Chapter 21 - Foundations - Pain Management, Comfort, Rest, and Sleep + Practice NCLEX

Why has pain become the fifth vital sign (604)?

A simple strategy to increase accountability for pain control is for an institution to make pain intensity ratings a routine part of the assessment and documentation of vital signs, making any presence of pain known and raising awareness of the problem of unmanaged pain. Giving pain assessment as much attention as that of other vital signs makes it more likely the pain will be treated properly, and using a pain rating scale allows patients to articulate their pain clearly, making them more likely to receive proper treatment.

What are some Non-pharmacologic interventions for pain - Pt 2. Psychological and cognitive interventions (606)?

A. music - music can promote relaxation and reduce anxiety. It can be used to manage chronic pain in the postoperative period and in labor & delivery. B. biofeedback - reduced mild/moderate pain and operative site muscle tension. Requires patient to have a high level of cognitive function. C. imagery - the patient is encouraged to focus internally on positive memories or environments. D. humor - humor and laughter increase oxygenation and circulation. Rest and sleep can also be improved in the periods after laughter. E. education - effective for reduction of all types of pain, should include sensory and procedural information and instruction aimed at reducing activity-related pain.

What is an Elastomeric pump (611)?

AKA "Pain balls" - these are used to administer local anesthetic medications. The medication, located inside of a ball, is administered through a small catheter that has been placed beneath the skin during a surgical procedure. The medication is intended as a supplement to the regularly prescribed narcotic postoperative pain medications. Dosages may be set to provide continuous administration, may allow for patient-necessitated adjustments to the dosage, or even allow demand bolus administrations in the event of breakthrough pain. When it is empty, it's removed easily by the patient or a caregiver in the home.

A patient who had a total abdominal hysterectomy two days ago reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first?

Administer the prescribed analgesic. Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision - this requires adequate pharmacological intervention to provide pain relief.

The home health nurse is instructing the family of an older adult patient with arthritis about sleep promotion. What intervention can best promote sleep for the older adult patient?

Administering diuretics in the morning.

What is the purpose of Epidural analgesia (611)?

Another method of delivery of analgesia is the insertion of an epidural catheter and the infusion of opiates into the epidural space. The epidural medication diffuses slowly from the epidural space across the dura and arachnoid membranes into the cerebrospinal fluid (CSF). Three methods of administering include bolus doses, continuous infusion, and by PCA epidurals. Epidural medications have a rapid onset, with relief experienced within 15 minutes.

What factors contribute to a patient's lack of comfort (601)?

Anxiety. Constipation. Constricting Enema. Depression. Diaphoresis. Diarrhea. Distention. Dry mouth. Dyspnea. Fatigue. Fear. Flatus. Grief. Headache. Hopelessness. Hyperthermia. Hypothermia. Hypoxia. Incontinence. Muscle cramping. Nausea. Pain. Powerlessness. Pruritis. Sadness. Singultus. Thirst. Urinary retention. Vomiting.

A nurse strains a back muscle when moving a patient up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort?

Apply a cold compress to the site. Heat or Cold therapy helps to close the gates to painful stimuli.

What is the "essential message" about pain assessment (604)?

Ask patients about their pain, accept and respect what they say, intervene to relieve their pain, and ask them again about their pain. This is a circle of assessment, intervention, and reassessment.

What nursing care is needed for patients with epidural infusions (612)?

Assess dressing. Assess catheter. Ensure the catheter remains unkinked and in place. Change dressing per agency policy. Monitor intake and output. Monitor vital signs and pulse oximetry. Monitor bowel and bladder habits. Assess for side effects of administration including pruritus, nausea, and vomiting. Administer medications as prescribed to manage side effects.

A patient requests pain medication for severe pain. Which should the nurse do first when responding to this patient's request?

Assess the various aspects of the patient's pain. All the factors that affect the pain experience should be assessed, and assessment must precede intervention.

Where does the nurse recognize that many institutions are now including pain assessment in implementing patient care?

Assessing vital signs

A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain?

