N101- Exam 3

Clients at risk for sensory deprivation and overload

Sensory Deprivation: Clients Who: -are confined in a non-stimulating or monotonous environment in the home or healthcare agency -have impaired vision or hearing -have mobility restrictions such as quadriplegia or paraplegia with bedrest, traction apparatus -are unable to process stimuli (e.g., clients who have brain damage or who are taking medications that affect the central nervous system) -have emotional disorders (e.g., depression) and withdraw within themselves -have limited social contact with family and friends (e.g., clients from a different culture). Sensory Overload: Clients Who: -have pain or discomfort -are acutely ill and have been admitted to an acute care facility -are being closely monitored in an intensive care unit (ICU) and have intrusive tubes such as IVs, catheters, or nasogastric or endotracheal tubes -have decreased cognitive ability (e.g., head injury).

Chronic vs Acute Pain

Chronic pain: Prolonged pain, usually recurring or persisting over 6 months or longer, that interferes with functioning Acute Pain: Pain that lasts only through the expected recovery period (as opposed to chronic) When pain lasts only through the expected recovery period of less than 3 months, it is described as acute pain, whether it has a sudden or slow onset, regardless of its intensity. Chronic pain, also known as persistent pain, is caused by pain signals firing in the nervous system beyond 3 months to even years. The pain may have been initiated by an injury (e.g., sprained back) or may exist because of an ongoing cause of pain, such as arthritis

Sensory Alterations....

Client Environment: A nurse should assess the client's environment for quantity, quality, and type of stimuli. The environment may produce insufficient stimuli, placing the client at risk for sensory deprivation, or excessive stimuli, placing the client at risk for sensory overload. Non-stimulating environments include those that (a) severely restrict physical activity and (b) limit social contact with family and friends. Because appropriate or meaningful stimuli decrease the incidence of sensory deprivation, the nurse must consider the client's healthcare environment for the presence of the following stimuli: Electronic devices (computers, iPADs, tablets, television, smart phones) Clock or calendar Reading material (or toys for children) Number and compatibility of roommates Number of visitors.

Confused Clients

Confusion can occur in clients of all ages, but it is most commonly seen in older people. Confusion often presents with subtle symptoms, and it is important for the nurse to differentiate between acute confusion (delirium) and chronic confusion (dementia). Delirium has an abrupt onset and a cause that, when treated, reverses the confusion. Dementia, often called chronic confusion, has symptoms that are gradual and irreversible

Misconceptions about pain

Correct conceptions: -Even after minor surgery, clients can experience intense pain. -The individual who experiences the pain is the only authority about its existence and nature. -Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. -Even with severe pain, periods of physiologic and behavioral adaptation can occur.

Observation of Behavioral and Physiologic Responses

-A client's self-report is an important component for pain assessment. Not all clients, however, are able to self-report. This group, referred to as "nonverbal" clients, includes the very young; individuals who are cognitively impaired, critically ill, or comatose; and some individuals at end of life. These clients are a challenge as the nurse provides effective pain management. -There are wide variations in nonverbal responses to pain. Facial expression is often the first indication of pain, and it may be the only one. Clenched teeth, tightly closed eyes, rapid blinking, biting of the lower lip, and other facial grimaces may indicate pain. Vocalizations such as sighing, moaning and groaning, crying, and screaming are sometimes associated with pain. -Immobilization of the body or a part of the body may also indicate pain. The client with chest pain often holds the left arm across the chest. A client with abdominal pain may assume the position of greatest comfort, often with the knees and hips flexed, and move reluctantly. -Purposeless body movements can also indicate pain—for example, tossing and turning in bed or flinging the arms about. Involuntary movements such as a reflexive jerking away from a needle inserted through the skin indicate pain. -Behavioral changes such as irritability, confusion, and restlessness may be indicators of pain in both cognitively intact and cognitively impaired clients. Older adults with chronic pain may become agitated or aggressive. -Physiologic responses vary with the origin and duration of the pain. Early in the onset of acute pain, the sympathetic nervous system is stimulated, resulting in increased blood pressure, pulse rate, respiratory rate, pallor, diaphoresis, and pupil dilation. The body does not sustain the increased sympathetic function over a prolonged period and, therefore, the sympathetic nervous system adapts, causing the responses to be less evident or even absent. Physiologic responses are likely to be absent in clients with chronic pain because of autonomic nervous system adaptation.

Nursing Management/Assessing

-Accurate pain assessment is essential for effective pain management. Given the highly subjective and individually unique nature of pain, a comprehensive assessment of the pain experience (physiologic, psychologic, behavioral, emotional, spiritual, and sociocultural) provides the necessary foundation for optimal pain control. -The extent and frequency of the pain assessment varies according to the situation and the organizational policy. For clients experiencing severe acute pain, the nurse may focus only on location, quality, and severity, and provide interventions to control the pain before conducting a more detailed evaluation. Clients with mild or moderate acute pain or chronic pain can usually provide a more detailed description of the experience. A simple screening question such as "Are you experiencing any discomfort right now?" will usually be adequate. Frequency of pain assessment may vary depending on the pain control measures being used and the clinical circumstances. -Major barriers to better pain control for both nurses and clients relate to failure to assess pain, underestimation of pain, failure to accept the client's report of pain, failure to act on the client's report of pain, and concerns about addiction. Given that many clients will not voice their pain unless asked about it, the nurse must initiate pain assessments. -Pain assessments consist of two major components: (a) a pain history to obtain facts from the client and (b) direct observation of behaviors, physical signs of tissue damage, and secondary physiologic responses of the client. It is important to remember that behaviors can vary greatly among clients; thus, behavior is only one aspect of a comprehensive pain assessment. The goal of assessment is to gain an objective understanding of a subjective experience.

Pain Quality/Assessing

-Descriptive adjectives help people communicate the quality of pain. A headache may be described as "unbearable" or an abdominal pain as "piercing like a knife." The smart clinician can collect subtle clinical clues from the quality of the pain described; thus, it is important to record the description exactly as described by the client. -Both pains are real physical conditions signaling an underlying condition, but the affective description "unbearable" suggests that there is a coexisting emotional distress that needs to be addressed as well. Pain described as burning or shock-like tends to be neuropathic in origin and may be responsive to anticonvulsants (e.g., gabapentin or pregabalin).

Preventing Sensory Overload

-For clients who are at risk of overstimulation, nurses should reduce the number and type of environmental stimuli. The nurse can counteract sensory overload by blocking unnecessary stimuli and by helping the client organize and alter responses to the stimuli that cannot be blocked. Minimize unnecessary light, noise, and distraction. Provide dark glasses and earplugs as needed. Control pain as indicated at the level desired by the client, on a scale of 0 to 10. Introduce yourself by name, and address the client by name. Provide orienting cues, such as clocks, calendars, equipment, and furniture in the room. Provide a private room. Limit visitors. Preventing Sensory Deprivation: For clients who are at risk for sensory deprivation, nurses can increase environmental stimuli in a number of ways. For example, newspapers, books, music, and television can stimulate the visual and auditory senses. Providing objects that are pleasant to touch, such as a pet to stroke, can provide tactile and interactive stimulation. Clocks that differentiate night from day by color can help orient a client to time. The olfactory sense can be stimulated by the presence of fresh flowers or plants. When communicating with a client who has impaired hearing, it is important to speak facing the client so that the client can see the nurse's mouth. This will enhance communication with clients who read lips.

Common chronic pain syndromes

-Post-herpetic neuralgia. This pain occurs when a case of herpes zoster (shingles) typically erupts decades after a primary infection (chickenpox) during a period of stress or compromised immune functioning. After the painful unilateral vesicular rash fades, burning or electric-shock pain in the area may persist for months or years. Advancing age is a risk factor for persistent post-herpetic neuralgia. -Phantom pain. Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. For many, this sensation is painful and it may occur spontaneously or be evoked (e.g., by a poor-fitting prosthesis). -Trigeminal neuralgia. This is an intense stab-like pain that is distributed by one or more branches of the trigeminal nerve (fifth cranial). -Headache. This commonly occurring painful condition can be caused by either intracranial or extracranial problems, or serious or benign conditions. To establish a plan to prevent or treat headache, the nurse needs to assess the quality, location, onset, duration, and frequency of the pain, as well as any signs and symptoms that precede the headache. -Low back pain. Nearly everyone suffers from low back pain at some time during their lives. Most occurrences of low back pain go away within a few days. -Fibromyalgia. This chronic disorder is characterized by widespread musculoskeletal pain, fatigue, and multiple tender points. This disease is poorly understood and primarily occurs in women. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders, and hips.

Four aspects of sensory process

-Stimulus. This is an agent or act that stimulates a nerve receptor. -Receptor. A nerve cell acts as a receptor by converting the stimulus to a nerve impulse. Most receptors are specific, that is, sensitive to only one type of stimulus, such as visual, auditory, or touch. -Impulse conduction. The impulse travels along nerve pathways either to the spinal cord or directly to the brain. For example, auditory impulses travel to the organ of Corti in the inner ear. From there the impulses travel along the eighth cranial nerve to the temporal lobe of the brain. -Perception: Perception, or awareness and interpretation of stimuli, takes place in the brain, where specialized brain cells interpret the nature and quality of the sensory stimuli. The client's level of consciousness affects the perception of the stimuli.

