Basic Needs and Comfort Measures

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

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

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

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

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

Abraham Maslow (1908 - 1970)

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

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.

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

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

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

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

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

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.

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)

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

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.

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

Nursing Process Assessment Diagnosis Planning Intervention Evaluation

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

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

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

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.

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

Comfort Measures - Pain

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”

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.”

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

Categories of Pain Duration Location or source Mode of transmission Etiology

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

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

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

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.

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

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

Referred Pain

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

Peripheral Neuropathy

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

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

Pain Process: Transduction, Transmission, Perception, Modulation

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

Pain Reception

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

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

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

Gate Control Theory

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

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

Pain Scale

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?

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

Establishing a Relationship

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

Transcutaneous electrical nerve stimulation (TENS unit)

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)

Selecting analgesics - WHO Ladder

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

PCA pump: Patient Controlled Analgesia

PCA: Patient Controlled Analgesia

Placement of an Epidural Catheter

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

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

Focus on the Patient