Assisting with relaxing imagery. In guided imagery, the patient concentrates on an image that helps relieve pain or discomfort. Help the patient choose a scene that holds especially pleasant memories. Ask the patient where he or she feels the most relaxed, such as at a lake, in a forest, or in a meadow, and then encourage the patient to use sensory memories to make the image as realistic as possible.

A nurse is teaching a community health education class about rest and sleep. Which concept related to sleep should the nurse include?

Bedtime routines are associated with an expectation of sleep.

When should a nurse administer prescribed analgesic medication when treating a postoperative patient?

Before activity.

At which time does a nurse medicate a client for pain for it to be considered preemptive analgesia?

Before doing a dressing change that has been painful in the past. Patient's should be premedicated if interventions or activities are planned that may cause increased discomfort.

During which hours do people have an increased tendency to feel sleepy (617)?

Between 2 am and 7 am.

A nurse is teaching a patient various techniques to promote sleep. Which internal stimulus that most commonly interferes with sleep should the nurse include in the teaching?

Bladder fullness.

The nurse explains that transcutaneous electrical nerve stimulation (TENS) provides a continuous mild electrical current to the skin. How does the TENS unit act to reduce pain?

Blocks pain impulses.

A young athlete asks the nurse why he felt little pain when he broke his leg during a game. What does the nurse describe as having an effect on this patient's perception of pain?

Endorphins.

A nurse is assessing a client in pain. Which word might the nurse use when documenting the pattern of a clients pain?

Episodic

A nurse is caring for a patient who is experiencing pain. For which common psychological response to pain should the nurse assess the patient?

Experiencing fear related to loss of independence. Fear of being dependent on others and loss of self-control are psychological responses to pain.

A patient reports to the nurse that he is experiencing a moderate amount of back pain rated 6 out of 10 on the pain scale. What should the nurse recognize about this assessment?

Pain is subjective for the patient. Pain is not objective for the nurse, it is not necessarily easy to recognize, and it is not necessarily easily relieved if found early.

The nurse is assessing pain reported by a Latino male patient. What is important for the nurse take into consideration when observing objective data?

Latino men feel it is unmanly to admit to pain.

The nurse is trying to reassure a patient who is concerned about receiving addictive drugs. What percentage of patients become addicted to analgesics?

Less than 1%.

The nurse reassures a patient that most acute pain is intense and of short duration. How long does can acute pain usually last?

Less than 6 months.

What action should the nurse implement when assisting a postoperative patient with pain control and comfort?

Lift the patient up in bed. Do NOT "pull" the patient up in bed.

A patient states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement?

Location. The patient is experiencing referred pain, which is related to the location of pain.

What should be known about Opioid analgesics (607)?

Morphine, meperidine (Demerol), hydromorphone (Dilaudid, and fentanyl (Actiq, Duragesic) act on higher centers of the brain to modify perception and reaction to pain. Opioids decrease the perception of pain by binding to pain receptor sites in the CNS, and opioid analgesics are the cornerstone for managing moderate to severe acute pain. Morphine is the standard agent in opioid therapy, as it is a highly effective drug. However, its use in the presence of compromised renal function must be carefully monitored. Opioid analgesics have the potential to depress vital nervous system functions. Of most significance is that opiates cause respiratory depression by depressing the respiratory center within the brainstem.

A nurse is caring for a patient who requires long-term management for severe pain. What should be the drug of choice for this patient?

Morphine.

The nurse clarifies that the term peripheral analgesics describes the group of drugs also referred to as?

NSAIDs

A nurse is obtaining a health history from a newly admitted patient. Which patient statement about alcohol intake is based on a common physiological response?

"After I go drinking, I have to urinate during the night." Alcoholic beverages have a mild diuretic effect - diuretics can lead to the need to urinate and disturb sleep.

A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic question the nurse can ask about the quality of the patient's sleep?

"How would you describe your sleep?". This is an open-ended question.

The nurse is trying to establish an effective relationship with a patient in pain. What is the best statement for the nurse to make when beginning the assessment?

"I believe you are in pain."

What is the most widely accepted definition of pain (602)?

"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" - McCaffery and Pasero, 2003. According to this definition, pain is a phenomenon with multiple components that makes an impact on a person's psychosocial and physical functioning, and it acknowledges the complexity of the pain experience.