Sensory Chapter Review

-The sensory experience consists of two components: sensory reception and sensory perception. -Sensory stimuli can be either external or internal. Visual, auditory, olfactory, tactile, and gustatory stimuli orient an individual to the external environment. Kinesthetic and visceral stimuli orient the individual to the internal environment. Kinesthetic stimuli make the individual aware of the position and movement of body parts. -Sensory perception involves the awareness and interpretation of stimuli into meaningful information. This process occurs in the cerebral cortex. The reticular activating system (RAS), with its many ascending and descending connections to other areas of the brain, monitors and regulates incoming stimuli. The RAS maintains, enhances, or inhibits cortical arousal. The normal, alert individual can assimilate many kinds of information at one time and respond appropriately through thought and action. Factors affecting sensory stimulation include developmental stage, culture, stress, medications, illness, and lifestyle and personality. Sensory deprivation occurs when an individual receives decreased sensory input or monotonous or meaningless sensory input. Sensory overload occurs when an individual experiences excessive sensory input and is unable to process or manage the stimuli. The individual feels overwhelmed and not in control. Responses to both sensory deprivation and sensory overload include perceptual changes (e.g., mild distortions or hallucinations), cognitive changes (e.g., decreased concentration and problem-solving ability), and affective changes (e.g., apathy, anxiety, anger, depression, and rapid mood swings). Clients at risk for sensory deprivation include (a) those who are homebound or institutionalized, (b) those on bedrest or isolation precautions, (c) those with sensory impairments, (d) those who come from a different culture, (e) those with certain affective disorders or disturbances of the nervous system, and (f) those on certain medications that affect the central nervous system. Clients at risk for sensory overload include (a) those in pain, (b) those in intensive care units, (c) those with intrusive and uncomfortable monitoring or treatment equipment, and (d) those with decreased cognitive ability (e.g., head injury). Assessment for sensory-perception disturbances includes (a) a nursing history to identify sensory impairments, (b) mental status examination, (c) physical examination, (d) identification of clients at risk, (e) the client's environment, and (f) the client's social support network. Examples of nursing diagnoses related to a client's sensory-perception impairments can include disturbances in thinking, inability to recall past experiences, potential for injury, diminished ability to communicate, and diminished personal relationships. Goals for clients with sensory-perception disturbances include (a) preventing injury, (b) maintaining the function of existing senses, (c) developing an effective communication mechanism, (d) preventing sensory deprivation or overload, (e) reducing social isolation, and (f) performing ADLs independently and safely. Interventions to prevent or modify sensory deprivation, sensory overload, and sensory impairments include promoting healthy sensory function, helping clients manage sensory impairments, and adjusting environmental stimuli. Clients with sensory impairments need instruction about sensory aids available to support residual sensory function, ways to promote the use of other senses, and methods to ensure safety from bodily harm. Nurses and support people need to devise and implement effective communication mechanisms for clients who have visual and hearing impairments. Clients with acute confusion (delirium) need care directed toward promoting their orientation to time, place, person, and situation.

Why clients may be reluctant to report pain

-Unwillingness to trouble staff who are perceived as busy -Do not want to be labeled as a "complainer" or "bad" -Fear of the injectable route of analgesic administration—especially children -Belief that unrelieved pain is an expected, normal part of recovery or aging -Belief that others will think they are weak if they express pain -Difficulty or inability to communicate their discomfort -Concern about risks associated with opioid drugs (e.g., addiction) -Concern about unwanted side effects, especially of opioid drugs -Concern that use of drugs now will make the drug inefficient later in life (etc.)

Comparison of Acute and Chronic Pain

Acute Pain: Mild to severe. Sympathetic nervous system responses: -Increased pulse rate -Increased respiratory rate -Elevated blood pressure -Diaphoresis -Dilated pupils ~Related to tissue injury; resolves with healing ~Client may be restless and anxious ~Client reports pain ~Client may exhibit behavior indicative of pain: crying, rubbing area, holding area Chronic Pain: Mild to severe. Parasympathetic nervous system responses: -Vital signs normal -Dry, warm skin -Pupils normal or dilated -Continues beyond healing -Client is usually depressed and withdrawn -Client often does not mention pain unless asked -Pain behavior often absent

Nursing Management

Assessing: Nursing assessment of sensory-perceptual functioning includes six components: (1) nursing history, (2) mental status examination, (3) physical examination, (4) identification of clients at risk, (5) the client's environment, and (6) the client's social support network. -Nursing History: During the nursing history the nurse assesses the client's current sensory perceptions, usual functioning, sensory deficits, and potential problems. In some instances, significant others can provide data the client cannot.

Lifespan Considerations to Pain

Children: Children often receive inadequate medication to treat their pain. This may be due to nurses' lack of knowledge about how to evaluate pain in children. The pain of infants and young children who cannot verbalize well is particularly difficult to assess. Nurses will benefit from learning how to use pain assessment tools and by being alert to the possibility that children may be experiencing significant levels of pain, even if they do not appear to be in pain. Older Adults: The presentation of pain may vary in older adults for a variety of reasons. Changes in nerve structure and functioning or vascular changes with aging may cause a variation in the pain sensation. Sometimes the pain is heightened in those whose nervous systems have been sensitized from previous unresolved pain, whereas at other times significant tissue damage (e.g., silent heart attack) may occur without pain being experienced. Maintaining optimal function is especially crucial for a high quality of life in older clients. If pain is not effectively controlled, the following areas are often affected in their daily lives: -Activity tolerance -Mobility -Ability to socialize -Sleep disturbance -Ability to perform ADLs -Ability to remain as independent as possible. -All efforts, pharmacologic and nonpharmacologic, should be used to help provide pain reduction, while maintaining or enhancing functional ability. Involvement of the client and family is important when working with the primary care provider, pharmacist, and nurse to plan which treatment is most appropriate and most acceptable to the client. -The principle "start low and go slow" is especially important when ordering dosages and pain medications for older adults. Typically, the starting dose of medicines for older adults is reduced by 25% to 50%, and then titrated for effect. Decreased renal and liver function may prolong the duration of action, but it also increases the risk of toxicity from pain medications in older clients.

Lifespan Considerations/Sensory

Children: Newborns should be screened for hearing loss before 1 month of age. The guidelines for collecting data on hearing loss have set a benchmark that a minimum of 90% of all children in each state will have access to early intervention including education and treatment. Infants with hearing impairment will begin treatment before 6 months of age. The development of a child with a hearing impairment should be monitored annually. Older Adults: Normal changes of aging often result in varying degrees of impairments in sensory perception and the senses—hearing, vision, smell, taste, and touch. Diseases and conditions that are more common in older adults are diabetes, strokes, and other neurologic disorders such as Parkinson's disease. Each of these conditions and others will alter the client's sensory perception. Nursing interventions need to be very specific and individualized. The interventions are directed to either increase or decrease sensory stimuli. The goals of nursing care should be focused on maintaining safety and communication with clients who have these impairments.

Sensory Perception Problem as the Etiology

Depending on the data obtained, alterations in sensory-perception function may affect other areas of human functioning and indicate other diagnoses. In these instances the sensory-perception problem becomes the etiology. Examples of nursing diagnoses for which sensory-perception disturbances are the etiology include potential for injury related to decreased vision, hearing, or tactile stimulation, changes in consciousness, or sensory impairment; and diminished personal relationships related to decreased hearing and increased or decreased sensory perception.

Cognitive Behavioral Interventions

Distraction: visual, auditory, tactile (slow, rhythmic breathing, massage), intellectual distraction (hobbies, card games, puzzles) The relaxation response: Stress increases pain, in part by increasing muscle tension, activating the sympathetic nervous system, and putting the client at risk for stress-related types of pain (e.g., tension headaches). The relaxation response decreases and counteracts the harmful effects of stress, including the effect it has on physical, cognitive, and emotional functioning. Producing this response requires more than simply helping someone to relax; rather, it involves a structured technique designed to focus the mind and relax muscle groups. Repatterning unhelpful thinking: Some clients harbor strong self-doubts, unrealistic expectations (e.g., "I just want someone to make the pain go away"), rumination (e.g., "I keep thinking about my pain and the person who did this to me"), helplessness (e.g., "I can't do anything"), and magnification (e.g., "My life is ruined, I'll never be a good parent because of my pain"). Facilitating coping: Nurses can help by intervening with clients who are anxious, are sad, or express overly pessimistic or helpless points of view. Awareness of the client's misperceptions or unrealistic expectations also helps the professional avoid a common cause of therapeutic failure. Evaluating: The goals established in the planning phase are evaluated according to specific desired outcomes, also established in that phase. To assist in the evaluation process, flow sheet records in the client's EHR or a client diary may be helpful.

Diagnosing

Examples of nursing diagnoses for clients experiencing pain or discomfort can include mild acute pain, moderate acute pain, severe acute pain, and chronic pain. When writing the diagnostic statement, the nurse should specify the location (e.g., right ankle pain or left frontal headache). Related factors, when known, should also be part of the diagnostic statement. Because the presence of pain can affect so many aspects of a client's functioning, pain may be the etiology of other nursing diagnoses. Examples of such nursing diagnoses follow: -Impaired coping related to prolonged continuous back pain, ineffective pain management, and inadequate support systems -Altered physical mobility related to pain and inflammation secondary to arthritic pain in knee and ankle joints -Impaired sleep related to increased pain perception at night.

Daily Pain Diary

For clients who experience chronic pain, a daily diary may help the client and healthcare provider identify pain patterns and factors that worsen or resolve the pain experience. In home care, the family or other caregiver can be taught to complete the diary with the family member who is unable to do so alone. The record could include the following: -Time of onset of pain -Activity or situation -Physical pain character (quality) and intensity level (0-10) -Emotions experienced and intensity level (0-10) -Use of analgesics or other relief measures (intervention) -Pain rating after intervention taken Comments. -Pain diaries have been shown to improve pain management. They avoid "recall bias" and allow clients to understand and express their pain experience and possibly determine patterns that can help providers suggest better interventions. The diary may also increase clients' sense of control by helping them use medication more effectively.

Impaired Vision

For clients with impaired vision, nurses need to do the following in a healthcare setting: Orient the client to the arrangement of room furnishings and maintain an uncluttered environment. Keep pathways clear and do not rearrange furniture without orienting the client. Ensure that housekeeping personnel are informed about this. Organize self-care articles within the client's reach and orient the client to his or her location. Keep the call light within easy reach and place the bed in the low position. Assist with ambulation by standing at the client's side, walking about 1 foot ahead, and allowing the client to grasp your arm. Confirm whether the client prefers grasping your arm with the dominant or nondominant hand. -The most common vision diseases affecting older adults are macular degeneration, cataracts, glaucoma, and diabetic retinopathy. Age-related macular degeneration (ARMD) is the leading cause of blindness in adults older than age 65. Cataracts are opacities of the lenses. Development is slow and painless and may be unilateral or bilateral. They are the leading cause of blindness worldwide.

Concepts Associated with Pain

It is useful for nurses to differentiate pain threshold from pain tolerance. Pain threshold is the least amount of stimuli that is needed for someone to label a sensation as pain. It may vary slightly from individual to individual, and may be related to age, gender, or race, but it changes little in the same individual over time. Pain tolerance is the maximum amount of painful stimuli that an individual is willing to withstand without seeking avoidance of the pain or relief. Pain tolerance varies significantly among individuals, even within the same individual at different times and in different circumstances. For example, a woman may tolerate a considerable amount of labor pain because she does not want to alter her level of alertness or the health of her baby. She likely would not tolerate a fraction of that pain during a routine dental procedure before requesting appropriate pain relief medicine.

Assessing continued...

