1. Chapters 41-42 By N.Haliyash, MD, BSN
Comfort and pain Sleep
Chapters 41-42
By N.Haliyash, MD, BSN

2. By the end of the lecture students will be able to:
Describe types of pain.
Assess the nature of pain as it relates to onset, intensity, and duration.
Discuss the physiology of pain.
Describe nonpharmacologic interventions in pain control.
Discuss the use of pharmacologic interventions in pain control.
Describe the stages of sleep.
Discuss age-related sleep variations.
State the outcomes of sleep deprivation on an individual.
Discuss nursing interventions that promote comfort, rest, and sleep.

3. All pain is real, and all pain is subjective.
“Pain is whatever the experiencing person says it is, existing whenever he says it does”
McCaffery and Pasero (1999)

4. The experience of pain and the quality of rest and sleep are both factors that can have a significant impact on a client’s health.
Both are personal experiences that can affect all other aspects of an individual’s health, including:
physical well-being,
mental status,
and effectiveness of coping mechanisms.

5. subjective = dependent on client’s perception
Pain
Pain is a universal experience.
Pain is a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation.
Pain is a subjective experience.
subjective = dependent on client’s perception

6. Pain
Nature of Pain
Can be a protective mechanism to prevent further injury
Warning of potential tissue damage

7. Nature of Pain Common Myths About Pain
The nurse is the best judge of a client’s pain.
If pain is ignored, it will go away.
Clients should not take any measures to relieve their pain until the pain is unbearable.
Most complaints of pain are purely psychological.
Taking pain medication causes addiction.

8. Types of Pain Pain can be described in two basic ways: Cause or origin
Description or nature

9. Types of Pain
Cutaneous pain is caused by stimulation of the cutaneous nerve endings in the skin.
Somatic pain is nonlocalized and originates in support structures.

10. Types of Pain Visceral pain is discomfort in the internal organs.
Referred pain is pain originating from the abdominal organ.
It is often called referred because the sensation of pain is not felt in the organ itself but instead is perceived at the spot where the organs were located during fetal development.

11. Types of Pain
Acute pain is most frequently identified by sudden onset and relative short duration.
Acute pain is mild to severe intensity, and a steady decrease in intensity over a period of days to weeks.
Once the noxious stimulus is resolved, the pain usually decreases.
Examples of noxious stimuli are:
needle sticks,
surgical incisions,
burns,
and fractures.

12. Types of Pain
Recurrent acute pain is identified by repetitive episodes that may recur over a prolonged period of time or throughout the client’s lifetime.
These painful episodes alternate with pain-free intervals.
Examples of recurrent pain include:
Migraine headaches,
sickle cell pain crises,
and the pain of angina pectoris due to myocardial hypoxia.

13. Types of Pain Chronic Pain
Long-term, (lasting 6 months or longer), persistent, nearly constant, or recurrent pain
Produces significant negative changes in client’s life
May last long after the pathology is resolved

14. Types of Pain
Chronic acute pain occurs almost daily over a long period, has the potential for lasting months or years, and has a high probability of ending.
Examples of pathophysiology that leads to chronic acute pain, which may last for long periods before the condition is cured or controlled:
Severe burn injuries
and cancer

15. Types of Pain
Chronic malignant pain occurs as a result of progressive tissue injury.
Chronic nonmalignant pain occurs in persons who do not have progressive tissue injury.

16. Types of Pain
There is a relationship between chronic conditions (including pain) and depression. Thus, the client experiencing chronic pain should always be assessed for the presence of depression.

17. Types of Pain
Examples of pathophysiology leading to chronic nonmalignant pain include:
Neuralgia (paroxysmal pain that extends along the course of one or more nerves)
Low back pain
Rheumatoid arthritis
Ankylosing spondylitis
Phantom limb pain (a form of neuropathic pain that occurs after amputation with pain sensations referred to an area in the missing portion of the limb)
Myofascial pain syndromes (a group of muscle disorders characterized by pain, muscle spasm, tenderness, stiffness, and limited motion)

18. Physiology of Pain
Nociceptive pain is the process by which an individual becomes consciously aware of pain.
Nociceptors are receptive neurons
for painful sensations

19. Physiology of Pain
Four principle processes are involved in nociception.
Transduction
Transmission
Perception
Modulation

20. Nociceptive Pain
Transduction of pain involves the changing of noxious stimuli in sensory nerve endings to energy impulses.

21. Nociceptive Pain
Transmission of pain involves the movement of impulses from site of origin to the brain.
Reflex arc

22. Reflex Arcs

23. Transmission of Pain Gate Control Theory of Pain
Recognizes the psychological aspects of pain.
A gate control system serves to block the individual’s s perception of pain.

24. Gate Control Theory: Blocking Transmission of Pain

25. Nociceptive Pain
Perception of pain occurs when the pain impulse has been transmitted to the cortex and the person develops conscious awareness of the intensity, location, and quality of pain.

26. Nociceptive Pain
Modulation of pain refers to activation of descending neural pathways that inhibit transmission of pain.

27. Factors Affecting the Pain Experience
Age and gender
Stress and anxiety
Previous experience with pain
Cultural norms and attitudes

28. Pain Assessment Data Collection Intensity Location
Quality (radiating, burning, diffuse)
Associated manifestations (factors that often accompany the pain, such as nausea, constipation, or dizziness)
Aggravating factors (variables that worsen the pain, such as exercise, certain foods, or stress)
Alleviating factors (measures the client can take that lessen the effect of the pain, such as lying down, avoiding certain foods, or taking medication)

29. Pain Assessment Data Collection
Pain threshold is the level of intensity at which pain becomes appreciable or perceptible and varies with each individual and type of pain.
Pain tolerance is the level of intensity or duration of pain the client is willing or able to endure.

30. Data Collection Assessment Tools Initial Pain Assessment Tool
Pain Intensity Scales
Pain Diary
Psychosocial Pain Assessment

31. Data Collection Developmental Considerations
Infants, children and adolescents
Older clients

32. Nursing Diagnoses
Acute Pain
Chronic Pain

33. Outcome Identification and Planning
Planning focuses on mutual goal-setting to reach realistic outcomes.
Both nonpharmacologic and pharmacologic interventions are used in planning strategies to control or maintain clients at desired levels of functioning and pain.

34. Implementation
Nurse-Client Relationship
Trust
Client Education

35. Implementation Principles of Pharmacologic Pain Management
Combine analgesics
Maintain therapeutic serum levels
Choose appropriate routes of administration

36. Implementation Principles of Pharmacologic Pain Management
Pain Medications
Nonsteroidal anti-inflammatory drugs (NSAIDS)
Opioid analgesics
Local anesthesia
Tolerance, Physical Dependence, and Addiction
Respiratory Depression

37. Implementation Treatment of Neuropathic Pain
Focus of treatment is optimizing functional abilities.
Medications

38. Implementation Cognitive-Behavioral Interventions Distraction
Reframing
Biofeedback
Cutaneous stimulation
Transcutaneous stimulation

39. Implementation Complementary and Alternative Therapies
Acupuncture and acupressure
Herbs
Nutrition
Physical stimulation
Relaxation techniques
Environment manipulation

40. Evaluation Client’s facial expression and posture
Presence (or absence) of restlessness
Vital sign monitoring
Ongoing use of pain assessment tools