2The Meaning of Comfort Comfort To give strength and hope, to cheer, and to ease the grief or trouble of anotherOne of the greatest challenges for the nurse is to provide comfort to the patientPromoting physical comfort is a vital part of the role of a nurse.
3Comfort and well-being can be promoted with eye contact and gentle touch.
4Providing ComfortLack of comfort can be the result of many factors and can take many forms such as:Anxiety NauseaDepression PainDiarrhea PowerlessnessDyspnea Urinary RetentionFatigue IncontinenceFear HypoxiaHeadache
5Providing ComfortThe nurse should pursue methods to assist the patient in achieving relief from discomfort.Actively listenRecognize non-verbal discomfort signalsBe diligent in your effortsIf interventions are not successful, pursue alternative interventions
6Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in the US.
7Nature of PainA complex, abstract, personal subjective experience
8Nature of PainPer 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.
9Nature of Pain -unpleasant sensation -noxious stimulation of the sensory nerveendings-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
10Pain is Multifaceted Interpretation and significance of the pain Individual’s learned experiencesPsychosocial and cultural factors.Expert is the person who is bearing the pain:-location intensity-quality patternDegree of pain relief obtained fromtherapy.
11Psychological factors that influence the perception of pain Increased PainSadness, DepressionFatigueAngerDiscomfortInsomniaAnxietyFearDecreased PainHappinessRestDiversionRelief of symptomsSleepSympathyUnderstanding
12Nature of Pain Nursing goal empower the patient to be an active partner in reporting information aboutthe painPain historypatient’s descriptionoptimal pain management.
13Nursing Assessment of Pt. Pain Obtain a baseline perspectiveIn the past, failed efforts to control the painplan future therapy.Complete a physical examinationPersistent pain consider:-physiologic cause is not alwaysobvious or identifiable
14Types 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 SystemFloods the body with epinephrine— mediator for “fight or flight” response
16Chronic PainGenerally characterized a pain lasting longer than 6 monthsContinuous or intermittentCan be intenseChronic 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 patientDevelopment of fear-avoidance strategiesPrecursor of chronic disability
17Chronic PainFundamental 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 ideationSyndrome of Chronic Pain
18Chronic Pain Treating chronic pain identify source [although it may be unknown]referral to Pain Management Specialist assoon as possiblerequires a multidisciplinary approach
19Referred Pain: Felt at a site other than the injured organ or part of the body
20NociceptorA peripheral nerve organ or mechanism for the reception and transmission of painful or injurious stimuli
22Theories of Pain Transmission Gate Control TheorySmall diameter nerve fibers carry pain stimulithrough a gate mechanismLarger diameter nerve fibers go through the samegateIf 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.
23Gate Control Theory Chemicals released by the body in response 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 endorphinsChemicals released by the body in responseto pain stimuli
24Endorphins Natural supply of morphine-like substances neurotransmitters that activate opiate receptorsStress and pain activate endorphins analgesiaCertain endorphins attach to opioid receptors in the brain preventing release of neurotransmitters inhibition of the transmission of pain impulse
25EndorphinsPeople 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.
26Older Adult Considerations Changes in drug absorption, distribution, metabolism and eliminationaffect the plasma levels/analgesic drug levelsdrug absorption may be alteredincreased gastric pH and decreased gastricmotilitydistribution of drugs may changedecrease in lean body mass or plasmaproteins and albumin level secondary to chronic illness and poor nutrition.
27Older Adult Considerations Hepatic blood flow, renal blood flow andglomerular filtration rate are decreasedElimination of drugs may change as renal andhepatic clearance decreases.Management of acute pain in the elderly involves:-careful “titration” of analgesic doses-assessing patients frequently for inadequatepain control and for adverse side effects
28Age and Pain Control Psycho-social issues in the elderly r/t pain: Misconceptionspain perception decreases with ageelderly cannot tolerate opioidsInadequate assessmentdifficult in patients with cognitive impairment, dementia, aphasia
29Age and Pain ControlPsycho-social issues in the elderly r/t pain: (cont.)Lack of educationfear of addiction (patient, health care giver)patient expects to have painpatient unfamiliar/unwilling to use equipment: e.g. PCAmay be as simple as HOH or needs repetitive instructions
30Analgesic options in the elderly Pharmacologic optionsuse around the clock dosingstart with low dose (25% to 50% of usual adult dose), titrate up slowlyuse adjuncts (acetaminophen or NSAID) for opioid sparing effectpatient monitoring for sedation, respiratory depression
31Analgesic 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
32Pediatric PainJust because you can’t talk, doesn’t mean you don’t have painCryingRestlessness or agitationThrashingStiffened arms and legsIncreases in heart rate and blood pressureAsk the mother !!!!!
