Chapter 31 Pain, Comfort, and Sleep Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 31 Lesson 31.1 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory 1) Discuss the application of The Joint Commission pain standards in planning patient care. 2) Give the rationale for why pain is considered the “fifth vital sign.” 3) Illustrate the physiology of pain using the gate control theory. 4) Describe the use of a variety of nursing interventions for pain control, including biofeedback, distraction, guided imagery, massage, and relaxation. Slide 3 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice 1) Assist the patient in accurately describing sensations of pain and discomfort. 2) Accurately and appropriately record the patient’s report of pain using clear, descriptive terms. 3) Assist the patient in using a transcutaneous electrical nerve stimulation (TENS) unit. 4) Evaluate the effects of various techniques used for pain control. 5) Assist with the care of patients receiving patient-controlled analgesia (PCA) or epidural analgesia. 6) Evaluate the effects of pain medication, and report and record observations appropriately. Slide 4 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain  Pain is the feeling of distress and discomfort  Affects or interferes with normal activity  No accurate objective measurement of pain  Pain assessment is performed along with each assessment of vital signs and is considered the “fifth vital sign” Slide 5 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain (cont’d)  Surgical patients experience postoperative pain  Many medical conditions cause pain  Headache, myocardial infarction  Cancer, fractures  Cuts and abrasions Slide 6 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Joint Commission: Pain Control Standards  Patients have the right to appropriate assessment and management of pain  Pain is assessed in all patients  Patients are educated about pain and managing pain as part of the treatment, as appropriate  The discharge process provides for continuing pain care based on the patient’s needs at the time of discharge Slide 7 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Theories of Pain  Pain defined as a feeling of distress or suffering caused by the stimulation of nerve endings  Pain serves as a warning of tissue damage and allows sufferer to withdraw from the source of the pain  Pain is transmitted through the nervous system Slide 8 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-1: Pain transmission Slide 9 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Gate Control Theory  Pain viewed as being controlled by a gate mechanism in the central nervous system  Opening the gate allows transmission of pain  Closing the gate blocks the transmission of pain  The gate may be opened by activity in small- diameter nerves, such as tissue damage  Large-diameter nerve activity seems to close the gate  Lack of input allows the gate to open Slide 10 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-2: The gate control theory of pain Slide 11 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endorphins  Endorphins are endogenous, naturally occurring opiate-like peptides that modify the perception of pain  They attach to opioid receptors and block pain  Physiologic and psychological stressors can cause the release of endorphins  Long-distance runners often get an endorphin high Slide 12 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain Descriptions  Type of pain  Severity of pain based on a pain scale  Quality of pain  Location of pain  Duration of pain  Degree of pain Slide 13 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Pain  Acute: short-term  Chronic: long-term  Nociceptive: injury to tissues  Neuropathic: sensitivity to stimuli  Phantom: after loss of body part Slide 14 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Acute Pain  Usually associated with injury, medical condition or surgical procedure  Short duration, lasting a few hours to a few days  May be described as aching or throbbing  Patient may be restless or agitated  Usually controlled with analgesics Slide 15 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Acute Pain (cont’d)  Causes include:  Burns, bone fractures, muscle strains  Pneumonia, sickle cell crisis, angina  Herpes zoster, inflammations, infections  May worsen in the presence of anxiety or fear  Usually relieved once the cause is removed Slide 16 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Chronic Pain  Pain that may continue for months or years  Often associated with conditions such as:  Arthritis  Chronic back pain  May be dull, constant, shooting, tingling, or burning  May be treated with both pharmacologic and nonpharmacologic interventions Slide 17 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Nociceptive Pain  Involves injury to the tissue in which receptors called nociceptors are located  May be found in skin, joints, or organ viscera  Four phases associated with nociceptive pain  Transduction  Transmission  Perception  Modulation Slide 18 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Nociceptive Pain (cont’d)  Treatments are aimed at one or all four phases  NSAIDs work at blocking transduction  Opioids block transmission  Distraction and guided imagery block perception  Drugs that block neurotransmitter uptake work on modulation Slide 19 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Neuropathic Pain  Associated with dysfunction of the nervous system  Pain receptors in the body become more sensitive to stimuli and send signals more easily  As nerve endings grow new branches, the signals become stronger  Often associated with Guillain-Barré syndrome, cancer, and HIV  Treated with NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids Slide 20 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Type of Pain: Phantom Pain  Occurs with loss of a body part from amputation  Patient may feel pain in the amputated part for years after the amputation  Not controlled by conventional methods  May be treated with TENS units implanted in the thalamus Slide 21 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Severity of Pain: Pain Scales  Pain scales  Number scale Rate the level of pain: 0 is pain-free; 10 is worst pain imaginable  Picture scale Shows faces in varying degrees of pain  NIPS (Neonatal Infant Pain Scale)  CRIES (Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, and Sleeplessness)  