31 Pain, Comfort, and Sleep

Question 1

Key terms

analgesic (/ˌa-nᵊl-ˈjē-zik/, p. 615)
biofeedback ( p. 613)
bolus (/ˈbō-ləs /, p. 616)
continuous positive airway pressure (CPAP) ( p. 621)
distraction ( p. 613)
endorphins (/en-ˈdȯr-fən) (p. 606)
epidural analgesia (/ˌe-pi-ˈd(y)u̇r-əl/ /ˌa-nᵊl-ˈjē-zh(ē-)ə/ , p. 618)
gate control theory ( p. 605)
guided imagery (/ˈi-mij-rē/, p. 614)

Answer 1

**hypnosis **(/hip-ˈnō-səs /, p. 614)
**insomnia **(, p. 621)
massage (mă-SĂJ, p. 614)
meditation (, p. 614)
narcolepsy (, p. 622)
non–rapid eye movement (NREM) sleep ( p. 620)
**nonsteroidal **anti-inflammatory drugs (NSAIDs) (, p. 608)
pain ( p. 605)
patient-controlled analgesia (PCA) (, p. 616)
rapid eye movement (REM) sleep ( p. 620)
relaxation (rē-lăk-ZĀ-shŭn, p. 613)
sleep apnea (SLĒP ĂP-nē-ă, p. 621)
transcutaneous electrical nerve stimulation (TENS) (, p. 610)

Question 2

Pain and Discomfort

Answer 2

Pain (a feeling of discomfort strong enough to be intrusive and to affect or interfere with normal activity) is experienced by the majority of patients sometime during their health care experience.

Question 3

incisional pain

Answer 3

After surgery, they were expected to experience significant incisional pain for the first day or two, with the degree of pain steadily decreasing with each passing day until it ceased altogether.

Question 4

The standards relative to direct patient care state:

Answer 4

• Patients have the right to appropriate assessment and management of pain.
• Pain is assessed in **all **patients.
• Patients are educated about pain and managing pain as part of treatment, as appropriate.
• The discharge process provides for continuing pain care based on the patient’s assessed needs at the time of discharge.

Question 5

There is also an increased use of nonpharmacologic methods of pain relief

Answer 5

such as biofeedback, distraction, guided imagery, massage, and relaxation techniques

Question 6

complementary health approaches

\ ˌkäm-plə-ˈmen-t(ə-)rē \

Answer 6

chiropractic, acupuncture, and acupressure

\ ˈkī-rə-ˌprak-tik , ˌkī-rə-ˈprak- \

Question 7

The fentanyl patch
\ ˈfen-tə-ˌnil \

Answer 7

one method for controlling chronic pain. It is replaced every 72 hours and can be managed at home by the patient.

Question 8

Fentanyl nasal spray

Answer 8

be used for breakthrough pain in adult cancer patients, but it comes with a warning that it should be prescribed only by physicians experienced in treating pain in patients with cancer because it can be extremely dangerous in other situations

Question 9

For postsurgical patients, the ON-Q Pain Relief System

Answer 9

a pump with a tiny catheter at the incision site that allows the patient to administer local anesthetic directly into the site. \ ˌa-nəs-ˈthe-tik \

an·​es·​the·​sia | \ ˌa-nəs-ˈthē-zhə \
Definition
1 : loss of sensation with or without loss of consciousness

Question 10

Pain

Answer 10

Pain is defined as a feeling of discomfort, distress, or suffering caused by the stimulation of nerve endings.

Question 11

Gate Control Theory

Answer 11

Stated in the simplest terms, opening the gate allows the transmission of pain sensation, and closing the gate blocks this transmission.

• The gate may be opened by activity in the small-diameter nerve fibers from such things as tissue damage. Activity in the large-diameter nerve fibers, such as that provided by massage or vibration, seems to close the gate.
• Brainstem impulses caused by a high sensory input seem to close the gate, whereas a lack of this input allows the gate to open. This may be why people who are bored or lonely can experience more intense pain than when they are occupied or distracted by visitors or an interesting program or activity.
• The cerebral cortex and thalamus play a role by opening the gate with impulses originating from an increase in anxiety or by closing it with impulses originating from a decrease in anxiety. For example, fear that the pain will get worse and that it will not be controlled can increase the intensity; knowing that pain can be and is being controlled can reduce the intensity.