33Pediatric Pain Developmental Effects of Unrelieved Pain Increased behavioral/physiologic responsesAltered temperamentsSomatization –psychological needs are expressed in physical symptomsMore distress behaviorsAltered development of the pain conduction systemStress disorders, addictive behavior and anxiety statesLowered pain threshold
34Pain “ The Fifth Vital Sign” American Pain Society recommendation’s 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
35Pain “The Fifth Vital Sign” Pain AssessmentAsk patients about their painAccept and respect what they sayUse Nursing ProcessAssessDiagnose and PlanImplementEvaluate50% of people who suffer moderate to severe pain will continue to suffer because nurses fail to assess pain.
36Pain “The Fifth Vital Sign” Unrelieved pain has harmful physical effectsIncreased oxygen demandRespiratory and cardiac function stressedDecreased gastrointestinal motilityConfusionDepressed immune responseAnxiety, depression and irritabilityInability to enjoy life Delaying analgesia until pain is severe has nobenefits
37JCAHO Standards for Pain Control Joint Commission on Accreditation of Healthcare OrganizationOur 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.
38JCAHO Standards for Pain Control Under the new JCAHO standardsHealth care providers-knowledgeable about pain assessmentand managementFacilities-develop policies and procedures-appropriate use of analgesics and otherpain control therapies.
39JACHO Standard of Care 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.
40JACHO Standard of CarePatients 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 patient’s need at the time of discharge, including the need for pain management
41Nursing Assessment of Pain Subjective Data collection:Obtain accurate information from the patient“pt. c/o pain” provides no useful dataAssess all characteristics of painObtain socio-cultural informationEncourage patients to use their own wordsQuote the patient as needed
42Nursing Assessment of Pain Subjective Data Collection (cont.)Validated pain scale.-use the same pain scale = the one thepatient chooses.Document so that all involved in thepatient’s care have a clear understandingof the pain problem.
43Pain History Critical Elements of the Pain History How the pain developedDescription of the painLocation of the pain and any spreadThe pattern of the pain over timeThe patient’s pre-morbid and current levels of function and impairment (how does the pain interfere with activity?)What aggravates or relieves painPreviously attempted treatments
44Nursing Assessment of Pain Objective DataCarefully observe the patient for:Tachycardia↑ rate and depth of breathingDiaphoresis↑ BPPallor; dilated pupilsIncreased muscle tension
45Nursing Assessment of Pain If the pain is chronic or less severe, observe for:Changes in facial expressionFrowning, gritting teethClenched fistsWithdrawal or c/oPacingWanting constant attention or to be left alone
46Nursing Interventions Comfort measures/pain control.Tighten wrinkled bed linens.Reposition drainage tubes or other objects onwhich patient is lying.Place warm blankets for coldness.Loosen constricting bandages.Change moist dressings.
47Nursing 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; handlegently.Position patient correctly on bedpan.Avoid exposing skin or mucous membranesto irritants.
48Nursing Interventions Other Comfort Measures: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”
49It’s 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
50Unrelieved Pain Erodes the patient’s quality of life. About 50 million Americans (1 in 5)report persistent or intermittent painannually.
51Unrelieved 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.
52Nursing Interventions Treated aggressivelyNurse’s role in pain management is importantAdvocate for the patient-clarifying concerns-answering questions-supplying information the patient needs to make decisions about care-supporting the patient’s decisions.
