acute overdose causes hepatic necrosis. Long-term ingestion of large doses can result in nephropathy Give with caution to children younger than age 2 Not to be administer to children for more than 5 days or to adults for more than 10 days Keep track of daily acetaminophen intake including combination drugs daily.
Nonselective NSAID Action: – anti-inflammatory – analgesic and antipyretic effects – inhibit prostaglandin synthesis by blocking two enzymes known as cyclooxygenase-1 (Cox-1) and cyclooxygenase-2 (COX-2) – also known as: COX-1 and COX-2 Inhibitors
Members of Selective NSAIDS Selectively block COX-2 enzymes, thereby inhibiting prostaglandin synthesis This produces the analgesic and anti-inflammatory effects without causing the adverse GI effects associated with COX-1 inhibition Valdecoxib (Bextra) Celecoxib (Celebrex) Rofecoxib (Vioxx) Off the market since 10/2004
Selective NSAIDS Adverse Reaction Dyspepsia Nausea and Vomiting GI Ulcer (lesser degree with nonselective NSAIDS) Hypertension Fluid retention Peripheral edema Dizziness Headache Controlled clinical trials show that the COX-2 selective agents (Vioxx, Celebrex, and Bextra) may be associated with an increased risk of serious cardiovascular events (heart attack and stroke) especially when they are used for long periods of time or in very high risk settings.
Risk for NSAID complications Age greater than 60 History of peptic ulcer disease Previous intolerance to NSAIDs History of GI Hemorrhage High-dose NSAID therapy Long-term NSAID therapy Cigarette smoking History of alcoholism Multiple NSAID use Anticoagulation therapy Corticosteroid therapy Concomitant serious illness
Opioid Analgesics Treat moderate to severe acute pain A derivative of opium plant Can obtain synthetic drug with similar properties Mimics the bodys natural pain control mechanism Affect the smooth muscles Affects contraction of the bladder and ureters Slows intestinal peristalsis Causes vasodilatation Suppress the cough center of the brain Constriction of the bronchial muscles
The Opioid Group of Drugs Codeine Fentanyl Citrate Hydrocodone Hydromorphone hydrochloride (Dilaudid) Levorphanol tartrate (Levo-Dromoran) Meperidine HCL Methadone HCL Morphine Sulfacte Oxycodone Oxymorphone (Opana) Propoxyphene Remifentanil (Ultiva) Sufentanil (Sufenta)
Opioid Analgesics Adverse Reaction *Most dangerous: potential to cause depression of vital nervous system functions Eg. Decreased rate and depth of breathing * Other adverse reactions: Nausea and vomiting Constipation Hypotension Pruritis MiosisPinpoint Pupils *May trigger asthmatic attacks in a susceptible patient *Flushing, orthostatic hypotension
Opioid Analgesics – Adverse Reactions cont. Myoclonus -higher opioid doses of Dilaudid. Urinary retention Sedation, confusion, euphoria, hallucinations, and dizziness The Toxicity Triad Catastrophic respiratory depression Stupor or coma Pinpoint pupils Demerol (Meperidine HCL) rarely used anymore because of neurotoxicity problems
Opioid Analgesics Pharmacokinetics – Administered by any route – Oral doses are absorbed readily – IV provides the most immediate reliable relief – transmucosal and intrathecal routes are fast acting – SQ and IM injections may have delayed absorption
Opioid-induced Constipation Due to: – delayed gastric emptying – slow bowel motility – decreases peristalsis – reduces secretions from the colonic mucosa – slow-moving, hard stool that is difficult to pass – ileus, fecal impaction, and obstruction. preventative bowel program
Constipation Treatment: – foods high in fiber -fresh fruits/vegetables -whole grain breads/cereals, -unprocessed bran – Dietitian consult – drink plenty of liquids. – exercise as much as tolerated
Constipation – Provide toilet or bedside commode – set aside time for sitting on the toilet or commode, preferably after a meal. – Provide hot drink about half an hour before planned time for a bowel movement. – bulk laxative such as Metamucil as ordered – Stool softeners – laxatives.
Tolerance and Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects A socially unacceptable use of drugs or chemical substance for non therapeutic purposes Involves a craving for and compulsive use of drugs Tolerance -reduced effect from the use of a substance resulting from its repeated use over time. -greater amount of substance to produce the same result
Tolerance and Addiction Habituation -repeated substance use in which a person feels better when using the substance than when not using it. Dependence - difficulty functioning unless under the influence of a drug or other chemical substance. - a persons body adapts to the drug. If the drug is stopped withdrawal symptoms which include: muscle aches, watery nose and eyes, irritability, sweating and diarrhea
Tolerance and Addiction Tolerance and physiological dependence : -unusual with short-term postoperative use -psychological dependence and addiction are extremely unlikely after taking opiates for acute pain (< 0.1%)
Tolerance and Addiction Finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle
Drug Classification Over-the-counter (OTC) Prescription (controlled substance) – Schedule Ihighest potential for abuse – Schedule II – Schedule III – Schedule IV – Schedule Vlowest potential for abuse
Controlled Substances Schedule I and II drugs -kept separate from all other records of the handler Schedule III, IV, and V substances -kept in a "readily retrievable" form. -kept under double lock. -narcotic count done at every change of shift. -one nurse counts drugs and one nurse records
Controlled Substances Licensed nurse/CMA has med cart keys -responsibility to account for all narcotics removed from drawer during her shift. Lost narcotic must be accounted for MDs have tracking numbers they must put on all narcotic prescriptions. Pharmacist must have original prescriptions... No copies, faxes, phone calls or s.
