Comfort - RNSG 1126 Notes

Comfort - Level 2 RNSG 1126

• M. Whittenberg, RN, MHA, MSN

Objectives

• Explain the correlation between imbalanced comfort (Sickle Cell Pain (Chronic pain), Post-operative Pain, Renal Calculi, and Peripheral Vascular Disease) to the concept of comfort: including compromised antecedents, deficit measurement in attributes, a list of negative consequences, and the interrelated concepts which may be involved.
• Identify conditions that place an individual at risk for imbalance leading to a compromised concept(s) resulting in impaired comfort (Sickle Cell Pain, Post-operative Pain, Renal Calculi and Peripheral Vascular Disease).
• Apply the nursing process with collaborative interventions for individuals experiencing impaired comfort (Sickle Cell Pain, Post-operative Pain, Renal Calculi and Peripheral Vascular Disease).

Exemplars

• Sickle Cell Anemia Chronic Pain
• Post-Operative Acute Pain
• Renal Calculi Acute Pain
• Peripheral Vascular Disease
• Neuropathic Pain

Nursing Care

• Primary, Secondary, Tertiary

Attributes

• Reports Being Comfortable
• Indicates Pain Scale Zero
• Relaxed Facial Expression and Body Posture
• Vital Signs Within Normal Limits (WNL) for Baseline

Antecedent

• Effective Circulatory System
• Able to Discern From Comfort to Discomfort Without Noxious Stimuli
• Intact Neurological/Sensory System

Comfort

• State of physical ease.

Sub Concepts

• Social Interactions
• Perfusion
• Coping
• Mobility
• Sensory Perception
• Chronic & Acute Pain
• Neuropathic Pain
• Nociceptive Pain
• Theory of Pain
• Mixed Pain Syndromes

Interrelated Concepts

• Mood and Affect

Consequences (Outcomes)

• Positive
  • Perform Activities of Daily Living
  • Adapt to Stressors
  • Control
  • Calm Demeanor
• Negative
  • Functional Ability
  • Shock
  • Tissue Damage
  • Limited Movement
  • Suffering
  • Unintentional Overdose
  • Developmental Issues
  • Increased Heart Rate, Respiratory Rate, and Blood Pressure

Sickle Cell Anemia

• CHRONIC PAIN

Who is at Risk?

• African Americans
• Hispanic Americans
• Mediterranean Descent
  • Genetic link
• Caribbean Descent
• Arabian Descent
• East Indian Descent

How does the pathophysiology of sickle cell directly impact the concept of comfort?

• Sickle red blood cells become hard, pointed & sticky.
• They cannot flow easily through tiny capillary beds and become clumped and cause obstruction.
• The obstructions can lead to ischemia and necrosis, which produce the expected findings of pain and hypoxia.

Patient Assignment: Anthony Perkins

• Anthony Perkins is a 15-year-old African American male who was at a medically monitored summer camp and participated in several sports activities when the outside temperature was greater than 90 degrees.
• He began having pain in his knees and was evaluated by the camp nurse. After evaluation, he was transported to his primary care provider and evaluated.
• Anthony was transferred as a direct admit to the pediatric floor of the community hospital where you are the primary nurse responsible for his care.
• He weighs 154 lbs.

Recognize and Analyze Cues

• African American
• outside temperature was greater than 90 degrees
• participates in several sports activities
• pain in his knees
• Higher risk for sickle cell anemia
• Sudden change in temperature causing vasoconstriction
• strenuous exercise causing a shortage of oxygen in the cells can trigger sickle cell crisis.
• Joint pain common symptom of sickle cell crisis, also assess for any fatigue and SOB.

Upon further assessment…Cues?

• Vital Signs
  • T: $99.4$ F. (oral)
  • R: $20$ (regular)
  • B/P: $102/74$ (lying)
  • Pulse: $92$ (Regular)
  • B/P: $92/42$ (Standing up)
  • Pulse: $132$
  • O2 sat: $96$
• Pain Assessment
  • P = Movement and weight bearing/Rest, elevation, warm compresses
  • Q = “My knees are really hurting…deep ache”
  • R = (Region) Bilateral Knees
  • S = (Severity) $8/10$
  • T=“Constant since around noon today”

Shift Assessment…Cues?

