Sleep, Comfort
The experience of pain and the quality of rest and sleep are both factors that can have a significant impact on a client’s health. Both are personal experiences that can affect all other aspects of an individual’s health, including physical well-being, mental status, and effectiveness of coping mechanisms. This chapter explores the nature of pain, the importance of rest and sleep, and nursing care to help clients maintain their optimal health when the presence of pain or rest/sleep disturbances threaten to compromise their health status.
PAIN
Pain is a universal human experience; it is defined as “a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation” (Carpenito, 1999, p. 51). Pain is a subjective experience that is often difficult for clients to describe and nurses to understand, yet it is among the most common complaints that cause individuals to seek health care. McCaffery and Pasero (1999) recognize the subjective nature of pain by stating “Pain is whatever the experiencing person says it is, existing whenever he says it does” (p. 17). Until recently, pain was viewed as a symptom that required diagnosis and treatment of the underlying cause. It is now clear that pain itself can be detrimental to the health and healing of clients.
“Unrelieved pain is not only detrimental, it’s avoidable” (Williams-Lee, 1999, p. 9). Pain is a stressor that can trigger both physiological and psychological discomfort.
Untreated pain can lead to physical disorders related to undernutrition, immobility, and immune suppression.
Nature of Pain
Pain, a response to noxious stimuli, can be a protective mechanism to prevent further injury, as is seen in clients who guard or protect an injured body part. The sensation of pain as the warning of potential tissue damage may be absent in people with nerve/spinal cord abnormalities, diabetic neuropathy, multiple sclerosis, and nerve/spinal cord injury.
Common Myths About Pain
Because pain is subjective (dependent on client’s perception) and cannot be objectively measured by another individual through a laboratory test or diagnostic data, pain is often misunderstood and misjudged. A client’s reports of level of pain will vary on the basis of cultural and experiential backgrounds, and the nurse’s interpretations of a client’s pain will be filtered through the nurse’s own biases and expectations. “Pain doesn’t go untreated (or under-treated) because of cruelty or apathy by the staff, but because of lack of knowledge. Just as [long-term care] residents have preconceived notions and concerns regarding pain and pain management, so do staff members” (Loeb, 1999, p. 49). Incongruence of the nurse’s view and the client’s perception of pain can often lead to undermedication and unnecessary suffering on the client’s part. The accompanying display outlines some of the common myths about pain, along with factual statements countering those beliefs.
Types of Pain
Pain can be qualified or described in two basic ways: by its cause or origin and by its description or nature.
Pain categorized by its origin is either cutaneous, somatic, or visceral. Cutaneous pain is caused by stimulation of the cutaneous nerve endings in the skin and results in a well-localized “burning” or “prickling” sensation; getting a knot in the hair that is pulled out during combing may cause cutaneous pain. Somatic pain is nonlocalized and originates in support structures such as tendons, ligaments, and nerves; jamming a knee or finger will result in somatic pain. Visceral pain is discomfort in the internal organs and is less localized and more slowly transmitted than cutaneous pain. Visceral pain is often difficult to assess because the location may not be directly related to the cause.
Pain originating from the abdominal organs is often called referred pain because the sensation of pain is not felt in the organ itself but instead is perceived at the spot where the organs were located during fetal development. Figure 33-1 shows the cutaneous areas where visceral pain is often referred.
Acute pain is most frequently identified by its sudden onset and relatively short duration, mild to severe intensity, and a steady decrease in intensity over a period of days to weeks. Some forms of acute pain may have a slower onset. Once the noxious stimulus is resolved, the pain usually decreases. Examples of noxious stimuli are needle sticks, surgical incisions, burns, and fractures.
Recurrent acute pain is identified by repetitive painful episodes that may recur over a prolonged period or throughout the client’s lifetime. These painful episodes alternate with pain-free intervals. Examples of recurrent pain include migraine headaches, sickle cell pain crises, and the pain of angina pectoris due to myocardial hypoxia.
Chronic pain is identified as long-term (lasting 6 months or longer), persistent, nearly constant, or recurrent pain that produces significant negative changes in the client’s life. Unlike acute pain, chronic pain may last long after the pathology is resolved.
Chronic acute pain occurs almost daily over a long period, has the potential for lasting months or years, and has a high probability of ending. Severe burn injuries and cancer are examples of pathophysiology that leads to chronic acute pain, which may last for long periods before the condition is cured or controlled.
Chronic nonmalignant pain (CNP), occurs almost daily and lasts for at least 6 months, with intensity ranging from mild to severe.
Chronic pain, a primary motivator for individuals to seek health care intervention, can greatly influence a client’s quality of life, including emotional, social, vocational, and financial areas.
There is a relationship between chronic conditions (including pain) and depression. Thus, the client experiencing chronic pain should always be assessed for the presence of depression. “Not only do patients with CNP have a higher rate of depression, but suicide potential is also a serious concern for this population” (McCaffery & Pasero, 1999, p. 487). Examples of pathophysiology leading to chronic nonmalignant pain include:
• Many forms of neuralgia (paroxysmal pain that extends along the course of one or more nerves) • Low back pain
• Rheumatoid arthritis
• Ankylosing spondylitis
• Phantom limb pain (a form of neuropathic pain that occurs after amputation with pain sensations referred to an area in the missing portion of the limb)
• Myofascial pain syndromes (a group of muscle disorders characterized by pain, muscle spasm, tenderness, stiffness, and limited motion)
CNP may be associated with several problems, including:
• Activity intolerance, which leads to physical deconditioning
• Functional impairment with resultant changes in role performance (parent, breadwinner)
• Social isolation, which alters relationships
• Sleep deprivation
• Frustration, anxiety, anger, and depression
When CNP is severe enough to disable the client, nurses understand that in order “To improve your patient’s quality of life, pain management becomes a priority” (Bral, 1998, p. 27).
Physiology of Pain
Noxious stimuli activate nociceptors (receptive neurons for painful sensations) that, together with the axons of neurons convey information to the spinal cord where reflexes are activated. The information is simultaneously transmitted to the brain supraspinally (Cleland & Gebhart, 1997). Long-lasting changes in cells within the spinal cord afferent (ascending) and efferent (descending) pain pathways may occur after a brief noxious stimulus.
Physiological responses (such as elevated blood pressure, pulse rate, and respiratory rate; dilated pupils; pallor; and perspiration) to even a brief acute pain episode will begin showing adaptation within a short period, possibly minutes to a few hours. Physiologically, the body cannot sustain the extreme stress response for other than short periods of time. The body conserves its resources by physiological adaptation (returning to normal or near normal blood pressure, pulse rate, and respiratory rate; normal pupil size, and dry skin) even in the face of continuing pain of the same intensity. Pain can be categorized into two types according to its pathophysiology; see Table 33-1.
Nociceptive Pain
The four fundamental processes involved in nociception (process by which individual becomes consciously aware of pain) are as follows (McCaffery & Pasero, 1999):
• Transduction—The changing of noxious stimuli in sensory nerve endings to energy impulses
• Transmission—Movement of impulses from site of origin to the brain
• Perception—Developing conscious awareness of pain
• Modulation—The changing of pain impulses
Transduction of Pain
When noxious stimuli occur, tissues are damaged. Cell damage releases the following sensitizing substances:
• Prostaglandins (PG)
• Bradykinin (BK)
• Serotonin (5HT)
• Substance P (SP)
• Histamine (H)
Release of these substances alters the electrical charge on the neuronal membrane. This change in electrical charge is a result of movement of Na+ and other ions into the cells. The impulse is then ready to be transmitted along the nociceptor fibers (McCaffery & Pasero, 1999).
Transmission of Pain
The specific action of pain varies depending on the type of pain. In cutaneous pain, cutaneous nerve transmissions travel through a reflex arc from the nerve ending (point of pain) to the brain at a speed of approximately
In the case of the hot stove, the sensory neuron synapses not only with an interneuron but also with an afferent sensory neuron. The impulse travels up the spinal cord to the thalamus, where a final synapse conducts the impulse to the cortex of the brain. Efferent or descending motor neuron response is conducted from the brain through the spinal cord, where it synapses with a motor neuron that exits the spinal cord and innervates the muscle.
In visceral pain, transmission of pain impulses is slower and less localized than in cutaneous pain. The internal organs (including the gastrointestinal tract) have a minimal number of nociceptors, which explains why visceral pain is poorly localized and is felt as a dull aching or throbbing sensation. However, internal organs have extreme sensitivity to distension. The cramping pain of colic (acute abdominal pain), for example, results when:
• Flatus or constipation causes distension of the stomach or intestines
• There is hyperperistalsis, as in gastroenteritis
• Something tries to pass through a lumen (an opening) that is too small
The physiology of ischemic pain, or pain occurring when the blood supply of an area is restricted or cut off completely, also differs from that of cutaneous pain. The restriction of blood flow causes inadequate oxygenation of the tissue supplied by those vessels, as well as inadequate metabolic waste product removal. Ischemic pain has the most rapid onset in an active muscle and a much slower onset in a passive muscle. Examples of ischemic pain are muscle cramps, sickle cell pain crisis, angina pectoris, and myocardial infarction. When ischemic pain occurs in a muscle that continues to work, a muscle spasm (cramp) is the outcome. If the blood supply to the heart is severely restricted or completely cut off and is not restored quickly, a myocardial infarction will occur.
In acute pain episodes, substances released from injured tissue lead to stress hormone responses in the client. This causes an increased metabolic rate, enhanced breakdown of body tissue, impaired immune function, increased blood clotting and water retention, and it triggers the fight-or-flight reaction, leading to tachycardia and negative emotions.
