Comfort (Class 13)

Pain

• Subjective

• Can affect a person’s physical, emotional, and cognitive well-being.

• Fifth vital sign

• A part of a nurse assessment

Nociception

• Activity in the nervous system that allows an individual to detect pain.

• CNS and PNS processing stimuli such as injury or temperature extremes.

Transduction

Painful stimuli is converted to an electrical impulse sent across a sensory peripheral pain nerve (nociceptive impulse.) First step.

Transmission

Nociceptive impulses are transmitted from the periphery to the spinal cord.

Perception

Impulse reaches the brain and the person becomes aware of the pain.

Modulation

Release of inhibitory neurotransmitters (endorphins, serotonin, norepinephrine)

Referred Pain

Pain in a part of the body separate from the sources of pain.

Idiopathic Pain

Chronic pain in the absence of an identifiable physical or psychological cause.

Visceral Pain

Pain is diffuse and radiates in several directions. Think organs.

Radiating Pain

Pain that is travelling down or along a body part.

Superficial Pain

Pain that has a short duration and is localized.

Concomitant Symptoms

Occur with pain and increases pain severity.

Somatic Pain

Comes from the joints, muscles, skin, and bones. Throbbing/aching in nature. Ex. Arthritis.

Acute Pain

• Protective

• (Usually) Has a definable cause

• Short duration

• Limited tissue damage and emotional response

• Predictable ending (healing)

Signs/Symptoms of Acute/Transient Pain

• Anxiety/fear

• Physical manifestations, Ex. Gritting teeth or guarding a side.

Chronic/Persistent Pain

• Not protective

• Last longer than 3-6 months

• No predictable ending

• Major cause of psychological and physical disability

• Does not always have an identifiable cause.

Signs/Symptoms of Chronic Pain

• Fatigue

• Anorexia

• Hopelessness/depression

• Insomnia

• Apathy

• Anger

Cancer Pain

Caused by tumor progression and related pathological processes, invasive procedures, toxicities of chemotherapies, infection, and physical limitation.

PQRSTU Assessment

P- Palliative or Provocative Factors

Q- Quality

R- Relief Measures/Region

S- Severity

T- Timing

U- Effect of Pain

Palliative or Provocative Factors

What makes your pain worse? What makes your pain better?

Quality

Describe your pain.

Relief Measures/Region

What do you take at home to gain relief? What makes your pain go away? Show me where your pain is?

Severity

Scale from 1-10, how bad is your pain? What is the worst pain you’ve had in the past 24 hours? What is the avg. pain? Only at certain times?

Timing

Do you have pain all the time? Only at certain times? Only on certain days?

Effect of Pain

Describe what you cannot do because of your pain. With whom do you live with and how do they help? “How does the pain effect U?”

Pain Assessment Tools

• Numerical 1-10

• Face → # Scale

• OUCHER! Scale

Psychological Reactions to Pain

• Decreased GI motility

• Dilation of pupils

• Increased muscle tension

• Diaphoresis

• Increased cortisol levels (short term)

• Increased blood glucose level

• Peripheral vasoconstriction (pallor, elevation in blood pressure)

• Increased heart rate

• Dilation of bronchial tubes and increased respiratory rate.

Nonverbal Pain Cues

• Grimacing

• Clenched teeth

• Restlessness

• Guarding

• Pacing

• Tightly closed eyes

• Immobilization

• Protective movements

• Lip biting

• Rhythmic or rubbing movements

NARCAN

Reversal agent for opioids:

• Morphine

• Fentanyl

• Oxycodone

• Opium

• Codeine

• Hydrocodone

• Methadone

Acetylcysteine

Reversal agent for acetaminophen.

Relaxation and Guided Imagery

Allow patients to alter affective-motivational and cognitive pain perception mental and physical freedom from stress or tension that provides individuals a sense of self control.

Distractions

Directs a patient’s attention to something other than pain and thus reduces awareness of it. Works best for short, intense pain. Ex. Music, playing games.

Music Therapy

Diverts attention and creates a relaxation response. Sessions usually last 20-30 minutes and can sometimes decreases the amount of medication used.

Cutaneous Stimulation

Uses gate control theory or releases endorphins that block painful stimuli. Reduces muscle tension. Good at-home treatment. Ex. Massages or warm baths.