• General Appearance: Uneasy in bed, changing position frequently, cooperative and responds to questions appropriately
• Cognition: PERRLA, 2mm, Alert and oriented to person, place, time, and situation (x4)
• Perfusion: Pink for ethnicity, warm and dry, no edema, heart sounds regular with no abnormal beats, no murmur noted, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks and denies chest pain.
• Gas Exchange: Breath sounds clear with equal aeration bilaterally, increased respiratory effort; mild nasal flaring noted, no retractions
• Elimination: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Voiding without difficulty, urine clear/dark amber in color
• Tissue Integrity: Skin integrity intact.
• Mobility: Knees swollen bilaterally, erythemic, warm to touch, decreased ROM of knees bilaterally, pain reported with movement.

Lab work Complete Blood Count (CBC)

Lab work Urine Analysis

Hypothesis?

• Impaired Comfort
• Impaired Gas Exchange
• Impaired Fluid & Electrolytes

Generate Solutions (What interventions do you anticipate?)

• Administer analgesics
• Administer fluids
• Administer Oxygen
• Repeat lab draws
• What can you do as a RN independently?
  • Comfort measures
  • Provide emotional support
  • Promote Hydration by mouth
  • Elevate swollen extremities
  • Promote peaceful and quiet environment

Take Action

• Apply Oxygen, 2 liters per minute (LPM) via nasal cannula (NC)
• Morphine patient-controlled analgesia (PCA) 1 mg continuous, PCA dose 1 mg every 10 minutes
• Initiate IV fluid therapy of D5 ½ NS with 20 MEq KCL @ 120 ml/h
• Repeat Lab:
  • Complete blood count (CBC) every 8 hours
  • Reticulocyte count
  • Basic metabolic panel (BMP)
  • Urine analysis (UA)

Pharmacological Interventions for Sickle Cell Pain

• Opioids
• NSAID's

Opioids for Sickle Cell & Vaso Crisis

• Morphine – Mechanism of Action
  • Receptor binding: Morphine binds to opioid receptors, primarily mu-opioid receptors, in the central nervous system.
  • CNS depression: This binding causes depression of the central nervous system.
  • Pain signal interruption: Morphine interrupts the transmission of pain signals between the brain and the body.
  • Reduced pain perception: The CNS depression leads to decreased sensation and reduced perception of pain.
  • Additional effects: Morphine also causes the release of histamine in the body, which can lead to vasodilation

NSAID’s for Sickle Cell Pain

• NSAID’s - Mechanism of Action:
  • Enzyme inhibition: NSAIDs work by inhibiting enzymes called cyclooxygenase (COX). There are two main types: COX-1 and COX-2.
  • Prostaglandin reduction: By inhibiting COX enzymes, NSAIDs reduce the production of prostaglandins, which are involved in inflammation, pain, and fever.
  • Non-selective inhibition: Both Ibuprofen and Diclofenac are non-selective COX inhibitors, meaning they inhibit both COX-1 and COX-2.
  • Pain and inflammation relief: The inhibition of COX-2 is primarily responsible for reducing pain, inflammation, and fever.
  • Side effects: Inhibition of COX-1 can lead to side effects, particularly in the gastrointestinal tract.

Acetaminophen for Sickle Cell Pain

• Pain relief: Acetaminophen works primarily in the central nervous system to reduce pain perception.
• COX enzyme inhibition: It inhibits cyclooxygenase (COX) enzymes, particularly in the brain, which leads to reduced production of prostaglandins.
• Pain threshold elevation: Acetaminophen raises the pain threshold, meaning it takes more pain for a person to feel it.
• Fever reduction: It targets the heat-regulating area in the brain (hypothalamus) to lower elevated body temperature.
• Limited anti-inflammatory effect: Unlike NSAIDs, acetaminophen has minimal anti- inflammatory properties, which is why it's often combined with other medications for sickle cell crisis

Non-Pharmacological Interventions?