What is the founding principle of effective pain management (612-613)?

"The failure to treat pain is inhumane and constitutes professional negligence". Every patient has the right to be free of pain and it is the nurse's responsibility to do everything possible to alleviate the patient's pain. Patients should not be expected to convince the healthcare team that the pain experienced is real. Pain management interventions begin as soon as the patient states that he or she is in pain.

A nurse is performing an admitting interview. Which patient statement about pain should cause the most concern for the nurse?

"They say my pain may get worse, and I can't stand it now."

Which are most important for a nurse to consider when a patient reports the presence of pain? Select all that apply.

1. Fatigue increases the intensity of pain experienced by the patient. 2. The person feeling the pain is the authority on the pain.

A nurse is assessing a patient experiencing chronic pain. Which characteristics are more common with chronic pain than with acute pain? Select all that apply.

1. Gradual onset. 2. Long duration. 3. Psychologically depleting.

The nurse should administer an analgesic to an unconscious patient after observing which signs? (Select all that apply.)

1. Increased heartrate from 82 to 94. 2. Increased muscle tension. 3. Perspiration on the upper lip. 4. Facial grimacing.

What are the behavioral characteristics of patients in pain (602)?

1. Is self-protective; guards the painful area by placing their hands over the area. 2. Has narrowed focus; can't think of anything but the pain, has reduced attention span. 3. May withdraw from social contact, and may avoid conversation or social thoughts. 4. Has impaired thought processes. 5. Demonstrates distraction behavior, which includes moaning, rocking, crying, pacing, restlessness, or seeking out different activities or possibly other people. 6. Presents facial mask of pain; eyes appear dull or lusterless, fixed or rapidly changing facial movements, grimacing, teeth clenching, lip biting, or jaw tightening. 7. Experiences alterations in muscle tone, ranging from flaccidity to rigidity. 8. Exhibits diaphoresis, changes in blood pressure and pulse rate, pupillary dilation, and increased or decreased rate of respiration. 9. Sometimes demonstrates no outward expression of pain. Remember that lack of pain expression does not mean lack of pain. There is no specific "picture" of a patient in pain.

What are some nursing principles for the administration of analgesics (612)?

1. Know the patient's previous response to analgesics. 2. Select proper medications when more than one is ordered. 3. Know the optimal dosage. 4. Determine the right time and interval for administration. 5. Choose the right route.

What are some factors that affect sleep (617)?

1. Physical illness. 2. Anxiety and Depression. 3. Drugs and substances. 4. Lifestyle. 5. Sleep patterns. 6. Stress. 7. Environment. 8. Exercise and fatigue. 9. Nutrition.

What are some safety alerts related to daytime sleepiness (619)?

1. Safety precautions are important for patients and residents who awaken during the night to use the bathroom and for those with excessive daytime sleepiness. 2. Set beds lower to the floor to lessen the chance that the patient or resident will fall when first standing. 3. Some patients/residents who experience daytime sleepiness fall asleep while sitting up in a chair/wheelchair. Position the person so that he/she will not fall out of the chair while sleeping.

What are some nursing interventions used to assist in pain control and comfort (615)?

1. Tighten wrinkled bed linens. 2. Reposition drainage tubes or other objects on which the patient is lying. 3. Place warm bath blankets if the patient is cold. 4. Loosen constricting bandages. 5. Change moist dressings. 6. Check the tape to prevent pulling on the skin. 7. Position the patient in anatomic alignment. 8. Check the temperature of hot and cold applications, including bath water. 9. Lift - do NOT "pull" - the patient up in bed; handle gently. 10. Position the patient correctly on a bedpan. 11. Avoid exposing skin or mucous membranes to irritants. 12. Prevent urinary retention by ensuring patency of Foley catheter. 13. Prevent constipation by encouraging appropriate fluid intake, diet, and exercise and by administering prescribed stool softeners.

To share assessment findings and pain relief interventions, which documentation sample is the most helpful?

1600: Patient reports sharp pain in left chest radiating to neck. Morphine sulfate 5 mg administered IM in right deltoid.

The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively?

4.

The home health nurse is caring for a patient with an implanted pacemaker. What type of pain management would be contraindicated?