Pain Perception
When the impulse has been transmitted to the cortex and is interpreted by the brain, the information is available on a conscious level. It is then that the person becomes aware of the intensity, location, and quality of pain. This information is interpreted in light of previous experience, adding the affective component to the pain experience.
Modulation
Modulation refers to activation of descending neural pathways that inhibit transmission of pain. “The pathways are described as descending because they involve neurons originating in the brain stem that descend to the dorsal horn of the spinal cord” (McCaffery & Pasero, 1999, p. 22). The descending fibers release substances that produce analgesia by blocking the transmission of noxious stimuli. Pain modulation is a result of the effects of endogenous opioids, also called enkephalins and endorphins.
Neuropathic pain arises from damage to portions of the peripheral or central nervous system. This pain is not nociceptive pain, nor that which is due to ongoing tissue injury or inflammation. It is important to differentiate neuropathic pain from other types of pain because the treatment differs significantly. Table 33-2 identifies some of the differences between nociceptive and neuropathic pain.
Neuropathic pain is a result of abnormal processing of sensory input by either the peripheral or central nervous system. Two types of neuropathic pain are allodynia (a nonpainful stimulus is felt as painful in spite of the tissue appearing normal) and paresthesia (abnormal sensation such as burning, prickling, or tingling).
Myofascial pain was first described by Travell and Rinzler (1952) as pain that occurs as a result of a small, hypersensitive region in a muscle, ligament, fascia, or joint capsule called a trigger point. The trigger point is a hypersensitive point that, when stimulated, causes a local twitch or “jump” response. Myofascial pain is often accompanied by a localized deep ache that is surrounded by a referred area of hyperalgesia, or extreme sensitivity to pain.
Gate Control Theory of Pain
Theories of pain transmission and interpretation attempt to describe and explain the pain experience. In 1965, Melzack and Wall proposed the gate control pain theory, which was the first to recognize that the psychological aspects of pain are as important as the physiological aspects. The gate control theory combines cognitive, sensory, and emotional components—in addition to the physiological aspects—and proposes that they can act on a gate control system to block the individual’s perception of pain. Bezkor and Lee (1997, p. 181) describe gate control as “regulation of pain perception through a gating mechanism at the dorsal horn of the spinal cord. Vasoconstriction and decreased nerve conduction velocity result in reduced transmission of noxious stimuli to the ‘gate.’” As a result, the level of conscious awareness of painful sensation is altered.
The gate control theory is based on the premise that pain impulses travel through either small-diameter nerve cells or large-diameter nerve cells, both of which pass through the same gate. The large-diameter cells have the ability, when properly stimulated, to “close the gate” and thus block transmission of the pain impulse to the brain (Figure 33-3). Stimulants such as cutaneous massage, opioid release, and excessive stimulation all activate the large-diameter cells to close the gate.
Clinically, the effectiveness of several nonpharmacologic modalities, such as massage, acupuncture, and acupressure, supports gate control theory.
Factors Affecting the Pain Experience
The subjective nature of pain varies from person to person and is influenced by several variables. Many factors account for the differences in a client’s individual response to pain, including age, previous experience with pain, and cultural factors.
Age
Age can greatly influence a client’s perception of the pain experience. Infants are sensitive to pain and typically exhibit discomfort through crying or physical movement. Toddlers also use crying and physical movement to indicate pain, and they begin to develop the skills needed to verbally describe pain or point to the area that is hurting. Children often do not understand why pain occurs and can therefore be frightened or resentful of the pain experience; in some cases, children revert to habits of their younger years (regression) as a coping mechanism when faced with pain they cannot otherwise manage.
Adolescents often sense great peer pressure and may be reluctant to admit having pain for fear of being called weak or sensitive. Adults may continue pain behaviors they learned as children and may also be reluctant to admit pain or seek medical care because of fear of the unknown or fear of the impact that treatment may have on their lifestyle.
Older adults may often ignore their pain, viewing it as an unavoidable consequence of aging; family and health care members may inadvertently support this stereotype and be less than responsive to an older client’s complaints of pain. Pain related to chronic disease is prevalent among the elderly population. Up to 70% of noninstutionalized older adults report the occurrence of pain (Luggen, 2000, p. 281). Frequently, pain is undertreated in older people. Loeb (1999) states that there are three major factors which contribute to inadequate pain management in older clients:
1. Pain is underreported by older people who believe the myth that pain is a normal part of aging. Older adults with such misconceptions believe nothing can be done to relieve the pain.
2. Underdetection of pain may be a result of the client’s cognitive-perceptual deficits.
3. Undertreatment of pain is a result of underreporting and underdetection.
Previous Experience with Pain
Clients’ previous exposures to pain will often influence their reactions. Coping mechanisms that were used in the past may affect clients’ judgments as to how the pain will affect their lives and what measures they can use to successfully manage the pain on their own. Client teaching about pain expectations and management methods can often allay client fears and lead to more successful pain management, especially in those clients who do not have previous pain experience or who have memories of a previous devastating pain experience that they do not wish to repeat.
Cultural Norms and Attitudes
Cultural diversity in pain responses can easily lead to problems in pain management. There are no significant differences among groups in the level of intensity at which pain becomes appreciable or perceptible. However, the level of intensity or duration of pain the client is willing to endure is culturally determined.
Expression of pain is also governed by cultural values.
In some cultures, tolerance to pain, and therefore “suffering in silence,” is expected; in others, full expression of pain may include animated physical and emotional responses. The nurse must be careful not to equate the level of expression of pain with the level of actual pain experienced, but to instead consider cultural influences that affect the expression of pain.
Assessment
Assessment of pain includes collection of subjective and objective data through the use of various assessment tools and construction of a database to use in developing a pain management plan. Pain assessment should be performed for every client. “In the normal course of doing business, pain should be nursing’s fifth vital sign, as basic to practice as temperature, pulse, respiration, and blood pressure” (Joel, 1999, p. 9).
Data Collection
Cheever (1999) emphasizes the need to prevent pain rather than treat it. Prevention calls for accurate assessment in order to alleviate pain before it escalates. “Even if a patient fails to report pain, you must make efforts to detect it” (Loeb, 1999, p. 52). Gathering subjective information regarding the client’s pain is the first step in pain assessment. The client’s perception of the pain should cover a description of several qualifiers, including:
• Intensity
• Location
• Quality (radiating, burning, diffuse)
• Associated manifestations (factors that often accompany the pain, such as nausea, constipation, or dizziness)
• Aggravating factors (variables that worsen the pain, such as exercise, certain foods, or stress)
• Alleviating factors (measures the client can take that lessen the effect of the pain, such as lying down, avoiding certain foods, or taking medication)
Nurses must look for nonverbal signs of pain such as changes in motor activity or facial expression. It is also important to ask family members to share their observations; they may be the first ones to note subtle behavior changes indicative of pain. When assessing a client’s report of pain, the nurse should also determine a client’s pain threshold and pain tolerance level. Pain threshold is the level of intensity at which pain becomes appreciable or perceptible and will vary with each individual and type of pain. Pain tolerance is the level of intensity or duration of pain the client is willing or able to endure. A client’s perceptions and attitudes about pain are dramatically influenced by many factors, including previous experiences and cultural background.
Clients’ behavioral adaptation may yield no report of pain unless questioned specifically. Distraction (focusing attention on stimuli other than pain) may also be used by clients. McCaffery and Pasero (1999) recognize that clients often minimize the pain behaviors they are able to control for a number of reasons including:
• To be a “good” client and avoid making demands
• To maintain a positive self-image by not becoming a “sissy”
• By using distraction as a method of making pain more bearable (young children are particularly adept at this)
• Exhaustion
Pain is fatiguing as a significant amount of energy is used to deal with pain. The longer a person suffers from pain, the greater the level of fatigue. Although there is no conscious awareness of pain during sleep, there may be a dream-state awareness (McCaffery & Pasero, 1999).
The stress response continues, and the body physiologically pays the price. Clients also wake up with considerably more pain than they had going to sleep, thereby requiring even more intervention (pharmacologic and nonpharmacologic) to reduce the pain.
Occasionally, there is a discrepancy between pain behaviors observed by the nurse and the client’s self-report of pain. Client pain behaviors (Acute Pain Management Guideline Panel, 1992) include splinting of the painful area, distorted posture, impaired mobility, insomnia, anxiety, attention seeking, and depression. Discrepancies between behaviors and the client’s self-report can be due to good coping skills (e.g., relaxation techniques or distraction), stoicism, anxiety, or cultural differences in expected pain behaviors. Whenever these discrepancies occur, they should be addressed with the client, and the pain management plan altered accordingly.
Assessment Tools
Pain assessment tools are the single most effective method of identifying the presence and intensity of pain in clients. These tools must be used, and the results must be believed. Tools used for assessing pain must be appropriate to the client’s age and cultural context.
“Make sure your assessments are culturally appropriate, keeping in mind that cultural mores and personal values can affect both the patient’s belies and pain and her responses to it” (Acello, 2000, p. 53). See Table 33-3 for sample questions used in pain assessment.
Initial Pain Assessment Tool
Figure 33-4 shows the Initial Pain Assessment Tool developed by McCaffery and Pasero (1999). This tool is particularly effective when clients have complex pain problems because it assesses location, intensity, quality, precipitating and alleviating factors, and how the pain affects function and quality of life. Once this tool is completed, another less detailed tool can be used for ongoing monitoring of the client’s pain level.