53AnalgesicsGoal: effective pain relief without causing loss of consciousnessSelection of proper analgesicEffectiveness of the agentDuration of actionDesired duration of therapyAbility to cause drug interactionsHypersensitivity of the clientAvailable routes of drug administration
54Placebo EffectOccurs 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 placebosEducational programs should be conducted for nurses and other healthcare providers about effective pain managementEthics committee should assist in developing and disseminating these policies
55Placebo 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 dosethan smaller pills-two pills appears more potent thanswallowing just one-injections have a more powerful effect thanpills.
56Noninvasive Pain Relief Techniques Advantages- some self control over the treatment ofpain- inexpensive and easy to perform- low risk and few side effects
57Noninvasive Pain Relief Techniques Transcutaneous Electrical Nerve Stimulation (TENS)A special device transmits low-voltageelectrical impulses through electrodes on the skin to an area of the body that is in painConsidered safeElectrical current that is too intense or use incorrectly can burn or irritate the skin.
59Noninvasive Pain Relief Techniques DistractionTurns attention to something other than the pain.-"take their minds off" the pain.RelaxationReduces tension in the muscles.Other: guided imagery, biofeedback, meditation, and hypnosisSee P. 399 FON Table 16-1
60Invasive Approach to Pain Management Invasive = Anything that enters the bodyRisks are highExamples invasive procedures/risks:Nerve blocksComplicationsPneumothorax, hemorrhage, infection , paresis, paralysis, bowel or bladder dysfunctionEpidural analgesicsunexpected and unusual side effects, pedal edema and excessive perspiration.
62Medication for Pain Management NonopioidsNSAIDS and Acetaminophenfrequently used, widely availableheadache, mild to moderate painover the counter (OTC), inexpensiveceiling effectdoses higher than the recommended dosewill not produce greater pain relief, butcan cause toxicity.no physical dependence
63NSAIDS Aspirin: inhibits the synthesis of prostaglandin Most widely usedOldest and cheapestReduce inflammation and paininhibits the synthesis of prostaglandinReduce feverstimulating the hypothalamusperipheral blood vessel dilationincrease sweating/promotes heat loss.
64NSAIDS Aspirin (cont.) Adverse Reactions Irritation of the GI tract -gastric ulceration/hemorrhageNausea /vomiting, thirstInterfere with blood clottingInterferes with Ibuprofen if taken concurrentlyCould cause Respiratory Alkalosis from respiratory center stimulation (hyperventilation)
65NSAIDS Aspirin (cont.) High doses -CNS over-stimulation -tinnitus and/or hearing loss-confusion, impaired visionChildren with viral infections (cold or chicken pox)-Risk for Reye’s Syndromeif take aspirin
66NSAIDS Acetaminophen OTC -over 200 types of pain relievers and cold remediesmaximal therapeutic dose is 4 Gram per day.-inhibiting prostaglandin synthesis in the centraland peripheral nervous system-inhibition of the synthesis or actions of othersubstances that sensitize pain receptors tostimulation.
67NSAIDS Acetaminophen (cont.) Reduces fever -acts on the heat-regulating center of thehypothalamus.-drug of choice to treat fever and flu-likesymptoms in children.
68NSAIDS Acetaminophen (cont.) Adverse Reaction Skin rash, hypoglycemia, neutropeniaAcute overdose causes hepatic necrosis.Long-term ingestion of large doses can result in nephropathyGive with caution to children younger than age 2Not to be administer to children for more than 5 days or to adults for more than 10 daysKeep track of daily acetaminophen intake including combination drugs daily.
69Nonselective NSAID Action: two enzymes known as cyclooxygenase-1 anti-inflammatoryanalgesic and antipyretic effectsinhibit prostaglandin synthesis by blockingtwo enzymes known as cyclooxygenase-1(Cox-1) and cyclooxygenase-2 (COX-2)also known as: COX-1 and COX-2 Inhibitors
71Members of Selective NSAIDS Selectively block COX-2 enzymes, thereby inhibiting prostaglandin synthesisThis produces the analgesic and anti-inflammatory effects without causing the adverse GI effects associated with COX-1 inhibitionValdecoxib (Bextra)Celecoxib (Celebrex)Rofecoxib (Vioxx)Off the market since 10/2004
72Selective NSAIDS Adverse Reaction Dyspepsia Nausea and Vomiting GI Ulcer (lesser degree with nonselective NSAIDS)HypertensionFluid retentionPeripheral edemaDizzinessHeadacheControlled 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.