A TENS unit.

What is important to note about the collection of objective data (615)?

Carefully observe the patient. Possible objective signs are: tachycardia, increased rate/depth of respirations, diaphoresis, increased systolic or diastolic blood pressure, pallor, dilated pupils, and increased muscle tension. Some patients complain of nausea or weakness. With chronic or less severe pain, the physiologic changes are likely to be less prominent.

What is the defining term for continuous or intermittent pain that does not serve as a warning of tissue damage?

Chronic.

A nurse is caring for a client who is experiencing pain. For which common physiological response to pain should the nurse assess the client?

Concerned about loss of control and independence.

A patient is receiving an opioid narcotic. What common side effect should the nurse be aware of when assessing this patient?

Constipation.

A patient is receiving epidural analgesics. What should the nurse monitor closely in this patient?

Decrease in respirations from 16 to 14

What are some Non-pharmacologic interventions for pain - Pt 1. Physical interventions (606)?

Deep tissue massage - reduced muscle tension and spasms and is effective for mild/moderate discomfort. Exercise - strengthens core muscles and stabilizes the spine to reduce discomfort. TENS - stimulates the skin with mild electrical current. Heat/cold application - moist heat relieves the stiffness of arthritis and relaxes muscles while cold applications reduce acute pain associated with inflammation from arthritis or from acute injury. Flotation therapy - involves a flotation period in a water chamber with Epsom salts (magnesium sulfate), which are linked to reduced musculoskeletal pain. Acupuncture - insertion of fine/thin needles into the skin to counteract imbalances in the body's energy flow. These are all examples of physical interventions.

A patient has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the patient?

Delirium. Mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability are possible with sleep deprivation.

A patient tearfully declares the use of relaxation techniques does not work for her. What is the best action for the nurse to implement?

Encourage the patient to try again.

What does the term Synergistic refer to (603)?

Fatigue, sleep disturbance, and depression may act in a type of synergistic relationship, in which the actions of two or more substances or organs achieve an effect that cannot be achieved by an individual substance or organ. The combination of fatigue, sleep disturbance, and depression has the potential to markedly change a person's perception of pain. Depression is associated with sleep disturbance, which in turn increases the intensity of fatigue. As the pain continues unmanaged and unchecked, the patient becomes less aware of other events and begins to focus solely on his/her own body and mind. As the focus narrows, they become trapped in a vicious cycle, making the pain difficult to treat.

A patient has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this patient?

Focusing on pain management intervention before pain is excessive.

Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care?

Fragmented sleep. Sleep deprivation occurs with frequent interruptions of sleep, because the sleeper returns to stage I rather than to the stage that was interrupted.

The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse using?

Gate control.

The nurse teaches noninvasive pain relief techniques, such as guided imagery, biofeedback, and relaxation. What is the primary advantage of these techniques?

Gives the patient some control.

What's important to know about sleep deprivation (619)?

Infants require 16 hours of sleep, teens require 9 hours, and adults require 8 hours per night. Sleep deprivation is often experienced during hospitalization, and involves decreases in the amount, quality, and consistency of sleep. When sleep is interrupted or fragmented, changes in the normal sequence of sleep stages occur, and cycles are not completed. Sleep deprivation has been tied to hypertension, diabetes, heart disease, and stroke.

A nurse is caring for patients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action?

Intravenous narcotics. IV analgesics act within 1-2 minutes, but also a fast drug inactivation, leading to a short duration of action.

What is important to note about Invasive pain relief techniques (605)?

Invasive means anything that enters the body. Examples of invasive techniques are nerve blocks, epidural analgesics, neurosurgical procedures, and acupuncture. Certain techniques offer relief for many patients with pain, however, careful patient selection and proper technique are essential due to the costs and risks being potentially high.

The nurse is caring for a patient using patient-controlled analgesia (PCA). What is a major advantage to this method?

It is quicker.

What should be known about non-opioid analgesics and opioid analgesics (607)?

