NURSE-UN 240 A&E I– FINAL EXAM STUDY GUIDE WEEK 6 – PAIN; SLEEP PAIN,100% CORRECT

NURSE-UN 240 A&E I– FINAL EXAM STUDY GUIDE WEEK 6 – PAIN; SLEEP PAIN What is Pain? - “Whatever the person experiencing pain says it is” - “Unpleasant sensory and emotional experience associated with actual or potential tissue damage” - Subjective: patient’s experience and self-report is essential Nature of pain - Involves physical, emotional, cognitive components - Subjective & individualized - Reduces quality of life - Not measurable objectively - May lead to serious physical, psychological, social and financial consequences Dimensions – psychologic, behavioral, cognitive, affective & social factors How Pain Travels 1st level (nociceptor  spine): alpha-delta and c-delta fibers go through dorsal root ganglion into the spinal cord 2nd level (spine  brain) 3rd level (brain to different parts that are going to interpret that pain responses) Nociceptive pain originates when the tissue is injured - Transduction – occurs when there is release of chemical mediators o Converts energy produced by these stimuli into electrical energy o Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential o Once transduction is complete, transmission of pain impulse begins - Transmission – involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex o Sending of impulse across a sensory pain nerve fiber (nociceptor) o Nerve impulses o Pain impulses - Perception – the conscious awareness of pain o The point at which a person is aware of pain o The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex (primarily limbic system) determines how a person feels about it o There is no single pain center - Modulation – involves signals from the brain going back down the spinal cord to modify incoming impulses o Inhibits pain impulse o A protective reflex response occurs w/ pain reception Physiology of pain - Gate-control theory of pain o Pain has emotional & cognitive components in addition to a physical sensation o Gating mechanisms in the CNS regulate or block pain impulses o Pain impulses pass through when a gate is open and are blocked when a gate is closed o Closing the gate is the basis for non-pharmacological pain relief interventions - As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system (ANS) – fight or flight - Continuous, severe or deep pain typically involving the visceral organs activates the parasympathetic nervous system (PNS) - Common indications of acute pain – clenching teeth, facial grimacing, holding or guarding the painful part, bent posture - Chronic pain affects pt’s activity and PNS & SNS does not react like they do to acute pain - Lack of pain expression does not indicate that a pt is not experiencing pain Types of pain - Acute/transient – protective (body tells you something is wrong), identifiable, short duration; limited emotional response - Chronic/persistent noncancer – not protective, has no purpose, may or may not have an identifiable cause - Chronic episodic – occurs sporadically over an extended duration; usually above their chronic baseline - Cancer – can be acute or chronic - Idiopathic – chronic pain w/o identifiable physical or psychological cause Factors influencing pain - Physiological – age, fatigue, genes (threshold and tolerance), neurological fxn (ie DM w/ ulcer) o Fatigue increases perception of pain and can cause problems w/ sleep and rest - Social – attention, previous experiences, family & social support - Spiritual – includes active searching for meaning in situations w/ questions such as “why am I suffering?” - Psychological – anxiety, coping style - Pain tolerance – the level of pain a person is willing to accept - Culture & ethnicity – meaning of pain Critical thinking – knowledge of physiology and the many factors that influence pain help you manage a pt’s pain Nursing Process & Pain - Pain mgmt needs to be systematic & needs to consider pt’s QOL - Clinical guidelines are available to manage pain – American pain society, sigma theta tau, nat’l guidelines clearinghouse Assessment - Through pt’s eyes – ask pt’s pain level - Use ABCs of pain management (OLDCARTS, PQRST) - Pain is not a # - Pt’s expression of pain – individualistic - Characteristics – timing, location, severity, quality, aggravating & precipitating factors, relief measures - Effects of pain on pt – behavioral, influence on ADLs - Concomitant symptoms – usually increases pain severity Pain assessment tools (5th vital sign) - COLDSPA Character, Onset, Location, Duration, Severity, Pattern, Associated Symptoms (factors increasing or relieving pain) - OLDCARTSP – onset, location, duration, character, associated sx, radiation, timing, severity, pattern - Simple Descriptive Pain Intensity Scale - COMFORT scales - FLACC scale - Beyer Ouchers pain scale - Wong-Bakers face scales – pediatrician - Be aware of possible errors in pain assessment Possible nursing - Anxiety - Insomnia - Impaired social interaction - Ineffective coping - Impaired physical mobility diagnoses - Activity intolerance - Fatigue Planning – analyze info from multiple sources, apply critical thinking, adhere to professional standards, use a concept map, goals & outcomes, setting priorities, teamwork & collaboration, “any wound changes?”, “does pt needs before tx? How long before?”, anything pertaining to safety Implementation – health promotion - Maintaining wellness – helps pt understand – health literacy – pt actively participates in their own well-being whenever possible Implementation - Pain Treatment Principles o Follow principles of assessment o Treatment based on patient’s goals o Use drug and non-drug therapies ▪ Know Patient's Previous Response to Analgesics ▪ Select Proper Medications When More Than One Is Ordered ▪ Know Accurate Dosage ▪ Assess Right Time and Interval for Administration o Use a multidisciplinary approach - Non-pharmacological pain-relief interventions o CBT (cognitive and behavior approach) o Hypnosis o Biofeedback o Therapeutic touch o Animal-facilitated therapy o Acupuncture o Humor o Relaxation & guided imagery (meditation techniques) o Distraction o Music o Cutaneous stimulation (warm baths) o Cold & heat application o TENS o Herbals o Reducing pain perception & reception o Massage (usually babies and elderly; really depends if pt like therapeutic touch) - Pharmacological pain therapies o Analgesics – “start low and go slow” ▪ Non-opioid: acetaminophen, aspirin and other salicylates, and non-steroidal anti-inflammatory drugs (NSAIDS) ▪ Opioid/narcotics (controlled substances): morphine, oxycodone, and codeine • Affects spinal cord and brain • Common side effects include: constipation (most common, nausea/vomiting, sedation, respiratory depression ▪ Adjuvant/co-analgesics: antidepressants, anti-epileptic drugs, and corticosteroids • Non-pain meds that is conjunctions with pain meds to alleviate pain o Topical analgesics – creams, ointments, patches o Local anesthesia – local infiltration of an anesthetic medication to induce loss of sensation to a body part ▪ Regional anesthesia o Perineural local anesthetic infusion o Epidural analgesia – regional – administered into epidural space Patient Controlled Analgesia (PCA) - PCA pumps are secured computerized programmable devices that deliver small, preset dose of opioid; usually for chronic or cancer pain - Allows pt to self-administer w/ minimal risk of overdose - Maintains constant plasma level of analgesic - On avg, systems are designed to deliver a specified # of doses q1-4 hr given every 5-15 mins - Nursing Responsibilities: o Patient teaching o Monitoring patient responses - Safety guidelines o The pt is the only person who should press the button to administer pain medication o Monitor for s/s of over sedation and respiratory depression o Monitor for potential side effects of opioid analgesics Implementation - Nursing implications o You maintain responsibility for providing emotional support to pts receiving local or regional anesthesia; numerous implications for mgmt. of epidural analgesia ▪ After administration of a local anesthetic, protect pt from injury until full sensory & motor fxn return ▪ Provide emotional support; not addressing pain # but addressing the pt overall (issues, QOL, address pain before meals, address pain before ADL) ▪ Establishing trusting nurse-pt relationship ▪ Manipulating factors affecting pain experience ▪ Initiating nonpharmacologic pain relief measures ▪ Managing pharmacologic interventions ▪ Relieving additional pain control measures (complementary and alternative relief measures) ▪ Considering ethical and legal responsibility to relieve pain o Invasive interventions for pain relief o Procedure pain mgmt. o Cancer pain & chronic non-cancer pain mgmt. o Scheduling ▪ Focus on prevention or control- Do not wait for severe pain ▪ Constant pain requires around-the-clock (ATC) administration (not PRN) – adjust dose to achieve max benefit with min side effects ▪ Allow pt as much control as possible over the regimen ▪ Fast-acting drugs for breakthrough pain • Breakthrough pain is a superimposed pain on continuous or persistent pain that could be classified as: incident pain, end-of-dose failure pain, spontaneous pain o ALWAYS USE 6 RIGHTS OF MEDICATION ADMINISTRATION - Physical dependence – a state of adaptation manifested by drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist; body needs it to work properly and normally - Addiction – a primary, chronic, neurobiological dz w/ genetic, psychosocial and environmental factors influencing its development & manifestations - Drug tolerance – a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time; the more you use, the more you get used to it you need more and more to have an effect (issue for chronic pt) - Restorative & continuing care o Pain clinics – treat pt on an inpt or outpt basis o Palliative care – goal is to learn how to live life fully w/ an incurable condition o Hospices – programs for end-of-life care o ANA supports aggressive treatment of pain & suffering even if it hastens a pt’s death Evaluation - Through pt’s eyes – patients help decide best times to attempt pain treatments, best judge of whether a pain-relief intervention works - Pt outcomes – evaluate for change in severity & quality of pain - What pt says; make sure pt is where they want to be with the agreed goal they set for themselves Barriers of Pain Management - Why clinicians under-treat pain: o Inadequate skills to assess and treat pain o Unwillingness to believe patient reports o Lack of time, expertise, and perceived importance of pain assessments o False concepts of addiction and tolerance ▪ Addiction is a chronic neuro-biologic disease influenced by genetic, psychosocial and environmental factors ▪ Tolerance is a state of adaptation to a drug SLEEP Sleep Physiology - Sleep = rest accompanied by altered consciousness and reactive inactivity - Rest refers to a condition in which the body is in a decreased states of activity, with the consequent feeling of being refreshed - Sleep is part of the sleep-wake cycle - Circadian rhythms – affected by LIGHT, TEMPERATURE, SOCIAL ACTIVITIES, WORK ROUTINES - Biological rhythm of sleep frequently becomes synchronized w/ other body functions - Regulated by a sequence of physiological states integrated by central nervous system activity - Wakefulness is a time of mental activity and energy expenditure - Sleep is a period of inactivity and restoration of mental and physical function - Hypothalamus - Reticular activating system (RAS) - Homeostatic process Adult sleep cycle - 4 stages of NREM - Sleep cycle lasts 90-100 mins - Stages 1 to 2 to 3 to 4 4 to 3 to 2 REM Functions of sleep - Purpose – remains unclear – physiological & psychological restoration & maintenance of biological fxns - Dreams – occur in NREM and REM sleep – important for learning, memory & adaptation to stress - Physical illness can cause pain, physical discomfort, anxiety, depression & sleep disturbances o HTN o Respiratory d/o o Nocturia o Restless leg syndrome (RLS) Sleep Disorders - Insomnia o Adjustment sleep d/o (acute insomnia), inadequate sleep hygiene, behavioral insomnia of childhood, insomnia caused by medical condition; more tired because of no sleep affecting general overall health - Sleep apnea o Primary central sleep apnea, central sleep apnea caused by medical condition, obstructive apnea syndromes (overwt, obese, large neck  throat closes  don’t breathe for a certain pd of time  loud snort  start breathing  stop for a pd of time  choke  wakes up), excessive daytime sleepiness - Narcolepsy o Cataplexy o Sleep paralysis - Sleep deprivation o Emotional stress, medications, environmental disturbances, symptoms - Parasomnias o Somnambulism (sleep walking), night terrors, nightmares, nocturnal enuresis (bed-wetting), body rocking, Bruxism (grinding teeth) Sleep & rest - Rest contributes to (1) mental relaxation, (2) freedom from anxiety, (3) state of mental, physical and spiritual activity - Bed rest does not guarantee that a pt will feel rested - Sleep more when younger, sleep less when older GROUP HOURS OF SLEEP NEEDED Neonates 16 hr/day Infants 8-10 at night, 15 total/day Toddlers 12 hr/day Preschoolers 12 hr/night School age 9-10 hr Adolescents Get ~7.5 hr Young adults Get 6-8.5 hr Middle and older adults Total # of hr declines Factors influencing sleep - Drugs & substances – hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants - Lifestyle – work schedule, social activities, routines - Usual sleep patterns – may be disrupted by social activity or work schedule - Emotional stress – worries, physical health, death, losses - Environment – noise, routines - Exercise & fatigue – moderate exercise and fatigue cause a restful sleep - Food & calorie intake – time of day, caffeine, nicotine, alcohol Critical thinking - in the case of sleep, integrate knowledge from nursing and disciplines such as pharmacology and psychology - Use personal experience - Professional standards Assessment - Pt & family can be sources for sleep assessment - Sleep history/diary - Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation o Conduct a more detailed history when a pt has a sleep problem, as this ensures that you provide appropriate therapeutic care o Open-ended questions help a pt describe a problem more fully o Ask specific questions related to the sleep problem o Have pts describe their normal sleep patterns - Thorough assessment to see what is impacting their sleep if that is what needs to be addressed Possible nursing diagnoses - Anxiety, ineffective breathing pattern, acute confusion, compromised family coping, ineffective coping, insomnia, fatigue, sleep deprivation, readiness for enhanced sleep Planning - Goals & outcomes - Setting priorities: frequent sleep disturbances are the result of other health problems - Teamwork & collaboration Implementation – health promotion - Environmental controls - Promoting bedtime routines - Promoting safety - Promoting comfort - Establishing periods of rest and sleep - Stress reduction - Bedtime snacks - Pharmacological approaches - Acute care – environmental controls, promoting comfort, establishing periods of rest and sleep, promoting safety, stress reduction - Restorative or continuing care – promoting comfort, controlling physiological disturbances, pharmacological approaches Evaluation - Through the pt’s eyes - Pt outcomes - Determine whether outcomes have been met – are you able to fall asleep within 20 mins of getting into bed? / Describe how well you slept when you exercise / Does the use of quiet music at bedtime help you relax? / do you feel rested when you wake up?