Nursing 112: Comfort, Pain, and Sleep - Exhaustive Study Guide

Introduction to Comfort and Nursing Principles

  • Definition of Comfort:     * A state of physical ease and freedom from pain or constraint.     * The easing or alleviation of a person’s feelings of grief or distress.     * To ease the grief or distress of, or to console.     * A feeling based on past experiences and expectations.     * Provision of comfort is a central concept of nursing.     * Nurses are morally and legally responsible for managing pain and relieving suffering.

  • Alterations in Comfort:     * Pain.     * Fatigue.     * Sleep Rest Disorders.

  • Comfort at the End of Life (Palliative and Hospice Care):     * Primary focus is comfort during the final stages of life.     * Pain management is a priority.     * Psychological support for both the patient and the family.     * Social and environmental concerns are addressed.     * Spiritual and religious aspects of care.     * Cultural aspects of the dying process.     * Communication of signs and symptoms of a worsening condition.     * Ethical and legal considerations.     * Organ donation procedures.

  • Caring Behaviors in Nursing:     * Attentive listening.     * Comforting techniques.     * Honesty and transparency.     * Patience.     * Responsibility.     * Providing information for informed decisions.     * Touch.     * Sensitivity.     * Respect.     * Addressing the patient by their preferred name.

Pain: Pathophysiology and Manifestations

  • General Concepts of Pain:     * An unpleasant sensory and emotional experience.     * Can impact a person’s psychosocial, emotional, or physical functioning.     * The standard clinical definition: ‘It is what the patient says it is.’     * Affects individuals of every age, gender, race, and socioeconomic class.     * Considered the 5th5^{th} vital sign.

  • Pathophysiology of Pain:     * Triggered by the peripheral nervous system (PNS).     * Nociceptors: Sensory receptors that respond to pain.     * Categories of noxious stimuli: Biological, mechanical, thermal, electrical, and chemical.     * Cellular injury triggers the release of biochemicals that act directly or indirectly to initiate pain.     * Etiology: Relates to the origin of pain, categorized as nociceptive versus neuropathic.

  • The Pain Process Stages:     * Transduction: Activation of pain receptors.     * Modulation: Initiation of the protective reflex response.     * Transmission: Conduction of the pain signal along nerve pathways.     * Perception: Awareness of the characteristics of pain.

  • Physiological Sequence of a Pain Signal (Example: Burned Finger):     1. A finger is burned.     2. The signal travels the length of the nerve to the dorsal horn on the spinal cord.     3. The signal reaches the hypothalamus (sensory center).     4. The signal reaches the cortex.     5. Pain relief begins as a signal from the brain descends by way of the spinal cord.     6. Endorphins are released to diminish the pain message from the injured finger.

  • Categories of Pain by Duration:     * Acute Pain:         * Lasts only through the expected recovery period.         * Usually defined as lasting from 3030 days to 33 months.         * Temporary and self-limiting.         * Displays both physiologic and behavioral responses.     * Chronic Pain:         * Lasts longer than 66 months and persists beyond the expected period of healing.         * Characterized as recurrent, intractable, or progressive.         * Ongoing nature lead to psychosocial implications.         * Includes Idiopathic pain.

  • Other Types of Pain:     * Breakthrough pain: Continuous chronic pain accompanied by more intense, spontaneous acute exacerbations.     * Central pain: Arises from the central nervous system.     * Psychogenic pain: Associated with psychological factors rather than physiological factors.     * Referred pain: Originates in one part of the body but is perceived in an area distant from its point of origin.     * Phantom pain: Pain felt in an amputated limb or body part.

  • Categories of Pain by Origin:     * Nociceptive Pain:         * Arises from damage to or inflammation of tissue.         * Described as throbbing or aching.         * Treated with opioids and non-opioids.         * Three types: Somatic, Visceral, and Cutaneous.     * Neuropathic Pain:         * Arises from abnormal or damaged peripheral or central nerves.         * Causes: Trauma, disease, chemicals, infections.         * Described as intense, shooting pain.         * Treated with adjuvant medications and topicals.