Non-opioid analgesics - Acetaminophen and NSAIDs, the non-opioid analgesics, are the most widely available and frequently used analgesic group. They are used primarily for mild to moderate pain but sometimes are also used to relieve certain types of severe pain. Some NSAIDs are available without a prescription, such as aspirin, ibuprofen, and naproxen sodium. Acetaminophen may block pain impulses peripherally that occur in response to the inhibition of prostaglandin synthesis, primarily in the CNS. Aspirin blocks pain impulses in the CNS and reduces inflammation. Note: the maximum recommended dosage of acetaminophen (Tylenol) is 4000mg in 24 hours - its toxic side effect, a basic consideration in all analgesic regimens, is hepatotoxicity. All NSAIDS pose the risk of GI bleeding.

What is NREM sleep (618)?

Non-rapid eye movement sleep. This has 4 stages. Stage 1 - the lightest level of sleep, lasting a few minutes. Autonomic activities such as heart rate reduction. Stage 2 - a period of sound sleep that lasts 10-20 minutes, where relaxation progresses but arousal is still easy. Body functions are still slowing. Stage 3 - the initial stage of deep sleep, lasting 15-30 minutes where arousal is difficult and movement is rare. Muscles are completely relaxed, and vital signs decline but remain regular. Growth hormone is secreted. Stage 4 - deepest stage of sleep, lasting approximately 15-30 minutes, and arousal is very difficult. If sleep loss has occurred, the sleeper spends most of the night in this stage. This restores and rests the body. Vitals are significantly lower than during waking hours. Sleepwalking and enuresis are possible. The hormonal response continues.

What else should we know about REM and NREM sleep (618-619)?

Normally, an adult's routine sleep pattern begins with a pre-sleep period, during which the person is aware only of a gradually developing drowsiness. This period normally lasts 10-30 minutes, although it can last 1 hour or longer in an individual with difficulty falling asleep. As they fall asleep, they progress through the 4 stages of NREM sleep. At the end of the 4th stage, they come out of a deep sleep, go back to stage 2, and then enter a period of REM sleep. A person reaches REM sleep in about 90 minutes on average, with a typical night's sleep consisting of 4-6 such cycles. Dreams occur during the NREM and REM stages. REM sleep dreams are believed to be functionally important, more vivid, and elaborate, allowing the individual to clarify emotions and prepare their mind for the next day's events. NREM sleep provides a period of body maintenance - this stage has been attributed to wound healing, immune functions, hormone release, and muscle restoration. A person's biological functions slow during NREM sleep. For example, a healthy adult has a heart rate of 70-80 BPM during the day; however, during sleep, the heart beats at 60 BPM or less. Respiration rate and BP also decrease during sleep. REM sleep is important for brain and cognitive restoration - during REM sleep, there are changes in cerebral blood flow and increases in cortical activity, O2 consumption, and epinephrine release, which are beneficial to memory storage and learning.

What are some considerations for older adults when it comes to sleep (618)?

Older adults require about the same amount of sleep as younger people but are more likely to achieve it in separate episodes; they take more daytime naps and get less sleep at night. 2. The sleep of an older adult is less deep. This increases the risk of early awakening and complaints of sleep disturbance. 3. Sleep is likely to be disturbed in older adults with chronic health problems such as arthritis, heart failure, and COPD. Adequate pain control and positioning facilitate breathing and help promote rest and sleep. 4. Many older adults take medications such as diuretics and theophylline that are likely to disturb sleep. Carefully assess the time of administration and the effect on sleep, and modify the schedule when possible. 5. Insufficient sleep may lead to memory and personality changes in older adults. 6. Include nonpharmacologic comfort measures among nursing interventions to promote rest and sleep.

A patient is experiencing anxiety. Which aspect of sleep should the nurse expect primarily will be affected as a result of the anxiety?

Onset. Anxiety increases norepinephrine blood levels through stimulation of the SNS, resulting in prolonged sleep onset.

How is opioid-induced constipation prevented and managed (609)?

Opioids often delay gastric emptying slow bowel motility, and decrease peristalsis. They also tend to reduce secretions from the colonic mucosa. The result is slow-moving, hard stool that is difficult to pass. At its worst, GI dysfunction can result in ileus, fecal impaction, and obstruction. A preventive approach, regular assessment, and aggressive management. Factors contributing to constipation in patients who take opioids include advanced age, immobility, abdominal disease, and concurrent medications that also may have constipating side effects. A stool softener may be prescribed alongside an opioid analgesic. Proper diet, fluids, and exercise are important but usually not sufficient, on their own, for the management of constipation.

