NURSE-UN 240 A&E I– FINAL EXAM STUDY GUIDE WEEK 6 – PAIN; SLEEP PAIN
What is Pain?
- “Whatever the person experiencing pain says it
... [Show More] is”
- “Unpleasant sensory and emotional experience associated with actual or potential tissue damage”
- Subjective: patient’s experience and self-report is essential
Nature of pain
- Involves physical, emotional, cognitive components
- Subjective & individualized
- Reduces quality of life
- Not measurable objectively
- May lead to serious physical, psychological, social and financial consequences Dimensions – psychologic, behavioral, cognitive, affective & social factors
How Pain Travels
1st level (nociceptor spine): alpha-delta and c-delta fibers go through dorsal root ganglion into the spinal cord 2nd level (spine brain)
3rd level (brain to different parts that are going to interpret that pain responses)
Nociceptive pain originates when the tissue is injured
- Transduction – occurs when there is release of chemical mediators
o Converts energy produced by these stimuli into electrical energy
o Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential
o Once transduction is complete, transmission of pain impulse begins
- Transmission – involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex
o Sending of impulse across a sensory pain nerve fiber (nociceptor)
o Nerve impulses
o Pain impulses
- Perception – the conscious awareness of pain
o The point at which a person is aware of pain
o The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex (primarily limbic system) determines how a person feels about it
o There is no single pain center
- Modulation – involves signals from the brain going back down the spinal cord to modify incoming impulses
o Inhibits pain impulse
o A protective reflex response occurs w/ pain reception
Physiology of pain
- Gate-control theory of pain
o Pain has emotional & cognitive components in addition to a physical sensation
o Gating mechanisms in the CNS regulate or block pain impulses
o Pain impulses pass through when a gate is open and are blocked when a gate is closed
o Closing the gate is the basis for non-pharmacological pain relief interventions
- As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system (ANS) – fight or flight
- Continuous, severe or deep pain typically involving the visceral organs activates the parasympathetic nervous system (PNS)
- Common indications of acute pain – clenching teeth, facial grimacing, holding or guarding the painful part, bent posture
- Chronic pain affects pt’s activity and PNS & SNS does not react like they do to acute pain
- Lack of pain expression does not indicate that a pt is not experiencing pain
Types of pain
- Acute/transient – protective (body tells you something is wrong), identifiable, short duration; limited emotional response
- Chronic/persistent noncancer – not protective, has no purpose, may or may not have an identifiable cause
- Chronic episodic – occurs sporadically over an extended duration; usually above their chronic baseline
- Cancer – can be acute or chronic
- Idiopathic – chronic pain w/o identifiable physical or psychological cause
Factors influencing pain
- Physiological – age, fatigue, genes (threshold and tolerance), neurological fxn (ie DM w/ ulcer)
o Fatigue increases perception of pain and can cause problems w/ sleep and rest
- Social – attention, previous experiences, family & social support
- Spiritual – includes active searching for meaning in situations w/ questions such as “why am I suffering?”
- Psychological – anxiety, coping style
- Pain tolerance – the level of pain a person is willing to accept
- Culture & ethnicity – meaning of pain
Critical thinking – knowledge of physiology and the many factors that influence pain help you manage a pt’s pain
Nursing Process & Pain
- Pain mgmt needs to be systematic & needs to consider pt’s QOL
- Clinical guidelines are available to manage pain – American pain society, sigma theta tau, nat’l guidelines clearinghouse
Assessment
- Through pt’s eyes – ask pt’s pain level
- Use ABCs of pain management (OLDCARTS, PQRST)
- Pain is not a #
- Pt’s expression of pain – individualistic
- Characteristics – timing, location, severity, quality, aggravating & precipitating factors, relief measures
- Effects of pain on pt – behavioral, influence on ADLs
- Concomitant symptoms – usually increases pain severity
Pain assessment tools (5th vital sign)
- COLDSPA Character, Onset, Location, Duration, Severity, Pattern, Associated Symptoms (factors increasing or relieving pain)
- OLDCARTSP – onset, location, duration, character, associated sx, radiation, timing, severity, pattern
- Simple Descriptive Pain Intensity Scale
- COMFORT scales
- FLACC scale
- Beyer Ouchers pain scale
- Wong-Bakers face scales – pediatrician
- Be aware of possible errors in pain assessment
Possible nursing
- Anxiety
- Insomnia
- Impaired social interaction
- Ineffective coping
- Impaired physical mobility
diagnoses
- Activity intolerance
- Fatigue
Planning – analyze info from multiple sources, apply critical thinking, adhere to professional standards, use a concept map, goals & outcomes, setting priorities, teamwork & collaboration, “any wound changes?”, “does pt needs before tx? How long before?”, anything pertaining to safety