Pain Assessment and Diagnostic Tools

  • Nursing Process in Pain Management:     * Assessment: What data is collected?     * Diagnosis: What is the problem?     * Planning: How to manage the problem?     * Implementation: Putting the plan into action.     * Evaluation: Did the plan work?

  • Data Collection Principles:     * Self-report of pain is the most reliable diagnostic measure.     * Involves a client interview and careful observation.     * Data points include: Location, duration, quantity, intensity, quality, chronology, aggravating factors, alleviating factors, physiological indicators, behavioral responses, and effect on lifestyle.

  • The OLDCARTS Assessment Tool:     * O—Onset: When did the pain begin?     * L—Location: Where is the pain?     * D—Duration: How long has it been going on?     * C—Characteristics: Describe the pain (crushing, sharp, dull, aching, stabbing).     * A—Aggravating/Associate Factors: What makes it worse? Any nausea, vomiting, weakness, diarrhea, or fatigue?     * R—Relieving Factors: What makes the pain better?     * T—Treatment: What has been tried, and was it successful?     * S—Severity: Intensity rating on a scale.

  • Common Responses to Pain:     * Physiologic: Hypertension, tachycardia, tachypnea.     * Behavioral: Grimacing, guarding.     * Affective: Withdrawal, anxiety, depression, fear.

  • Pain Assessment Scales:     * WONG Baker FACES: Used with permission from 1983 Wong-Baker FACES Foundation. Faces range from 00 (No Hurt) to 1010 (Hurts Worst). Scale increments: 0,2,4,6,8,100, 2, 4, 6, 8, 10.     * Numeric 0-10 Scale: 00 is No pain, 55 is Moderate pain, 1010 is Worst possible pain.     * Verbal Descriptor Scale: Uses terms like No Pain, Mild, Moderate, Severe, Very Severe, and Worst Possible.     * CHEOPS (Children's Hospital of Eastern Ontario Pain Scale): Evaluates Cry (None, Moaning, Crying, Screaming), Facial Expression (Composed, Grimace, Smiling), Verbal (None, Complaints, Both), Torso (Neutral, Shifting, Tense, Shivering, Upright, Restrained), Touch (Not touching, Reach, Touch, Grab, Restrained), and Legs (Neutral, Squirming, Tensed, Standing, Restrained).     * FLACC (Face, Legs, Activity, Cry, Consolability): Behavioral scale for nonverbal/preverbal patients. Scoring: 0−30-3 (none/mild), 4−64-6 (moderate), 7−107-10 (severe).     * Behavioral Pain Scale (BPS): Used for ICU patients (intubated/non-intubated). Scoring: 0−30-3 (painless), 4−64-6 (mild), 7−97-9 (moderate), 1010 (severe).

Pain Management and Nursing Interventions

  • Ongoing Assessment Protocols:     * Assess and reassess pain at least every 44 hours.     * Reassessment timing: PO analgesia after 11 hour; IV analgesia within 15−3015-30 minutes.

  • Risk Factors for Undertreatment:     * Cultural/societal attitudes.     * Lack of knowledge or fear of addiction.     * Fear of respiratory depression.     * At-risk populations: Infants, children, older adults, and individuals with substance use disorders.

  • Pain in Cognitively Impaired Patients:     * Monitor for facial expressions, verbalizations, body movements, changes in interpersonal interactions, changes in activity/patterns, and changes in mental status.

  • Nonpharmacologic Interventions:     * Biofeedback, Therapeutic touch, Yoga.     * Animal facilitated therapy (therapy dogs).     * Heat and ice application, TENS unit.     * Positioning, Distraction, Humor, Music, Imagery.     * Relaxation, meditation, acupuncture, hypnosis.