• Relaxation techniques
• Heat therapy
• Distraction
• Hydration by drinking water
• Rest
• Gentle massage

Evaluate Outcomes

• Normal RR/O2 sat, non labored breathing
• Pain reduced from $8/10$, PCA will be used properly by patient for pain relief.
• Rehydration
• Trend for abnormal CBC labs improve
• Trend for improvement of production of RBC’s
• Trend for improvement of kidney function, electrolytes remain stable
• UA WNL

Complications

• What is the worst possible/most likely complication to anticipate?
  • CVA, heart failure, renal damage/failure
• What nursing assessment(s) will you need to initiate to identify this complication if it develops?
  • Neuro assessment, LOC, I&O, pulses, cap refill.
• What nursing interventions will you initiate if this complication develops?
  • Positioning (fowler’s), calm environment, administer medications

Abdominal Pain

• Postoperative
• ACUTE PAIN

Patient Assignment Sarah Johnson

• Patient: Sarah Johnson, 49-year-old female
• Procedure: Laparoscopic cholecystectomy (gallbladder removal)
• Time: 24 hours post-surgery
• Complaining of moderate abdominal pain ($6/10$ on pain scale)
  • Shallow breathing due to pain
  • Reluctant to move or cough
  • Vital signs: BP $138/88$, HR $92$, RR $18$
  • Temp $98.6$ F
  • SpO2 $97$% on room air

Applying clinical judgment: Noticing

• Assess the pain:
  • Pain intensity currently is $6/10$, location, characteristics, aggravating and alleviating factors
• Assess for signs of complications:
  • Vital signs
  • Wound appearance
  • Urine output
  • Bowel function

Interpreting

• Determine pain is not due to a post op complication

Responding

• Review medication orders and administer appropriate analgesics:
  • Consider a multimodal approach (e.g., opioids, NSAIDs, acetaminophen)
  • Ensure timely administration to maintain consistent pain control

Patient Controlled Analgesia (PCA)

• PCA is a method of pain control that allows patients to self-administer prescribed pain medication using a computerized pump connected to their IV line.
  • Postoperative pain management
  • Managing pain from conditions like pancreatitis or sickle cell disease
  • Patients unable to take oral medications

How to use the PCA?

• The pump is programmed by healthcare providers with specific parameters:
  • Dose amount
  • Lockout interval
  • Hourly limits
  • Optional background infusion rate
• Patients press a button to self-administer medication when they experience pain1.
• Only the patient should press the button, never family or friends

Patient Assessment While Using the PCA

• Pain severity: Every 4 hours (typically)
• Responsiveness: Every 4 hours
• Respiratory rate: Every 1 hour
• Vital signs (HR, BP, temperature): Every 4 hours
• Oxygen saturation via pulse oximetry
• Side effects of analgesia: Every 4 hours
• IV site and patency
• Effectiveness of pain relief, especially after pump setting changes

Patient & Family Education

• Only the patient should press the PCA button.
• Explain how the pump works and its safety features.
• Encourage patients to use the PCA before pain becomes severe.
• Inform healthcare providers if pain is not adequately controlled.
• Report side effects such as nausea, itching, confusion, or difficulty urinating.
• Family members should alert nurses to any concerns about breathing problems or other side effects.

Responding

• What other actions should you consider and why?
  • Implement non-pharmacological interventions:
    • Assist with position changes to enhance comfort
    • Apply cold packs to the surgical site
    • Teach and encourage deep breathing and relaxation techniques
    • Teach and encourage Ambulation
      • Reduces muscle spasms, improves breathing, enhances blood flow, aids in normal bowel function

Postoperative Period to Transition Period

• IV analgesia immediate postoperative
• Transition patient to oral analgesia as pain is properly managed
• Expect to administer a larger dose of oral analgesics when transitioning
• Patients should receive doses that are gradually titrated down until they can be comfortable without medication or at a minimal dose

Renal Calculi Pain

• Often painful when passed

Stone passes through kidney - stones, ureter and bladder

Who is at risk?

• Male assigned at birth
• Climate-Warm climates that increase fluid losses.
• Diet-Large intake of dietary proteins that increase uric acid such as liver, beef kidney, brain, sweetbreads (Organ meats)
• Dehydration
• Alcohol
• Genetic factors - Family history. The cystine stones are associated with hereditary renal disease.
• Sedentary lifestyle

How does the pathophysiology of renal calculi directly impact the concept of comfort?

• The stones form in the pelvis of the kidney and may range in size from tiny to staghorn stones the size of the renal pelvis itself.
• The pain generated is primarily caused by dilation, stretching, and spasms from the acute ureteral obstruction by the stone.
• Severe pain!