73Risk for NSAID complications Age greater than 60History of peptic ulcer diseasePrevious intolerance to NSAIDsHistory of GI HemorrhageHigh-dose NSAID therapyLong-term NSAID therapyCigarette smokingHistory of alcoholismMultiple NSAID useAnticoagulation therapyCorticosteroid therapyConcomitant serious illness
74Opioid Analgesics Treat moderate to severe acute pain A derivative of opium plantCan obtain synthetic drug with similar propertiesMimics the body’s natural pain control mechanismAffect the smooth musclesAffects contraction of the bladder and uretersSlows intestinal peristalsisCauses vasodilatationSuppress the cough center of the brainConstriction of the bronchial muscles
75The Opioid Group of Drugs CodeineFentanyl CitrateHydrocodoneHydromorphone hydrochloride (Dilaudid)Levorphanol tartrate (Levo-Dromoran)Meperidine HCLMethadone HCLMorphine SulfacteOxycodoneOxymorphone (Opana)PropoxypheneRemifentanil (Ultiva)Sufentanil (Sufenta)
76Opioid Analgesics Adverse Reaction *Most dangerous: potential to cause depression of vital nervous system functionsEg. Decreased rate and depth of breathing* Other adverse reactions:Nausea and vomitingConstipationHypotensionPruritisMiosis—Pinpoint Pupils*May trigger asthmatic attacks in a susceptible patient*Flushing, orthostatic hypotension
77Opioid Analgesics Adverse Reactions cont. “The Toxicity Triad” Myoclonus -higher opioid doses of Dilaudid.Urinary retentionSedation, confusion, euphoria, hallucinations, and dizziness“The Toxicity Triad”Catastrophic respiratory depressionStupor or comaPinpoint pupilsDemerol (Meperidine HCL) rarely used anymore because of neurotoxicity problems
78Opioid Analgesics Pharmacokinetics Administered by any route Oral doses are absorbed readilyIV provides the most immediate reliable relieftransmucosal and intrathecal routes are fast actingSQ and IM injections may have delayed absorption
79Opioid-induced Constipation Due to:delayed gastric emptyingslow bowel motilitydecreases peristalsisreduces secretions from the colonic mucosaslow-moving, hard stool that is difficult topassileus, fecal impaction, and obstruction.preventative bowel program
80Constipation Treatment: -fresh fruits/vegetables foods high in fiber-fresh fruits/vegetables-whole grain breads/cereals,-unprocessed branDietitian consultdrink plenty of liquids.exercise as much as tolerated
81Constipation planned time for a bowel movement. Provide toilet or bedside commodeset aside time for sitting on the toilet orcommode, preferably after a meal.Provide hot drink about half an hour beforeplanned time for a bowel movement.bulk laxative such as Metamucil as orderedStool softenerslaxatives.
82Tolerance and Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience it’s psychic effectsA socially unacceptable use of drugs or chemical substance for non therapeutic purposesInvolves a craving for and compulsive use of drugsTolerance-reduced effect from the use of asubstance resulting from its repeated useover time.-greater amount of substance to producethe same result
83Tolerance and Addiction Habituation-repeated substance use in which a personfeels better when using the substance thanwhen not using it.Dependence- difficulty functioning unless under theinfluence of a drug or other chemicalsubstance.- a person’s body adapts to the drug. If the drug is stopped withdrawal symptoms which include: muscle aches, watery nose and eyes, irritability, sweating and diarrhea
84Tolerance and Addiction Tolerance and physiological dependence :-unusual with short-term postoperative use-psychological dependence and addiction areextremely unlikely after taking opiates for acute pain (< 0.1%)
85Tolerance and Addiction Finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle
86Drug Classification Over-the-counter (OTC) Prescription (controlled substance)Schedule I—highest potential for abuseSchedule IISchedule IIISchedule IVSchedule V—lowest potential for abuse
87Controlled Substances Schedule I and II drugs-kept separate from all other records ofthe handlerSchedule III, IV, and V substances-kept in a "readily retrievable" form.-kept under double lock.-narcotic count done at every change ofshift.-one nurse counts drugs and one nurserecords
88Controlled Substances Licensed nurse/CMA has med cart keys-responsibility to account for all narcoticsremoved from drawer during her shift.“Lost” narcotic must be accounted forMDs have tracking numbers they must put on all narcotic prescriptions.Pharmacist must have original prescriptions No copies, faxes, phone calls or s.