What does the term Noxious refer to (602)?

Pain is a complex, abstract, personal subjective experience. It is an unpleasant sensation caused by noxious (injurious to physical health) stimulation of the sensory nerve endings.

What is involved in the collection of subjective data (613)?

Pain is a subjective experience, so you must become well-versed and competent as a practitioner of the art of pain assessment. Characteristics worth noting include the site, the severity, the duration, and the location of the pain. When documenting its presence, describe the specific location and intensity of the pain. Ask the patient what relieves the pain (alleviating factors), what actions cause it to worsen (aggravating factors), and what doesn't relieve the pain. Sociocultural information is beneficial.

What is important to note about Non-invasive pain relief techniques (605)?

Pain is controlled most effectively through a combination of noninvasive pain relief measures and pharmacologic therapy. The purpose of noninvasive pain techniques, which are sometimes helpful even when used alone, is to decrease the patient's perception of pain and to improve the patient's sense of control. This increases cutaneous stimulation (heat, cold, massage, and TENS), the removal of painful stimuli, distraction, relaxation, guided imagery, meditation, hypnosis, and biofeedback.

What else should we know about pain (602)?

Pain serves as a warning to the body - it often occurs with actual or potential tissue damage. Pain is often a cardinal symptom of inflammation and is valuable in the diagnosis of many disorders and conditions. It may also occur when there is no tissue damage, such as the emotional pain of grief at the death of a loved one or the pain of migraine headaches. Pain causes fatigue and decreases the patient's ability to cope physically, emotionally, and mentally. Pain can potentially be totally debilitating and is one of the most common reasons that patients seek out a healthcare provider.

Which is most important for nurses to understand when caring for patients in pain?

Patients need to know that the nurse believes what they say about their pain. Pain is a personal experience, and the nurse must validate its presence and severity as perceived by the patient.

What are some physiologic and psychological signs and symptoms possible from sleep deprivation (619)?

Physiologic signs/symptoms: hand tremors, decreased reflexes, slowed response time, reduction in word memory, decreased reasoning and judgment, and cardiac dysrhythmias. Psychological signs/symptoms: mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability.

An American Indian patient requests that an egg yolk be placed in a saucer and put under his bed to absorb the pain. What should the nurse do?

Place the egg in a saucer under the bed.

What is REM sleep (618)?

Rapid eye movement sleep - one of two sleep phases. Rem sleep includes a stage of vivid, full-color dreaming consistent with sensory experiences. This first occurs approximately 90m after sleep has begun, thereafter occurring at the end of each NREM cycle. The duration increases with each cycle and averages 20 minutes. It is typified by the autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. There is a loss of skeletal muscle tone. REM sleep is responsible for mental restoration and is the stage in which the sleeper is most difficult to arouse.

A patient has pain in the left arm secondary to coronary insufficiency. This is an example of what type of pain?

Referred pain

What is required by the Joint Commission in terms of pain control (604)?

TJC states, "the management of pain is appropriate for all patients, not just dying patients". TJC has created standards for pain assessment and treatment and now requires accredited facilities and organizations to develop policies and procedures that formalize this obligation. Under new TJC standards, HCPs are expected to be knowledgeable about pain assessment and management, and facilities are expected to develop policies and procedures supporting the appropriate use of analgesics and other pain control therapies.

What delineates the difference between referred, acute, or chronic pain (603)?