Pain Intensity Scales
Pain intensity scales are another quick, effective method for clients to rate the intensity of their pain (Figure 33-5). The verbal rating scale (VRS) and the numeric rating (NRS) are often used together to collect more accurate client input. The VRS uses adjectives ranging from “no pain” to “excruciating pain” in order to describe intensity. Frequent use of these tools will increase understanding of the pain severity. When using the NRS, clients are asked to assign their pain a number, with zero meaning no pain and 10 representing the worst possible pain. “On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain you could ever have, how much do you hurt right now?” If there are multiple painful areas, this question can be asked regarding each area.
Pain Diary
Client input is essential if accurate assessment data are to be collected. Self-monitoring of symptoms can be promoted by having clients complete a pain diary; see the accompanying display.
Psychosocial Pain Assessment
Plaisance and Price (1999) state the following questions should be included on the psychosocial assessment of a client experiencing pain:
• Do the client and family/caregivers understand the diagnosis?
• How have previous experiences with pain affected the client and family?
• How does the client usually cope with pain and/or stress?
• What concerns do the client and family have about using certain medications such as opioids?
• Do the client and family understand the differences between tolerance, dependence, and addiction?
Developmental Considerations
Because pain experiences and reports can be influenced by age and developmental level, special consideration should be used to factor in those influences.
Children and Adolescents
Infants, children, and adolescents provide a special challenge in pain assessment because their pain behaviors often differ from those considered normal in the adult population. Certain myths hinder the accurate assessment and management of pain in children; see Table 33-4.
Two useful tools for assessing pain in children are the Wong/Baker Faces Rating Scale and the Poker Chip Tool. The Wong/Baker Faces Rating Scale can be used with children as young as 3 years, and it helps children express their level of pain by pointing to a cartoon face that most closely resembles how they are feeling (Figure 33-6).
The Poker Chip Tool consists of four red poker chips that can easily be carried in a pocket to be available wheeeded. The chips are aligned horizontally on a hard surface in front of the child, and they are described as “pieces of hurt.” The chips are described from left to right as just a little bit of hurt, a little more hurt, more hurt, and the most hurt you could ever have.
The child is then asked, “How many pieces of hurt do you have right now?” This tool can be used with children 4 to 13 years old. The verbal 0 to 10 scale is also frequently used for school-age and adolescent clients in a number of settings. It is important to remember that any child under stress or with anxiety will regress, and regression may make use of the verbal 0 to 10 scale in children under 8 to 10 years of age of questionable value.
Nursing Diagnosis
The two primary nursing diagnoses used to describe pain are Acute Pain and Chronic Pain. According to NANDA (2001), Acute Pain is defined as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage . . . (with) sudden or slow onset of any intensity from mild to severe, with an anticipated or predictable end and a duration of less than 6 months” (p. 72). Chronic Pain is defined as Acute Pain, with the last phrase replaced by “constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.” Presenting characteristics of Acute Pain and Chronic Pain are listed in the Nursing Process Highlight.
If the client presents with problems in addition to pain, the nurse must be alert to the possibility that the pain may be the cause (not the effect) of another problem. For example, a client may be experiencing Impaired Physical Mobility or Activity Intolerance related to pain caused by a broken leg, as evidenced by verbal complaint, fatigue, and guarding of the affected leg.
Outcome Identification and Planning
When planning care for the client experiencing pain, mutual goal setting is of utmost importance. After assessing the client’s perception of the problem, work with the client in developing realistic outcomes. Be sure to use both nonpharmacologic and pharmacologic interventions in planning strategies to help clients achieve desired levels of functioning and pain control.
When asking about the client’s goal for pain relief, the nurse often has to state, “We can’t usually get rid of all your pain, but if we could get it down to a place that it didn’t bother you so much, what would that be?” Thus, the family, and health care professionals involved will all be aware of a realistic goal for pain relief.
“Providing the best possible pain relief to patients requires regular and consistent communication among all members of the health care team, including the patient” (Collins, Sparger, Richardson, Schriver, & Bergenstock, 1999, p. 20). Treatment goals for CNP clients include the following (McCaffery & Pasero, 1999):
1. Reduce pain level whenever possible.
2. Improve functioning.
3. Develop self-help skills for coping.
4. Alleviate psychopathology, including anxiety and depression.
5. Improve relationships with family members and health care providers in order to meet individual needs.
Terminally ill clients pose a special challenge in the area of pain management. According to Bral (1998), approximately 15% of deaths occur in people receiving hospice care. Thus, pain management is the responsibility of nurses who have no specialization in palliative care. Joel (1999, p. 9) states “no death is a good or peaceful one if attended by suffering. Suffering can take the form of isolation, confusion, emotional deprivation, depersonalization, pain . . . All of this falls within the province of comfort and caring, and consequently becomes the work of nursing.”
In its Position Statement on Promotion of Comfort and Relief of Pain in Dying Patients, the American Nurses Association (1991) states: One of the major concerns of dying patients and their families is the fear of intractable pain during the dying process. Indeed, overwhelming pain can cause sleeplessness, loss of morale, fatigue, irritability, restlessness, withdrawal, and other serious problems for the dying patient. (p. 1)
The American Nurses Association (1991) advises nurses to administer doses of pain medication that are effective enough to manage pain in the dying client. Planning of care leads to the development of an individual treatment plan for each client. Wheurses understand that the existence of pain and its intensity is best defined by the client, “they acknowledge that every person with pain has a complex, multidimensional, and unique experience” (Bral, 1998, p. 7).
Implementation
The accompanying display lists AHRQ recommendations on caring for clients experiencing pain.
“Assessing and managing pain has long been a core nursing responsibility. Now, The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) is requiring accredited facilities and organizations to develop policies and procedures that formalize this obligation” (Acello, 2000, p. 52). The JCAHO calls for health care providers to (Williams-Lee, 1999):
• Recognize each client’s right to pain assessment and treatment
• Monitor client responses to pain management strategies
• Educate staff and clients about pain management
Some key concepts of JCAHO’s standard on pain management include the following (Acello, 2000, p. 52):
• Clients have the right to appropriate pain assessment.
• Pain is to be assessed and regularly reassessed.
• Clients will be treated for pain or referred for treatment.
• Clients will be taught the importance of effective pain management.
• Clients will be taught that pain management is a part of treatment.
• Clients will be involved in making health care decisions.
• Analgesics are to be administered as needed.
• Discharge planning and teaching will include continuing needs for pain management.
Nurse-Client Relationship
Establishment of a therapeutic relationship is the foundation for effective nursing care of the client experiencing pain. Clients who trust their nurses to be there, to listen, and to act, are the clients who are most likely to be comfortable.
Client Education
Client education regarding pain management begins with defining pain, identifying the probable causes, introducing clients to pain assessment tools, and allowing them to choose the tool they would like to use. The importance of talking with health care providers about their pain and of using a preventive approach to pain management must also be emphasized. Provide written information to reinforce verbal explanations. Teach the importance of around-the-clock dosing instead of PRN administration of analgesic medications. Refer to the Client Teaching Checklist for pain management information.
When a client is to be discharged from a health care facility, discharge teaching should include pain management information with specific guidelines about the need for seeking follow-up advice/treatment. The accompanying display lists content for a comprehensive pain management teaching plan.
Both nonpharmacologic and pharmacologic interventions can be effective in caring for clients with pain. In some cases of mild pain, nonpharmacologic techniques may be the primary intervention, with medication available as “backup.” In cases of moderate to severe pain, nonpharmacologic techniques can be an effective adjunctive, or complementary treatment.
Pharmacologic Pain Management
Listed below are principles for the care of clients experiencing pain:
• Assess the pain.
• Treat the contributing factors (pathology).
• Individualize analgesic therapy to each client.
• Choose the least invasive route of administration.
• Administer analgesics at regularly scheduled intervals (around-the-clock dosing) rather than on an asneeded (PRN) basis.
• Keep clients in control of their own analgesia as much as possible.
• Titrate doses to provide maximum pain relief and minimum side effects (Bral, 1998, p. 30). Know that the right dose is “whatever it takes to relieve the pain with the fewest side effects” (Newshan, 2000, p. 83).
Other general principles that guide practice are discussed below.
Combine Analgesics
Combining analgesics on the basis of the World Health Organization’s three-step analgesic ladder is imperative to provide effective pharmacologic intervention for clients with all types of pain. The use of adjuvant medication is recommended (Management of Cancer Pain Guideline Panel, 1994). Adjuvant medications are those drugs used to enhance the analgesic efficacy of opioids, to treat concurrent symptoms that exacerbate pain, and to provide independent analgesia for specific types of pain. Adjuvant medication (medications without intrinsic analgesic properties) are often helpful in treating chronic pain. Adjuvant drugs include anticonvulsants, antidepressants, and sedatives. Gabapentin (Neurontin) is one anticonvulsant useful in treating older clients experiencing chronic pain (Luggen, 2000). Education for clients taking adjuvant medication must explain the need to continue to take the analgesic drug with the adjuvant medication. Table 33-5 lists some common adjuvant medications used in pain management.
Maintain Therapeutic Serum Levels
Establishing and maintaining a therapeutic serum level is another important pain management strategy. Peaks and valleys of drug serum levels often occur when analgesics are administered in the traditional PRN manner.
When the dose is administered on an intermittent schedule, a larger dose is often required, causing the client to have a peak serum drug level in the sedation range. The client must wait for the return of pain before requesting the next dose of analgesic. Depending on the length of time it takes to obtain the medication and, once taken, to reestablish an adequate blood level, there could be a period of up to an hour or so with inadequate pain control.