Pattern: The pattern of pain includes time of onset, duration, and recurrence or intervals without pain. The nurse therefore determines when the pain began; how long it lasts; whether it recurs and, if so, the length of the interval without pain; and when the pain last occurred. Attention to the pattern of pain helps the nurse anticipate and meet the needs of the client, as well as recognize patterns of serious concern (e.g., chest pain only on exertion). Precipitating Factors: Certain activities sometimes precede pain. For example, physical exertion may precede chest pain, or abdominal pain may occur after eating. These observations can help prevent pain and determine its cause. Environmental factors such as extreme cold or heat and extremes of humidity can affect some types of pain. For example, clients with rheumatic conditions have worse pain on cold, damp days or just before a storm. Alleviating Factors: Nurses must ask clients to describe anything that they have done to alleviate the pain (e.g., home remedies such as herbal teas, medications, rest, applications of heat or cold, prayer, or distractions like TV). It is important to explore the effect any of these measures had on the pain, if relief was obtained, or whether the pain became worse. It is helpful to recommend a diary be kept for gathering this information. Associated Symptoms: Also included in the clinical appraisal of pain are associated symptoms such as nausea, vomiting, dizziness, and diarrhea. These symptoms may relate to the onset of the pain or they may result from the presence of the pain. Effects of Activities of Daily Living: Knowing how ADLs are affected by pain helps the nurse understand the client's perspective on the pain's severity. The nurse should ask the client to describe how the pain has affected the following aspects of life: -Sleep -Appetite -Concentration -Work or school -Interpersonal relationships -Marital relations or sex -Home activities -Driving and walking -Leisure activities -Emotional status (mood, irritability, depression, anxiety). A rating scale of none, a little, or a great deal, or another range can be used to determine the degree of alteration in ADLs. Coping Resources: Everyone exhibits personal ways of coping with pain. Strategies may relate to earlier pain experiences or the specific meaning of the pain; some may reflect religious or cultural influences. Nurses can encourage and support the client's use of methods known to have helped in modifying pain, unless they are specifically contraindicated. Affective Responses: Affective responses vary according to the situation, the degree and duration of pain, the interpretation of it, and many other factors. The nurse needs to explore the client's feelings of anxiety, fear, exhaustion, level of function, depression, or a sense of failure. Because many people with chronic pain become depressed and potentially suicidal, it may also be necessary to assess the client's suicide risk.

Nursing management/Assessing continued..

Location: To ascertain the specific location of the pain, ask the client to point to the site of the discomfort. A chart consisting of drawings of the body can assist in identifying pain locations. The client marks the location of pain on the chart. This tool can be especially effective with clients who have more than one source of pain. -Asking the child to point to the pain helps clarify the child's word usage to identify location. The use of figure drawings can assist in identifying pain locations. Parents can also be helpful in interpreting the meaning of a child's words. When documenting pain location the nurse may use various body landmarks. Further clarification is possible with the use of terms such as proximal, distal, medial, lateral, and diffuse. Pain intensity or rating scales: -The single most important indicator of the existence and intensity of pain is the client's report of pain. Pain assessment that is inaccurate or incomplete leads to undertreatment of pain. Appropriate pain assessment tools based on age, developmental level, and cognitive function should be used. The use of pain intensity scales is an easy method of determining the client's pain intensity. -Another way to evaluate the intensity of pain for clients who are unable to use the numeric rating scales is to determine the extent of pain awareness and degree of interference with functioning. For example, 0 = no pain; 2 = awareness of pain only when paying attention to it; 4 = can ignore pain and do things; 6 = cannot ignore pain, interferes with functioning; 8 = impairs ability to function or concentrate; and 10 = intense incapacitating pain. 🌟The FLACC scale has been validated in children 2 months up to adolescence and rates pain behaviors as manifested by Facial expressions, Leg movement, Activity, Cry, and Consolability measures that yield a score of 0 to 10. The Wong-Baker FACES scale can also be used for clients ranging in age from 3 months to adults. It includes a number scale along with an illustrated facial expression so that the pain intensity can be documented. 🌟When using the FACES rating scale, it is important to remember that the client's facial expression does not need to match the picture. The client points to the picture that represents how much pain the client is experiencing. The Faces Pain Scale—Revised is another scale that uses illustrations of facial expressions. It can be used with clients ranging from 3 years to adults. It is recommended over the Wong-Baker FACES scale for older adults because the illustrations look less cartoonish and uses impersonal, more realistic expressions, and the absence of smiles and tears seems more appropriate to older or stoic clients 🌟Perception is reality. The client's self-report of pain is what must be used to determine pain intensity. The nurse is obligated to record the pain intensity as reported by the client. By challenging the believability of the client's report, the nurse is undermining the therapeutic relationship and preventing the fulfillment of advocacy and helping clients with pain.

Factors Affecting the Pain Experience continued....

Meaning of pain: -Some clients may accept pain more readily than others, depending on the circumstances and the client's interpretation of its significance. A client who associates the pain with a positive outcome may withstand the pain amazingly well. For example, a woman giving birth to a child or an athlete undergoing knee surgery to prolong her career may tolerate pain better because of the benefit associated with it. -By contrast, clients with unrelenting chronic, persistent pain may suffer more intensely. Persistent pain affects the body, mind, spirit, and social relationships in an undesirable way. Physically, the pain limits functioning and contributes to the disuse or deconditioning alluded to previously. For many, the change in activities of daily living (ADLs), such as eating, sleeping, and toileting, also takes a toll. The side effects of the many medications used to try to control the pain also place a heavy burden on the body. -Mentally, clients with chronic pain change their outlook, becoming more pessimistic, often to the point of helplessness and hopelessness. Mood often becomes impaired when pain persists, because the sadness of being unable to do important or enjoyable activities combines with self-doubts and learned helplessness to produce depression. Anxiety, worry, and uncertainty about coping with the pain may escalate emotionally, to the point of panic. Spiritually, pain may be viewed in a variety of ways. It may be perceived as a punishment for wrongdoing, a betrayal by a higher power, a test of fortitude, or a threat to the essence of who the client is. Pain may be a source of spiritual distress, or it may be a source of strength and enlightenment. Socially, pain often strains valued relationships, in part because of the impaired ability to fulfill role expectations. Emotional Responses to Pain: -Anxiety often accompanies pain. Prolonged anxiety associated with pain can lead to other emotional disturbances, such as depression or difficulty coping. Fear of the unknown and the inability to control the pain or the events surrounding it often raises pain perception. When clients are experiencing pain, they often become fatigued. Fatigue reduces a client's ability to cope, thereby increasing pain perception. With anxiety, depression, and fatigue, sleep disturbances can occur. When pain interferes with sleep, fatigue and muscle tension often result and increase the pain; thus, a cycle of pain, fatigue, and increased pain develops. -Some anxious clients in pain think about the worst consequence they can imagine happening, which leads them to perceive that their pain is extremely life-threatening. This process, called catastrophizing, has been associated with pain disability, avoiding activity, and higher levels of pain intensity. -Clients in pain who believe that they have control of their pain have less fear and anxiety, which decreases their pain perception. A perception of lacking control or a sense of helplessness tends to increase pain perception.

Sensory Alterations..

Mental Status Examination: Mental status is critical to any evaluation of the sensory-perceptual process. Data on mental status, including level of consciousness, orientation, memory, and attention span, are usually obtained during the nursing history Physical Examination: Specific sensory tests include the following: -Visual acuity, using a Snellen chart or other reading material such as a newspaper, and visual fields -Hearing acuity, by observing the client's conversation with others and by performing the whisper test and the Weber and Rinne tuning fork tests -Olfactory sense, by asking the client to identify specific aromas -Gustatory sense, by asking the client to identify three tastes such as lemon, salt, and sugar -Tactile sense, by testing light touch, sharp and dull sensation, two-point discrimination, hot and cold sensation, vibration sense, position sense, and stereognosis.

Physiology of Pain

Nociception: The peripheral nervous system includes specialized primary sensory neurons that detect mechanical, thermal, or chemical conditions associated with potential tissue damage. When these nociceptors are activated, signals are transduced and transmitted to the spine and brain where the signals are modified before they are ultimately understood and then "felt." The physiologic processes related to pain perception are described as nociception. Four physiologic processes are involved in nociception: transduction, transmission, perception, and modulation. Transduction: Specialized pain receptors or nociceptors can be excited by mechanical, thermal, or chemical stimuli. During the transduction phase, harmful stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, which sensitize nociceptors. Painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Transmission: The second process of nociception, transmission of pain, includes three segments. During the first segment of transmission, the pain impulses travel from the peripheral nerve fibers to the spinal cord. Substance P serves as a neurotransmitter, enhancing the movement of impulses across the nerve synapse from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord. Perception: The third process, perception, is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system (CNS) that may shape the character and intensity of pain perceived (e.g., sharp, burning, pressure) and give meaning to the pain. Modulation: Often described as the "descending system," this final process occurs when neurons in the brain send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit or reduce the ascending painful impulses in the dorsal horn. In contrast, excitatory amino acids (e.g., glutamate, N-methyl-d-aspartate [NMDA]) can increase these pain signals.

Factors affecting the pain experience

Numerous factors can affect an individual's perception of and reaction to pain. These include the individual's ethnic and cultural values, developmental stage, environment and support people, previous pain experiences, the meaning of the current pain, and emotional responses to pain. ⭐Ethnic and Cultural Values: Ethnic background and cultural heritage are factors that can influence both an individual's reaction to pain and the expression of that pain. Behavior related to pain is a part of the socialization process. For example, individuals in one culture may learn to be expressive about pain, whereas individuals from another culture may have learned to keep those feelings to themselves. ⭐To become culturally competent, nurses must become knowledgeable about differences in the meaning of and responses to pain. They must be sympathetic to concerns and develop the skills needed to address pain in a culturally sensitive way. It is important, therefore, to develop an effective and caring relationship with the client. This relationship is based on respect, that is, respecting the client's statement of pain and asking about the client's beliefs and how the client copes with pain.

Client Teaching: Monitoring Pain in the Home Setting

Pain Control: -Teach the use of preferred and selected nonpharmacologic techniques such as relaxation, guided imagery, distraction, music therapy, massage, heat, and cold. -Discuss the actions, side effects, dosages, and frequency of administration of prescribed analgesics. -Suggest ways to handle side effects of medications. -Provide accurate information about tolerance, physical dependence, and addiction if opioid analgesics are prescribed. -Instruct the client to use pain control measures before the pain becomes severe. Inform the client of the effects of untreated pain. -Demonstrate and have the client or caregiver in return demonstrate appropriate skills to administer analgesics (e.g., skin patches, injections, infusion pumps, or patient-controlled analgesia).

