Fundamentals of Nursing - Pain, Comfort, and Sleep Study Notes

Fundamentals of Nursing

Chapter 31: Pain, Comfort, and Sleep

  • Copyright © 2022 by Elsevier Inc. All rights reserved.

Overview of Pain and Comfort

Learning Outcomes: Theory
  1. Discuss the physiology and characteristics of pain.
    • Understanding the biological mechanisms that govern pain sensation, transmission, and perception.
  2. Describe the legal, ethical, and moral considerations of pain management.
    • Aspects concerning patient rights, informed consent, and ethical treatment in pain management.
  3. Assess the client experiencing pain.
    • Evaluating patient's pain levels, signs, and symptoms.
  4. Identify nursing responsibilities related to interventions for pain management.
    • Involvement in pain mitigation, management strategies, and documentation.
Learning Outcomes: Clinical Practice
  1. Assist the patient in accurately describing sensations of pain and discomfort.
    • Encourage patients to articulate their pain experiences effectively.
  2. Accurately and appropriately record the patient’s report of pain using clear, descriptive terms.
    • Documentation practices to ensure effective communication.
  3. Assist the patient in using a transcutaneous electrical nerve stimulation (TENS) unit.
    • Training and support in the use of TENS for pain relief.
  4. Evaluate the effects of various techniques used for pain control.
    • Assessing outcomes from different pain management interventions.
  5. Care for patients receiving patient-controlled analgesia (PCA) or epidural analgesia.
    • Monitoring and supporting patients utilizing PCA and epidural techniques.
  6. Evaluate the effects of pain medication, and accurately report and record observations.
    • Vigilance and accuracy in monitoring pharmacotherapy effects.

Understanding Pain and Discomfort

Definition of Pain
  • Pain is described as the feeling of distress and discomfort that affects or interferes with normal activities.
Measurement Challenges
  • There is no accurate objective measurement of pain; therefore, pain assessment accompanies each vital signs check and is considered the “fifth vital sign.”
Surgical and Medical Pain Conditions
  • Postoperative Pain: Common occurrence after surgical procedures.
  • Medical Conditions Causing Pain:
    • Headaches
    • Myocardial Infarction
    • Cancer
    • Fractures
    • Cuts and Abrasions

Pain Control Standards (The Joint Commission)

Patients' Rights
  • Patients have the right to appropriate assessment and management of pain.
  • Pain is mandated to be assessed in all patients.
  • Patients are educated on pain and management as relevant to their treatment.
  • The discharge process should consider continued pain care based on the individual’s needs.
Clarification of Standards
  • Recent revisions emphasize the inclusion of pharmacologic and non-pharmacologic pain management methods, alongside the benefits and risks of strategies when formulating an effective pain management plan.

Theories of Pain

Definition
  • Pain is defined as a feeling of distress or suffering caused by nerve ending stimulation.
  • It serves a crucial warning function by highlighting potential tissue damage and enabling withdrawal from harmful stimuli.
Transmission Mechanism
  • Pain is transmitted through the nervous system.

Gate Control Theory

Overview
  • Pain regulation is perceived through a gate mechanism within the central nervous system.
Mechanism Explanation
  • Opening the Gate:
    • Allows the transmission of pain signals.
    • Typically stimulated by small-diameter nerve activity (e.g., from tissue damage).
  • Closing the Gate:
    • Blocks pain signal transmission.
    • Influenced by the activity of large-diameter nerves (e.g., touch).
  • Lack of sensory input allows for the gate to open, facilitating pain perception.

Role of Endorphins

Definition and Function
  • Endorphins are naturally occurring peptides functioning similarly to opioids that modify pain perception.
  • They attach to opioid receptors in the brain to block pain.
Release Stimuli
  • Physiological and psychological stressors can trigger endorphin release.
    • Example: Long-distance runners often experience an "endorphin high."