Gate Control Theory

Small fibers activated by painful stimuli open the gate for feeling pain, and the large diameter fibers that we can activate to close the gate, or stop the pain.

Factors Influencing Pain in Older Adults

• Muscle mass decreases

• Body fat increases

• Poor diet and low albumen levels

• Liver and renal function naturally decline

• Thinning and loss of elasticity in the skin effect the absorption of topical analgesics

Herbal Supplements

• Ex. Echinacea, ginseng, turmeric, and garlic.

• May interact with prescribed medications

• Not FDA approved

Reducing Pain Perception/Reception

Remove or prevent the painful stimuli. Ex. Ambulating a patient, increasing fluids, requesting laxatives for a patient at risk for constipation.

Hot or Cold Therapy

• Ice for acute pain

• Heat for chronic Pain

• Works similarly to the gate control theory.

Barrier to Pain Management

• Fear of addiction

• Concern about being a good patient

• Belief that pain is inevitable

• Healthcare provider: bad assessment, concern about addiction, fear of legal ramifications

Nonopioids

• Ex. Acetaminophen

  • Tylenol

• Ex. NSAIDs

  • Aspirin

  • Aleve

  • Naproxen

  • Ibuprofen

Acetaminophen

Reduces pain/fever, but not inflammation and has limited effects on the PNS. Max dose is 4 g. Hepatotoxicity is the major adverse effect.

NSAIDs

Relieve mild to moderate acute intermittent pain (Ex. headache or muscle strain.) Inhibit COX. Inhibit cellular responses to inflammation. Acts on the PNS. Can irritate GI and patients with asthma or aspirin allergies may be allergic.

Opioids

Act on higher brain centers and spinal cord by binding with opiate receptors to modify perceptions of pain.

Side Effects of Opioids

• Vomiting

• Constipation

• Nausea

• Memory/thought changes

Adjuvants

Drugs originally developed to treat conditions other than pain but have analgesic properties. Successfully treat chronic pain, especially neuropathic pain. Enhance pain control and relieves other symptoms. Ex. Gabapentin

Topical and Transdermal Analgesics

Work locally. Have few side effects, must be applied directly over painful area. Meds absorbs through the skin by the blood stream overtime. Wear gloves and wash hands to avoid dosing yourself with the medication.

Patient Controlled Analgesia (PCA)

Drug delivery system that allows patients to self administer opioids with the push of a button with minimal overdose risk. Uses less medication and reduces patient anxiety.

True

True or False: Patients with PCA should have NARCAN at the bedside.

Local Anesthesia

Used for inpatient and outpatient procedures. A catheter is run near a nerve or group of nerves and medication runs through it. Can temporarily block motor and sensory nerves, but this resolves. Ex. Lidocaine

Epidural Analgesia

A form of regional anesthesia that is injected into the epidural space (a catheter is placed.) Often reduces overall opioid requirement, but there is a risk of bleeding and subsequent hematoma formation.

Breakthrough Pain

Temporary pain increase in someone who has relatively stable and controlled pain. Occurs spontaneously and due to specific triggers.

Breakthrough Pain Treatments

• Non-pharm. management

• Modification of pathological processes

• Lifestyle changes

• Management of reversible conditions

• Rescue medication doses

• Interventional techniques

WHO Analgesic Ladder

A recommended approach for the slow introduction and upward titration of analgesics for maintaining pain.

Circadian Rhythm Disruptions Lead To…

• Physiological functions change

• Anxiety

• Restlessness

• Irritability

• Impaired judgements

• Negatively influences overall health

Hypothalamus

Sleep center of the body that secretes hypocretins, prostaglandins D2, L-tryptophan, and growth factors to control sleep.

NREM

Non-rapid eye movement

NREM N1

• Nonrapid eye movement sleep

• Lightest level of sleep

• Lasting a few minutes

• Decreased physiological activity begins with gradual fall in vital signs and metabolism

• Sensory stimuli such as noise easily arouses sleeper

• If awakened person feels like daydreaming occurred.