REM Sleep

REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes. Most dreams take place during REM sleep but usually will not be remembered unless the individual arouses briefly at the end of the REM period.

What are the five health-related behaviors that lead to the development of chronic disease?

Smoking, alcohol consumption, obesity, lack of exercise, and insufficient amounts of sleep contribute to an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke.

Sensory Alterations.......

Social Support Network: The degree of isolation an individual feels is significantly influenced by the quality and quantity of support from family members and friends. A nurse should assess (a) whether the client lives alone, (b) who visits and when, and (c) any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms.

Responses to pain

The body's response to pain is a complex process. It has both physiologic and psychosocial aspects. Initially, with acute pain, the sympathetic nervous system responds, resulting in the fight-or-flight response, with a noticeable increase in pulse and blood pressure. The client may hold his or her breath, or have short, shallow breathing. Unrelieved pain has a potentially harmful effect on an individual's well-being. For example, pain interferes with sleep, affects appetite, and lowers the quality of life for clients and their family members. A natural response to pain is to stop activity, tense muscles, and withdraw from the pain-provoking activities. This reduced mobility may produce muscle atrophy and painful spasm, putting the client at risk of complications related to immobility or cardiopulmonary deconditioning. Uncontrolled pain impairs immune function, which slows healing and increases susceptibility to infections and pressure injuries. Persistent, severe pain changes the nervous system in a way that intensifies, spreads, and prolongs the pain, risking the development of incurable chronic pain syndromes. Beginning at 24 hours, persistent, unrelieved, severe acute pain changes the structure and function of the nervous system in a way that prolongs and intensifies the pain experience.

Physical Interventions

The goals of physical intervention include providing comfort, altering physiologic responses to reduce pain perception, and optimizing functioning. Cutaneous stimulation can provide effective temporary pain relief. It distracts the client and focuses attention on the tactile stimuli, away from the painful sensations, thus reducing pain perception. Cutaneous stimulation is also believed to interrupt the pain pathway. Selected cutaneous stimulation techniques include the following: Massage Application of heat or cold Acupressure Contralateral stimulation.

Components of the Sensory Experience

The sensory process involves two components: reception and perception. Sensory reception is the process of receiving stimuli or data. These stimuli are either external or internal to the body. External stimuli are visual (sight), auditory (hearing), olfactory (smell), tactile (touch), and gustatory (taste). Gustatory stimuli can be internal as well. Other types of internal stimuli are kinesthetic or visceral. Kinesthetic refers to awareness of the position and movement of body parts. For example, an individual walking is aware of which leg is forward. A related sense is stereognosis, the ability to perceive and understand an object through touch by its size, shape, and texture. For example, an individual holding a tennis ball is aware of its size, round shape, and soft surface without seeing it. Visceral refers to any large organ within the body. Visceral organs may produce stimuli that make an individual aware of them (e.g., a full stomach). Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information.

Pain Assessment and Management

Types of Pain: Pain may be described in terms of location, duration, intensity, and etiology. Location: Classifications of pain based on location (e.g., head, back, chest) may be problematic. Complicating the categorization of pain by location is the fact that some pains radiate (spread or extend) to other areas (e.g., low back to legs). Pain may also be referred (appear to arise in different areas) to other parts of the body. For example, cardiac pain may be felt in the shoulder or left arm, with or without chest pain. Visceral pain (pain arising from organs or hollow viscera) is often perceived in an area remote from the organ causing the pain. Duration: When pain lasts only through the expected recovery period of less than 3 months, it is described as acute pain, whether it has a sudden or slow onset, regardless of its intensity. Chronic pain, also known as persistent pain, is caused by pain signals firing in the nervous system beyond 3 months to even years. Intensity: Most practitioners classify intensity of pain by using a numeric scale: 0 (no pain) to 10 (worst pain imaginable). Linking the rating to health and functioning scores, pain in the 1 to 3 range is considered mild pain, a rating of 4 to 6 is moderate pain, and pain reaching 7 to 10 is viewed as severe pain and is associated with the worst outcomes. Etiology: Designating types of pain by etiology can be done under the broad categories of nociceptive pain and neuropathic pain. The process of pain awareness is nociception. Nociceptive pain is experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. Subcategories of nociceptive pain include somatic and visceral. Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain. Neuropathic pain is associated with damaged or malfunctioning nerves due to illness (e.g., post- herpetic neuralgia, diabetic peripheral neuropathy), injury (e.g., phantom limb pain, spinal cord injury pain), or undetermined reasons. Neuropathic pain is typically chronic; it is often described as burning, "electric-shock," or tingling, painful numbness, dull, and aching.

Pain History /Assessing

While taking a pain history, the nurse must provide an opportunity for clients to express in their own words how they view the pain. This will help the nurse understand what the pain means to the client and how the client is coping with it. Remember that each individual's pain experience is unique and that the client is the best interpreter of the experience. This history should be geared to the specific client. For example, questions asked of a car crash victim would be different from those asked of a postoperative client or someone suffering from chronic pain. The initial pain assessment for someone in severe acute pain may consist of only a few questions before intervention occurs. -Location: Where is your discomfort? Ask client to point to the location and document the exact location (e.g., left lower abdomen instead of abdominal pain). -Quality: Tell me what your discomfort feels like. -Intensity: On a scale of 0 to 10, with "0" representing no pain (substitute the term client uses, e.g., "no burning") and "10" representing the worst pain imaginable (e.g., "burning sensation"), how would you rate the degree of discomfort you are having right now? Pattern: Time of onset: When did or does the pain start? Duration: How long have you had it, or how long does it usually last? Constancy: Do you have pain-free periods? When? And for how long? (etc.) -Data that should be obtained in a comprehensive pain history include pain location, intensity, quality, pattern, precipitating factors, alleviating factors, associated symptoms, effect on ADLs, coping resources, and affective responses. Other data include past pain experiences and the meaning of pain to the client, as previously discussed. Questions to elicit these data are shown in the Assessment Interview.

Clinical physiology of sleep

~Sleep deprivation in hospitalized clients contributes to delirium. Delirium initially presents as agitation, confusion, or combative behavior. Secondary delirium is hypoactive with inattention and disorganized thoughts. ~Clients who experience sleep deprivation will more commonly experience an increase in fatigue. Sleep deprivation results in a significant increase in thyroid stimulating hormone, which increases tension, anger, and hostility.

Arousal Mechanism

~The reticular activating system (RAS) in the brainstem is thought to mediate the arousal mechanism. The RAS has two components: the reticular excitatory area (REA) and the reticular inhibitory area (RIA). The REA is responsible for arousal and wakefulness. -Sensoristasis is the term used to describe the state in which an individual is in optimal arousal. Beyond this comfort zone individuals must adapt to the increase or decrease in sensory stimulation. An absence of stimuli from the RAS to the cerebrum results in the brain becoming inactive or useless. -Awareness is the ability to perceive internal and external stimuli, and to respond appropriately through thought and action.

Normal Sleep Patterns and Requirements during the lifespan

⁎Newborns: Newborns sleep 12 to 18 hours a day, on an irregular schedule with periods of 1 to 3 hours spent awake. Unlike older children and adults, newborns enter REM sleep (called active sleep during the newborn period) immediately. Rapid eye movements are observable through closed lids, and the body movements and irregular respirations may be observed. ⁎Infants: At first, infants awaken every 3 or 4 hours, eat, and then go back to sleep. Periods of wakefulness gradually increase during the first months. By 6 months, most infants sleep through the night (from midnight to 5 A.M.) and begin to establish a pattern of daytime naps. At the end of the first year, an infant usually takes two naps per day and should get about 14 to 15 hours of sleep in 24 hours. About half of the infant's sleep time is spent in light sleep. During light sleep, the infant exhibits a great deal of activity, such as movement, gurgles, and coughing. Parents need to make sure that infants are truly awake before picking them up for feeding and changing. Putting infants to bed when they are drowsy but not asleep helps them to become "self-soothers." ⁎Toddlers: Between 12 and 14 hours of sleep are recommended for children 1 to 3 years of age. Most still need an afternoon nap, but the need for midmorning naps gradually decreases. The toddler may exhibit a great deal of resistance to going to bed and may awaken during the night. Nighttime fears and nightmares are also common. A security object such as a blanket or stuffed animal may help. Parents need assurance that if the child has had adequate attention from them during the day, maintaining a daily sleep schedule and consistent bedtime routine will promote good sleep habits for the entire family. ⁎Preschoolers: The preschool-age child (3 to 5 years of age) requires 11 to 13 hours of sleep per night, particularly if the child is in preschool. Sleep needs fluctuate in relation to activity and growth spurts. Many children of this age dislike bedtime and resist by requesting another story, game, or television program. The 4- to 5-year-old may become restless and irritable if sleep requirements are not met. Parents can help children who resist bedtime by maintaining a regular and consistent sleep schedule. It also helps to have a relaxing bedtime routine that ends in the child's room. ⁎School-Age Children: The school-age child (5 to 12 years of age) needs 10 to 11 hours of sleep per night, but most receive less because of increasing demands (e.g., homework, sports, social activities). They may also be spending more time at the computer and watching TV. Some may be drinking caffeinated beverages. All of these activities can lead to difficulty falling asleep and fewer hours of sleep. Nurses can teach parents and school-age children about healthy sleep habits. A regular and consistent sleep schedule and bedtime routine need to be continued. ⁎Adolescents: Adolescents (12 to 18 years of age) require 8 to 10 hours of sleep each night; however, few actually get that much sleep. Teens are sleepy at times and in places where they should be fully awake—at school, at home, and on the road. This can result in lower grades, negative moods (e.g., unhappy, sad, tense), and increased potential for car crashes. Interestingly, although more than half of adolescents knew they were not getting enough sleep, 90% of the parents believed their adolescent was getting enough sleep. Nurses can teach parents to recognize signs and symptoms that indicate their teen is sleep deprived. As children reach adolescence, their circadian rhythms tend to shift. Research in the 1990s found that later sleep and wake patterns among adolescents are biologically determined; the natural tendency for teenagers is to stay up late at night and wake up later in the morning. ⁎Adults: Most healthy adults get 7 to 9 hours of sleep per night. This amount of sleep will assist in decreasing daytime sleepiness and contribute to health . However, individual needs do vary—some adults may be able to function well (e.g., without sleepiness or drowsiness) with 6 hours of sleep, and others may need 10 hours to function optimally. Signs that may indicate that an individual is not getting enough sleep include falling asleep or becoming drowsy during a task that is not fatiguing, not being able to concentrate or remember information, and being unreasonably irritable with others. Lack of sleep also contributes to short-term memory loss and inadequate performance on newly learned tasks. Taking a nap in the middle of the day improves mood, increases memory, reduces fatigue, and lowers blood pressure. ⁎Older adults: A hallmark change with age is a tendency toward earlier bedtime and wake times. Older adults (65 to 75 years) usually awaken 1.3 hours earlier and go to bed approximately 1 hour earlier than younger adults (ages 20 to 30). Older adults may show an increase in disturbed sleep that can create a negative impact on their quality of life, mood, and alertness. They may awaken an average of six times during the night. Although the ability to sleep becomes more difficult, the need to sleep does not decrease with age. During sleep, an older adult has a flattened circadian rhythm. This is noted by the earlier bedtime and morning arousal. Medical conditions and pain are factors that interrupt sleep. Older adults who have several medical conditions and complain of having sleeping problems should discuss this with their primary care provider. The older individual may have a major sleep disorder that is complicating treatment of other conditions. It is important for the nurse to teach about the connection between sleep, health, and aging. Some older clients with dementia may experience sundown syndrome. Although not a sleep disorder directly, it refers to a pattern of symptoms (e.g., agitation, anxiety, aggression, and sometimes delusions) that occur in the late afternoon (thus the name). These symptoms can last through the night, further disrupting sleep.