Patient-controlled analgesia (PCA) (client self-administration of intravenous pain medication via a programmable pump), with a loading dose when first started and a booster dose if needed, is a method to obtain a smooth analgesic level (Figure 33-7). PCA also allows the client to have control over pain management. The major advantage of PCA over the traditional, nurse-administered analgesia is that clients are enabled to seek pain relief whenever they feel it is necessary: “the best advice you can give your patients is to press the PCA button whenever they feel a need for pain medication” (Van-Couwenberghe & Pasero, 1998, p. 15). Requirements for the use of PCA are the cognitive ability to understand how to use the pump and the physical ability to push the button. The method is effective if the appropriate titrations are made on the basis of reassessment and client pain report.
Clients need to be taught that complete pain relief may be an unrealistic expectation. Instead, the goal of PCA is for the client to be comfortable and alert enough to participate in therapy. “The best time to teach patients about PCA is before it has started, when they’re lucid enough to understand your instructions” (Van-Couwenberghe & Pasero, 1998, p. 14).
Choose Appropriate Routes of Administration
Available routes of administration play an important role in choice of pain management technique. In general, the oral route (
The rectal route is effective when clients are nauseated and vomiting or when they are NPO. Suppositories of morphine, hydromorphone, and oxymorphone are available.
Contraindications to rectal administration include diarrhea, lesions of the rectum or anus, or immunosuppressed status. The transdermal route bypasses gastrointestinal absorption but has a slow onset and a slow decline in blood level after the patch is removed.
With continuing documentation of unreliable absorption of intramuscular (IM) injections of opioids, the prudent approach is to switch to subcutaneous or intravascular administration. Continuous infusions are possible by either intravenous (IV) or subcutaneous methods.
Analgesia using epidural, intrathecal (intraspinal), or intraventricular routes are reserved for settings in which experience, expertise, extensive support systems, and sophisticated follow-up are available (Management of Cancer Pain Guideline Panel, 1994). See Table 33-6 for an overview of administration routes; see Chapter 29 for a complete discussion of medication administration routes.
Nonsteroidal Anti-Inflammatory Drugs
The nonopioid class of pharmacologic agents consists of a group of medications classified as nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs work by inhibiting the synthesis of prostaglandin, a class of chemicals that:
• Can be found in almost every body tissue
• Cause allodynia even in low concentrations
• Are always released when cells are damaged
• Contribute to edema and erythema
• Sensitize afferent nerve endings to bradykinin (a pain substance) (McCaffery & Pasero, 1999)
NSAIDs are useful in treating mild to moderate pain, especially painful conditions involving inflammation. NSAIDs are used frequently because of the following (Cleland & Gebhart, 1997, p. 32):
• They can be administered orally.
• They do not cause CNS or respiration depression.
• Several are available over-the-counter.
The widespread use of NSAIDs makes them the culprit in many adverse drug effects. The use of some NSAIDs can result in adverse gastrointestinal, hematologic, and renal effects. Aspirin is the standard NSAID against which the efficacy of all NSAIDs are measured due to its long history of relative safe usage, low cost, and availability without a prescription (Jones, 1997). In fact, aspirin is so commonly used that many individuals fail to consider it to be a drug. Clients must be taught about aspirin’s adverse effects; see Table 33-7.
NSAIDs are also subject to the ceiling effect (as the dose of medication is increased above a certain level, the analgesic effect remains the same), and only the adverse effects continue to increase. For example, acetaminophen is relatively easy on the gastrointestinal tract and does not affect platelet aggregation, but large doses over time have caused liver damage, with extreme overdoses causing liver failure. The remaining NSAIDs all have significant multisystem side effects and adverse effects, with the most worrisome being severe gastric irritation, gastric bleeding, and renal problems. NSAIDs must be used cautiously in elderly clients. The risk of gastrointestinal problems (such as peptic ulcer disease and gastrointestinal bleeding) increases with the use of NSAIDs in older clients (Pasero, Reed, & McCaffery, 1998). “Given the large number of NSAID users, protection against GI complications is a priority” (Peloso, 2000, p. 36).
Opioid Analgesics
The opioids and NSAIDs exert pain relief through different mechanisms. For example, the opioids act on several sites in the central nervous system (CNS) rather than on the peripheral nervous system as do the NSAIDs. Opioids alter the release of neurotransmitters, and, therefore, pain transmission is interrupted at several sites in the CNS. The result is an altered perception of and response to pain (Plaisance & Price, 1999).
The opioid analgesics fall into three classes: pure opioid agonists, partial agonists, and mixed agonistantagonists (a compound that blocks opioid effects on one receptor type while producing opioid effects on a second receptor type). Pure agonists are those that produce a maximal response from cells when they bind to the cells’ opioid receptor sites. Morphine (the gold standard against which all other opioids are measured), fentanyl, methadone, hydromorphone, and codeine are pure agonists. Meperidine, although classified as a pure agonist, is not recommended except in clients with a true allergy to all other narcotics, because of its neurotoxicity.
Meperidine produces clinical analgesia for only 2.5 to 3.5 hours when given intramuscularly in adults. In pediatric clients receiving intravenous meperidine, analgesia may last for only 1.5 to 2.0 hours. In the elderly, most of whom show decreased glomerular filtration rates, there is generally a higher peak and longer duration of action as it takes longer to excrete the opioid as well as its toxic metabolite, normeperidine.
Meperidine should be reserved for very brief courses in otherwise healthy patients who have demonstrated an unusual reaction (e.g., local histamine release at the infusion site) or allergic response during treatment with other opioids such as morphine or hydromorphone. (Acute Pain Management Guideline Panel, 1992, p. 42) Unlike the NSAIDs, pure agonist opioids are not subject to the ceiling effect. As the dosage is increased, there is increasing pain relief, with the only limiting factor being the degree of side effects, particularly respiratory depression and constipation. Many of the analgesic medications (especially opioids) can cause the unwanted effect of constipation. The accompanying display lists measures for prevention.
Other side effects that occur frequently in clients on opioid medications are pruritus and nausea, but the degree to which they are present from each medication varies among individuals. Clients must be instructed regarding these normal responses to opioids and informed that it does not mean that they are allergic to them. A true allergy to opioids would be indicated by a rash or hives that starts after receiving the opioid, a local histamine release at the site of infusion, or anaphylaxis.
Clients also need to know that the pruritus and nausea generally subside after 4 to 5 days of opioid therapy. In the meantime, an antihistamine such as diphenhydramine or hydroxyzine may be used for pruritus, and an antiemetic such as metoclopromide or trimethobenzamide can be used to treat the nausea. Almost all medications used to treat side effects have their own side effect of sedation. Thus, there is the possibility of a cumulative effect of severe sedation.
Mixed agonist-antagonist opioids are believed to be subject to the ceiling effect for pain relief, as well as a ceiling effect for respiratory depression. Mixed agonistantagonist opioids activate one opioid receptor type while simultaneously blocking another type. Butorphanol, pentazocine, and nalbuphine are the most frequently used in pain management.
Addiction, Tolerance, and Physical Dependence
As a result of fears of addiction, family caregivers tend to undermedicate their relative’s pain. Family/client education about addiction and pain medication should be a priority for those receiving opioid therapy. McCaffery and Pasero (1999) define addiction, or psychological dependence, as behavior of overwhelming involvement with obtaining and using a drug for other than approved medical reasons. Therefore, a client taking opioids for an appropriate medical reason is not addicted. “The fear of addiction is perhaps the single most persistent barrier to achieving pain relief with opioid analgesics . . . it may be the most challenging aspect of educating patient, their families, and even health care professionals” (McCaffery & Pasero, 1998, p. 18). Tolerance can occur after repeated administration of an opioid analgesic, when a specific dose loses its effectiveness and the client requires larger and larger doses to produce the same level of analgesia.
The first indication of tolerance is decreased duration of action, then decreased analgesia. If this pattern is noted in clients with continuing opioid needs, the analgesic dose needs to be titrated higher immediately.
Physical dependence is the reaction of the body, commonly known as withdrawal syndrome, to abrupt discontinuation of an opioid after repeated use.
Respiratory Depression
Titrating opioid analgesics to obtain optimal pain management with minimal side effects is a difficult task. See Table 33-8 for a list of risk factors predisposing to respiratory depression in clients receiving appropriate dosages of sedatives or opioid analgesics. This list should be used to identify clients of all ages who require increased vigilance, possible cardiac and pulse oximetry (determination of oxygen saturation of arterial blood) monitoring, and frequent assessment when taking opioid analgesics.
It is not to be construed as a reason for denying the client adequate pain management. When caring for clients receiving opioid analgesics, the nurse should periodically identify the presence and intensity of risk factors.
Local Anesthesia
Local anesthetics are effective for pain management in a variety of settings. Topical anesthetics are available for teething, sore throats, denture pain, laceration repair, and intravenous catheter insertions. EMLA® cream is a mixture of local anesthetics, combining prilocaine and lidocaine. It produces complete anesthesia for at least 60 minutes when topically applied to intact skin.
Another topical anesthetic, TAC, is available for anesthesia during closure of lacerations. It is a combination of tetracaine 0.5%, adrenaline 1:2000, and cocaine 11.8% in a normal saline solution that can be applied directly to the open wound surface in place of local anesthetic infiltration with a needle. This allows painfree cleansing of the laceration as well as suturing.
Because both adrenaline (epinephrine) and cocaine cause vasoconstriction, TAC cannot be used in areas supplied by end-arteriolar blood supply such as digits, the ear, or the nose. It also is contraindicated on burned or abraded skin because this could lead to increased systemic absorption of cocaine and tetracaine, thus placing the client at risk for seizures.