89Opioid Antagonist Drugs: Have a greater attraction for opiate receptors than opiods doAttach to opiate receptors but don’t stimulate themPrevent opioid drugs from producing their effects reversing sx/s of opioid drug depression of CNSDrugs:Naloxone hydrochloride (Narcan)Naltrexone hydrochloride (Revia)Used primarily in the management of alcohol and opoid dependence.
90Opioid Antagonist Side Effects Drug Interactions Pharmokinetics Nausea and vomitingHypertension, tachycardiaHyperventilationMuscle tremorsDrug InteractionsNonePharmokineticsAdministered IM, SC or IVMetabolized by the liver and excreted by the kidneys
91Adjuvant AnalgesicsAdjuvant 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.
92Administration Routes for Analgesics OralOptimal route, especially for chronic painConvenient, flexible, and relatively steady blood levelsUse as soon as the patient can tolerate oral intakeFor ambulatory surgical patientsIntravenous (IV)Route of choice after major surgeryBolus and continuous infusionIntramuscular (IM)Unreliably absorbedPainful and traumaticMay cause fibrosis of muscle and soft tissue
93Administration Routes Sublingual or buccalPlace in the mouth, either under the tongue (sublingual) or between the gum and the cheek (buccal)Eg. NitroglycerinSmall, quick-dissolving tablets, sprays, lozenges, suckers or liquid suspensionsExtremely effective, because it bypasses the hepatic systemNot all medications can be prepared for sublingual or buccal administration
94Administration Routes Skin Patchesused to relieve moderate to severe pain that occurs constantlyRectal SuppositoriesGood choice if oral route is unavailable and drug is unavailable as sublingual.Most drugs can be compounded in a pharmacyMany clients reluctant to use this route
95Patient-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.
96Epidural AnalgesiaInsertion of an epidural catheter and the infusion of opiates into the epidural spaceMedication diffuses slowly from the epidural space across the dura and arachnoid membranes into the cerebrospinal fluidSide effectsurinary retention,postural hypotension,pruritus,nausea/vomiting,respiratory depression
98Food/Drug/Herb Interaction -In China it is common for herbs to becombined with drugs-Herbs reduce the side effects of drugs andhelp them to perform their function better;herb formula work more strongly and quickly-more desirable result than either takenalone-little attention has been paid to adverseherb-drug interactions.
100Sleep and Rest A patient at rest feels: mentally relaxed free from worryphysically calmfree from physical/mental exertion.
101Sleep 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 person’s energy and feeling of well-being.
102Sleep and Rest Sleep Cycle Two Phases Rapid eye movement (REM)Nonrapid eye movement (NREM)NREM is further divided into four stagesThrough which a sleeper progresses during a typicalsleeping cycle.See Figure 16-7; p.411 FON
103Sleep-wake cycles across the life span. Sleep DeprivationDecreases 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 developsSleep-wake cycles across the life span.
104dangerous!! Sleep deprivation is -sleep-deprived people tested by using a drivingsimulator or by performinga hand-eye coordinationtask-performed as badly as orworse than those who areintoxicated-magnifies alcohol's effectson the body-a fatigued person whodrinks will become muchmore impaired thansomeone who is well-rested.
105Sleep Deprivation Physiologic Signs and Symptoms Hand tremorsDecreased reflexesSlowed response timeReduction in word memoryDecrease in reasoning and judgmentCardiac dysrhythmiasPsychological Signs and SymptomsMood swingsDisorientationIrritabilityDecreased motivationFatigueSleepinessHyperexcitablity
106Promoting 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.
107Promoting Rest and Sleep Limit interruptions during the night-delete night shift vitals-quiet environment-comfortable room temperature.-limit the number of visitors/duration of visitsHave patient ‘schedule’ visits times with family-carry out all procedures within a given timeframe.
108Promoting Rest and Sleep Preparing the Patient for SleepWash the patient’s 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.