Other Symptoms

• Urinary frequency
• Nausea/Vomiting
• Fever
• Oliguria
• Anuria
• Hematuria
• Tachycardia and high blood pressure

Types of Urinary Stones

• Calcium oxalate
• Calcium phosphate
• Cystine
• Struvite
• Uric acid

Patient Assignment John Smith

• Patient: John Smith, 42-year-old male
• Chief Complaint: Severe left flank pain radiating to the groin
• Pain score: $9/10$, described as sharp and colicky
• Nauseous with one episode of vomiting
• Restless and anxious
• Frequent urination with small amounts of urine
• Vital signs:, RR $22$, Temp $100.04$ degrees Farenheight, SpO2 $98$% on room air

Applying Clinical Judgment: Recognizing Cues

• Assess the pain:
  • Evaluate pain intensity, location, and characteristics, what alleviates?, what worsen? and time?
• Note any changes in pain patterns

Analyzing Cues

• Severe left flank pain radiating to the groin
• Restless and anxious
• BP $150/90$, HR $110$
• Nausea and vomiting
• Frequent urination with small amounts of urine
• Temperature $100.4$ Farenheight

Hypothesis?

• Impaired Comfort
• Impaired Fluid & Electrolytes
• Impaired Elimination

Generate Solutions

*    What will you do next?

• Administer
  • Administer prescribed analgesics as ordered
• Apply
  • Administer nonpharmacological
• Assist
  • Promote hydration Encourage increased oral intake to 3 L/day
• Promote elimination

Pharmacological Interventions for Renal Colic Pain

• Opioids
• NSAID's
• Combination

Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Ibuprofen, Ketorolac, Diclofenac
• These medications are nonsteroidal anti-inflammatory drugs (NSAIDs) that work by inhibiting prostaglandin synthesis2.
• They reduce pain, inflammation, and ureteric activity in renal colic
• Risk of gastrointestinal side effects: NSAIDs can cause gastric irritation and ulceration
• Renal effects: NSAIDs can potentially interfere with renal auto-regulatory responses
  • They should be used with caution in patients with pre-existing renal disease, dehydration, or cirrhosis2.
  • Long-term use of high doses can cause kidney damage, even in individuals with healthy kidneys

Opioids for Renal Calculi Pain

• Morphine – Mechanism of Action
  • Receptor binding: Morphine binds to opioid receptors, primarily mu-opioid receptors, in the central nervous system.
  • CNS depression: This binding causes depression of the central nervous system.
  • Pain signal interruption: Morphine interrupts the transmission of pain signals between the brain and the body.
  • Reduced pain perception: The CNS depression leads to decreased sensation and reduced perception of pain.
  • Additional effects: Morphine also causes the release of histamine in the body, which can lead to vasodilation

Take Action

• Nonpharmacological Comfort Interventions
  • Provide a quiet environment to promote rest
  • Offer antiemetics as prescribed for nausea
  • Assist with frequent position changes as needed
  • Encourage ambulation

Take Action Promote hydration

• Maintain IV fluids ordered by the healthcare provider
• Encourage fluid intake of 2-4 liters per day, unless contraindicated
• Patient Education on gradual increase: Advise the patient to increase water intake slowly if it represents a significant change from their usual habits4.
• Assess urine characteristics
• Monitor urine output
• Monitor electrolytes

Evaluate Outcomes

• Pain management: Assess the effectiveness of pain relief measures, whether through medications or other interventions.
• Stone passage: Monitor for signs that the stone has passed, such as the patient reporting stone passage in urine or a reduction in pain.
• Urinary function: Observe for improvements in urinary symptoms, including reduced frequency, urgency, and hematuria.
• Hydration status: Assess for adequate fluid intake and urine output, aiming for a 24- hour urine volume of 2.5 to 3 liters1.
• Infection control: Monitor for signs of urinary tract infection, such as fever, cloudy urine, or flank pain.
• Renal function: Observe for normal urine production and any signs of renal impairment.

Extracorporeal Shock Wave Lithotripsy (ESWL)

• Extracorporeal shock wave lithotripsy (ESWL):
  • This non-invasive procedure uses sound waves to break kidney stones into smaller pieces that can pass more easily through the urinary tract

Cystoscopy/Ureteroscopy

NCLEX Type Question

• The nurse has received care of a patient who has just undergone a cystoscopy. Which cue identified by the nurse should be considered clinically significant and considered a possible complication?
  • Back pain
  • Bright red urine
  • Urinary frequency
  • Burning on urination

PVD & Neuropathic Pain

• Peripheral neuropathy happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged.
• $8$% of general population has pain with neuropathic characteristics.
• Every nerve in the peripheral system has a specific job. Symptoms depend on the type of nerves affected.
• Numbing, stabbing, shooting, burning or tingling. Sometimes symptoms get better, especially if caused by a condition that can be treated.
• Can be sudden, intense, short lived or lingering.