NREM N2

• Relaxation progresses

• Arousal is still relatively easy

• Brain and muscle activity continues to slow

NREM N3

• Slow wave sleep

• Deepest stage of sleep

• Sleeper is difficult to arouse and rarely moves

• Brain and muscle activity are significantly decreased.

REM

• Vivid full color dreaming occurs

• Stage begins about 90 minutes after sleep begins

• Autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increase of fluctuating blood pressure.

• Loss of skeletal muscle tone

• Gastric secretions increase

• Difficult to arouse sleeper

• Duration increases with each cycle and averages 20 minutes.

Functions of Sleep

• Preserve cardiac function

• Restoration

• Restorative biological processes

• Memory consolidations

Physiological Effects of Inadequate Sleep

• Hypertension

• CVD

• Obesity

• Depression

• Diabetes

• Delusions

• Impaired immune function

What Impairs Sleep (Generally)

• Pain and discomfort

• Hypertension

• Respiratory diseases (Ex. Chronic lung disease, asthma, bronchitis)

• Cold with nasal congestion

• Nocturia

Insomnia

Difficulty falling asleep, frequent awakenings, short sleep, nonrestorative. Commonly caused by:

• Situational stress

• Jet lag

• Illness

• Poor sleep hygiene

• Depression

Sleep Apnea

Lack of airflow through the nose and mouth and the individual is unable to breathe and sleep at the same time. Lasts for periods of 10 sec to 1-2 minutes. The most common is obstructive sleep apnea.

Risk Factors:

• Obesity

• Hypertension

• Smoking

• Heart Failure

• Family history

• Large neck circumference

Narcolepsy

Dysfunction of the processes that regulate sleep and wake states (lack of brain chemical hypocretin._ During the day, the person suddenly feels an overwhelming wave of sleepiness and falls asleep. They g into REM within 15 minutes of falling asleep. Sudden muscle weakness during intense emotions such as anger, sadness, and laughter can occur causing the person to lose all muscle control and fall to the floor.

Sleep Deprivation Causes

• Sleep disorder

• Illness

• Emotional distress

• Environmental disturbances

• Medications

• Stress

Parasomnias

Occur more in children than adults. Broad term for sleep problems:

• Leg cramps

• Sleep walking/talking

• Teeth grinding

• Bedwetting

• Sleep paralysis

• Nightmares

• Night terrors

Non-Pharmacological Nursing Interventions for Sleep

• Limit caffeine and nicotine in the late afternoon.

• Promote a routine

• Reduce lighting (night-light for safety)

• Relaxing music

• Keep noise to a minimum

• Bedtime snack (carbs or milk)

Pharmacological Nursing Interventions for Sleep

• Sedatives (calming/soothing effect)

• Hypnotics (induce sleep)

• Ex. Benzodiazepines, benzo-like, and trazadone

Promoting Sleep in the Hospital Setting

• Close doors to patient’s room when possible

• Keep doors to work areas on unit closed when in use

• Reduce volume of nearby telephone and paging equipment

• Wear rubber-soled shoes. Avoid clogs.

• Turn off bedside oxygen and other equipment not in use

• Turn down alarms and beeps on bedside monitoring equipment.

• Turn off room television and radio unless patient prefers soft music

• Avoid abrupt loud noise such as flushing a toilet or moving a bed.

• Keep necessary conversations at low levels, particularly at night.

• Designate a time during the day for “quiet time” for patients.

Influences of Pain

• Psychological factors

• Social factors

• Physiological factors

• Cultural factors

Physiological Factors

Age can affect a patient’s response and coping to pain. Older adults may have difficulty interpreting pain due to acute and chronic conditions. Pain is not an inevitable part of aging.

Social Factors

Previous experience can cause certain reactions but education about pain relief can help.

Psychological Factors

The degree to which a patient focuses attention on pain influences the patient’s perception of pain. Increase attention leads to increased pain. Distraction leads to diminished pain.

Cultural Factors

Cultural beliefs and values affect how individuals cope with pain. They learn what is expected and accepted by their culture, including how to react to pain.

Rest

Contributes to a state of mental, physical, and spiritual activity that leaves one refreshed, rejuvenated, and ready to resume the activities of the day.

Recommended Sleeping Requirement for Adults

Young Adults: 7-9 hours

Middle → Older Adults: 6-8.5 hours