Module 22 Rest & Sleep, Comfort & Pain Management

rest

condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed

sleep

- state of rest accompanied by altered consciousness and relative inactivity

- part of the sleep-wake cycle

- period of inactivity and restoration of mental and physical function

wakefulness

time of mental activity and energy expenditure

reticular activating system (RAS)

Facilitates reflex and voluntary movements

Controls cortical activities related to state of alertness

bulbar synchronizing region

works with RAS to control the cyclic nature of sleep

hypothalamus

control center for sleeping and waking

non-rapid eye movement (NREM)

consists of 4 stages

•Stages I and II: 5% to 50% of sleep, light sleep

•Stages III and IV—10% of sleep, deep-sleep states (delta sleep)

rapid eye movement (REM)

•20% to 25% of a person's nightly sleep time

•Pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase; skeletal muscle tone and deep tendon reflexes are depressed

effects of insufficient sleep

•May affect normal growth and development in children

•May increase obesity risk in both children and adults

•Lowers leptin levels and elevates ghrelin levels

•Leptin: hormone that tells the brain to stop eating

•Ghrelin: promotes continued eating

lifestyle/habits that increase sleep

- activity and exercise

- amino acid L-tryptophan

- small protein snack combined with a healthy complex carb before bed

lifestyle/habits that decrease sleep

- large quantities of alcohol

- caffeine

- smoking and nicotine

psychological stress

•Can be caused by illness or life situations

•Disturbs sleep

•Difficult to obtain the amount of sleep needed

•REM sleep decreases, leading to anxiety and stress

illnesses associated with sleep disturbances

•Gastroesophageal reflux

•Coronary artery diseases

•Epilepsy seizures

•Liver failure and encephalitis

•Hypothyroidism

•End-stage renal disease

meds that affect sleep

•Benzodiazepines

•Amphetamines

•Antidepressants

•Diuretics

•Antiparkinsonian drugs

•Antidepressants

•Antihypertensives

•Steroids

•Decongestants

•Caffeine

•Asthma medications

insomnia

•Characterized by difficulty falling asleep, intermittent sleep or difficulty maintaining sleep, despite adequate opportunity and circumstances to sleep

•As many as 30% to 35% of adults in the United States

•People with a history of depression are more likely to experience

•Many cases are related to disruptions in circadian rhythms

•may be short term or chronic in nature

obstructive sleep apnea (OSA)

•Characterized by five or more predominantly obstructive respiratory events

•The absence of breathing (apnea)

•Diminished breathing efforts (hypopnea)

•Respiratory effort-related arousals during sleep, accompanied by sleepiness, fatigue, insomnia, snoring

•Subjective nocturnal respiratory disturbance

•Observed apnea and associated health disorders

•Gasping for air during sleep

idiopathic hypersomnia

•Characterized by excessive sleep, particularly during the day

narcolepsy

•Characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep

•Up to 70% of people also experience cataplexy, the sudden, involuntary loss of skeletal muscle tone lasting from seconds to one or two minutes

circadian rhythm sleep-wake disorders

•Chronic or recurrent pattern of sleep-wake rhythm disruption

•Primary causes:

•An alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required

•A sleep-wake disturbance (e.g., insomnia or excessive sleepiness)

•Associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder)

parasomnias

sleep d/o characterized by abnormal behaviors

•Somnambulism

•REM sleep behavior disorder (RBD)

•Sleep terrors

•Nightmare disorder

•Sleep enuresis

•Sleep-related eating disorder

somnambulism

sleepwalking

parasomnias: REM related

recurrent isolated sleep paralysis, nightmare d/o

sleep terrors

person quickly awakens from sleep in a terrified state

nightmare disorder

frequent and distressing nightmares that cause significant distress or impairment in daily functioning

sleep enuresis

bedwetting

sleep related eating disorder

a sleep disorder in which the sleeper will sleepwalk and eat compulsively

restless legs syndrome (RLS)

•also known as Willis-Ekbom disease (WED), is a common sleep-related movement disorder that affects up to 15% of the population, most often middle-aged and older adults

•cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs

•Nonpharmacologic treatments

obtaining a sleep hx

•Nature of problem

•Cause of problem

•Related signs and symptoms

•When the problem began and how often it occurs

•How the problem affects everyday living

•Severity of the problem and how it can be treated

•How the patient is coping with the problem and success of treatments attempted

screening tools to assess sleep disturbances

Sleep Diary

The Epworth Sleepiness Scale

The Pittsburgh Sleep Quality Index (PSQI)

STOP-Bang Questionnaire (OSA)

Stanford Sleepiness Scale

info recorded in a sleep diary

•Time patient retires

•Time patient tries to fall asleep

•Approximate time patient falls asleep

•Time of any awakening during the night and resumption of sleep

•Time of awakening in morning

•Presence of any stressors affecting sleep

•Record of food, drink, or medication affecting sleep

•Record of physical and mental activities

•Record of activities performed 2 to 3 hours before bedtime

•Presence of worries or anxieties affecting sleep

sleep characteristics to assess

Restlessness

Sleep postures

Sleep activities

Snoring

Leg jerking

key findings of physical assessment

Energy level

Facial characteristics

Behavioral characteristics

Physical data suggestive of sleep problems

teaching interventions to promote sleep

•Prepare a restful environment

•Promote bedtime rituals

•Offer appropriate bedtime snacks and beverages

•Promote relaxation and comfort

•Respect normal sleep-wake patterns

•Schedule nursing care to avoid disturbances

•Use medications to produce sleep

•Teach about rest and sleep

treatment for dyssomnias

Pharmacologic therapy

•Sedatives

•Hypnotics

Nonpharmacologic therapy

Cognitive behavioral therapy (CBT)

•Progressive muscle relaxation measures

•Stimulus control

•Sleep restriction; sleep hygiene measures

•Biofeedback and relaxation therapy

pain

- whatever the pt says that it is, whenever it is

- a personal experience influenced by biologic, psychological, and social factors

- pain and nociception are different

- learned through an individual's life experiences

- serves an adaptive role

- expressed in many ways-not just verbally

gate control theory of pain

Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions

Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain.