Treatment of Neuropathic Pain
Neuropathic pain is often refractory to treatment with NSAIDs and opioids. When increasing doses of opioids are ineffective in controlling postoperative pain, an immediate search for the underlying cause should begin, and the diagnosis of neuropathic pain should be considered. Once diagnosed, the focus of treatment is optimizing functional abilities. Information on pharmacologic interventions for neuropathic pain found in the Management of Cancer Pain Guideline (1994) includes a number of options, which are discussed in the following paragraphs.
Trial of a tricyclic antidepressant is frequently the first step in a client who describes dull, aching, or throbbing pain. Amitriptyline is often the drug of choice because it has been the most widely studied. This class of medications is useful in pain management as a result of:
• Mood elevation
• Potentiation of opioid analgesia
• Direct analgesic effects
Clients with neuropathic pain often have significant sleep deprivation. Amitriptyline’s action and the side effect of drowsiness improve the client’s ability to fall asleep and to sleep for longer periods. Amitriptyline must be started at very low doses especially in children, the debilitated, or elderly clients, then increased slowly. It should be administered at bedtime to promote sleep and to minimize falls resulting from orthostatic hypotension. The onset of analgesic effects occurs within 1 to 2 weeks, and maximal effect can be seen in 4 to 6 weeks.
Anticonvulsants are often tried first for clients with burning, sharp, shocking, shooting, or lancinating (piercing or stabbing) pain. Carbamazepine is often the drug of choice, with other possibilities being clonazepam or phenytoin. These medications suppress spontaneous neuronal firing that leads to the lancinating pain of nerve injury. Carbamazepine may cause a transient bone marrow suppression and requires regular monitoring of serum drug levels, blood counts, and liver function. It should be avoided if possible in clients with any form of bone marrow suppression (e.g., those undergoing chemotherapy, radiation therapy, or taking immunosuppressants posttransplantation).
Corticosteroid effects include mood elevation, anti-inflammatory effects, and appetite stimulation.
Corticosteriods are effective in reducing the neuropathic pain caused by pressure oerves both centrally and peripherally. The two corticosteroids most frequently used in pain management are dexamethasone and prednisone.
If muscle spasms are a major contributor to the client’s discomfort, baclofen can be tried for its antispasmodic effect. This is particularly effective for clients with spinal cord injury or upper motor neuron dysfunction, including cerebral palsy.
For many individuals, the use of nonpharmacologic methods enhances pain relief. These nonpharmacologic strategies are often used in combination with medication.
Complementary/alternative methods are being used with increasing frequency to treat pain. The use of such strategies is often influenced by the client’s culture. The accompanying display lists some commonly used complementary treatment approaches.
In some cases of mild pain, nonpharmacologic techniques may be the primary intervention, with medication available as “backup.” In cases of moderate to severe pain, nonpharmacologic techniques can be an effective adjunctive, or complementary treatment.
Cognitive-Behavioral Interventions
Cognitive-behavioral interventions are designed to educate clients and to modify client attitudes and behaviors. These nonpharmacologic approaches are an important part of the multimodal approach to pain management and can be used in conjunction with appropriate analgesics. A major goal of these interventions is to help the client gain a sense of control over the pain. The effectiveness of selected therapies is outlined in Table 33-9.
Distraction
Distraction is a pain management strategy that focuses the client’s attention on something other than the pain and associated negative emotions. Children and adolescents seem to be particularly adept at using distraction.
As many parents know, interactive games or listening to music can be powerful distraction techniques for children; they can also be effective for adults experiencing pain.
Reframing
Reframing is a technique that teaches clients to monitor their negative thoughts and replace them with ones that are more positive. Teaching a client to view pain by expressing not, “I can’t stand this pain, it’s never going away” but instead, “I’ve had similar pain before, and it’s gotten better” is an example of effective reframing.
Relaxation Techniques
Relaxation techniques (a variety of methods used to decrease anxiety and muscle tension), imagery (a strategy that uses mental images to assist with relaxation), and progressive muscle relaxation (a strategy in which muscles are alternately tensed and relaxed) are used to achieve both mental and physical relaxation. Physical relaxation leads to reduction of skeletal muscle tension; mental relaxation is used to alleviate anxiety.
Biofeedback
Biofeedback training is another method that may be helpful for the client in pain, especially one who has difficulty relaxing muscle tension. Biofeedback is a process through which individuals learn to influence their physiological responses. Through the use of biofeedback, clients can alter their pain experience.
Cutaneous Stimulation
Counterstimulation is the term used to identify techniques believed to activate the endogenous opioid and monoamine analgesia systems. These interventions are effective by decreasing swelling through cryotherapy (or cold applications), decreasing stiffness (heat applications), and increasing large-diameter nerve fiber input to block small-diameter pain fiber messages (cold, heat, pressure, vibration, or massage). Therapeutic heat and cold are effective pain management tools; they are readily available and easy to use. Both heat and cold can produce analgesia for pain. Heat therapy increases blood flow, increases tissue metabolism, decreases vasomotor tone, and increases the viscoelasticity of connective tissue, making it particularly effective in easing joint stiffness/pain (Bezkor & Lee, 1997). The use of heat as therapy should be closely monitored as it can produce increased inflammation and edema.
Cold therapy exerts many benefits, including the following:
• Alleviates edema by reducing vascular flow
• Counteracts inflammation
• Reduces fever
• Diminishes muscle spasms
• Elevates pain threshold as a result of decreasing the velocity of nerve conduction
Application of cold is inappropriate for clients with cold intolerance, vascular insufficiency, and conditions aggravated by cold (e.g., Reynaud’s phenomenon).
Transcutaneous Stimulation
Transcutaneous stimulation is achieved through use of transcutaneous electrical nerve stimulation, acupuncture, and acupressure. Transcutaneous electrical nerve stimulation (TENS) is a method of applying minute amounts of electrical stimulation to large-diameter nerve fibers via electrodes placed on the skin. Placement of the electrodes is determined by identifying which nerve innervates the painful area, then determining where that nerve is superficial, or where an anesthetic block would be placed to numb that nerve.
Other modalities of pain management should not be abandoned while a trial of TENS occurs. Although TENS can be successful, there are two major contraindications:
1. No electrodes should be placed in the area over or surrounding demand cardiac pacemakers.
2. No electrodes can be placed over the uterus of a pregnant woman.
Acupuncture is another counterstimulation technique; it is performed by a specialist and accomplished by insertion of small solid needles into the skin and musculature at specific sites and at various depths.
Acupressure accomplishes the same stimulation through cutaneous pressure over the selected site.
When the client seeks acupressure, acupuncture, or TENS treatment, it is important to determine the efficacy of the present treatment regime.
Acupressure has been used in TCM since the 5th century B.C. Firm pressure is applied by the fingers to specific acupuncture points on the body to unblock the chi (energy); see Figure 33-8.
Encourage Exercise
Exercise is an important treatment for chronic pain because it strengthens weak muscles, helps mobilize joints, and helps restore balance and coordination.
Passive range of motion should not be used if it increases pain or discomfort. Immobilization is frequently used for clients with episodes of acute pain or to stabilize fractures; however, prolonged immobilization should be avoided whenever possible because it can lead to muscle atrophy and cardiovascular deconditioning.
Nutrition
Dietary practices may affect pain by inhibiting biochemical events associated inflammation. Some foods may actually trigger a painful episode; for example, red wine, cheese, citrus fruits, and cured meats often contribute to the onset of migraine headaches (Howell, 1997).
Other foods may help alleviate the pain associated with chronic diseases. For example, cherries and berries with red, blue, or black skins have high amounts of bioflavonoids, substances with antiinflammatory properties.
Table 33-10 lists foods with properties that exert a pain reducing effect.
Herbals
Many herbs are also useful in mediating pain; see Table 33-11. Howell (1997) reports treatment of mouth pain in cancer patients with candy that contains capsaicin.
Environment
The environment can exert influence on the perception of pain; therefore, changes in one’s environment may reduce pain levels. Pet therapy, consisting of interactive sessions between client and animals, is helpful for some people experiencing chronic pain.
Horticultural therapy (treatment that includes looking at, touching, and growing plants) has several therapeutic benefits, including pain reduction, relaxation, and improved energy level. Participation in gardening can provide distraction from chronic pain.
Music therapy may help ease pain by producing relaxation and providing distraction. See the Nursing Tips for suggestions on using music to alleviate pain.
Pain may be manifested differently by older individuals.For example, pain may be referred (gallbladder pain is felt in the shoulder). Also, the intensity of pain in some elders may not accurately reflect the severity of the underlying pathology; (e.g., a myocardial infarction may be felt as a fluttering sensation, Eliopoulous, 1999). Some of the outcomes of untreated pain in older adults include the following (Loeb, 1999):
• Sleep alterations
• Nutrition problems
• Impaired gait
• Cognitive impairments
• Decreased socialization
• Increased incidence of falls
• Decreasing ability to function independently
“Compared to race, site of pain, and intensity of pain, age is the most important variable influencing analgesic response” (Pasero, Reed, & McCaffery, 1998, p. 12.).
The general guideline for administering analgesics to older clients is to start low and go slow. Many elderly individuals receive health care in their homes. The accompanying display lists recommendations for home health nurse to use with clients experiencing pain.
