1. Chapter 19 Pain Management, Rest, and Restorative Sleep

2. Classifications of Pain
Acute: Sudden pain; short duration of less than 6 months
Chronic: Pain that lasts longer than 6 months
Intractable: Pain that cannot be relieved
Referred: Pain felt in an area other than where it was produced
Radiating: Pain that begins at a specific site and shoots out to a larger area beyond the origin site
Objective #1: Define various terms associated with pain management, rest, and restorative sleep.
Teach your students that pain serves as a warning sign indicating that actual damage has occurred or that the potential exists for damage of tissue. Define the following terms related to pain management:
Acute pain
Chronic pain
Intractable pain
Referred pain
Radiating pain (Refer to Figure 19-1.)
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.
Objective #5: Compare the different types of nociceptive and neuropathic pain.
Teach your students that there are many different classifications of pain.

3. Neuropathic Pain vs. Nociceptive Pain
Occurs due to injury or destruction of peripheral nerves or CNS
Extends beyond local region to broad area
Nociceptive
Occurs from the stimulation of nerve pain receptors (nociceptors)
Generally localized within a specific area
Objective #1: Define various terms associated with pain management, rest, and restorative sleep.
Compare and contrast neuropathic pain and nociceptive pain.
Discuss the descriptors of neuropathic pain: sharp, burning, prickly pin and needles, even numbness.
Discuss the descriptors of nociceptive pain: aching, cramping.
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.
Objective #5: Compare the different types of nociceptive and neuropathic pain.
Teach your students that there are many different classifications of pain.

4. Gate Control Theory
Explains the transmission and perception of pain and how interventions relieve the pain
Purports that the transmission of pain impulse to the CNS is controlled by a gate that responds to sensory input
The gate is open for pain to be transmitted to the brain
The gate is closed when the nerve impulse for pain is blocked from transmission
Objective #2: Explain the gate control theory.
Discuss the gate control theory. Point out that this theory states that the transmission of pain impulses to the central nervous system is controlled by a gate, which opens and closes in response to sensory input.

5. Stimulation of Nerve Fibers
Broad nerve fibers close the gate
Stimulated by exercise, heat, cold, massage, and transcutaneous electrical nerve stimulation (TENS)
Smaller, narrower nerve fibers open the gate
Stimulated by injury and damage to tissues
Objective #2: Explain the gate control theory.
Point out that experts believe that the thalamus can open and close the gate in relationship to stress and anxiety: an increase in stress can cause the gate to open, while decreased stress and anxiety can cause the gate to close. Note that stimulation of the broad nerve fibers is thought to close the gate, while stimulation of the narrow nerve fibers is thought to open the gate. Review the factors that stimulate the broad and narrow nerve fibers.

6. Patient Pain The pain is always what the patient says it is
It does not matter if the patient does not appear to be in pain
Falling asleep does not mean the patient does not have pain
Objective #3: Identify the expert regarding the level of a patient’s pain.
Teach your students that it is important to develop an understanding of pain and how to assist patients with pain relief or skills to cope with unrelieved pain. Note that the patient is always the expert about the pain he or she is experiencing.
Objective #8: Correlate acknowledgment and acceptance to treatment of pain.
Stress that the first step in assisting a patient to obtain maximum pain relief is letting the patient know you believe that he or she is in pain.
Point out that after obtaining a complete description of the patient’s pain, the nurse should be quick to respond with relief measures.

7. True/False Question
Endorphins are synthetic chemicals administered for pain management that act like morphine does to produce feelings of euphoria and well-being. A. True B. False
Objective #4: Describe the role endorphins play in pain perception and relief.
Point out that thoughts and emotions are believed to have an effect on opening and closing the gate by stimulation of endorphin production.
Teach your students that endorphins are natural body chemicals produced by the brain in response to pleasant thoughts or feelings, exercise, laughter, sex, and massage. Note that they act similar to morphine and produce feelings of euphoria, well-being, and pleasure.