Gating mechanism determines the impulses that reach the brain.

pain process

transduction, transmission, perception, modulation

transduction

activation of pain receptors

transmission

conduction along pathways (A-delta and C-delta fibers)

perception of pain

awareness of the characteristics of pain

modulation

inhibition or modification of pain

types of pain

- duration: acute, chronic

- localization/location: localized, somatic, visceral, cutaneous, referred

somatic pain

diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves

visceral pain

most common produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed

cutaneous pain

superficial pain; usually involves the skin or subcutaneous tissue

referred

originate in one part of the body but be perceived in an area distant from its point of origin

acute pain

•Rapid in onset, varies in intensity and duration

•Protective in nature

chronic pain

•May be limited, intermittent, or persistent

•Lasts beyond the normal healing period

•Periods of remission or exacerbation are common

etiology of pain

nociceptive, neuropathic, nociplastic, intractable, phantom

nociceptive

•initiated by nociceptors that are activated by actual or threatened damage to noneural tissue and is representative of the normal pain process

neuropathic

•pain caused by a lesion or disease of the peripheral or central somatosensory nervous system

nociplastic

•not classified as nociceptive or neuropathic in nature and is addressed in the class of chronic primary pain

intractable

•pain is resistant to therapy and persists despite a variety of interventions

phantom

does not have an identifiable physiologic or pathologic cause

responses to pain

- behavioral (voluntary): moving away, grimacing, moaning, crying

- physiologic (involuntary): increased BP, increased RR, pupil dilation, muscle tension

- affective (psychological): withdrawal, stoicism, anxiety, depression, rear, anorexia, insomnia

terms used to describe pain

-Quality (sharp, dull, diffuse, shifting)

-Severity (severe or excruciating, moderate, slight or mild)

-Periodicity (continuous, intermittent, brief or transient)

general assessments of pain

•Patient's verbalization and description of pain

•Onset and duration of pain

•Etiology or mechanism of injury, if known

•Location of pain

•Quality, character, and intensity of pain

•Aggravating or causal factors

•Alleviating or relieving factors

•Effect on function

•Pain management goal

basic methods of assessing pain

•Patient self-report

•Identify pathologic conditions or procedures that may be causing pain; consider physiologic measures (increased blood pressure and pulse)

•Report of family member, other person close to the patient or caregiver familiar with the person

•Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area

•Physiologic measures: increased blood pressure and pulse

•Attempt an analgesic trial and monitor the results

pain assessment tools

•0-10 Numeric Rating Scale

•Adult Nonverbal Pain Scale (NVPS)

•Behavioral Pain Scale (BPS)

•Checklist of Nonverbal Indicators

•COMFORT Behavior Scale

•CRIES Instrument

•Critical-Care Pain Observation Tool (CPOT)

•Faces Pain Scale—revised (FPS-R)

•FLACC Behavioral Scale

•Iowa Pain Thermometer (IPT) and Revised (IPT-R)

•Oucher Pain Scale

•Pain Assessment in Advanced Dementia Scale (PAINAD)

•Wong-Baker FACES

nursing interventions for pain

•Establishing trusting nurse-patient relationship

•Manipulating factors affecting pain experience

•Initiating complementary health approaches and integrative health care

•Managing pharmacologic relief measures

•Ensuring ethical and legal responsibility to relieve pain

•Understanding the placebo controversy

complementary health approaches and integrative health care

•Distraction

•Humor

•Music

•Imagery

•Mindfulness practice

•Cutaneous stimulation

•Acupuncture

•Hypnosis

•Biofeedback

•Healing/therapeutic touch

•Animal-assisted intervention

pharmacologic pain relief measures

Analgesic administration: opioid, adjuvant, nonopioid

numeric sedation scale

S: sleep, easy to arouse: no action necessary

1: awake and alert; no action necessary

2: occasionally drowsy, but easy to arouse; no action necessary

3: frequently drowsy, drifts off to sleep during conversation; reduce dosage

4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

general principles for analgesic administration

•Ongoing assessment

•Management of breakthrough pain

•Concern about prescription analgesic abuse

pain management regimens for cancer or chronic pain

•Give medications orally if possible

•Administer medications ATC rather than PRN

•Adjust the dose to achieve maximum benefit with minimum side effects

•Allow patients as much control as possible over the regimen

additional methods for administering analgesics

•Patient-controlled analgesia

•Epidural analgesia and peripheral nerve blocks

•Topical anesthesia

teaching about pain

•Should include family members or caregivers

•Explanation about pain scales

•Safety: avoid driving, operating machinery, alcohol or other CNS depressants

•Keep diary of pain and medications taken

•Diet: do not take on an empty stomach

•Do not breastfeed without checking with provider