Pain Management, Comfort, Rest, and Sleep

1. Pain Management, Comfort, Rest, and Sleep

2. The Meaning of Comfort • Comfort • To give strength and hope, to cheer, and to ease the grief or trouble of another • One of the greatest challenges for the nurse is to provide comfort to the patient • Promoting physical comfort is a vital part of the role of a nurse.

3. Comfort and well-being can be promoted with eye contact and gentle touch.

4. Providing Comfort • Lack of comfort can be the result of many factors and can take many forms such as: • Anxiety Nausea • Depression Pain • Diarrhea Powerlessness • Dyspnea Urinary Retention • Fatigue Incontinence • Fear Hypoxia • Headache

5. Providing Comfort • The nurse should pursue methods to assist the patient in achieving relief from discomfort. • Actively listen • Recognize non-verbal discomfort signals • Be diligent in your efforts • If interventions are not successful, pursue alternative interventions

6. Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in the US.

7. Nature of Pain • A complex, abstract, personal subjective experience

8. Nature of Pain • Per the American Pain Society and the International Association for the Study of Pain: • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

9. Nature of Pain • -unpleasant sensation • -noxious stimulation of the sensory nerve endings • -warning system to the body • -actual or potential tissue damage • -sign of inflammation and/or infection • -diagnosis of many disorders and conditions • -no tissue damage, such as the pain of grief

10. Pain is Multifaceted • Interpretation and significance of the pain • Individual’s learned experiences • Psychosocial and cultural factors. • Expert is the person who is bearing the pain: • -location -intensity • -quality -pattern • Degree of pain relief obtained from therapy.

11. Psychological factors that influencethe perception of pain • Increased Pain • Sadness, Depression • Fatigue • Anger • Discomfort • Insomnia • Anxiety • Fear • Decreased Pain • Happiness • Rest • Diversion • Relief of symptoms • Sleep • Sympathy • Understanding

12. Nature of Pain • Nursing goal • empower the patient to be an active partner in reporting information about the pain • Pain history • patient’s description • optimal pain management.

13. Nursing Assessment of Pt. Pain • Obtain a baseline perspective • In the past, failed efforts to control the pain • plan future therapy. • Complete a physical examination • Persistent pain consider: -physiologic cause is not always obvious or identifiable

14. Types of Pain • Acute Pain • Intense and of short duration -comes on quickly -very definite symptoms -can be quite intense -heal in a relatively brief period of time. • Autonomic response -Sympathetic Nervous System • Floods the body with epinephrine— mediator for “fight or flight” response

15. Acute Injury

16. Chronic Pain • Generally characterized a pain lasting longer than 6 months • Continuous or intermittent • Can be intense • Chronic pain does not serve as a warning of tissue damage in process but rather signals the fact of its having occurred. • Changes in the behavior of the patient • Development of fear-avoidance strategies • Precursor of chronic disability

17. Chronic Pain • Fundamental mechanisms sustaining the pain has become independent of the initial injury or damage • -difficult to treat • -very frustrating for patient and health providers. • -chronic low self-esteem • -change in social identity • -changes in role and social interaction • -fatigue • -sleep disturbance • -depression/suicidal ideation • Syndrome of Chronic Pain

18. Chronic Pain • Treating chronic pain • identify source [although it may be unknown] • referral to Pain Management Specialist as soon as possible • requires a multidisciplinary approach

19. Referred Pain: Felt at a site other than the injured organ or part of the body

20. Nociceptor • A peripheral nerve organ or mechanism for the reception and transmission of painful or injurious stimuli

21. Peripheral Nociceptors • Unspecialized cell • endings • -free endings • -detect chemical • substances released • from damaged • tissue. • -skin, muscle, joints, • and some visceral • tissues

22. Theories of Pain Transmission • Gate Control Theory • Small diameter nerve fibers carry pain stimuli through a gate mechanism • Larger diameter nerve fibers go through the same gate • If other cutaneous stimuli besides pain are transmitted, the “gate” through which the pain impulse must travel is temporarily “blocked” by the other stimuli. • The brain does not have the capacity to acknowledge the pain impulse when it is interpreting the other stimuli. • When gates are open, pain impulses flow freely.

23. Gate Control Theory Pain – Gate Theory cont. - The “gate” is shut by stimulating nerves responsible for carrying the touch signal  bombardment of sensory impulses -Enables the relief of pain through massage techniques, rubbing, and application of hot and cold packs - The gate mechanism is shut by stimulating the release of endorphins • Chemicals released by the body in response to pain stimuli

24. Endorphins • Natural supply of morphine-like substances • neurotransmitters that activate opiate receptors • Stress and pain activate endorphins  analgesia • Certain endorphins attach to opioid receptors in the brain  preventing release of neurotransmitters  inhibition of the transmission of pain impulse

25. Endorphins • People who have less pain than others from a similar injury have been found to have higher endorphin levels. • Acupuncture, TENS unit and placebos are believed to cause the release of endorphins.

26. Older Adult Considerations • Changes in drug absorption, distribution, metabolism and elimination • affect the plasma levels/analgesic drug levels • drug absorption may be altered • increased gastric pH and decreased gastric motility • distribution of drugs may change • decrease in lean body mass or plasma proteins and albumin level secondary to chronic illness and poor nutrition.