8. Answer
B. False Rationale: Endorphins are natural body chemicals that act like morphine and are produced by the brain in response to pleasant thoughts or feelings, exercise, laughter, sex, and massage.
Objective #4: Describe the role endorphins play in pain perception and relief.
Point out that thoughts and emotions are believed to have an effect on opening and closing the gate by stimulation of endorphin production.
Teach your students that endorphins are natural body chemicals produced by the brain in response to pleasant thoughts or feelings, exercise, laughter, sex, and massage. Note that they act similar to morphine and produce feelings of euphoria, well-being, and pleasure.
Discussion Point: Ask for volunteers to describe personal experiences involving the release of endorphins causing a positive sense of well-being (e.g., “runner’s high,” a massage, a good laugh with friends). Discuss how the endorphins acted on the brain to cause these feelings. Relate this concept to the role endorphins play in pain perception and pain relief.

9. Types of Nociceptive Pain
Cutaneous: Pertains to the skin surface and underlying subcutaneous tissue
Visceral: Soft-tissue pain caused by stimulation of deep internal pain receptors
Deep somatic (osteogenic): Bone, ligament, tendon, and blood vessel pain
Objective #5: Compare the different types of nociceptive and neuropathic pain.
Review the three different types of nociceptive pain, including cutaneous, visceral, and deep somatic pain (osteogenic pain).

10. Multiple Choice Question
Which of the following types of nociceptive pain would be experienced by a patient with liver cancer? A. Cutaneous B. Visceral C. Deep somatic D. Osteogenic
Objective #5: Compare the different types of nociceptive and neuropathic pain.
Review the three different types of nociceptive pain, including cutaneous, visceral, and deep somatic pain (osteogenic pain).

11. Answer
B. Visceral Rationale: Cutaneous pain is related to skin tissue; visceral pain is soft-tissue pain; and deep somatic or osteogenic pain originates in bone, ligament, tendon, and blood vessels.
Objective #5: Compare the different types of nociceptive and neuropathic pain.
Review the three different types of nociceptive pain, including cutaneous, visceral, and deep somatic pain (osteogenic pain).
Describe neuropathic pain as the burning, stabbing, or sometimes deep ache that a patient describes when there is nerve damage or compression caused by pressure from tumors, lymphedema, or compression fractures of the spine.
Student Assignment: Divide the class into two groups and assign each group one of two topics: nociceptive pain and neuropathic pain. Ask them to research the type of pain they were assigned and make a list of examples of these types of pain. Have them share their results with their group and as a group devise a nursing care plan for a patient with one of the examples they found in their research. In a class discussion, review the different classifications and origins of pain and pain-management techniques. Share each group’s results and care plans with the class as a whole.

12. Factors Affecting Pain and Pain Perception
Ethnic and cultural beliefs
Developmental stage
Individual values
Previous pain experiences
Personal support systems
Emotions and stress level
Fatigue
Objective #6: Outline the factors that affect pain and pain perception.
Review the many factors that affect pain and its expression.
Discussion Point: Discuss the various factors that affect pain and its expression. Ask for volunteers from the class to describe how members of their own ethnic or cultural group perceive and express pain. Ask what they do to manage their pain and what their individual values are regarding pain. Brainstorm with the class to formulate transcultural nursing measures effective for managing pain.

13. True/False Question
Pain perception does not change with age and it is not natural for elderly patients to have more pain simply due to aging. A. True B. False
Objective #6: Outline the factors that affect pain and pain perception.
Stress the point that pain perception does not change with advancing age, nor is it natural for elderly individuals to have more pain simply because they are aging.

14. Answer
A. True Rationale: Pain perception does not change with age and it is not natural for elderly patients to have more pain simply due to aging. However, some older adults believe they are expected to hurt more when they age and as a consequence may suffer in silence.
Objective #6: Outline the factors that affect pain and pain perception.
Stress the point that pain perception does not change with advancing age, nor is it natural for elderly individuals to have more pain simply because they are aging.