Factors Affecting Sensory Function

☀A number of factors affect sensory reception and perception, including an individual's developmental stage, culture, level of stress, medications, illness, lifestyle, and personality. Developmental Stage: Perception of sensation is critical to the intellectual, social, and physical development of infants and children. Infants learn to recognize the face of their mother or caregiver and establish bonding essential to later emotional development. Culture: An individual's culture may determine the amount of sensory stimulation that he or she considers usual or normal. For example, a child reared in a big-city neighborhood where extended families share responsibilities for all the children may be accustomed to more stimulation than a child reared in a suburb of scattered single-family homes. Cultural deprivation, or cultural care deprivation, is a lack of culturally assistive, supportive, or facilitative acts. The displacement of clients from their origin of birth can lead to a sense of isolation and loneliness. Nurses should encourage clients who want to have such symbols present to do so, and to follow practices with which they are comfortable, provided that these practices do not endanger their health. Stress: During times of increased stress, people may find their senses already overloaded and thus seek to decrease stimulation. For example, a client dealing with physical illness, pain, hospitalization, and diagnostic tests may wish to have only close support people visit. In addition, a client may need the nurse's help to decrease unnecessary stimuli (e.g., noise) as much as possible. On the other hand, clients may seek sensory stimulation during times of low stress. Medication and Illness: Certain medications can alter an individual's awareness of environmental stimuli. Narcotics, antiepileptic agents, and sedatives, for example, can decrease awareness of stimuli. Some antidepressants can also alter perceptions of stimuli. When administering these medications the nurse is responsible for protecting the client from injury that can result from impaired sensory perception. The nurse should educate clients and their families on the effect medications produce that alter sensory perception. Lifestyle and Personality: Lifestyle can influence the quality and quantity of stimulation to which a client is accustomed. A client who is employed in a large company may be accustomed to many diverse stimuli, whereas a client who is self-employed and works in the home is exposed to fewer, less diverse stimuli. Clients' personalities also differ in terms of the quantity and quality of stimuli with which they are comfortable.

Concepts Associated with Pain continued...

☀Acute pain: Pain that is directly related to tissue injury and resolves when tissue heals. Usually lasts less than 3 months. ☀Cancer-related pain: Pain associated with the disease, treatment, or some other factor in individuals with cancer. Can be acute, recurrent, or chronic. ☀Chronic or persistent pain: Pain that persists beyond 3 to 6 months secondary to chronic disorders or nerve malfunctions that produce ongoing pain after healing is complete. ☀Intractable pain: A pain state (generally severe) for which no cure is possible even after accepted medical evaluation and treatments have been implemented. The focus of treatment turns from cure to pain reduction, functional improvement, and the enhancement of quality of life. ☀Neuropathic pain: Pain that is related to damaged or malfunctioning nervous tissue in the peripheral or CNS. ☀Nociceptive pain: Pain that is directly related to tissue damage. May be somatic (e.g., damage to skin, muscle, bone) or visceral (e.g., damage to organs). ☀Pain threshold: The least amount of stimuli necessary for an individual to label a sensation as pain. ☀Pain tolerance: The most pain an individual is willing or able to tolerate before taking evasive actions. ☀Procedural pain: Pain associated with any medical intervention. Nurses need to anticipate type of expected pain and provide appropriate interventions. The following states indicate abnormal nerve functioning, and the associated cause needs to be identified and treated (as soon as possible) before irreversible damage occurs: ☀Allodynia: Sensation of pain from a stimulus that normally does not produce pain (e.g., light touch). ☀Dysesthesia: An unpleasant abnormal sensation that can be either spontaneous or evoked. ☀Hyperalgesia: Increased sensation of pain in response to a normally painful stimulus. The following concepts are important reasons to prevent pain or treat it as soon as possible to prevent the amplification, spread, and persistence of pain: ☀Sensitization: An increased sensitivity of a receptor after repeated activation by noxious stimuli. ☀Windup: Progressive increase in excitability and sensitivity of spinal cord neurons, leading to persistent, increased pain.

Nursing Management

☁Assessing: A complete assessment of a client's sleep difficulty includes a sleep history, health history, physical exam, and, if warranted, a sleep diary and diagnostic studies. All nurses, however, can take a brief sleep history and educate their clients about normal sleep. ☁Sleep History: A brief sleep history, which is usually part of the comprehensive nursing history, should be obtained for all clients entering a healthcare facility. It should, however, be deferred or omitted if the client is critically ill. Key questions to ask include the following: ☀When do you usually go to sleep? And when do you wake up? Do you nap? If so, when? If the client is a child, it is also important to ask about bedtime rituals. This information provides the nurse with information about the client's usual sleep duration and preferred sleep times, and allows for the incorporation of the client's preferences in the plan of care. ☀Do you have any problems with your sleep? Has anyone ever told you that you snore loudly or thrash around a lot at night? Are you able to stay awake at work, when driving, or engaging in your usual activities? These questions elicit information about sleep complaints including the possibility of excessive daytime sleepiness. ☀Do you take any prescribed medications, over-the-counter (OTC) medications, or herbal remedies to help you sleep? Or to stay awake? This information alerts the nurse to the use of prescription hypnotics and stimulants as well as the use of OTC sleep aids and herbal remedies. ☀Is there anything else I need to know about your sleep? This allows the client to voice any concerns or bring up topics that the nurse may not have asked about. ☂If the client is being admitted to a long-term care facility, it is also appropriate to ask about preferred room temperature, lighting (complete darkness versus using a night light), and preferred bedtime routine. A more detailed assessment is required if the client indicates any difficulty sleeping, difficulty remaining awake during the day, or recent changes in sleep pattern. This detailed history should explore the exact nature of the problem and its cause, when it first began and its frequency, how it affects daily living, what the client is doing to cope with the problem, and whether these methods have been effective. ☁Health History: A health history is obtained to rule out medical or psychiatric causes of the client's difficulty sleeping. It is important to note that the presence of a medical or psychiatric illness (e.g., depression, Parkinson's disease, Alzheimer's disease, or arthritis) does not preclude the possibility that a second problem (e.g., obstructive sleep apnea) may be contributing to the difficulty sleeping. Because medications can frequently cause or exacerbate sleep disturbances, information should be obtained about all of the prescribed and nonprescription medications, including herbal remedies, that a client consumes. ☁Physical Examination: Rarely are sleep abnormalities noted during the physical examination unless the client has obstructive sleep apnea or some other health problem. Common findings among clients with sleep apnea include an enlarged and reddened uvula and soft palate, enlarged tonsils and adenoids (in children), obesity (in adults), and in male clients a neck size greater than 17.5 inches. ☁Sleep Diary: A sleep specialist may ask clients to keep a sleep diary or log for 1 to 2 weeks in order to get a more complete picture of their sleep complaints. A sleep diary may include all or selected aspects of the following information that pertain to the client's specific problem: -Time of (a) going to bed, (b) trying to fall asleep, (c) falling asleep (approximate time), (d) any instances of waking up and duration of these periods, (e) waking up in the morning, and (f) any naps and their duration -Activities performed 2 to 3 hours before bedtime (type, duration, and time) -Consumption of caffeinated beverages and alcohol and amounts of those beverages -Any prescribed medications, OTC medications, and herbal remedies taken during the day -Bedtime rituals before sleep ☁Diagnostic Studies: Sleep is measured objectively in a sleep disorder laboratory by polysomnography in which an electroencephalogram (EEG), electromyogram (EMG), and electro-oculogram (EOG) are recorded simultaneously. Electrodes are placed on the scalp to record brain waves (EEG), on the outer canthus of each eye to record eye movement (EOG), and on the chin muscles to record the structural electromyogram (EMG).

Nursing Management continued...