Question 12

Endorphins

Answer 12

Endorphins are endogenous, naturally occurring, opiate-like peptides that reduce or block the perception of pain.

Like morphine, endorphins attach to nerve endings in opioid receptors and block pain transmission.

Question 13

Types of Pain

Answer 13

Acute Pain
Chronic Pain
Nociceptive Pain/ˌnō-si-ˈsep-tiv /
Neuropathic Pain/ˌnu̇r-ə-ˈpa-thik /
Phantom Pain/ˈfan-təm/

Question 14

Acute Pain

Answer 14

Acute pain is usually associated with an injury, medical condition, or surgical procedure. It is of short duration, lasting from a few hours to a few days.
Injuries causing acute pain may include burns, bone fractures, and muscle strains.
Medical conditions causing acute pain may include pneumonia, sickle cell crisis, angina, herpes zoster, inflammations, infections, and blockages.
Acute pain may be described as aching, throbbing, or searing. The patient may be agitated or restless and may protect the painful area by splinting or supporting the area.
Pain also may be accompanied by an increase in heart rate, blood pressure, and respiratory rate.
Acute pain may worsen in the presence of anxiety or fear. The cause is usually easily determined, and the pain is well controlled with analgesics (pain medications), surgery, or other techniques. Once the cause is removed, acute pain will be relieved.

Question 15

Chronic Pain

Answer 15

Chronic pain may continue for months or possibly years.

Chronic pain is associated with ongoing conditions, such as arthritis and back problems. Many medical problems can cause chronic pain.

The limitations imposed by chronic pain can cause long-lasting psychosocial effects for the patient because of necessary changes in lifestyle.

Chronic pain may be described as dull, constant, shooting, tingling, or burning.

The increased heart rate, blood pressure, and respiratory rate seen with acute pain are often* absent* with chronic pain.

A combination of pharmacologic and nonpharmacologic treatments is recommended to alleviate chronic pain. This therapeutic combination would include medication with treatments such as guided imagery, application of heat and cold, and massage.

Question 16

Nociceptive Pain

Answer 16

Nociceptive pain involves injury to tissue in which receptors called nociceptors are located.

Nociceptors may be found in skin, joints, or organ viscera.

Injuries triggering nociceptive pain may be caused by trauma, burns, or surgery.

Nociceptive pain involves four phases:
(1) transduction begins when tissue damage causes the release of substances that stimulate the nociceptors and start the sensation of pain,
(2)** transmission** involves movement of the pain sensation to the spinal cord,
(3) perception occurs when pain impulses reach the brain and the pain is recognized,
(4) **modulation occurs when neurons in the brain send signals back down the spinal cord by release of neurotransmitters.
Treatment of nociceptive pain may be directed toward one or all of the four phases. Nonsteroidal antiinflammatory drugs (NSAIDs) **work by blocking the production of the substances that trigger the nociceptors in the transduction phase.
Drugs that interfere with the transmission phase include **opioids.
Nonpharmacologic treatments such as distraction and guided imagery may be effective during the perception phase.
Drugs that block neurotransmitter** uptake work in the modulation stage.

Question 17

Neuropathic Pain

Answer 17

Neuropathic pain is usually associated with a dysfunction of the nervous system—specifically, an abnormality in processing sensations. Pain receptors in the body become sensitive to stimuli and send pain signals more easily. Nerve endings grow additional branches that send stronger pain signals to the brain. As the branches grow, they influence touch and warmth receptors, and these receptors begin to send pain signals. In some cases, the pain signal that normally moves from the periphery toward the brain reverses and is sent in the opposite direction. These changes in the nervous system are often associated with medical conditions rather than tissue damage. Diabetes, Guillain-Barré syndrome, multiple sclerosis, cancer, human immunodeficiency virus (HIV), and nutritional deficiencies are examples of medical conditions associated with neuropathic pain.
Analgesics and opioids alone usually do not relieve neuropathic pain. Neuropathic pain is sometimes managed with common analgesics such as those in the NSAID family but also increasingly managed with adjuvant medications such as tricyclic antidepressants, anticonvulsants, and corticosteroids.