15. Body Responses to Pain Physiological Psychological Behavioral
Objective #6: Outline the factors that affect pain and pain perception.
Discuss how the body responds to pain physiologically, psychologically, and behaviorally.
Note the signs and symptoms of acute and chronic pain. (Refer to Table 19-1.)

16. Assessment Parameters for Pain
Level or extent of pain using a pain scale
Site of pain
Characteristics of the pain
Whether the pain is continuous or intermittent
Whether the pain is acute or chronic
What elicits the pain
Patient’s desires in relation to the pain
Objective #7: Paraphrase how to thoroughly assess pain.
Teach your students that before pain can be effectively treated, they must acquire as much information about the pain as possible; and this is known as a pain assessment. Discuss the assessment parameters for pain.
Review the use of a pain scale to assess pain. (Refer to Chapter 17, Vital Signs.)

17. Nonpharmaceutical Pain Relief Measures
Hot and cold packs
Massage and effleurage
Transcutaneous electrical nerve stimulator (TENS)
Acupressure and acupuncture
Relaxation
Guided imagery
Distraction
Objective #9: Identify at least three nonpharmacological methods of pain relief.
Review the non-pharmaceutical methods of pain relief that should be incorporated into a pain management plan as an adjuvant, along with pharmacological therapies.

18. Multiple Choice Question
A nurse reads a story to a 6-year-old cancer patient undergoing chemotherapy. This is an example of which nonpharmaceutical pain relief measure? A. TENS B. Relaxation C. Guided imagery D. Distraction
Objective #9: Identify at least three nonpharmacological methods of pain relief.
Review the non-pharmaceutical methods of pain relief that should be incorporated into a pain management plan as an adjuvant, along with pharmacological therapies.

19. Answer
D. Distraction Rationale: TENS is a device that stimulates the nerves; relaxation and guided imagery are techniques that guide the patient into a relaxed state; and distraction decreases the conscious awareness of the pain through the different senses.
Objective #9: Identify at least three nonpharmacological methods of pain relief.
Review the non-pharmaceutical methods of pain relief that should be incorporated into a pain management plan as an adjuvant, along with pharmacological therapies.

20. Types of Distraction and Examples
Visual: Reading a book or newspaper; watching a movie
Auditory: Listening to music, poetry, chanting, sounds of nature, talking book, sermon
Tactile: Receiving a back rub, foot rub, head massage, or hair brushing
Intellectual: Having a conversation; studying; working a crossword puzzle or Sudoku; playing Scrabble, Monopoly, dominoes, or card games
Objective #9: Identify at least three nonpharmacological methods of pain relief.
Discuss the types of distraction that are used for pain management based on the different senses.

21. Pharmaceutical Pain Management
NSAIDS: Reduce inflammation
Nonopioids: Non-narcotic pain relievers
Opioid narcotics: Analgesics that relieve visceral and deep somatic pain
Adjuvant drugs: Produce pain relief from another method or increase effects of opiates, opioids, and non-opioid drugs
Objective #10: Differentiate between classifications of analgesics.
Teach your students that there are various classifications of medications that are effective against pain, including non-steroidal anti-inflammatory drugs (NSAIDS), non-opioids, opioid narcotics, and adjuvant drugs. Note that these medications can be used alone or in conjunction with non-pharmaceutical methods of pain relief. (Refer to Figure 19-3.)
Student Assignment: Ask your students to research one drug from each of the following categories of pharmaceutical pain relievers: NSAIDs, non-opioids, opioid narcotics, and adjuvant drugs. Have them write a brief report describing its indications/contraindications, dosage, route of administration, and efficacy. Ask students to share their reports in a class discussion.