Opioid Antagonist Have a greater attraction for opiate receptors than opiods do Attach to opiate receptors but dont stimulate them Prevent opioid drugs from producing their effects reversing sx/s of opioid drug depression of CNS Drugs: Naloxone hydrochloride (Narcan) Naltrexone hydrochloride (Revia) Used primarily in the management of alcohol and opoid dependence.
Opioid Antagonist Side Effects Nausea and vomiting Hypertension, tachycardia Hyperventilation Muscle tremors Drug Interactions None Pharmokinetics Administered IM, SC or IV Metabolized by the liver and excreted by the kidneys
Adjuvant Analgesics Adjuvant analgesics are drugs whose initial use was not for pain but rather for other conditions. They are a diverse group of drugs that includes steroids, antidepressants, anticonvulsants and others.
Administration Routes for Analgesics Oral Optimal route, especially for chronic pain Convenient, flexible, and relatively steady blood levels Use as soon as the patient can tolerate oral intake For ambulatory surgical patients Intravenous (IV) Route of choice after major surgery Bolus and continuous infusion Intramuscular (IM) Unreliably absorbed Painful and traumatic May cause fibrosis of muscle and soft tissue
Administration Routes Sublingual or buccal Place in the mouth, either under the tongue (sublingual) or between the gum and the cheek (buccal) Eg. Nitroglycerin Small, quick-dissolving tablets, sprays, lozenges, suckers or liquid suspensions Extremely effective, because it bypasses the hepatic system Not all medications can be prepared for sublingual or buccal administration
Administration Routes Skin Patches – used to relieve moderate to severe pain that occurs constantly Rectal Suppositories – Good choice if oral route is unavailable and drug is unavailable as sublingual. – Most drugs can be compounded in a pharmacy – Many clients reluctant to use this route
Patient-Controlled Analgesic Device. This drug delivery system allows patients to administer pain medications whenever needed. Analgesia is more effective when the patient in control of dosage. Patient must be alert, oriented, and able to follow simple directions.
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 – Side effects urinary retention, postural hypotension, pruritus, nausea/vomiting, respiratory depression
Food/Drug/Herb Interaction -In China it is common for herbs to be combined with drugs -Herbs reduce the side effects of drugs and help them to perform their function better; – herb formula work more strongly and quickly -more desirable result than either taken alone -little attention has been paid to adverse herb-drug interactions.
Sleep and Rest
A patient at rest feels: – mentally relaxed – free from worry – physically calm – free from physical/mental exertion.
Sleep and Rest Sleep is: – A cyclical physiologic process that alternates with longer periods of wakefulness. – A time for repair and recovery of body systems for the next period of wakefulness. – Restorative : it restores a persons energy and feeling of well-being.
Sleep and Rest Sleep Cycle – Two Phases Rapid eye movement (REM) Nonrapid eye movement (NREM) – NREM is further divided into four stages Through which a sleeper progresses during a typical sleeping cycle. See Figure 16-7; p.411 FON
Sleep Deprivation 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. Cumulative sleep deprivation develops Sleep-wake cycles across the life span.
S leep deprivation is dangerous!! - sleep-deprived people tested by using a driving simulator or by performing a hand-eye coordination task -performed as badly as or worse than those who are intoxicated -magnifies alcohol's effects on the body -a fatigued person who drinks will become much more impaired than someone who is well-rested.
Sleep Deprivation – Physiologic Signs and Symptoms Hand tremors Decreased reflexes Slowed response time Reduction in word memory Decrease in reasoning and judgment Cardiac dysrhythmias – Psychological Signs and Symptoms Mood swings Disorientation Irritability Decreased motivation Fatigue Sleepiness Hyperexcitablity
Promoting Rest and Sleep – Determine the patients usual rest and sleep patterns, decide whether they are sufficient, and note why the patient is not getting sufficient rest.
Promoting Rest and Sleep – Limit interruptions during the night -delete night shift vitals -quiet environment -comfortable room temperature. -limit the number of visitors/duration of visits – Have patient schedule visits times with family -carry out all procedures within a given time frame.
Promoting Rest and Sleep – Preparing the Patient for Sleep Wash the patients back. Gently massage the back. Change the linens. Make certain the patient is warm enough. Offer a decaffeinated beverage such as milk. Change soiled dressings. Have the patient void. Dim the lights and decrease the noise level.