Question 18

Phantom Pain

Answer 18

Phantom pain occurs after the loss of a body part from amputation. The patient may “feel” pain in the amputated part for years after the amputation has occurred.
If this cannot be controlled with conventional methods, pain may be controlled by continuous electrical stimulation from electrodes surgically implanted in the thalamus.

Question 19

Perception of Pain

Answer 19

One of the most difficult aspects of pain management is the assessment of pain and the evaluation of the effectiveness of interventions.
Cultural background influences how people show pain. Some cultures teach that outward expressions of pain are to be avoided.
Men in some cultures may believe that denying the presence of pain shows bravery and strength.
Care must be taken to ensure that adequate pain management is provided.
The older adult may not express pain because they mistakenly believe it is a logical consequence of aging, because they do not want to be a bother, or because they have been culturally trained not to complain about pain.

Question 20

Observable indicators of pain

Answer 20

Observable indicators of pain include* moaning, crying, irritability, inability to sleep, grimacing or frowning, restlessness, and a rigid posture in bed.* Remember that these things can also indicate sorrow, worry, fear, and fatigue. In addition, some stoic **patients may show none of these outward expressions of pain. Other detectable signs of pain can be an elevation in blood pressure, heart rate, and respirations or the presence of nausea or diaphoresis.
Fully assess the patient’s pain and encourage the patient to express the perception of the pain being experienced. Some patients may perceive pain to be less than or greater than what you may have seen before for the same condition.

Question 21

Pain Assessment

Answer 21

• History of pain: Events or factors that precipitated the pain, location and radiation, intensity, quality (what the pain feels like),** aggravating factors**, relieving measures, past episodes, past successful treatments, surgery, fracture, burns, and injury
• Medications: Present treatment and past treatment, including prescriptions, over-the-counter medications, herbal preparations or supplements, and alcohol or other drug use
• Verbal indicators: Severity of pain (pain scale assessment), words used to describe pain; moaning, grunting, crying, as well as the timing of when the pain began and whether it has changed
• Nonverbal indicators: Grimacing, guarding, splinting, evident muscle tension, pacing, rocking, fetal positioning, wincing, inability to sleep, restless movements, and withdrawal from others
• Social or psychological factors: Fear or anxiety, extreme stress, worry, or depression
  * Treatments used: Medications, heat, cold, massage, vibration, acupuncture, chiropractic adjustment, brace or splint, or aromatherapy
• Contributing factors: Constipation, sleep deprivation, fatigue, constant cough, rash, gastrointestinal upset, or **esophageal **reflux

Question 22

PQRST

Answer 22

A Mnemonic Device for Pain Assessment Is PQRST
P:** Precipitating** events
Q: Quality of pain or discomfort
R: Radiation of pain
S: Severity of pain
T: Timing

Question 23

Descriptive Terms for Pain

Answer 23

Absent, minimal, mild

Type of Description Specific Terms
Degree of pain

Question 24

Pain Scales

Question 25

FLACC

Answer 25

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is used for preverbal children or noncommunicative patients

Question 26

pain scales for infants

Answer 26

For infants, one of several scales is used:** Neonatal Infant Pain Scale (NIPS)**; Crying, Requires oxygen to maintain saturation, Increased vital signs, Expression, and Sleeplessness (CRIES); or Premature Infant Pain Profile (PIPP).

Question 27

Problem statements

Answer 27

• Acute pain
• Chronic pain
• Fatigue
• Altered self-care ability
• Insufficient knowledge
• Disrupted sleep pattern
• Anxiety
• Fear

Question 28

A possible goal

Answer 28

“patient will report pain at a level of less than 3 on a 0-to-10 scale within 2 days.”