Evaluation
Evaluating the efficacy of the pain management interventions is ongoing, with client input throughout the process. Evaluation focuses primarily on the client’s subjective reports. Objective data used to evaluate pain management efficacy include:
• Client’s facial expression and posture
• Presence (or absence) of restlessness
• Vital sign monitoring
• Ongoing use of pain assessment tools
Regular reassessment is an integral part of effective pain management. In addition to client self-report and nursing observation, family input is a valuable source of information for evaluating the effectiveness of care.
REST AND SLEEP
Rest and sleep are fundamental components of wellbeing. All individuals require certain periods of calm and lesser activity so that their bodies can regain energy and rebuild stamina. The need for rest and sleep varies with age, developmental level, health status, activity level, and cultural norms. Pain and impaired sleep are closely related in most people. According to Doghramji and Fredman (1999), 50–70% of clients experiencing pain also suffer sleep disturbance. On the other hand, sleep deprivation can decrease pain tolerance and, thus, may exacerbate pain (especially headaches).
Rest refers to a state of relaxation and calmness, both mental and physical. Activity during rest periods can range from lying down to reading a book to taking a quiet walk. When discussing a client’s rest patterns, the nurse should try to understand what activities and environments the client defines as restful.
Sleep refers to a state of altered consciousness during which an individual experiences minimal physical activity and a general slowing of the body’s physiological processes. Sleep generally occurs in a periodic cycle and usually lasts for several hours at a time; disruptions in the usual sleep routine can be distressing to clients and will most likely impair sleep further. As a restorative function, sleep is necessary for physiological and psychological healing to occur. It is important for clients, their significant others, and health care providers to understand the normal sleep-wake cycle and how sleep affects mood and healing.
Physiology of Rest and Sleep
The cycles of wakefulness and sleep are controlled by centers in the brain and influenced by routines and environmental factors. An individual’s biological clock also helps determine the specific cycles that will be followed for wakefulness and sleep.
Stages of Sleep
Electroencephalograph (EEG) patterns, eye movements, and muscle activity are used to identify stages of sleep. The stages of sleep are classified in two categories: non-rapid eye movement (NREM) and rapid eye movement (REM) sleep.
NREM Sleep
With the onset of sleep, the heart rate and respiratory rate slow slightly and remain regular. This first phase of sleep is referred to as non-rapid eye movement, or NREM, sleep. NREM sleep consists of four different stages. As the client enters stage 1 sleep, there is a general slowing of EEG frequency but an appearance of wave spikes; the eyes tend to roll slowly from side to side, and muscle tension remains absent except in the facial and neck muscles. In adult clients with normal sleep patterns, stage 1 sleep usually lasts only 10 minutes or so.
Stage 1 NREM sleep is of a very light quality, which means that during this stage a sleeper can be easily awakened.
Stage 2 sleep is still fairly light sleep, with a further slowing of EEG patterns and loss of slow rolling eye movements. Fifty percent of normal adult sleep may be spent in stage 2. After an initial 20 minutes or so of stage 2 sleep, a deep form of sleep called stage 3 to 4 is entered.
Stage 3 and stage 4 sleep are frequently discussed together because of the difficulty of identifying and separating the two. Stage 3 refers to medium-depth sleep, and stage 4 signals the deepest sleep. During these stages, all cortical brain cells appear to be firing at the same time, resulting in large slow waves on the EEG. When roused from stage 3 to 4 sleep, an adult can take 15 seconds or so to become fully awake. This difficulty in awakening is even more pronounced in children.
Stage 3 to 4 sleep is where most sleepwalking, sleeptalking, enuresis, and night terrors occur.
Stage 3 to 4 sleep is felt to have restorative value, necessary for physical recovery. After sleep deprivation studies, stage 3 to 4 sleep is the first to be regained. The majority of growth hormone is secreted at night, peaking during stage 3 to 4 sleep near the beginning of a sleep period. Growth hormone is required not only for growth but also for normal tissue repair in clients of all ages. Stage 3 to 4 sleep accounts for approximately 25% of sleep in children, declines slightly in young adulthood, then gradually declines in middle age and may be absent in elderly clients.
REM Sleep
After the initial 90 minutes or so of NREM sleep in adults, the client enters rapid eye movement, or REM, sleep. The EEG pattern resembles that of the awake state; there are rapid conjugate eye movements; heart rate and respiratory rate are irregular and often higher than when awake; and muscles, including those of the face and neck, are flaccid, leaving the body immobilized. Dreams occur 80% of the time clients are in REM sleep. Unlike stage 3 to 4 sleep, which is most abundant during the early portion of a sleep period, REM sleep periods become longer as the night progresses and the individual becomes more rested. An adult typically has four to six REM sleep periods through the night, accounting for 20% to 25% of sleep. REM sleep makes up 50% of sleep in the newborn, then gradually declines to 20% to 25% of sleep by early childhood and remains fairly constant throughout the remainder of the life span.
Sleep Cycle
A sleep cycle refers to the sequence of sleep that begins with the four stages of NREM sleep in order, with a return to stage 3, then 2, then passage into the first REM stage (Figure 33-9). The duration of a sleep cycle is generally between 70 and 90 minutes, and the typical sleeper will pass through four to six sleep cycles during an average sleep period of 7 to 8 hours.
The length of the NREM and REM periods of sleep will change as the overall sleep period progresses and the person becomes more relaxed and re-energized.
There is less need for stage 3 to 4 sleep and more need for REM sleep as the sleep period progresses, and dreams during the REM phases of later sleep may become more vivid and intense. If the sleep cycle is broken at any point, a new sleep cycle will start, beginning again at stage 1 of NREM sleep and progressing through all the stages to REM sleep.
Biological Clock
The biological clock (an endogenous mechanism that measures time) controls the daily fluctuations in hundreds of physiological processes, including body temperature, respiratory rate, performance, alertness, and hormone levels.
Chronobiology is a relatively new branch of science that studies these rhythms that are controlled by our biological clocks. The most widely studied are the circadian rhythms, or those that cycle on a daily basis. Other biological rhythms include:
• Ultradian—those much shorter than a day
• Infradian—those lasting a month or more
• Circannual—those requiring about 1 year to complete the cycle
When external time cues such as day-night, sleepwake, and mealtimes are inconsistent, a desynchronization, or mismatching, of the circadian biological rhythms occurs. This internal desynchronization disrupts the timing of physiological and behavioral activity, which in turn causes chronic fatigue, disrupts sleep patterns, and causes decreased performance and coping abilities. An example of desynchronization is that of the newborn, whose biological rhythms are not established until 3 to 4 months of age. At this point, infants will start to develop longer sleep periods at night and become more predictable in their waking and sleeping patterns.
Factors Affecting Rest and Sleep
Several factors can influence the quality and quantity of both sleep and rest. Often, sleep problems result from a combination of many factors.
Degree of Comfort
Comfort is a highly subjective experience. The nurse must assess the degree to which the client’s physical and psychological needs have been met. Whenever basic needs are unmet, the person experiences discomfort which leads to physiological tension, resultant anxiety, and potential impairments in sleep/rest.
Anxiety
A restless body and mind interfere with the ability to sleep. When trying to go to sleep, many individuals often have intrusive thoughts or muscular tension, which interfere with rest and sleep. Anxiety related to work pressures, family demands, and other stressors does not automatically cease when an individual attempts to go to sleep. Anxiety often results in difficulty falling or staying asleep.
Environment
Environmental factors can either enhance or impair sleep. Lighting, temperature, odors, ventilation, and noise level can all interrupt the sleep process when they differ from the norms of the client’s usual sleep environment.
Lifestyle
A fast-paced life filled with multiple stressors can result in the person’s inability to relax easily or to fall asleep quickly. Relaxation precedes healthy sleep.
Another lifestyle factor that interferes with sleep is having a work schedule that does not coincide with an individual’s biological clock (e.g., working at times other than the day shift). Individuals who frequently change work shifts have a real challenge in trying to stabilize biological rhythms and rest comfortably.
Diet
The type of food consumed has an impact on the quality and quantity of sleep. Foods high in caffeine, such as coffee, colas, and chocolate, serve as stimulants and often disrupt the normal sleep cycle. Also, consuming a large, heavy, or spicy meal just before bedtime may cause indigestion, which will likely interfere with sleep.
Conversely, going to bed when hungry can also result in sleep problems because the individual may be preoccupied with food and hunger pangs instead of concentrating on sleep.
Drugs and Other Substances
Alcohol and nicotine use can impair sleep. Small amounts of alcohol may help some people fall asleep; however, in others alcohol may interfere with REM sleep, causing very restless and nonrefreshing sleep.
Nicotine, which is a stimulant, can also impair the sleep cycle by stimulating the body, resulting in difficulty falling and staying asleep. Many medications (both prescription and over-the-counter) cause fatigue, sleepiness, restlessness, agitation, or insomnia, thus affecting the quality and quantity of rest and sleep.
Cultural Norms
Cultural and societal expectations also affect sleep. Some people perceive sleep as a luxury to be indulged in when they are not too busy with “important” activities. Others view sleep as an absolute necessity. The amount of sleep that a person considers to be necessary is partially determined by the attitudes of family and culture.
Life Span Considerations
A person’s need for sleep changes with age in a fairly predictable pattern. Although sleep and rest patterns are closely tied to lifestyle and other variables, there are some common variations:
• The neonate (birth to 1 month) sleeps in 3- to 4-hour intervals for a total of about 16 to 20 hours per day. The newborn usually is very passive, with little activity during sleep (“sleeping like a baby”), and typically sleeps very soundly. For the first few days or weeks of life, a baby’s biological clock is not attuned to regular day-night patterns, so there is ofteo difference in sleep patterns between day and night.