  • Pharmacologic Interventions:     * Non-opioids: For mild-moderate pain. Acetaminophen (risk of Hepatotoxicity), NSAIDs (Ibuprofen, Ketorolac), Salicylates/Aspirin (monitor for bleeding).     * Opioids: For moderate-severe pain. Includes Morphine, Codeine, Oxycodone, Meperidine, Hydromorphone, Fentanyl, Methadone. Highly addictive; controlled substances.     * Adverse Effects of Opioids: Sedation, respiratory depression, orthostatic hypotension, urinary retention, nausea, vomiting, constipation, sexual dysfunction, pruritus.     * Adjuvant/Co-analgesics: Antidepressants, Antianxiety, Anticonvulsants, Corticosteroids, Topical anesthetics.

  • Patient Controlled Analgesia (PCA):     * Allows clients to self-administer safe opioid doses.     * Common with morphine, hydromorphone, or fentanyl.     * The patient (and only the patient) should press the button.

  • Numeric Sedation Scale:     * 1: Awake and alert (no action).     * 2: Occasionally drowsy, easy to arouse (no action).     * 3: Frequently drowsy, drifts off during conversation (reduce dosage).     * 4: Somnolent with minimal/no response to stimuli (discontinue opioid, consider naloxone, call rapid response).

  • Emergency Reversal:     * Naloxone (Narcan): Opioid reversal agent for overdose.     * Routes: Intranasal, IM, SQ, or IV.     * Immediate actions for severe depression: Call rapid response/code blue, resuscitate with ambu-bag and 100%100\% O2O_2, administer IV Narcan.

  • Joint Commission Pain Control Standards:     * Right to appropriate assessment, management, and control of pain.     * All clients must be assessed and reassessed.     * Right to be treated with respect, not as a drug-user.

Specialized Pain Syndromes

  • Complex Regional Pain Syndrome: Also referred to as causalgia. Characterized by prolonged inflammation following injury, burning, throbbing, temperature sensitivity, and color changes.
  • Postherpetic Neuralgia: Follows acute CNS infection (Herpes Zoster/Shingles). Unilateral vesicular eruption in a band-like cluster; pain lasts months to years.
  • Phantom Limb Pain: Neuropathic pain in an amputated part; involves brain neurological activity previously connected to the limb. Triggered by stump touch, fatigue, or stress.
  • Trigeminal Neuralgia: Also called Tic Douloureux. Affects the 5th5^{th} cranial nerve. Causes lightning-like stabbing pain in the mouth, gums, nose, and head. Triggered by talking or brushing teeth.
  • Diabetic Neuropathy: Complication of long-term diabetes. Metabolic/vascular changes damage peripheral and autonomic nerves. Leads to sensory loss, injury, gangrene, and potential amputation.

Sleep and Rest: Foundations and Physiology

  • Definitions:     * Rest: A state of relaxation free from stressors; body is in decreased activity and feels refreshed.     * Sleep: A state of rest with altered consciousness and relative inactivity; associated with healing and restoration.

  • Sleep Physiology:     * Reticular Activating System (RAS): Facilitates reflex/voluntary movements and controls cortical activities related to alertness.     * Bulbar Synchronizing Region: Takes over when stimulus (light, noise) decreases.     * Hypothalamus: Control system for sleeping and waking.     * Circadian Rhythm: Natural sleep-wake cycle repeated every 2424 hours; internal clock requiring consistency.

  • Stages of Sleep:     * Stage 1 (NREM): Lightest stage, regular breathing, muscle tone present.     * Stage 2 (NREM): Deeper sleep, no eye movements detected.     * Stage 3 (NREM): Short-term hibernation, deepest sleep, characterized by Delta waves.     * Stage 4 (REM): 20−25%20-25\% of sleep; vivid dreams and cognitive restoration.