PIPP (Premature Infant Pain Profile) Slide 22 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-4: Pain number rating scale Slide 23 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-5: Wong-Baker FACES Pain Rating Scale for children Slide 24 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Quality of Pain: Perception of Pain  Assessment of pain: whatever the person says it is  Observable indicators (may not always be present)  Moaning  Crying  Irritability  Grimacing  Frowning  Rigid posture in bed  Described as rushing, throbbing, pulsating, twisting, pulling, burning, searing, stabbing, tearing, biting, blinding, nauseating, debilitating Slide 25 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Location of Pain  Area of pain  Name of affected body part (e.g., foot, hand, leg, or upper/lower abdomen)  Localized, radiating, generalized  Frequency of pain  Constant, intermittent, occasional Slide 26 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pain Control: Nonmedicinal Methods  Transcutaneous electrical nerve stimulation (TENS)  Percutaneous electrical nerve stimulation (PENS)  Binders  Application of heat and cold  Relaxation  Biofeedback  Distraction  Guided imagery and meditation  Music  Hypnosis  Massage Slide 27 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-6: TENS unit blocks pain signal transmission Slide 28 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Medicinal Pain Control: Medicinal Methods  Analgesic medications  Oral  Topical  Injected  Intravenous  Patient-controlled analgesia  Epidural analgesia Slide 29 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 31-9: CADD portable PCA pump in use by patient Slide 30 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 There are several different types of pain. Which type of pain occurs after the loss of a body part from an amputation? 1) Acute pain 2) Nociceptive pain 3) Neuropathic pain 4) Phantom pain Slide 31 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Kathy is working in a mother-baby unit. Which pain scale is used to determine if the baby is in pain? 1) FACES pain rating scale for children 2) FLACC scale 3) PIPP scale 4) NIPS Slide 32 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Karen’s patient is prescribed a COX-2 inhibitor for her pain. Which of the following is an example of a COX-2 inhibitor? 1) Aspirin 2) Morphine 3) Antiinflammatory 4) Antidepressant Slide 33 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 31 Lesson 31.2 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory 5) Analyzethe need for normal sleep. 6) Recognize how the need for sleep changes over the life span. 7) Delineate factors that can interfere with sleep. 8) Define the sleep disorders insomnia, sleep apnea, and narcolepsy. Slide 35 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice 7) Gather data regarding a patient’s sleep difficulties. 8) Develop a plan designed to assist the patient in getting adequate sleep. Slide 36 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Functions of Sleep  Adequate rest and sleep important factors in general health and recovery from illness  Being rested increases pain tolerance and allows improved response to analgesia Slide 37 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Stages of Sleep  Rapid eye movement (REM) sleep  Time in which you dream  A period of a high level of activity  Heart rate, blood pressure, and respirations are similar to that when awake Slide 38 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Stages of Sleep (cont’d)  Non–rapid eye movement (NREM) sleep  Believed to be the time when the body receives the most rest  Heart rate, blood pressure, and respirations decline Slide 39 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Normal Sleep Requirements  Newborns: At least 16 hours of sleep per day  Age 1: hours per day  Preschool: hours  School-Age: hours of sleep per night  Adolescents: 9-10 hours of sleep a night  Adults: 8 hours sleep a night Slide 40 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Factors Affecting Sleep  Working night or evening shifts, changing shifts  Traveling (jet lag), exposure to sunlight  Snoring  Caffeine, nicotine, or alcohol consumption  Exercise, taking naps  Stress, illness, fatigue  Discomfort  Environmental factors—heat, cold, light, noise Slide 41 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Insomnia  Difficulty in getting to sleep or staying asleep at night  Transient insomnia may be caused by stress, depression  Chronic insomnia can have many causes; may require treatment from a health care provider specializing in sleep disorders Slide 42 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Sleep Apnea  A condition in which the person will stop breathing for brief periods during sleep  Obstructive apnea—most common and severe; airway blocked at back of throat; snoring common; treatment is CPAP  Central apnea—diaphragm and chest stops working; person awakens to resume breathing  Mixed sleep apnea—combination of both Slide 43 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Snoring  Harsh sounds caused by vibration and/or obstruction of the air passages at the back of the mouth and nose  May be caused by poor muscle tone, excessive tissue, or deformities such as a deviated septum  A partial blockage of the airway  Sleeping on the side or losing weight may help Slide 44 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sleep Disorders: Narcolepsy  Sudden-onset, recurrent, uncontrollable, brief episodes of sleep during normal hours of wakefulness  May occur at any time and last from a few seconds to 30 minutes  Usually begins around age 25  No known cure Slide 45 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Karen’s patient is experiencing sudden-onset, recurrent, and uncontrollable brief episodes of sleep during hours of wakefulness. What condition does Karen’s patient have? 1) Insomnia 2) Sleep apnea 3) Narcolepsy 4) REM sleep Slide 46 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 Karen’s patient is going home with a prescription for a sleep aid. When teaching the patient about the medication, Karen should be sure to include: 1) medications should be used with alcohol. 2) medications for sleep are for short-term relief. 3) over-the-counter medications for sleep will keep you alert. 4) hypnotics are not used for sleep. Slide 47 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.