☁Diagnosing: Impaired sleep, the diagnosis given to clients with sleep problems, is usually made more explicit with descriptions such as "difficulty falling asleep" or "difficulty staying asleep"; for example, impaired sleep (delayed onset of sleep) related to overstimulation prior to bedtime. Various factors or etiologies may be involved and must be specified for the individual. These include physical discomfort or pain; anxiety about actual or anticipated loss of a loved one, loss of a job, loss of life due to serious disease process, or worry about a family member's behavior or illness; frequent changes in sleep time due to shift work or overtime, etc. ~Sleep pattern disturbances may also be stated as the etiology of another diagnosis, in which case the nursing interventions are directed toward the sleep disturbance itself. Examples include: -Altered ability to cope related to insufficient quality and quantity of sleep, fatigue related to no restorative sleep pattern, alteration in tissue perfusion related to sleep apnea, insufficient knowledge (nonprescription remedies for sleep) related to lack of information, etc. ☁Planning: The major goal for clients with sleep disturbances is to maintain (or develop) a sleeping pattern that provides sufficient energy for daily activities. Other goals may relate to enhancing the client's feeling of well-being or improving the quality and quantity of the client's sleep. The nurse plans specific nursing interventions to reach the goal based on the etiology of each nursing diagnosis. These interventions may include reducing environmental distractions, promoting bedtime rituals, providing comfort measures, scheduling nursing care to provide for uninterrupted sleep periods, and teaching stress reduction, relaxation techniques, and good sleep hygiene. ☁Implementing: The term sleep hygiene refers to interventions used to promote sleep. Nursing interventions to enhance the quantity and quality of clients' sleep involve largely nonpharmacologic measures. These involve health teaching about sleep habits, support of bedtime rituals, the provision of a restful environment, specific measures to promote comfort and relaxation, and appropriate use of hypnotic medications. -For hospitalized clients, sleep problems are often related to the hospital environment or their illness. Assisting the client to sleep in such instances can be challenging to a nurse, often involving scheduling activities, administering analgesics, and providing a supportive environment. Explanations and a supportive relationship are essential for the fearful or anxious client. ☁Client Teaching: Healthy individuals need to learn the importance of sleep in maintaining active and productive lifestyles. They need to learn (a) the conditions that promote sleep and those that interfere with sleep, (b) safe use of sleep medications, (c) effects of other prescribed medications on sleep, (d) effects of their disease states on sleep, and (e) importance of long periods of uninterrupted sleep. ☁Supporting Bedtime Rituals and Creating a restful environment: -Most individuals are accustomed to bedtime rituals or pre sleep routines that are conducive to comfort and relaxation. Altering or eliminating such routines can affect a client's sleep. Common prebedtime activities of adults include listening to music, reading, taking a soothing bath, and praying. Children need to be socialized into a pre sleep routine such as a bedtime story, holding onto a favorite toy or blanket, and kissing everyone goodnight. -In institutional settings, nurses can provide similar bedtime rituals—assisting with a hand and face wash, providing a massage or hot drink, plumping pillows, and providing extra blankets as needed. Conversing about accomplishments of the day or enjoyable events such as visits from friends can also help to relax clients and bring peace of mind. -Everyone needs a sleeping environment with minimal noise, a comfortable room temperature, appropriate ventilation, and appropriate lighting. Although most individuals prefer a darkened environment, a lowlight source may provide comfort for children or those in a strange environment. Infants and children need a quiet room usually separate from the parents' room, a light or warm blanket as appropriate, and a location away from open windows or drafts. -Environmental noises include the sound of paging systems, telephones, and call lights; monitors beeping; doors closing; elevator chimes; furniture squeaking; and linen carts being wheeled through corridors. Staff communication is a major factor creating noise, particularly at staff change of shift. To create a restful environment, the nurse needs to reduce environmental distractions, reduce sleep interruptions, ensure a safe environment, and provide a room temperature that is satisfactory to the client. The environment must also be safe so that the client can relax. Clients who are unaccustomed to narrow hospital beds may feel more secure with side rails. Additional safety measures include: -Placing beds in low positions. -Using night lights. -Placing call bells within easy reach. ☁Promoting Comfort and Relaxation: Comfort measures are essential to help the client fall asleep and stay asleep, especially if the effects of the client's illness interfere with sleep. A concerned, caring attitude, along with the following interventions, can significantly promote client comfort and sleep: -Provide loose-fitting nightwear. -Assist clients with hygienic routines. ~Individuals of any age, but especially older adults, are unable to sleep well if they feel cold. Changes in circulation, metabolism, and body tissue density reduce the older adult's ability to generate and conserve heat. To compound this problem, hospital gowns have short sleeves and are made of thin polyester. ~Emotional stress obviously interferes with an individual's ability to relax, rest, and sleep, and inability to sleep further aggravates feelings of tension. Sleep rarely occurs until an individual is relaxed. Relaxation techniques can be encouraged as part of the nightly routine.

Sensory Alterations

☁Individuals become accustomed to certain sensory stimuli, and when these change markedly an individual may experience discomfort. For example, when clients enter a hospital they usually experience stimuli that differ in quantity and quality from those to which they are accustomed. These changes may cause clients to become confused and disoriented. ☁Sensory Deprivation: Sensory deprivation is generally thought of as a decrease in or lack of meaningful stimuli. When an individual experiences sensory deprivation, the balance in the RAS is disturbed. The RAS is unable to maintain normal stimulation to the cerebral cortex. Because of this reduced stimulation, an individual becomes more acutely aware of the remaining stimuli and often perceives them in a distorted manner. -Excessive yawning, drowsiness, sleeping -Decreased attention span, difficulty concentrating, decreased problem-solving ability -Impaired memory -Periodic disorientation, general or nocturnal confusion -Preoccupation with somatic complaints, such as palpitations -Hallucinations or delusions -Crying, annoyance over small matters, depression -Apathy, emotional lability ☁Sensory Overload: Sensory overload generally occurs when an individual is unable to process or manage the amount or intensity of sensory stimuli. Three factors contribute to sensory overload: -Increased quantity or quality of internal stimuli, such as pain, dyspnea, or anxiety -Increased quantity or quality of external stimuli, such as a noisy healthcare setting, intrusive diagnostic studies, or contacts with many strangers -Inability to disregard stimuli selectively, perhaps as a result of nervous system disturbances or medications that stimulate the arousal mechanism. 🌟Sensory overload can prevent the brain from ignoring or responding to specific stimuli. Because of the many stimuli, the individual has difficulty perceiving the environment in a way that makes sense. As a result the individual's thoughts race in many directions, causing restlessness and anxiety. The individual usually feels overwhelmed and does not feel in control. It is important for nurses to remember that sights and sounds that are familiar to them often represent overload to clients. Clients who have sensory overload may appear fatigued. They often cannot internalize new information and they experience cognitive overload. Sensory Overload: -Complaints of fatigue, sleeplessness -Irritability, anxiety, restlessness -Periodic or general disorientation -Reduced problem-solving ability and task performance -Increased muscle tension -Scattered attention and racing thoughts ☁Sensory Deficits: A sensory deficit is impaired reception, perception, or both, of one or more of the senses. Blindness and deafness are sensory deficits. When the loss of sensory function is gradual, individuals often develop behaviors to compensate for the loss; sometimes these behaviors are unconscious. -Clients with sensory deficits are at risk for both sensory deprivation and sensory overload. For example, clients with visual problems may be unable to read, watch television, or recognize nurses by sight, which could lead to sensory deprivation. -Hospitalized clients are at risk for developing hospital delirium that can lead to adverse effects such as falls and injury. Dementia results in the alteration of memory and judgment. Standard care for older adults' admission to the hospital should include assessment for changes in memory and cognition. Providing education on the recognition of dementia and changes in mood or behavior will enhance the outcome of care and increase client safety. Discharge planning should be initiated within 24 hours of admission. Longer hospital stays can increase the risk of adverse client outcomes.

Comfort: Chapter 30

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Chapter 38: Sensory Perception

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Common Sleep Disorders

✨A knowledge of common sleep disorders can help nurses assess the sleep complaints of their clients and, when appropriate, make a referral to a specialist in sleep disorders medicine. 💫Insomnia: Insomnia is described as the inability to fall asleep or remain asleep. Individuals with insomnia do not awaken feeling rested. Insomnia is the most common sleep complaint in America. Acute insomnia lasts one to several nights and is often caused by personal stressors or worry. If the insomnia persists for longer than a month, it is considered chronic insomnia. More often, individuals experience chronic-intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns. The two main risk factors for insomnia are older age and female gender. Women suffer sleep loss in connection with hormonal changes (e.g., menstruation, pregnancy, and menopause). The incidence of insomnia increases with age, but it is thought that this is caused by some other medical condition. -Difficulty falling asleep -Waking up too early or frequently during the night -Difficulty returning to sleep -Waking up too early in the morning -Unrefreshing sleep -Daytime sleepiness -Difficulty concentrating -Irritability -Non-restorative sleep -Fatigue and irritability -Difficulty at work or school -Difficulty with personal relationships Treatment: -Stimulus control: creating a sleep environment that promotes sleep -Cognitive therapy: learning to develop positive thoughts and beliefs about sleep -Sleep restriction: limiting time in bed in order to get to sleep and stay asleep throughout the night. 💫Excessive Daytime Sleepiness: Clients may experience excessive daytime sleepiness as a result of hypersomnia, narcolepsy, sleep apnea, and insufficient sleep: Hypersomnia: Hypersomnia refers to conditions where the affected individual obtains sufficient sleep at night but still cannot stay awake during the day. Hypersomnia can be caused by medical conditions, for example, CNS damage and certain kidney, liver, or metabolic disorders, such as diabetic acidosis and hypothyroidism. Rarely does hypersomnia have a psychologic origin. Narcolepsy: Narcolepsy is a disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep. Clients with narcolepsy have sleep attacks or excessive daytime sleepiness, and their sleep at night usually begins with a sleep-onset REM period (dreaming sleep occurs within the first 15 minutes of falling asleep). The majority of clients also have cataplexy or the sudden onset of muscle weakness or paralysis in association with strong emotion, sleep paralysis (transient paralysis when falling asleep or waking up), hypnagogic hallucinations (visual, auditory, or tactile hallucinations at sleep onset or when waking up), and/or fragmented nighttime sleep. -CNS stimulants such as methylphenidate (Ritalin) or amphetamines have been used to reduce excessive daytime sleepiness. Xanthines, such as caffeine, stimulate the cerebral cortex to increase alertness. Antidepressants, both older monoamine oxidase inhibitors (MAOIs) and the newer serotonergic antidepressants, are usually quite effective for controlling cataplexy. Sleep Apnea: Sleep apnea is characterized by frequent short breathing pauses during sleep. Although all individuals have occasional periods of apnea during sleep, more than five apneic episodes or five breathing pauses longer than 10 seconds per hour is considered abnormal and should be evaluated by a sleep medicine specialist. Symptoms suggestive of sleep apnea include loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness, difficulties falling asleep at night, morning headaches, memory and cognitive problems, and irritability. Although sleep apnea is most frequently diagnosed in men and postmenopausal women, it may occur during childhood. ~Three common types of sleep apnea are obstructive apnea, central apnea, and mixed apnea. Obstructive apnea occurs when the structures of the pharynx or oral cavity block the flow of air. The individual continues to try to breathe; that is, the chest and abdominal muscles move. ~Treatment for sleep apnea is directed at the cause of the apnea. For example, enlarged tonsils may be removed. Other surgical procedures, including laser removal of excess tissue in the pharynx, reduce or eliminate snoring and may be effective in relieving the apnea. In other cases, the use of a nasal continuous positive airway pressure (CPAP) device at night is effective in maintaining an open airway. Weight loss may also help decrease the severity of symptoms. Sleep apnea profoundly affects an individual's work or school performance. In addition, prolonged sleep apnea can cause a sharp rise in blood pressure and may lead to cardiac arrest. Over time, apneic episodes can cause cardiac arrhythmias, pulmonary hypertension, and subsequent left-sided heart failure. Insufficient Sleep: Healthy individuals who obtain less sleep than they need will experience sleepiness and fatigue during the daytime hours. Depending on the severity and chronicity of this voluntary, albeit unintentional sleep deprivation, individuals may develop attention and concentration deficits, reduced vigilance, distractibility, reduced motivation, fatigue, malaise, and occasionally diplopia and dry mouth. Although the effects of obtaining less than optimal amounts of sleep are generally considered benign, there is growing evidence that insufficient sleep can have significant deleterious effects. Staying awake 19 consecutive hours produces the same impairments in reaction times and cognitive function as a blood alcohol level of 0.05, and staying awake for 24 consecutive hours has the same effects on reaction times and cognitive function as being legally drunk (with a blood alcohol level of 0.1). Parasomnias: A parasomnia is behavior that may interfere with sleep and may even occur during sleep. It is characterized by physical events such as movements or experiences that are displayed as emotions, perceptions, or dreams. The International Classification of Sleep Disorders subdivides parasomnias into three classes: non-rapid eye movement, rapid eye movement, and miscellaneous with no specific stage of sleep. Parasomnias with non-rapid eye movement are associated with confusion upon arousal, sleep tremors, and sleep walking. Parasomnias with rapid eye movement are associated with arousal disorders such as sleep paralysis. SUCH AS: -Bruxism. Usually occurring during stage 2 NREM sleep, this clenching and grinding of the teeth can eventually erode dental crowns, cause teeth to come loose, and lead to deterioration of the temporomandibular (TMJ) joint, which is called TMJ syndrome. -Enuresis. Bed-wetting during sleep can occur in children over 3 years old. More males than females are affected. It often occurs 1 to 2 hours after falling asleep, when rousing from NREM stage 3. -Periodic limb movement disorder (PLMD). In this condition, the legs jerk twice or three times per minute during sleep. It is most common among older adults. This kicking motion can wake the client and result in poor sleep. -Sleep talking. Talking during sleep occurs during NREM sleep before REM sleep. It rarely presents a problem to the individual unless it becomes troublesome to others. -Sleepwalking. Sleepwalking (somnambulism) occurs during stage 3 of NREM sleep. It is episodic and usually occurs 1 to 2 hours after falling asleep. Sleepwalkers tend not to notice dangers (e.g., stairs) and often need to be protected from injury.