• The infant averages about 12 to 16 hours of sleep per day. As the infant ages, the amount of sleep needed decreases. At approximately 2 months of age, infants can begin to sleep through the night and will typically nap two or three times during the day.
• During toddlerhood the daily average amount of sleep is 12 to 14 hours, which is usually broken down into 10 to 12 hours at night with one or two daytime naps. During this stage, bedtime rituals often develop and assume great importance in providing nighttime security. Repeated and predictable nighttime routines such as baths, brushing teeth, and reading books are helpful in establishing expectations and comfort.
• The preschool child sleeps approximately 10 to 12 hours per day. Daytime napping decreases or ceases, unless cultural norms dicate otherwise. Night sleep is often filled with vivid dreams and nightmares, which often awaken children several times during the night.
• A school-age child also averages about 10 to 12 hours of sleep daily. Resistance to bedtime and struggles for independence are hallmarks of the school-age child. During this time, the child may develop fear of the dark and will need reassurance and methods to handle this fear.
• Adolescents sleep about 8 to 10 hours per day and often decide themselves their bedtime routines and hours. High activity levels often interfere with regular sleep patterns and irregular sleeping habits often become the norm at this stage.
• The young adult averages about 8 hours of sleep per day. During this stage, sleep is often interrupted by young children in the home or work responsibilities. Lifestyle patterns cause many young adults to experience difficulties falling or staying asleep.
• The middle-aged adult sleeps about 6 to 8 hours a day. Daily stressors may continue to result in insomnia, and use of sleep-inducing medications is common.
• The sleep requirements for the older adult decrease to 5 to 7 hours per day, and often include a daytime nap. The quality of sleep often diminishes due to frequent waking, physical pain, and shortened REM sleep. Many elderly people misinterpret this decreased need for sleep as insomnia and are thus unduly concerned about not getting “enough” sleep.
Illness or Hospitalization
The stress imposed by illness usually disrupts sleep. Sleep is especially disrupted when a person is hospitalized. Some factors associated with hospitalization that lead to sleep impairment include:
• Physical or emotional pain
• Loss of familiar surroundings
• Loss of routine
• Fear of the unknown
• Timing of procedures and treatments
• Noise level (especially unfamiliar noises)
• Loss of privacy
Alteration in Sleep Patterns
Sleep disturbances can take many forms and are quite common. According to Carpenito (1999), sleep pattern disturbance is defined as: The state in which an individual experiences or is at risk of experiencing a change in the quantity or quality of his or her rest pattern as related to the person’s biological and emotional needs. (p. 291)
Alterations in sleep patterns are generally viewed as either primary sleep disorders (those in which the sleep alteration is the fundamental problem) or secondary sleep disorders (those in which the alteration has a medical or clinical cause that results in or contributes to the sleep alteration). The most common sleep alterations include insomnia, hypersomnia or narcolepsy, sleep apnea, sleep deprivation, and parasomnias.
Chronic insomnia is a widespread problem, affecting 10–20% of Americans; approximately 40–50% report occasional insomnia (Doghramji & Fredman, 1999). Listed below are problems associated with sleep disturbances:
• Decreased work productivity (more missed days of work)
• Increased utilization of health care services
• Greater risk of accidents
• Short-term memory problems
• Cognitive and motor performance impairments
Insomnia
Insomnia refers to the chronic inability to sleep or inadequate quality of sleep due to sleep prematurely ended or interrupted by periods of wakefulness. Insomnia is not a disease, but it may be a manifestation of many illnesses.
The person experiencing insomnia often gets caught up in a vicious cycle of not being able to sleep, trying harder to fall asleep, increasing anxiety about not sleeping, which in turn increases the inability to fall asleep. Perception of sleep quantity can also be important; many insomniacs actually sleep significantly more than they think they do, so there is a discrepancy between perception and reality.
Sleep disturbances are common for individuals experiencing chronic pain. Sleep impairment can exacerbate pain, and, thus, a vicious cycle is established. “A poor night’s sleep contributes to depression, muscle soreness, difficulty thinking, and decreased motivation” (McCaffery & Pasero, 1999, p. 500). Treatment for insomnia is best directed at modifying those factors or behaviors that are causing it. It is impossible to force sleep.
Hypersomnia or Narcolepsy
Hypersomnia is an alteration in sleep pattern characterized by excessive sleep, especially in the daytime. Persons suffering from hypersomnia often feel that they cannot get enough sleep at night, and therefore they sleep very late into the morning and nap several times throughout the day. Causes of hypersomnia can be physical or psychological; treatment depends on addressing the underlying cause.
Narcolepsy, another sleep alteration, manifests as sudden uncontrollable urges to fall asleep during the daytime. Individuals suffering from narcolepsy often achieve adequate sleep at night but are overwhelmed by sleepiness at unexpected and unpredictable periods during the day. Effective treatments for narcolepsy include avoiding substances or activities that cause sleepiness, taking short daytime naps, or taking prescribed stimulant medications.
Sleep Apnea
Sleep apnea refers to periods of sleep during which airflow stops for 10 seconds or more. Sleep apnea gives rise to complications as a result of oxygen desaturation and carbon dioxide retention. Short-term consequences may include cognitive impairment (including memory changes), personality changes, and impotence. A major problem is daytime sleepiness, which may interfere with functional abilities such as driving and working. If untreated, sleep apnea can result in the following (
• Hypertension
• Cardiac arrhythmias
• Right-sided congestive heart failure
• Cerebral vascular accident (stroke)
• Cognitive dysfunction
• Death
The first line of defense against apnea is treating its cause (emotional, cardiac, or respiratory alteration). Use of a nasal continuous positive airway pressure (CPAP) device may also give relief. With some individuals, surgical intervention is required to correct the cause of the apnea.
Sleep Deprivation
Sleep deprivation is a term used to describe prolonged inadequate quality and quantity of sleep, either of the REM or the NREM type. Sleep deprivation can result from age, prolonged hospitalization, drug and substance use, illness, and frequent changes in lifestyle patterns.
Sleep and dreaming have a restorative value necessary for mental and emotional recovery, and enhance the ability to cope with emotional problems.
Therefore, sleep deprivation can cause symptoms ranging from irritability, hypersensitivity, and confusion to apathy, sleepiness, and diminished reflexes. Treating or minimizing the factors that cause the sleep deprivation is the most effective resolution.
Parasomnia
Parasomnias refer to sleep alterations resulting from “an activation of physiological systems at inappropriate times during the sleep-wake cycle” (American Psychiatric Association, 1994, p. 579). Somnambulism (sleepwalking), sleeptalking, bed wetting, and bruxism (teeth grinding) are the most common parasomnias.
Treatment for parasomnias varies, and care should be focused on helping the client and family understand the disorder and its potential safety risks.
Assessment
Discussion of sleep habits is included as part of the regular health history. Any client acknowledging a sleep disturbance should be thoroughly assessed to determine sleep routines, sleep alterations, type of disturbances, and impact of sleep problems. Typically the client is a reliable source for this information, but a spouse or partner who shares sleeping arrangements may be able to add valuable information to the client’s report. Questions regarding the client’s usual sleep patterns should include:
1. Nature of sleep (restful, uninterrupted)
2 Quality of sleep (usual sleep pattern, schedules, hours of sleep, feeling on waking)
3. Sleep environment (description of room, temperature, noise level)
4. Associated factors (bedtime routines, use of sleep medications or any other sleep inducers)
5. Opinion of sleep (adequate, restores energy adequately, inadequate, problematic)
Questions regarding altered sleep patterns are intended to discover such information as:
1. Nature of the problem (inability to fall asleep, difficulty remaining asleep, inability to fall asleep after awakening, restless sleep, daytime sleepiness)
2. Quality of the problem (number of hours of sleep versus number of hours spent trying to sleep, number of hours of sleep a night, duration and frequency of naps or other compensatory measures, number of wakings per sleep period)
3. Environmental factors (lighting, bed, noise level, surrounding stimulation, sleep partner)
4. Associated factors (relation to meals eaten, activity before retiring, life stressors, work stressors, anxiety level, pain, recent illness or surgery)
5. Alleviating factors (mild diet, warm drink before retiring, reading a book, listening to quiet music, taking a hot bath, taking sleeping pills)
6. Effect of problem (fatigue, irritability, confusion)
For clients whose sleep problems do not seem to be well defined, a daily journal of sleep patterns may prove useful.
This written account can mirror the preceding outline.
Nursing Diagnosis
After information about the sleep impairment has been collected, data need to be analyzed to formulate appropriate nursing diagnoses. The primary diagnosis for individuals experiencing sleep problems is Disturbed Sleep Pattern.
According to NANDA (2001), Disturbed Sleep Pattern is defined as “a disruption of sleep time [that] causes discomfort or interferes with desired lifestyle” (p. 59).
Alterations in sleep can manifest through verbal complaints of the client, physical signs such as yawning or dark circles under the eyes, or alterations in mood such as apathy or irritability.
If the client presents with problems in addition to the sleep disturbance, the nurse must be alert to the possibility that the sleep disturbance is the cause (not the effect) of another problem. For example, a client may be experiencing Activity Intolerance related to lack of sleep as evidenced by verbal complaint, extreme fatigue, disorientation, confusion, and lack of energy.
Outcome Identification and Planning
The plan of care for the sleep-disordered client must be individualized. For the nursing care to be effective, client input should be incorporated when developing expected outcomes. It is important to tailor the outcomes and plan of care to the true cause related to the sleep disturbance or alteration. For example, if the client is experiencing Disturbed Sleep Pattern because of bedwetting, then the bedwetting should be targeted for intervention.