Question 29

Nonmedicinal Methods of Pain Control

Answer 29

Transcutaneous electrical nerve stimulation (TENS)
Percutaneous electrical nerve stimulation
Binders and braces
Application of heat and cold
Relaxation
Biofeedback
Distraction
Guided imagery and meditation
Music
Hypnosis
Massage

Question 30

Medical Methods of Pain Control

Answer 30

Analgesic medications
Patient-controlled analgesia
Epidural analgesia

Question 31

Analgesic medications

Answer 31

The four basic categories of medications for the relief of pain are
(1) nonopioid pain medications, a category that includes NSAIDs;
(2)** cyclooxygenase-2** (COX-2) inhibitors;
(3) narcotics or opioids;
(4) adjuvant analgesics.

Question 32

Analgesics may be given via several routes

Answer 32

oral,
sublingual (SL),
topical,
intramuscular (IM) injection,
ntravenous (IV) injection or infusion,
PCA,
epidural infusion.

Question 33

Categories of Analgesic Medications

Answer 33

Nonopioid analgesics, including NSAIDs

Block pain at the peripheral nervous system level

Over-the-counter: aspirin, acetaminophen, ibuprofen (nonprescription dose), naproxen

Prescription: ibuprofen (prescription dose), naproxen, indomethacin

COX-2 inhibitors

Block the COX-2 enzyme, which plays a role in arthritis pain

Anti-inflammatories: celecoxib is currently the only FDA-approved COX-2 inhibitor

Narcotics or opioids

Block pain at the central nervous system level

Narcotic agonists: morphine, oxycodone, hydrocodone, hydromorphone, codeine, levorphanol, oxymorphone, and meperidine (used less frequently because of significant side effects)

Adjuvant analgesics

Various methods of action

Anticonvulsants: phenytoin, carbamazepine

Antidepressants: amitriptyline, imipramine, SSRIs

Muscle relaxants: baclofen

Stimulants: caffeine, dextroamphetamine

Question 34

Topical medications

Answer 34

Various topical preparations, such as** capsaicin, ibuprofen, diclofenac, or menthol **cream or gels, may provide relief for muscle or joint pain. Medication patches, such as fentanyl patches, allow the analgesic medicine to be absorbed slowly through the skin. Lidoderm patches are often helpful for neuropathic pain. Fentanyl is approved for relief of severe chronic pain only.

A pain medication patch containing metal must be removed before a patient undergoes a magnetic resonance imaging (MRI) scan, otherwise a burn to the skin may occur.

Question 35

Epidural analgesia

Answer 35

The epidural route has been used for anesthesia for many years. Epidural analgesia, however, is a newer form of pain control.

Question 36

Functions of Sleep

Answer 36

Sleep influences memory, mood, cognitive function, secretion of various hormones, immune function, body temperature, and kidney function.
Adequate rest and sleep are important factors in general health and recovery from illness. Adequate sleep also plays a major role in pain control. Being rested increases pain tolerance and allows an improved response to analgesia.
People who do not get adequate rest often suffer from daytime drowsiness and fatigue. Irritability, depression, and impaired concentration and memory are also common. Both accidents and illness increase in frequency.

Question 37

Stages of Sleep

Answer 37

Normal sleep follows a course through two states: non–rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. REM sleep is the time in which you dream and a period of a high level of activity. Heart rate, blood pressure, and respirations are similar to the levels when awake. NREM sleep is believed to be the time when the body receives the most rest. During this stage, heart rate, blood pressure, and respirations decline. During the night, a person goes through these two states in 90-minute cycles, repeating the cycles five or six times.

Question 38

NREM sleep

Answer 38

NREM sleep is divided into four stages.
The first is* a transition stage. As a person falls into a light sleep, the muscles relax. This stage usually lasts a few minutes, followed by** stage 2,*** when the person falls into a deeper sleep. Brain wave activity becomes larger, with bursts of electrical activity. This stage lasts 10 to 20 minutes.
As stage 3 begins, the person enters a period called delta sleep, or slow-wave sleep, named for the high voltage slow brain waves that occur. Respirations and heart rate slow in this stage, and the body becomes immobile. This deep sleep stage lasts 20 to 40 minutes, and dreaming is common. Stage 3 sleep is followed by the deepest stage of sleep, stage 4. During this stage, it is difficult to arouse the sleeping person. This stage lasts approximately 30 minutes.