Non-pharmacologic and pharmacologic approaches to pain management

✿Multimodal Pain Management: Multimodal pain management incorporates both pharmacologic and nonpharmacologic approaches to achieve the best possible outcomes for the client. Multimodal analgesia combines analgesics from two or more drug classes and a variety of delivery approaches for the analgesics that result in reducing, and often eliminating, the need for opioids. This is also referred to as opioid-sparing therapy. Multimodal pain therapies include therapies that are independent of or in addition to pharmacologic therapy and include nonpharmacologic therapies such as yoga, massage, biofeedback, acupuncture, mind-body therapies, and physical therapies. ✿Pharmacologic Approaches: Pharmacologic approaches can involve the use of nonopioids such as NSAIDs, opioids, and adjuvant drugs. Because many analgesics are ordered to be administered on a prn basis, the decision to administer the prescribed medication is frequently the nurse's, requiring judgment as to the dose and the time of administration. Examples: Nonopioid, opioid, adjuvants.

Chapter 32: Safety

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Sleep/Rest: Chapter 45

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Factors Affecting the Pain Experience continued...

⭐Developmental Stage: The age and developmental stage of a client is an important variable that will influence both the reaction to and the expression of pain. Infant: Perceives pain. Responds to pain with increased sensitivity. Older infant tries to avoid pain; for example, turns away and physically resists. Interventions: Give a glucose pacifier. Use tactile stimulation. Play music or tapes of a heartbeat. Toddler/Preschooler: Develops the ability to describe pain and its intensity and location. Often responds with crying and anger because child perceives pain as a threat to security. Reasoning with child at this stage is not always successful. May consider pain a punishment. Interventions: Distract the child with toys, books, pictures. Involve the child in blowing bubbles as a way of "blowing away the pain." School-age child: Tries to be brave when facing pain. Rationalizes in an attempt to explain the pain. Responsive to explanations. Can usually identify the location and describe the pain. Interventions: Use imagery to turn off "pain switches." Provide a behavioral rehearsal of what to expect and how it will look and feel. Provide support and nurturing. Adolescent: May be slow to acknowledge pain. Recognizing pain or "giving in" may be considered weakness. Interventions: Provide opportunities to discuss pain. Provide privacy. Present choices for dealing with pain. Adult: Behaviors exhibited when experiencing pain may be gender-based behaviors learned as a child. May ignore pain because to admit it is perceived as a sign of weakness or failure. Interventions: Deal with any misconceptions about pain. Focus on the client's control in dealing with the pain. Alleviate fears and anxiety when possible. Older Adult: May have multiple conditions presenting with vague symptoms. May perceive pain as part of the aging process. May have decreased sensations or perceptions of the pain. Lethargy, anorexia, and fatigue may be indicators of pain. May withhold statements of pain because of fear of the treatment, of any lifestyle changes that may be involved, or of becoming dependent. Interventions: Take a thorough history and assessment. Spend time with the client and listen carefully. Clarify misconceptions. Encourage independence whenever possible. -The field of pain management for infants and children has grown significantly. It is now accepted that anatomic, physiologic, and biochemical elements necessary for pain transmission are present in newborns, regardless of their gestational age. For many years, people believed the myth that infants and children do not feel pain. Now, it is universally accepted that environmental, nonpharmacologic, and pharmacologic interventions are to be used to prevent, reduce, or eliminate pain in neonates. Physiologic indicators may vary in infants, so behavioral observation is recommended for pain assessment. Environment and Support People: A strange environment such as a hospital, with its noises, lights, and activity, can compound pain. In addition, the lonely client who is without a support network may perceive pain as severe, whereas the client who has supportive people around may perceive less pain. Some clients prefer to withdraw when they are in pain, whereas others prefer the distraction of people and activity around them. Family caregivers can provide significant support to a client in pain. Expectations of significant others can affect an individual's perceptions of and responses to pain. In some situations, girls may be permitted to express pain more openly than boys. Family role can also affect how a client perceives or responds to pain. For instance, a single mother supporting three children may ignore pain because of her need to stay on the job. Previous Pain Experience: Previous pain experiences alter a client's sensitivity to pain. Clients who have personally experienced pain or who have been exposed to the suffering of someone close to them are often more threatened by anticipated pain than those without a pain experience. In addition, the success or lack of success of pain relief measures influences a client's expectations for relief and future response to interventions.

Lifespan Considerations; Sleep disturbances

✨Children: Learning to sleep alone without the parent's help is a skill that all children need to master. Regular bedtime routines and rituals such as reading a book help children learn this skill and can prevent sleep disturbance. Some sleep disturbances seen in children include the following: ★Trained night feeder. Infants who are fed during the night, who are fed until they fall asleep and then put into bed, or who have a bottle left with them in their bed learn to expect and demand middle-of-the-night feedings. ★Sleep refusal. Many toddlers and young children are resistant to settling down to sleep. This sleep refusal may be due to not being tired, anxiety about separation from the parent, stress (e.g., a recent move), lack of a regular sleep routine, the child's temperament, or changes in sleep arrangements (e.g., move from a crib to a "big" bed). ★Night terrors. Night terrors are partial awakenings from NREM stage 3 sleep. They are usually seen in children 3 to 6 years of age. The child may sleepwalk, or may sit up in bed screaming and thrashing about. They usually cannot be wakened, but should be protected from injury, helped back to bed, and soothed back to sleep. ✨Adults: New jobs, pregnancy, and babies are common examples that often disrupt the sleep of a young adult. The sleep patterns of middle-aged adults can be disrupted by the need to take care of older parents or chronically ill partners in the home. ✨Older Adults: Side effects of medications: Gastric reflux disease Respiratory and circulatory disorders, which may cause breathing problems or discomfort. Pain from arthritis, increased stiffness, or impaired mobility, nocturia depression, loss of life partner or close friends, confusion related to delirium or dementia. 🌃Interventions to promote sleep and rest can help enhance the rejuvenation and renewal that sleep provides. The following interventions can help promote sleep: 🌠Reduce or eliminate the consumption of caffeine and nicotine. 🌠Be sure the environment is warm and safe, especially if clients get out of bed during the night. 🌠Provide comfort measures, such as analgesics if indicated, and proper positioning. 🌠Enhance the sense of safety and security by checking on clients frequently and making sure that the call light is within reach. Answer the call light promptly. 🌠If lack of sleep is caused by medications or certain health conditions, interventions should focus on resolving the underlying problem. 🌠Evaluate the situation and find out what the rest and sleep disturbances mean to the client. The client may not perceive nighttime sleeplessness to be a serious problem, and will just do other activities and sleep when tired.