Implementation – health promotion
- Maintaining wellness – helps pt understand – health literacy – pt actively participates in their own well-being whenever possible
Implementation
- Pain Treatment Principles
o Follow principles of assessment
o Treatment based on patient’s goals
o Use drug and non-drug therapies
▪ Know Patient's Previous Response to Analgesics
▪ Select Proper Medications When More Than One Is Ordered
▪ Know Accurate Dosage
▪ Assess Right Time and Interval for Administration
o Use a multidisciplinary approach
- Non-pharmacological pain-relief interventions
o CBT (cognitive and behavior approach)
o Hypnosis
o Biofeedback
o Therapeutic touch
o Animal-facilitated therapy
o Acupuncture
o Humor
o Relaxation & guided imagery (meditation techniques)
o Distraction
o Music
o Cutaneous stimulation (warm baths)
o Cold & heat application
o TENS
o Herbals
o Reducing pain perception & reception
o Massage (usually babies and elderly; really depends if pt like therapeutic touch)
- Pharmacological pain therapies
o Analgesics – “start low and go slow”
▪ Non-opioid: acetaminophen, aspirin and other salicylates, and non-steroidal anti-inflammatory drugs (NSAIDS)
▪ Opioid/narcotics (controlled substances): morphine, oxycodone, and codeine
• Affects spinal cord and brain
• Common side effects include: constipation (most common, nausea/vomiting, sedation, respiratory depression
▪ Adjuvant/co-analgesics: antidepressants, anti-epileptic drugs, and corticosteroids
• Non-pain meds that is conjunctions with pain meds to alleviate pain
o Topical analgesics – creams, ointments, patches
o Local anesthesia – local infiltration of an anesthetic medication to induce loss of sensation to a body part
▪ Regional anesthesia
o Perineural local anesthetic infusion
o Epidural analgesia – regional – administered into epidural space
Patient Controlled Analgesia (PCA)
- PCA pumps are secured computerized programmable devices that deliver small, preset dose of opioid; usually for chronic or cancer pain
- Allows pt to self-administer w/ minimal risk of overdose
- Maintains constant plasma level of analgesic
- On avg, systems are designed to deliver a specified # of doses q1-4 hr given every 5-15 mins
- Nursing Responsibilities:
o Patient teaching
o Monitoring patient responses
- Safety guidelines
o The pt is the only person who should press the button to administer pain medication
o Monitor for s/s of over sedation and respiratory depression
o Monitor for potential side effects of opioid analgesics
Implementation
- Nursing implications
o You maintain responsibility for providing emotional support to pts receiving local or regional anesthesia; numerous implications for mgmt. of epidural analgesia
▪ After administration of a local anesthetic, protect pt from injury until full sensory & motor fxn return
▪ Provide emotional support; not addressing pain # but addressing the pt overall (issues, QOL, address pain before meals, address pain before ADL)
▪ Establishing trusting nurse-pt relationship
▪ Manipulating factors affecting pain experience
▪ Initiating nonpharmacologic pain relief measures
▪ Managing pharmacologic interventions
▪ Relieving additional pain control measures (complementary and alternative relief measures)
▪ Considering ethical and legal responsibility to relieve pain
o Invasive interventions for pain relief
o Procedure pain mgmt.
o Cancer pain & chronic non-cancer pain mgmt.
o Scheduling
▪ Focus on prevention or control- Do not wait for severe pain
▪ Constant pain requires around-the-clock (ATC) administration (not PRN) – adjust dose to achieve max benefit with min side effects
▪ Allow pt as much control as possible over the regimen
▪ Fast-acting drugs for breakthrough pain
• Breakthrough pain is a superimposed pain on continuous or persistent pain that could be classified as: incident pain, end-of-dose failure pain, spontaneous pain
o ALWAYS USE 6 RIGHTS OF MEDICATION ADMINISTRATION
- Physical dependence – a state of adaptation manifested by drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist; body needs it to work properly and normally
- Addiction – a primary, chronic, neurobiological dz w/ genetic, psychosocial and environmental factors influencing its development & manifestations
- Drug tolerance – a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time; the more you use, the more you get used to it you need more and more to have an effect (issue for chronic pt)
- Restorative & continuing care
o Pain clinics – treat pt on an inpt or outpt basis
o Palliative care – goal is to learn how to live life fully w/ an incurable condition
o Hospices – programs for end-of-life care
o ANA supports aggressive treatment of pain & suffering even if it hastens a pt’s death
Evaluation
- Through pt’s eyes – patients help decide best times to attempt pain treatments, best judge of whether a pain-relief intervention works
- Pt outcomes – evaluate for change in severity & quality of pain
- What pt says; make sure pt is where they want to be with the agreed goal they set for themselves
Barriers of Pain Management
- Why clinicians under-treat pain:
o Inadequate skills to assess and treat pain