Types of Pain

Classification
  1. Acute Pain:
    • Short-term pain that typically occurs after injury, medical condition, or surgical procedure.
    • Lasts from a few hours to a few days.
    • Described as aching or throbbing; often results in restlessness.
    • Generally manageable with analgesics.
  2. Chronic Pain:
    • Long-term pain persisting for months or years, often associated with conditions like arthritis or chronic back pain.
    • Descriptive characteristics include dullness, constant throbbing, or burning sensations.
  3. Nociceptive Pain:
    • Caused by tissue injury affecting nociceptors (pain receptors).
    • Associated with four phases: Transduction, Transmission, Perception, Modulation.
  4. Neuropathic Pain:
    • Related to dysfunction in the nervous system.
    • Occurs when pain receptors increase sensitivity, often linked with conditions like Guillain-Barré syndrome.
  5. Phantom Pain:
    • Pain sensation resulting after the loss of a body part, frequently felt in the amputated area for years post-surgery.

Characteristics of Acute Pain

Description and Duration
  • Generally indicates injury or illness.
  • Can last from hours to a few days.
Observable Indicators
  • Patient may appear restless, agitated, and may describe pain as aching or throbbing.
Common Causes
  • Burns, fractures, muscle strains; medical conditions such as pneumonia or sickle cell crisis;
  • Typically alleviated when the underlying cause is resolved.

Characteristics of Chronic Pain

Pain Duration
  • May persist for months to years.
Descriptive Elements
  • Can be dull, constant, shooting, tingling, or burning.
Treatment Approaches
  • May require combined pharmacologic and nonpharmacologic interventions to alleviate symptoms.

Nociceptive Pain Phases

Phases Defined
  1. Transduction:
    • Conversion of noxious stimuli into neural impulses.
  2. Transmission:
    • Conducting pain signals to the central nervous system.
  3. Perception:
    • Recognizing and interpreting pain in the brain.
  4. Modulation:
    • Alteration of pain signal transmission, can enhance or dampen perception of pain.
Treatments Targeting Phases
  • NSAIDs: block transduction.
  • Opioids: block transmission.
  • Distraction and guided imagery: affect perception.
  • Neurotransmitter uptake blockers: focus on modulation.

Neuropathic Pain

Definition and Mechanism
  • Arises from dysfunction in the nervous system, leading to an increased sensitivity of pain receptors and stronger signals.
Associated Conditions
  • Often related to diseases such as cancer, HIV.
Treatment Options
  • May involve NSAIDs, tricyclic antidepressants, anticonvulsants, or corticosteroids.

Phantom Pain

Definition and Experience
  • Pain that is experienced in an area of the body that has been amputated.
  • Pain sensations can persist for years, despite the absence of the body part.
Treatment Challenges
  • Often not responsive to conventional pain management methods.
  • Potential treatment: TENS units can be implanted in the thalamus for some relief.

Perception of Pain

Pain Assessment Principles
  • Pain is defined as what the patient describes it to be.
Observable Indicators
  • Observable symptoms may include:
    • Moaning, crying, irritability, grimacing, frowning, rigid posture.
Pain Descriptions Used by Patients
  • Described in terms like rushing, throbbing, pulsating, twisting, pulling, burning, searing, stabbing, tearing, biting, blinding, and debilitating.

Location and Frequency of Pain

Factors to Consider
  1. Area of Pain:
    • Localization: specific body parts (e.g., foot, hand), categorized as localized, radiating, or generalized.
  2. Frequency of Pain:
    • Patterns: can be constant, intermittent, or occasional.

Pain Scales

Types of Pain Assessment Tools
  1. Number Scale:
    • Patients rate pain from 0 (no pain) to 10 (worst pain imaginable).
  2. Picture Scale:
    • Use of images showing faces reflecting varying pain levels.
  3. Specific Scales:
    • NIPS (Neonatal Infant Pain Scale),
    • CRIES (Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, Sleeplessness),
    • PIPP (Premature Infant Pain Profile).

Nonmedicinal Methods of Pain Control

Techniques and Interventions
  • Examples include:
    • Transcutaneous electrical nerve stimulation (TENS)
    • Percutaneous electrical nerve stimulation (PENS)
    • Binders
    • Heat and cold application
    • Relaxation techniques
    • Biofeedback
    • Distraction methods
    • Guided imagery and meditation
    • Music therapy
    • Hypnosis
    • Massage therapy

Medicinal Methods of Pain Control

Types of Medications Used
  1. Analgesic Medications:
    • Routes include oral, topical, injected, and intravenous administration.
  2. Patient-Controlled Analgesia (PCA):
    • Allows patients to self-administer pain relief as needed.
  3. Epidural Analgesia:
    • Administering anesthetics or analgesics in the epidural space to relieve pain.