Effective outcome identification and planning will also consider the fact that many sleep disturbances will require extended periods of time (weeks or months) to correct. Sleep patterns are by nature habitual and intertwined with lifestyle patterns, and these types of disturbances typically require interventions that have long-term goals. When planning care, the nurse should remember to perform procedures and treatments in a manner that disturbs sleep time and routines as little as possible.
Implementation
Several interventions can promote rest and sleep in clients. The interventions range from simple (e.g., correct bedmaking techniques) to complex (teaching clients about necessary lifestyle modifications). Several interventions that facilitate sleep are discussed here.
Establish a Trusting Nurse-Client Relationship
The quality of the nurse-client relationship can enhance a client’s ability to rest and sleep. Knowing that the nurse is a trustworthy individual allows the client to relax and feel secure. The nursing checklist provides guidelines for communicating with the sleep-impaired client. Anxiety can be decreased by the nurse’s use of therapeutic communication skills. The therapeutic use of self helps allay client anxiety.
Create a Relaxing Environment
Arranging the immediate surroundings to promote sleep is important for the sleep-impaired client. A place to sleep should be inviting. Determine the type of environment the client finds relaxing, then provide this environment in the inpatient setting, or help the client establish this type of environment in the home setting.
Initiate Relaxation Techniques
The client’s mood before sleep is of utmost importance.
The belief that one can—and will—sleep greatly affects sleep quality and quantity. The client who is calm and relaxed is likely to fall asleep quickly and stay asleep all night. Relaxation techniques are useful sleep aids.
Progressive muscle relaxation is especially therapeutic for the person who needs to lessen muscular tension and quiet the mind.
Ensure Appropriate Nutrition
Certain foods can actually enhance sleep. Tryptophan, a substance in milk, promotes sleep by stimulating the brain’s production of the neurotransmitter serotonin.
The old wives’ tale that drinking warm milk promotes sleep is supported by scientific data. Other dietary considerations include avoiding large or heavy meals close to bedtime, refraining from eating spicy or other foods that cause gastrointestinal distress, and avoiding caffeine after noon.
Initiate Pharmacologic Interventions
If unrelieved pain is a factor in the client’s sleep disturbance, pain management should be the focus of initial interventions. Many of the nonpharmacologic relaxation and imagery interventions can be effective in clients with sleep disturbances.
Pharmacologic agents that may be therapeutic for clients with sleep disturbances include tricyclic antidepressants, antihistamines, and short-acting hypnotics (McCaffery & Pasero, 1999). The tricyclic antidepressants of choice are amitriptyline (Elavil®) or doxepin (Sinequan®). Amitriptyline improves the client’s ability to fall asleep and stay asleep by causing sedation when given 1 to 3 hours before bedtime. Doses of amitriptyline for sleep disturbances are significantly lower than doses for treatment of depression, starting at 10 to 25 mg at bedtime and titrating up by 10 to 25 mg every 2 or 3 days until therapeutic effect is achieved.
Antihistamines such as hydroxyzine (Vistaril®, Atarax®) and diphenhydramine (Benadryl®) have mild sedative effects that could promote sleep if given at bedtime.
If anxiety throughout the day is of concern, low doses of these medications at regular intervals throughout the day may be effective.
The final group of pharmacologic interventions for sleep disturbances are the short-acting hypnotics. These are not recommended for routine or long-term use, but they may be effective as a short-term intervention. When they are chosen, it is recommended that one with a short half-life be used.
Provide Client Education
Educating the client on sleep-promoting activities is a good investment of the nurse’s time. By empowering clients to help themselves relax, the nurse helps them gain a sense of control over their sleep disturbance and boosts their confidence that they can successfully meet their sleep and rest needs.
Evaluation
The plan of care must be individualized for and negotiated with the client. It must be updated on a regular schedule and additional interventions initiated as needed. One of the strongest supportive activities nurses can perform is to make sure clients understand that there is help for sleep problems and that they are not alone in having difficulty successfully managing their sleep patterns. The Nursing Process Highlight lists variables to be considered in evaluating the care of the sleep disturbed client.
KEY CONCEPTS
• Pain is a subjective and individualized experience.
• Pain is defined as whatever the client says it is.
• Pain is increased by anxiety and fatigue.
• Several factors influence the perception of pain, including developmental level, culture, previous experience.
• The amount of sleep required differs according to developmental stage.
• Nonpharmacologic interventions may be used in managing pain and promoting rest and sleep.
• Pharmacologic agents can be therapeutic for clients experiencing pain or sleep pattern disturbance. However, the medications should not be the only interventions used.
HOT & COLD THERAPY PROCEDURES
Hot and cold therapy is a commoon-invasive procedure used by professional care givers and laymen for the relief of pain. The technique utilizes the alternation of hot and cold compresses on a painful area to help reduce inflammation, pain and muscle spasms.
Heat Therapy
Applying a very warm or hot compress to the skin over an area of pain helps flood blood into that area. This increase of blood flow also increases the volume of healing oxygen and nutrients carried by the blood to that area of the body. In addition, heat applied to painful tissues helps relieve muscle tension, muscle spasms and helps increase mobility and range of motion. Don’t place a hot pack against swollen areas, as this will increase blood flow to already engorged locations. Place the hot pack on the area for about 15 minutes. When using heating pads or hot packs, always protect the skin by wrapping the hot pack in a towel.
Cold Therapy
Also known as cryotherapy, applying cold to a painful area helps constrict blood vessels, also known as vasoconstriction, thereby reducing swelling of the affected area. As with application of hot packs or pads to an affected area, cold packs, ice packs, damp towels placed in a freezer or ice blocks should be wrapped in a towel before placing against the skin. Avoid leaving cold packs on the skin for more than 15 to 20 minutes at a time. Cold therapy is most effective when begun immediately after an injury such as a muscle strain or sprain Ascertain if the Individual is coherent and able to voice concerns if the treatment is too cold. Determine mobility limitations. If the Individual is paralyzed, more intensive observations are necessary and time frames for treatment must be altered to meet individual needs.
COLD PACK TREATMENT
1. PURPOSE:
Cold pack treatment is a form of therapy used after a sudden onset of acute inflammation or swelling. Vasoconstriction resulting from cold application reduces blood flow to the injured part and thus limits fluid accumulation and slows bleeding. The lower temperature also suppressed inflammation and produces local anesthetic response. When used appropriately, cold application can significantly lessen pain and immobility by reducing swelling of injured tissues.
2. POLICY:
1. No cold pack treatment shall be administered without a current order form a licensed physician, dentist, podiatrist, or person authorized to give such orders.
2. No Individual shall be left alone unsupervised while cold pack treatment is being applied.
3. Only licensed Psychiatric Technician or Registered Nurse can administer cold pack treatment. The treatment nurse is expected to be familiar with the nursing considerations, method of application, Individual teaching, and contraindications for cold pack treatments y consulting with medical doctor, pharmacy, or by reviewing the unit’s nursing clinical skills book.
3. DEFINITION:
A rubber or plastic device filled with ice chips and covered with a protective fabric before application to the Individual’s body site. Vasoconstriction of peripheral vessels is caused by cold application.
4. ASSESSMENT:
Consider during assessment:
5. PLAN:
Promote healing or reduction of pain and future complications
6. EQUIPMENT:
1. Plastic bags, conventional ice bags or ice pack from Central Supply
2. Protective covering for bags
3. Ice chips, clean basin with ice and water for cold compress
4. Bath blanket or face towel
5. Screen (for privacy) if needed
6. Gloves (if blood or body fluids are present)
7. IMPLEMENTATION AND INTERVENTIONS:
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NURSING ACTION KEY POINTSA. Check physician’s orders for location and duration of application |
A. Physician’s order is required for all cold application |
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B. Inspect and document condition of injured or affected part. Gently palpitate the area |
B. Provides baseline for determining change in condition |
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C. Consider time in which the injury occurred |
C. Cold-pack treatment should be applied quickly after an injury to prevent edema. Application of cold is most effective if started within 24 hours of injury. |
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D. Assess area to be treated for Sensitivity to temperature, light touch, and pain for adequate circulation. |
D. Determine if Individual is sensitive to cold extremes |
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E. Prepare equipment and supplies |
E. Organization prevents unnecessary delays |
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F. Explain procedure to the Individual and assess his understanding of procedure. |
F. To gain Individual’s cooperation and compliance of treatment. |
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G. Wash hands and put on gloves |
G. Reduces spread o microorganisms |
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H. Position the Individual carefully, keep body part in proper alignment and exposing only the area to be treated. |
H. Prevents further injury to body part. Avoids unnecessary exposure of body parts, maintaining Individual’s comfort ad privacy. |
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and submerge gauze or face towel into filled basin, wring out excess moisture. b. Apply compress to affected area, molding it gently over site |
tissue damage. Dripping gauze or face towel is uncomfortable to Individual. b. Ensure that cold is directed over site of injury. |
8. EVALUATION:
1. After cold pack administration the affected area should be inspected for change in condition and appearance of skin. Report undesirable changes to physician immediately.
2. The Individual’s response is important and should be noted. Untoward reactions to the application should be reflected
3. If area is edematous, sensation may be reduced and extra caution must be used during cold therapy.
4. Numbness and tingling are common sensations with cold applications and indicate adverse reactions only when sever coupled with other symptoms
5. Document Individual’s response to health teachings, describe any instructions given and Individual’s ability to demonstrate the procedure in the I.D. notes.