27. Older Adult Considerations • Hepatic blood flow, renal blood flow and glomerular filtration rate are decreased • Elimination of drugs may change as renal and hepatic clearance decreases. • Management of acute pain in the elderly involves: -careful “titration” of analgesic doses -assessing patients frequently for inadequate pain control and for adverse side effects

28. Age and Pain Control • Psycho-social issues in the elderly r/t pain: • Misconceptions • pain perception decreases with age • elderly cannot tolerate opioids • Inadequate assessment • difficult in patients with cognitive impairment, dementia, aphasia

29. Age and Pain Control • Psycho-social issues in the elderly r/t pain: (cont.) • Lack of education • fear of addiction (patient, health care giver) • patient expects to have pain • patient unfamiliar/unwilling to use equipment: e.g. PCA • may be as simple as HOH or needs repetitive instructions

30. Analgesic options in the elderly • Pharmacologic options • use around the clock dosing • start with low dose (25% to 50% of usual adult dose), titrate up slowly • use adjuncts (acetaminophen or NSAID) for opioid sparing effect • patient monitoring for sedation, respiratory depression

31. Analgesic Options in the Elderly • Nonpharmacologic Options -heat or cold -massage -exercise -transcutaneous electrical nerve stimulation (TENS). -Cognitive-behavioral techniques -education/instruction -relaxation -imagery -music -biofeedback

32. Pediatric Pain • Just because you can’t talk, doesn’t mean you don’t have pain • Crying • Restlessness or agitation • Thrashing • Stiffened arms and legs • Increases in heart rate and blood pressure • Ask the mother !!!!!

33. Pediatric Pain • Developmental Effects of Unrelieved Pain • Increased behavioral/physiologic responses • Altered temperaments • Somatization –psychological needs are expressed in physical symptoms • More distress behaviors • Altered development of the pain conduction system • Stress disorders, addictive behavior and anxiety states • Lowered pain threshold

34. Pain“ The Fifth Vital Sign” • American Pain Society recommendation’s goal is to ensure pain is treated with the same zeal as any changes in pulse, temperature, blood pressure, and respirations would receive. • A strategy to increase accountability for pain control

35. Pain “The Fifth Vital Sign” • Pain Assessment • Ask patients about their pain • Accept and respect what they say • Use Nursing Process • Assess • Diagnose and Plan • Implement • Evaluate 50% of people who suffer moderate to severe pain will continue to suffer because nurses fail to assess pain.

36. Pain “The Fifth Vital Sign” • Unrelieved pain has harmful physical effects • Increased oxygen demand • Respiratory and cardiac function stressed • Decreased gastrointestinal motility • Confusion • Depressed immune response • Anxiety, depression and irritability • Inability to enjoy life • Delaying analgesia until pain is severe has no benefits

37. JCAHO Standards for Pain Control • Joint Commission on Accreditation of Healthcare Organization • http://www.jointcommission.org/ • Our Mission: To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. 

38. JCAHO Standards for Pain Control • Under the new JCAHO standards • Health care providers -knowledgeable about pain assessment and management • Facilities -develop policies and procedures -appropriate use of analgesics and other pain control therapies.

39. JACHO Standard of Care • Key Concepts • Patients have the right to: -appropriate assessment. -be treated for pain or referred for treatment. -be assessed and regularly reassessed. -be taught effective pain management. -be taught that pain management is a part of treatment.

40. JACHO Standard of Care Patients have the right to: (cont.) -be involved in making care decisions. -routine and PRN analgesics are to be administered as ordered. -continuing care based on the patient’s need at the time of discharge, including the need for pain management

41. Nursing Assessment of Pain • Subjective Data collection: • Obtain accurate information from the patient • “pt. c/o pain” provides no useful data • Assess all characteristics of pain • Obtain socio-cultural information • Encourage patients to use their own words • Quote the patient as needed

42. Nursing Assessment of Pain • Subjective Data Collection (cont.) • Validated pain scale. -use the same pain scale = the one the patient chooses. • Document so that all involved in the patient’s care have a clear understanding of the pain problem.

43. Pain History • Critical Elements of the Pain History • How the pain developed • Description of the pain • Location of the pain and any spread • The pattern of the pain over time • The patient’s pre-morbid and current levels of function and impairment (how does the pain interfere with activity?) • What aggravates or relieves pain • Previously attempted treatments

44. Nursing Assessment of Pain • Objective Data Carefully observe the patient for: • Tachycardia • ↑ rate and depth of breathing • Diaphoresis • ↑ BP • Pallor; dilated pupils • Increased muscle tension

45. Nursing Assessment of Pain • If the pain is chronic or less severe, observe for: • Changes in facial expression • Frowning, gritting teeth • Clenched fists • Withdrawal or c/o • Pacing • Wanting constant attention or to be left alone

46. Nursing Interventions • Comfort measures/pain control. • Tighten wrinkled bed linens. • Reposition drainage tubes or other objects on which patient is lying. • Place warm blankets for coldness. • Loosen constricting bandages. • Change moist dressings.

47. Nursing Interventions • Comfort Measures cont. • Check tape to prevent pulling on skin. • Position patient in anatomic alignment. • Check temperature of hot or cold applications, including bath water. • Lift, not pull, patient up in bed; handle gently. • Position patient correctly on bedpan. • Avoid exposing skin or mucous membranes to irritants.

48. Nursing Interventions • OtherComfort Measures: • Prevent urinary retention by ensuring patency of Foley catheter. • Prevent constipation by encouraging appropriate fluid intake, diet, and exercise and by administering prescribed stool softeners. • Just saying “I believe that you are in pain and I will assist you in whatever way I can to relieve your pain”

49. It’s as easy as ABCDE ! • Ask about pain regularly. Assess pain systematically. • Believe the patient and family in their reports of pain and what relieves it. • Choose pain control options appropriate for the patient, family and setting. • Deliver intervention in timely, logical and coordinated fashion. • Empower patients and their family. Enable them to control their course to the greatest extent possible

50. Unrelieved Pain • Erodes the patient’s quality of life. • About 50 million Americans (1 in 5) report persistent or intermittent pain annually.