Who is at risk?

• Trauma
• Autoimmune diseases: rheumatoid arthritis
• Diabetes (Diabetic neuropathy)
• Infections: Lyme disease HIV, Hepatitis B, Herpes Zoster
• Tumors: From Cancers
• Bone Marrow Disorders: Multiple Myeloma
• Alcohol use disorder
• Chemotherapy agents

Patient Assignment: Mr. Hernandez

• 67-year-old male
• Chief Complaint: Burning and tingling pain in both feet, increasing in severity over the past 6 months
• Pain score: $7/10$, described as burning, tingling, and occasionally sharp
• Difficulty sleeping due to pain
• Reluctant to walk or stand for extended periods
• Reports numbness in toes
• Vital signs: BP $135/85$, HR $78$, RR $16$, Temp $36.8$°C, SpO2 $99$% on room air

Applying Clinical Judgment: Recognizing Cues

• Assess the pain:
  • Evaluate pain intensity, location, and characteristics, what alleviates?, what worsen? and time?
• Assess for signs of underlying conditions (e.g., diabetes, vitamin deficiencies)

Analyzing Cues

• Restless and anxious
• Pain score: $7/10$, described as burning, tingling, and occasionally sharp
• Difficulty sleeping due to pain
• Reluctant to walk or stand for extended periods
• Reports numbness in toes
• Burning and tingling pain in both feet, increasing in severity over the past 6 months

Hypothesis?

• Impaired Comfort
• Impaired Sleep
• Impaired mobility

Generate Solutions

*    What will you do next?

• Administer
  • Administer prescribed medications (e.g., gabapentin, pregabalin, & amitriptyline)
• Administer nonpharmacological
  • Apply topical treatments like capsaicin cream or lidocaine patches Apply topical treatments like capsaicin cream or lidocaine patches
  • Teach on proper use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit

Adjuvant: Gabapentin/Pregabalin

• Mechanism of Action:
  • Gabapentin and Pregabalin work by attaching to specific parts of calcium channels in brain and spinal cord cells.
  • These channels control the flow of calcium into nerve cells, which affects how pain signals are transmitted.
  • By binding to these channels, these medications can help reduce pain sensations in the body.
• Monitor patients for common side effects such as dizziness, drowsiness, and peripheral edema.
• Teach patients to take the medication as prescribed and not to stop abruptly, as this can lead to withdrawal symptoms.
• Pregabalin is absorbed more rapidly and completely than Gabapentin, which may affect dosing schedules.
• Both medications may be used as first-line treatments for neuropathic pain, with Pregabalin showing slightly faster and more significant pain relief in some studies.
• Monitor kidney function as both drugs are primarily excreted by the kidneys.

Adjuvant: Amitriptyline

• Amitriptyline increases levels of serotonin and norepinephrine in the brain by blocking their reuptake. These chemicals help regulate mood and pain perception.
• Ion channel effects: The drug blocks certain ion channels (sodium, potassium, and NMDA) in the central nervous system and spinal cord, which helps reduce pain signals.
• Pain signal modulation: By affecting neurotransmitters and ion channels, amitriptyline alters how pain messages are sent to the brain, ultimately reducing the perception of pain.
• Central sensitization reduction: Amitriptyline helps decrease the nervous system's heightened reactivity to pain, which is often seen in chronic pain conditions.

Teaching for Amitriptyline

• Administer in the evening to help with the common side effect of drowsiness.
• Monitor for common side effects such as dizziness, drowsiness, and dry mouth.
• Take the medication as prescribed and not to stop abruptly.
• Inform patients that pain relief may not be immediate and full effect may take several weeks.
• Explain that the goal is to reduce pain to improve functioning and quality of life, not necessarily eliminate pain completely.

What safety measures would you teach?

• Assist with exercises to improve strength and balance
• Educate on proper footwear and foot care
• Report signs of skin breakdown or presence of ulcers
• Provide fall prevention strategies
• Report changes in muscle strength or sensation