22. Restorative Sleep vs. Resting
Allows the individual to awaken feeling rested, refreshed, and energized
Partial loss of consciousness occurs; more difficult to arouse the person
Resting
May or may not involve sleep
External noises will awaken the individual
Objective #11: Characterize restorative sleep.
Tell your students that restorative sleep is that which allows an individual to awaken feeling rested, refreshed, rejuvenated, and energized, and ready to meet new challenges. Compare restorative sleep with resting.
It helps the patient to get better restorative sleep if his or her pain is controlled.

23. Occurrences Without Restorative Sleep
Healing is slow and incomplete
Immunity and pain tolerance decrease
Fragile emotions and impatience affect relationships
Cognitive functions are impaired
Work performance suffers
Accidents increase dramatically
Objective #11: Characterize restorative sleep.
Discuss what may occur without restorative sleep.

24. Amount of Sleep Need by Age Group
Newborns: 16 to 18 hours per day
Infants up to 2 years: 12 to 14 hours per day
Children 3 to 6 years: 12 hours per day
Children 7 to 12 years: 10 hours per night
Adolescents: 8.5 to 9.5 hours per night
Young adults: 7.5 to 8 hours per night
Older adults: Gradual decrease to 5.5 or 6 hours
Objective #12: Enumerate sleep requirements for different age groups.
Remind your students that the body has a 24-hour cyclical pattern known as the circadian rhythm, during which body metabolism and functions increase and decrease in rhythmic patterns. Review the two sleep cycles that have been identified: nonrapid eye movement sleep, known as NREM, and rapid eye movement sleep, known as REM. (Refer to Table 19-2.)
Review the amount of sleep needed for each age group.

25. Factors Affecting Sleep
Lifestyle
Stress and anxiety
Environment
Illness and health problems
Sleep disorders
Objective #13: Name six specific factors that affect sleep.
Discuss the physiological, emotional, and environmental factors that affect rest and restorative sleep. (Refer to Table 19-3.)

26. Interventions to Promote Sleep
Prepare the environment
Promote comfort and relaxation
Provide pain relief and sleep medications if needed
Objective #14: Describe interventions you might use to promote sleep.
Give examples of interventions that may be used to promote sleep. Note that these interventions can also assist normal body functions and make the environment more conducive to sleep.

27. Common Myths about Pain Management, Rest, and Restorative Sleep
Pain control is necessary for quality restorative sleep
Just because a patient who requests medication falls asleep before it is administered doesn’t mean the patient isn’t hurting
The nurse should awaken the patient and administer the analgesic
Objective #15: Identify common myths regarding pain management, rest, and restorative sleep.
Talk about adequate pain control being necessary to obtain quality restorative sleep.
Discuss when a patient requests pain medication but falls asleep before the medication is delivered, that it does not mean that the patient is not really hurting. Explain that the nurse should awaken the patient and administer the analgesic. 27

28. Information in the Connection Features
Clinical Connection
Knowledge
Real World
Supervision/Delegation
Patient Teaching
Post Conference
Objective #16: Discuss information found in the Connection features in this chapter.
Divide students into groups and have each group take one of the Connection features.
Ask the group to share the information in the feature with the class and to discuss ways that it can apply in a broader sense to their practice of nursing. 28

29. Information in the Safety Features
Why are the particular safety features so important that they are highlighted as safety issues?
What could happen if those safety guidelines are not followed?
Objective #17: Identify specific safety issues.
Remind students to review the red safety features within the chapter. Point out to them that the information in those safety features is very important (and that they might see a related test question).
Ask the students why those particular items were so important that they were highlighted as safety issues. What could happen if those safety guidelines are not followed? 29

30. Information in the Skills Procedure
Review the steps of the skills procedure.
Make sure you understand why the steps are important.
What could happen if each of the steps are not followed or are followed out of order?
Objective #18: Answer questions about the skills in this chapter.
Ask students questions about the steps of performing the skills and the rationales for those steps. Ensure that students understand why they do what they do during the skills procedure. (Refer to Skill 19-1.) 30