This is followed by a period of REM sleep. Brain waves become active, almost the same as when awake. This is the stage in which vivid dreams occur, and it lasts approximately 20 minutes. About 25% of the night is spent in REM sleep, and the proportion increases with each sleep cycle during the night.

Question 39

Factors Affecting Sleep

Question 40

Sleep Disorders

Answer 40

Insomnia
Insomnia is difficulty in getting to sleep or staying asleep at night. This may be short-term, lasting only a few nights, or chronic, lasting a month or longer.
Sleep Apnea
Sleep apnea is a condition in which the person stops breathing for brief periods during sleep. There are three types of sleep apnea: obstructive, central, and mixed complex. They can be further classified as mild, moderate, and severe.
Obstructive apnea is the most common type. It is caused by a relaxation of the soft tissues, which allows partial to total obstruction of the airway.
Central apnea is caused by a failure of the brain to communicate with the respiratory muscles. This results in cessation of breathing with no observable respiratory effort. As the oxygen saturation decreases, the individual resumes breathing. This is much less common than obstructive apnea. Mixed complex sleep apnea is, as the name implies, a combination of obstructive and central sleep apnea.

Snoring
Snoring, or harsh sounds that accompany breathing during sleep, is caused by vibration and/or obstruction of the air passages at the back of the mouth and nose.

Narcolepsy
Narcolepsy is sudden onset, recurrent, uncontrollable, brief episodes of sleep during normal hours of wakefulness in a well-rested person.

Question 41

Possible problem statements for the patient with sleep disturbances are:

Answer 41

• Disrupted sleep pattern
• Insomnia
• Fatigue
• Acute pain
• Chronic pain
• Anxiety
• Altered breathing pattern
• Risk for restricted airway

Question 42

Nonopioid analgesics, including NSAIDs

Block pain at the peripheral nervous system level

Answer 42

Over-the-counter:
aspirin,** acetaminophen**, ibuprofen (nonprescription dose), naproxen
/ə-ˌsē-tə-ˈmi-nə-fən/ /nə-ˈpräk-sən/

Prescription:
ibuprofen (prescription dose),** naproxen**, indomethacin
/ˌin-dō-ˈme-thə-sən/

Question 43

Narcotics or opioids
Block pain at the central nervous system level

Answer 43

Narcotic agonists: /när-ˈkä-tik/ /ˈa-gə-nist/
morphine,
oxycodone, /ˌäk-sē-ˈkō-ˌdōn/
hydrocodone, /ˌhī-drō-ˈkō-ˌdōn/
hydromorphone, / -ˈmȯr-ˌfōn/
codeine, /ˈkō-ˌdēn/
levorphanol, /ˌlev-ˈȯr-fə-ˌnȯl /
oxymorphone, /-ˈmȯr-ˌfōn /
and meperidine (used less frequently because of significant side effects) /mə-ˈper-ə-ˌdēn/

Question 44

COX-2 inhibitors

Block the COX-2 enzyme, which plays a role in arthritis pain

Answer 44

Anti-inflammatories: celecoxib is currently the only FDA-approved COX-2 inhibitor** /ˌsel-ə-ˈkäk-sib/**

Question 45

Adjuvant analgesics
/ ˈa-jə-vənt/ /ˌa-nᵊl-ˈjē-zik /

Various methods of action

Answer 45

Anticonvulsants: /ˌan-tē-kən-ˈvəl-sənt, ˌan-tī-/
phenytoin, carbamazepine
/fə-ˈni-tə-wən/ /ˌkär-bə-ˈma-zə-ˌpēn/

Antidepressants: /ˌan-tē-di-ˈpre-sᵊnt /
amitriptyline, imipramine, SSRIs
/ˌa-mə-ˈtrip-tə-ˌlēn/ /i-ˈmi-prə-ˌmēn/

Muscle relaxants:
baclofen /ˈbak-lō-ˌfen/

Stimulants:
caffeine, dextroamphetamine
/ ˈdek-(ˌ)strō-am-ˈfe-tə-ˌmēn /