Referred pain - is felt at a site other than the injured or diseased organ or part of the body. Ex: the pain of coronary artery insufficiency that sometimes is felt in the left shoulder/arm. Acute pain - is intense and of short duration, usually lasting less than 6 months. In general, acute pain provides a warning to the individual of actual or potential tissue damage. It creates an autonomic response that originates within the sympathetic nervous system, flooding the body with epinephrine and commonly referred to as the fight-or-flight response. Anxiety usually is associated with pain. Because of its short duration, HCPs are likely to prescribe opioids and other analgesics. Chronic pain - generally characterized as pain lasting longer than 6 months. Sometimes it is continuous and sometimes it is intermittent. At times, it may be as intense as acute pain. Chronic pain doesn't serve as a warning of tissue damage in process; rather, it signals that such damage has occurred. It may be linked to arthritis, back injuries, fibromyalgia, accidents, or neurologic conditions. The pain may be the result of an active condition or from the damage left to a body structure such as a joint. Because of the prolonged time involved, many patients develop chronic low self-esteem, change in social identity, changes in role and social interaction, fatigue, sleep disturbance, and depression. They are also more likely to experience comorbid psychiatric conditions.

A patient is experiencing discomfort associated with gastroesophageal reflux. In which position should the nurse teach the patient to sleep?

Semi-Fowler position - gastric secretions increase during REM sleep, this position limits reflux as gravity allows the abdominal organs to drop, reducing pressure on the stomach and less contents flowing upward into the esophagus.

Although denying pain, a patient is irritable, responds slowly, and exhibits periods of tachycardia. What should the nurse assess for in this patient?

Sleep deprivation

How do sleep patterns influence future attempts to fall asleep (617)?

Sleep patterns do this because of changes in circadian rhythm. Sleeping 1 hour later results in falling asleep 1 hour later the next night.

The nurse obtains information from a patient about the site, severity, and duration of the pain. What type of data is this considered?

Subjective data.

What are some administration routes for analgesics (609)?

The IV route is best for administration of opioids after major surgery - it provides a rapid onset of pain relief and best manages escalating pain. This is suitable for PCA - eliminating the need for the patient to wait for medication to be administered. Intramuscular (IM) - this is associated with wide fluctuations in absorption, including delayed absorption in postoperative patients, making it an ineffective and potentially dangerous method of managing pain. Repeated IM injections are often painful and traumatic, and IM routes should generally be avoided. Oral route - often the optimal route, especially for chronic pain treatment, because it is convenient and flexible, as well as producing relatively steady blood levels. It is appropriate as soon as the patient can tolerate oral intake.

What should we know about Endorphins (603)?

The body produces morphine-like substances called endorphins, or potent polypeptides composed of many amino acids, found in the pituitary gland and other areas of the CNS. Stress and pain activate endorphins. Analgesia results when certain endorphins attach to opioid receptor sites in the brain and prevent the release of neurotransmitters, thereby inhibiting the transmission of pain impulses. Pain relief measures, such as transcutaneous electric nerve stimulation (TENS), acupuncture, and placebos, may cause the release of endorphins.

What are some considerations for pain control in older adults (608)?

The effects of aging on the pain process sometimes are compounded in an older adult who has a chronic illness that affects the nervous system. Older adults well instructed in the use of pain measurement tools and without any diseases affecting their nervous system tend to report pain intensity similar to that reported by younger persons. The risk for gastric and renal toxicity from NSAIDs is increased. Changes in peripheral vascular function and skin, along with decreased pain transmission impulses, increase the risk of being unable to sense pain. Older age is associated with chronic health problems, increased risk for musculoskeletal pain, depression, and limitations in ADLs. Increased pain intensity has been noted in those where adequate treatment is not provided for chronic and recurrent pain. Treatment of pain in older adults is as likely to be successful as that in younger persons. Many older adults have some degree of renal insufficiency - Demerol is a particularly poor choice of pain control in such patients. Changes in serum proteins, liver and renal function and a reduction in cardiac output can sometimes make older adults susceptible to the side effects of opioids.

Which concept should the nurse consider when assessing a patient's pain?

The expression of pain is not always congruent with the pain experienced. An obvious response to pain is not always apparent, because psycho-sociocultural factors may dictate behavior.

What is Transcutaneous electric nerve stimulation (TENS) (605)?

The use of a pocket-sized, battery-operated device that provides a continuous, mild electric current to the skin via electrodes attached to a stimulator by flexible wires. This current is adjustable. Like other forms of cutaneous stimulation, it is thought to work by stimulating large nerve fibers to "close the gate" in the spinal cord, thus blocking the transmission of pain impulses. It's also hypothesized to stimulate endorphin production.

What is important to know about tolerance and addiction to opioids, and about abuse deterrent analgesics (608)?