Reflection Questions

Pain Types
  • What type of pain occurs after the loss of a body part from an amputation?
    • Options: 1) Acute pain 2) Nociceptive pain 3) Neuropathic pain 4) Phantom pain
Pain Scale in Pediatric Patients
  • Which pain scale is employed for assessing pain in infants and children?
    • Options: 1) FACES pain rating scale 2) FLACC scale 3) PIPP scale 4) NIPS
COX-2 Inhibitors Example
  • Which of the following medications is an example of a COX-2 inhibitor?
    • Options: 1) Aspirin 2) Morphine 3) Anti-inflammatory 4) Antidepressant

Overview of Sleep

Learning Outcomes: Theory
  1. Describe the functions, physiology, and stages of sleep.
  2. Describe the characteristics of common sleep disorders.
  3. Explore nursing interventions that can help promote a client’s rest and sleep.
Learning Outcomes: Clinical Practice
  1. Gather data regarding a patient’s sleep difficulties.
  2. Develop a plan designed to assist the patient in getting adequate sleep.

Functions of Sleep

Importance for Health
  • Proper rest and sleep are crucial for general health and recovery from illnesses.
  • Adequate sleep increases pain tolerance and improves the effectiveness of analgesics.

Stages of Sleep

Rapid Eye Movement (REM) Sleep
  • Characterized by dreaming, high levels of brain activity, and physiological changes.
    • Heart rate, blood pressure, and respiratory rates resemble those of wakefulness.
Non-Rapid Eye Movement (NREM) Sleep
  • The phase where the body achieves maximum rest, showing declines in heart rate, blood pressure, and respirations when compared to wakefulness.

Normal Sleep Requirements

Age-based Sleep Needs
  • Newborns: 16 hours per day.
  • 1 Year Old: 12-14 hours.
  • Preschool Age: 11-13 hours.
  • School Age: 10-11 hours per night.
  • Adolescents: 9-10 hours per night.
  • Adults: 8 hours per night.

Factors Affecting Sleep

Identifiable Influences
  • Shift work, travel, environmental factors (heat, cold, light, noise), snoring, consumption of caffeine, nicotine, alcohol, stress, illness, fatigue, discomfort, exercise, and napping patterns can all affect sleep quality.

Sleep Disorders

Insomnia
  • Lack of ability to initiate or maintain sleep.
    • Transient insomnia may occur due to stress and can resolve without intervention.
    • Chronic insomnia may require specialist intervention.
Sleep Apnea
  • Characterized by brief periods of apnea during sleep.
    • Obstructive Sleep Apnea (OSA): Most common variant, where the airway is blocked leading to snoring and requires CPAP treatment.
    • Central Apnea: Involves failure of the diaphragm and chest wall to function, waking the person to breathe.
    • Mixed Sleep Apnea: Combination of both obstructive and central.
Snoring
  • The sound produced by the vibration and obstruction of airflow in the nasal passages.
    • Often due to poor muscle tone, excessive tissue, or structural deformities.
    • Treatment includes positional changes or weight management.
Narcolepsy
  • A neurological disorder characterized by unexpected sleep episodes occurring during waking hours, lasting from seconds to 30 minutes, usually beginning around age 25, and currently has no known cure.

Reflection Questions

Identifying Narcolepsy
  • What condition is indicated by sudden-onset, uncontrolled episodes of sleep during normal waking hours?
    • Options: 1) Insomnia 2) Sleep apnea 3) Narcolepsy 4) REM sleep
Educating on Sleep Medications
  • When teaching patients about sleep aids, which information is critical?
    • Options: 1) Medications should be combined with alcohol 2) Used for short-term relief 3) Over-the-counter medications keep you alert 4) Hypnotics are not utilized for sleep.