  • Recommended Sleep Duration by Age:     * Newborns (birth-2828 days): 14−1714-17 hours.     * Infants (11 month-11 year): 12−1512-15 hours.     * Toddlers (1−31-3 years): 11−1411-14 hours.     * Preschool (3−63-6 years): 10−1310-13 hours.     * School age (6−126-12 years): 9−119-11 hours.     * Adolescents (12−2012-20 years): 8−108-10 hours.     * Young adults (20−3520-35 years): 7−97-9 hours.     * Middle adults (35−6535-65 years): 7−97-9 hours.     * Older adult (65+65+): 7−87-8 hours.

Sleep and Rest Disorders: Dyssomnias and Parasomnias

  • Dyssomnias (Quantity and Timing Disorders):     * Insomnia: Most common; inability to feel rested. Can be acute, chronic, or intermittent.     * Hypersomnia: Abnormal daytime drowsiness despite adequate night sleep; causes poor memory and irritability.     * Narcolepsy: Sudden uncontrollable sleep attacks; may involve hallucinations or cataplexy (muscle weakness).     * Hypersomnolence disorder: Excessive daytime sleepiness lasting at least 33 months.     * Sleep Apnea: More than 55 breathing cessations (>10 seconds each) per hour.         * Types: Central (CNS failure) and Obstructive (OSA - airway occlusion).         * Factors: Male, age >60, obesity, large neck, smoking.         * Treatment: CPAP (Nasal, Full face, or Nasal pillow), weight management, smoking cessation.     * Restless Leg Syndrome (RLS): Irresistible urge to move legs, usually at night.

  • Parasomnias (Waking Behaviors during Sleep):     * Somnambulism: Sleep-walking, more common in children.     * REM Behavior Disorder (RBD): Dream enactment behaviors due to loss of REM sleep.     * Sleep Terrors (Night Terrors): Screaming/intense fear while remaining asleep.     * Nightmares: Bad dreams that awaken the person.     * Bruxism: Teeth grinding; causes headaches and jaw pain.     * Enuresis: Bed wetting; not a concern before age 77.     * Sleep Related Eating Disorder: Unusual eating (often high calorie or toxic substances) during sleep.

Nursing Care and Interventions for Sleep

  • Assessment Parameters:     * Nature/cause of problem, signs/symptoms, severity, and coping mechanisms.     * Sleep Diary: Tracking retirement time, time to fall asleep, awakenings, resumption of sleep, and morning wake time.

  • Nursing Actions to Promote Sleep:     * Limit waking clients at night; schedule care to avoid disturbances.     * Prepare environment (cool, dark) and promote rituals (warm bath).     * Dietary Education: Avoid caffeine and alcohol 44 hours before bed; limit fluids 2−42-4 hours before bed; avoid exercise 2−32-3 hours before bed.

  • Pharmacological Sleep Aids:     * Anticonvulsants: Gabapentin (Neurontin).     * Antidepressants: Amitriptyline (Elavil), Bupropion (Wellbutrin), Doxepin (Sinequan), Trazodone (Desyrel).     * Antihistamines: Diphenhydramine (Benadryl).     * Benzodiazepines: Diazepam (Valium), Lorazepam (Ativan).     * Z-drugs: Zolpidem (Ambien), Eszopiclone (Lunesta).     * Melatonin Agonists: Ramelteon (Rozerem).

Questions & Discussion

  • Question: What is comfort?     * Response: It is a state of physical ease, freedom from pain/constraint, and the easing of grief or distress. It is subjective based on past experiences.
  • Instructional Prompts/Blanks from Transcript:     * Central concept of nursing is the provision of comfort: ‘Is subjective.’     * Caring behaviors: Addressing patient by ‘preferred name.’     * Pain is considered the: ‘5th5^{th} vital sign.’     * Nociceptive pain is described as: ‘Throbbing, aching.’     * Neuropathic pain is described as: ‘Intense, shooting pain.’     * In PCA delivery, the ‘patient’ should press the button.     * Hypersomnolence disorder lasts at least ‘33’ months.     * Sleep apnea treatment includes ‘smoking’ cessation.