There is a rising incidence of opioid addiction. In response, the FDA is encouraging the development of analgesics that are "abuse deterrent". These medications have properties that allow the management of pain but also have properties that limit their use for abusive purposes. Examples include formulations that limit the ability to crush the tablets for snorting or dissolving for injecting - these are common routes of usage for addicts. Note: Opioid tolerance and physiologic dependence are unusual with short-term postoperative use, psychological dependence and addiction are extremely unlikely after a course of opiates for acute pain.

What is Patient-controlled analgesia (PCA) (610)?

This is a drug delivery system that allows patients to self-administer analgesics whenever needed. This is based on the idea that only the patient can feel the pain and only the patient knows how much analgesic will relieve it. Allowing patients to determine the need for doses addresses the significant variations in analgesic requirements between individuals. To be a PCA candidate, a patient must be alert, oriented, and able to follow simple directions. Note: patient teaching includes: teaching the use of PCA prior to surgery so the patient will understand how to use it after awakening from anesthesia, instructing patients on the purpose of PCA as well as operating instructions, explaining that the pump prevents overdose, telling family/friends not to operate the PCA for the patient, and asking the patient to demonstrate the use of the PCA delivery button.

What is the Gate Control Theory of pain (603)?

This theory suggests that pain impulses are regulated and even blocked by gating mechanisms located along the CNS. The proposed location of the gates is in the dorsal horn of the spinal cord. Pain and other sensations of the skin and muscles travel the same pathways through the large nerves in the spinal cord. If other cutaneous stimuli besides pain are transmitted, the gate through which the pain impulse must travel is temporarily blocked by the stimuli - the brain doesn't have the capacity to acknowledge the pain while it is interpreting the other stimuli. When the gates are open, pain impulses flow freely. When the gates are closed, pain impulses become blocked. Some patients may be distracted from pain by removing the sensation of pain from their center of attention. Gating mechanisms are subject to alteration by thoughts feelings, and memories.

Why should a nurse promptly administer a prescribed analgesic after a pain assessment?

Unrelieved pain can cause setbacks.

What is the best approach for a nurse to use when planning pain relief measures?

Use a variety of pain relief methods.

What are some guidelines for individualizing pain therapy (616)?

Use different types of pain relief measures - using more than one therapy has an additive effect in reducing pain, and the character of pain often changes throughout the day. 2. Provide pain relief measures before the pain becomes severe - it's easier to prevent severe pain than to relieve it, giving an analgesic 30-40 minutes before ambulation or other care activities may help in proactive pain management. 3. Use measures the patient believes are effective - the patient is the expert on the pain and likely has realistic ideas about what measures to use. 4. Consider the patient's ability or willingness to participate in pain relief measures - because of fatigue, sedation, or altered levels of consciousness, some patients are unable to assist actively with pain therapy. 5. Chose pain relief measures that are appropriate to the severity of the pain as reflected by the patient's behavior - it'd be poor judgment to administer a potent opioid to a patient who is displaying only mild pain. 6. If therapy is ineffective at first, encourage the patient to try it again before abandoning it - often, anxiety or doubt prevents patients from obtaining relief from therapy. Some approaches necessitate practice. 7. Keep an open mind about what has the potential to relieve pain - new ways to control pain sometimes are found and much remains to be learned about the pain experience. 8. Keep trying - it's easy to become frustrated when efforts at pain relief fail - do not abandon the patient when pain persists. 9. Protect the patient - pain therapy that causes more distress than the pain is misguided and inappropriate. Always observe the response to therapy.

A nurse is assessing a patient experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain?

Variations in vital signs. Acute pain stimulates the SNS, which responds by increasing pulse, respirations, and BP.

What should we know about Pain rating scales and the visual analog scale (614)?

Visual analog scales and numeric scales are used commonly to qualify the intensity of the pain experience. With the visual analog scale, the patient marks a spot on a horizontal line to indicate pain intensity, with intensity increasing as the line moves from left to right. The most frequently used numeric scale is from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. A visual scale with numeric ratings combines both, providing a description and facial expressions with assigned numbers from 0 to 10.

The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse using?

gate control