Factors affecting sleep

✨Illness: Illness that causes pain or physical distress (e.g., arthritis, back pain) can result in sleep problems. Individuals who are ill require more sleep than normal, and the normal rhythm of sleep and wakefulness is often disturbed. Individuals deprived of REM sleep subsequently spend more sleep time than normal in this stage. ★Respiratory conditions can disturb an individual's sleep. Shortness of breath often makes sleep difficult, and individuals who have nasal congestion or sinus drainage may have trouble breathing and hence may find it difficult to sleep. ★Individuals who have gastric or duodenal ulcers may find their sleep disturbed because of pain, often a result of the increased gastric secretions that occur during REM sleep. ★Certain endocrine disturbances can also affect sleep. Hyperthyroidism lengthens pre-sleep time, making it difficult for a client to fall asleep. Hypothyroidism, conversely, decreases stage 3 sleep. Women with low levels of estrogen often report excessive fatigue. In addition, they may experience sleep disruptions due, in part, to the discomfort associated with hot flashes or night sweats that can occur with reduced estrogen levels. ★Elevated body temperatures can cause some reduction in delta sleep and REM sleep. The need to urinate during the night also disrupts sleep, and individuals who awaken at night to urinate sometimes have difficulty getting back to sleep. ✨Environment: Environment can promote or hinder sleep. The individual must be able to achieve a state of relaxation prior to entering a period of sleep. Any change, such as noise in the environment, can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent individuals from sleeping. Hospital environments can be quite noisy, and special care needs to be taken to reduce noise in the hallways and nursing care units. In fact, some hospitals have instituted "quiet times" in the afternoon on nursing units where the lights are lowered and activity and noise are purposefully decreased so clients can rest or nap. ★Discomfort from environmental temperature (e.g., too hot or cold) and lack of ventilation can affect sleep. Light levels can be another factor. An individual accustomed to darkness while sleeping may find it difficult to sleep in the light. Another influence includes the comfort and size of the bed. An individual's partner who has different sleep habits, snores, or has other sleep difficulties may become a problem for the individual also. ✨Lifestyle: Following an irregular morning and nighttime schedule can affect sleep. Moderate exercise in the morning or early afternoon is usually conducive to sleep, but exercise late in the day can delay sleep. The individual's ability to relax before retiring is an important factor affecting the ability to fall asleep. It is best, therefore, to avoid doing homework or office work before or after getting into bed. ★Night shift workers frequently obtain less sleep than other workers and have difficulty falling asleep after getting off work. Wearing dark wraparound sunglasses during the drive home and light-blocking shades in the bedroom can minimize the alerting effects of exposure to daylight, thus making it easier to fall asleep when body temperature is rising. ✨Emotional Stress: Stress is considered by most sleep experts to be the one of the greatest causes of difficulties in falling asleep or staying asleep. Clients who are consistently exposed to stress will increase the activation of the hypothalamic-pituitary-adrenal (HPA) axis leading to sleep disorders. An individual who becomes preoccupied with personal problems (e.g., school- or job-related pressures, family or marriage problems) may be unable to relax sufficiently to get to sleep. Anxiety increases the nor epinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings. ✨Stimulants and Alcohol: Caffeine-containing beverages act as stimulants of the central nervous system (CNS). Drinking beverages containing caffeine in the afternoon or evening may interfere with sleep. Individuals who drink an excessive amount of alcohol often find their sleep disturbed. Alcohol disrupts REM sleep, although it may hasten the onset of sleep. While making up for lost REM sleep after some of the effects of the alcohol have worn off, individuals often experience nightmares. The alcohol-tolerant individual may be unable to sleep well and become irritable as a result. ✨Diet: Weight gain has been associated with reduced total sleep time as well as broken sleep and earlier awakening. Weight loss, on the other hand, seems to be associated with an increase in total sleep time and less broken sleep. Dietary L-tryptophan—found, for example, in cheese and milk—may induce sleep, a fact that might explain why warm milk helps some individuals get to sleep. ✨Smoking: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than non-smokers. Smokers are usually easily aroused and often describe themselves as light sleepers. By refraining from smoking after the evening meal, the individual usually sleeps better; moreover, many former smokers report that their sleeping patterns improved once they stopped smoking. ✨Motivation: Motivation can increase alertness in some situations (e.g., a tired individual can probably stay alert while attending an interesting concert or surfing the web late at night). Motivation alone, however, is usually not sufficient to overcome the normal circadian drive to sleep during the night. Nor is motivation sufficient to overcome sleepiness due to insufficient sleep. A combination of boredom and lack of sleep can contribute to feeling tired. ✨Medications: Some medications affect the quality of sleep. Most hypnotics can interfere with deep sleep and suppress REM sleep. Beta blockers have been known to cause insomnia and nightmares. Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent awakenings and drowsiness. Tranquilizers interfere with REM sleep. Although antidepressants suppress REM sleep, this effect is considered a therapeutic action. In fact, selectively depriving a depressed client of REM sleep will result in an immediate but transient improvement in mood. Clients accustomed to taking hypnotic medications and antidepressants may experience a REM rebound (increased REM sleep) when these medications are discontinued. Warning clients to expect a period of more intense dreams when these medications are discontinued may reduce their anxiety about this symptom.

Key Strategies in Pain Management

✨Key strategies to reduce pain include acknowledging and accepting the client's pain, assisting support people, reducing misconceptions about pain, reducing fear and anxiety, and preventing pain. ✧Acknowledging and Accepting Clients' Pain: -Acknowledge the possibility of the pain. "Many people with your condition are bothered by leg pain. Are you experiencing any leg discomfort? -Listen attentively to what the client says about the pain, restating your understanding of the reported discomfort. -Convey that you need to ask about the pain because, despite some similarities, everybody's experience is unique. -Attend to the client's needs promptly. It is unacceptable to believe the client's report of pain and then do nothing. ✧Assisting Support People: Support people (e.g., family, significant others, caregivers) often need assistance to respond in a helpful manner to the client experiencing pain. ✧Reducing Misconceptions About Pain: Reducing a client's misconceptions about pain and its treatment will remove one of the barriers to optimal pain relief. ✧Reducing Fear and Anxiety ✧Preventing Pain: A preventive approach to pain management involves the provision of measures to treat the pain before it occurs or before it becomes severe. Preemptive analgesia is the administration of analgesics before surgery to decrease or relieve pain after surgery and reduce the need for opioid pain control.

Enhancing Sleep with Medications

✨Sleep medications often prescribed on a prn (as-needed) basis for clients include the sedative-hypnotics, which induce sleep, and antianxiety drugs or tranquilizers, which decrease anxiety and tension. When prn sleep medications are ordered in institutional settings, the nurse is responsible for making decisions with the client about when to administer them. These medications should be administered only with complete knowledge of their actions and effects and only when indicated. ✨Both nurses and clients need to be aware of the actions, effects, and risks of the specific medication prescribed. Although medications vary in their activity and effects, considerations include the following: -Sedative-hypnotic medications produce a general CNS depression and an unnatural sleep; REM or NREM sleep is altered to some extent, and daytime drowsiness and a morning hangover effect may occur. -Antianxiety medications decrease levels of arousal by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation. -Sleep medications vary in their onset and duration of action and will impair waking function as long as they are chemically active. Some medication effects can last many hours beyond the time that the client's perception of daytime drowsiness and impaired psychomotor skills have disappeared. -Sleep medications affect REM sleep more than NREM sleep. Clients need to be informed that one or two nights of increased dreaming (REM rebound) are usual after the drug is discontinued after long-term use. -Initial doses of medications should be low and increases added gradually, depending on the client's response. Older adults, in particular, are susceptible to side effects because of their metabolic changes; they need to be closely monitored for changes in mental alertness and coordination. -Regular use of any sleep medication can lead to tolerance over time (e.g., 4 to 6 weeks) and rebound insomnia. In some instances, this may lead clients to increase the dosage. About half of the clients who seek medical intervention for sleep problems are treated with sedative-hypnotics. Sometimes the prescription of hypnotics can be appropriate. ✨Evaluating: Using data collected during care and the desired outcomes developed during the planning stage as a guide, the nurse judges whether client goals and outcomes have been achieved. If the desired outcomes are not achieved, the nurse and client should explore the reasons, which may include answers to the following questions: -Were etiologic factors correctly identified? -Has the client's physical condition or medication therapy changed? -Did the client comply with instructions about establishing a regular sleep-wake pattern? -Did the client avoid ingesting caffeine? (1156, etc.)

Drugs that disrupt sleep/that may cause excessive daytime sleepiness

✨These drugs may disrupt REM sleep, delay onset of sleep, or decrease sleep time: -Alcohol -Amphetamines -Antidepressants -Beta-blockers -Bronchodilators -Caffeine -Decongestants -Narcotics -Steroids These drugs may be associated with excessive daytime sleepiness: -Antidepressants -Antihistamines -Beta blockers -Narcotics

Nonpharmacologic Approaches

✺Nonpharmacologic pain management consists of a variety of physical, cognitive-behavioral, and lifestyle pain management strategies that target the body, mind, spirit, and social interactions. Physical modalities include cutaneous stimulation, ice or heat, immobilization or therapeutic exercises, transcutaneous electrical nerve stimulation (TENS), and acupuncture. Mind-body (cognitive-behavioral) interventions include distracting activities, relaxation techniques, imagery, meditation, biofeedback, hypnosis, cognitive reframing, emotional counseling, and spiritually directed approaches such as therapeutic touch or Reiki. Lifestyle management approaches include symptom monitoring, stress management, exercise, nutrition, disability management, and other approaches needed by many clients with persistent pain that has drastically changed their life. ✺Body: Reducing pain triggers, promoting comfort, Deep, slow breathing, Massage, Applying heat or ice, Electrical stimulation (TENS)Positioning, bracing (selective immobilization)Acupressure, acupuncture, Diet, nutritional supplements, Exercise, pacing activities, Invasive interventions (e.g., nerve blocks), Sleep hygiene ✺Mind: Relaxation, imagery, Self-hypnosis, Pain diary, journal writing, Distracting attention, Repatterning thinking, Attitude adjustment, Reducing fear, anxiety, stress, Reducing sadness, helplessness, Information about pain ✺Spirit: Music therapy, Prayer, meditation, Self-reflection regarding life and pain, Meaningful rituals, Energy work (e.g., therapeutic touch, Reiki)Spiritual healing ✺Social interactions: Functional restoration, Improved communication. Pet therapy. Family therapy. Problem solving. Vocational training. Volunteering. Support groups

Sleep Chapter Key points

🌟Sleep is needed for optimal psychologic and physiologic functioning. 🌟Insufficient sleep is widespread among all age groups in this country. Approximately 50 million to 70 million Americans suffer from a chronic disorder of sleep and wakefulness that hinders daily functioning and adversely affects health. Reports from government agencies have stated that sleep disorders and sleep deprivation are an unmet public health problem. 🌟Sleep is a naturally occurring altered state of consciousness in which an individual's perception and reaction to the environment are decreased. 🌟The sleep cycle is controlled by specialized areas in the brainstem and is affected by the individual's circadian rhythm. 🌟NREM sleep consists of three stages, progressing from stage 1, very light sleep, to stage 3, deep sleep. NREM sleep dominates during naps and nocturnal sleep periods. NREM sleep is essential for physiologic well-being. 🌟REM sleep recurs about every 90 minutes and is often associated with dreaming. REM sleep is essential for psychosocial and mental equilibrium. 🌟During a normal night's sleep, an adult has four to six sleep cycles, each with NREM (quiet sleep) and REM (rapid-eye-movement) sleep. 🌟The ratio of NREM to REM sleep varies with age. 🌟Many factors can affect sleep, including illness, environment, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, motivation, and medications. 🌟Common sleep disorders include insomnia, hypersomnia, narcolepsy, parasomnias (such as somnambulism, sleep talking, and bruxism), and sleep apnea. 🌟Assessment of a client's sleep includes a sleep history, a health history, and a physical examination to detect signs that may indicate the presence of sleep apnea. 🌟Nursing responsibilities to help clients sleep include (a) teaching clients ways to enhance sleep, (b) supporting bedtime rituals, (c) creating a restful environment, (d) promoting comfort and relaxation, and (e) enhancing sleep with medications.