o Unwillingness to believe patient reports
o Lack of time, expertise, and perceived importance of pain assessments
o False concepts of addiction and tolerance
▪ Addiction is a chronic neuro-biologic disease influenced by genetic, psychosocial and environmental factors
▪ Tolerance is a state of adaptation to a drug
SLEEP
Sleep Physiology
- Sleep = rest accompanied by altered consciousness and reactive inactivity
- Rest refers to a condition in which the body is in a decreased states of activity, with the consequent feeling of being refreshed
- Sleep is part of the sleep-wake cycle
- Circadian rhythms – affected by LIGHT, TEMPERATURE, SOCIAL ACTIVITIES, WORK ROUTINES
- Biological rhythm of sleep frequently becomes synchronized w/ other body functions
- Regulated by a sequence of physiological states integrated by central nervous system activity
- Wakefulness is a time of mental activity and energy expenditure
- Sleep is a period of inactivity and restoration of mental and physical function
- Hypothalamus
- Reticular activating system (RAS)
- Homeostatic process
Adult sleep cycle
- 4 stages of NREM
- Sleep cycle lasts 90-100 mins
- Stages 1 to 2 to 3 to 4 ➔ 4 to 3 to 2 ➔ REM
Functions of sleep
- Purpose – remains unclear – physiological & psychological restoration & maintenance of biological fxns
- Dreams – occur in NREM and REM sleep – important for learning, memory & adaptation to stress
- Physical illness can cause pain, physical discomfort, anxiety, depression & sleep disturbances
o HTN
o Respiratory d/o
o Nocturia
o Restless leg syndrome (RLS)
Sleep Disorders
- Insomnia
o Adjustment sleep d/o (acute insomnia), inadequate sleep hygiene, behavioral insomnia of childhood, insomnia caused by medical condition; more tired because of no sleep affecting general overall health
- Sleep apnea
o Primary central sleep apnea, central sleep apnea caused by medical condition, obstructive apnea syndromes (overwt, obese, large neck throat closes don’t breathe for a certain pd of time loud snort start breathing stop for a pd of time choke wakes up), excessive daytime sleepiness
- Narcolepsy
o Cataplexy
o Sleep paralysis
- Sleep deprivation
o Emotional stress, medications, environmental disturbances, symptoms
- Parasomnias
o Somnambulism (sleep walking), night terrors, nightmares, nocturnal enuresis (bed-wetting), body rocking, Bruxism (grinding teeth)
Sleep & rest
- Rest contributes to (1) mental relaxation, (2) freedom from anxiety, (3) state of mental, physical and spiritual activity
- Bed rest does not guarantee that a pt will feel rested
- Sleep more when younger, sleep less when older
GROUP HOURS OF SLEEP NEEDED
Neonates 16 hr/day
Infants 8-10 at night, 15 total/day
Toddlers 12 hr/day
Preschoolers 12 hr/night
School age 9-10 hr
Adolescents Get ~7.5 hr
Young adults Get 6-8.5 hr
Middle and older adults Total # of hr declines
Factors influencing sleep
- Drugs & substances – hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants
- Lifestyle – work schedule, social activities, routines
- Usual sleep patterns – may be disrupted by social activity or work schedule
- Emotional stress – worries, physical health, death, losses
- Environment – noise, routines
- Exercise & fatigue – moderate exercise and fatigue cause a restful sleep
- Food & calorie intake – time of day, caffeine, nicotine, alcohol
Critical thinking
- in the case of sleep, integrate knowledge from nursing and disciplines such as pharmacology and psychology
- Use personal experience
- Professional standards
Assessment
- Pt & family can be sources for sleep assessment
- Sleep history/diary
- Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation
o Conduct a more detailed history when a pt has a sleep problem, as this ensures that you provide appropriate therapeutic care
o Open-ended questions help a pt describe a problem more fully
o Ask specific questions related to the sleep problem
o Have pts describe their normal sleep patterns
- Thorough assessment to see what is impacting their sleep if that is what needs to be addressed
Possible nursing diagnoses
- Anxiety, ineffective breathing pattern, acute confusion, compromised family coping, ineffective coping, insomnia, fatigue, sleep deprivation, readiness for enhanced sleep
Planning
- Goals & outcomes
- Setting priorities: frequent sleep disturbances are the result of other health problems
- Teamwork & collaboration
Implementation – health promotion
- Environmental controls
- Promoting bedtime routines
- Promoting safety
- Promoting comfort
- Establishing periods of rest and sleep
- Stress reduction
- Bedtime snacks
- Pharmacological approaches
- Acute care – environmental controls, promoting comfort, establishing periods of rest and sleep, promoting safety, stress reduction
- Restorative or continuing care – promoting comfort, controlling physiological disturbances, pharmacological approaches
Evaluation
- Through the pt’s eyes
- Pt outcomes
- Determine whether outcomes have been met – are you able to fall asleep within 20 mins of getting into bed? / Describe how well you slept when you exercise / Does the use of quiet music at bedtime help you relax? / do you feel rested when you wake up? [Show Less]