Transcript Module I Comfort, Sleep and Rest, student copy

Comfort, Sleep and Rest Management
1
Chapter 42
Sleep
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Circadian rhythms
◦ Affected by light, temperature, social activities,
and work routines.
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The biological rhythm of sleep frequently
becomes synchronized with other body
functions.
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Regulated by a sequence of physiological
states integrated by central nervous
system (CNS) activity
Hypothalamus
Reticular activating system (RAS)
Bulbar synchronizing region (BSR)
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Walter Murphy is 82 years old and has resided in the
local nursing home for the past 3 months. His wife,
Mary, still lives at home but visits Walter on a daily
basis. Walter is confined to a wheelchair as a result
of osteoarthritis and a mild stroke he experienced 1
year ago. Even though he has physical limitations, he
is alert and oriented.
Over the past several weeks, Mary found her
husband to be very sleepy when visiting him just
before lunchtime. Walter tells Mary that he has
trouble falling asleep at night, and once he does fall
asleep, he reawakens frequently during the night.
NREM
Stage 2
NREM
REM
Stage 3
NREM
NREM
Stage 2
Stage 4
NREM
Stage 3
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Purpose of sleep
◦ Remains unclear
◦ Physiological and psychological restoration
◦ Maintenance of biological functions
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Dreams
◦ Occur in nonrapid eye movement (NREM) and
rapid eye movement (REM) sleep
◦ Important for learning, memory, and adaptation
to stress
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Physical illness can cause pain, physical
discomfort, anxiety, depression, and sleep
disturbances:
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Hypertension
Respiratory disorders
Nocturia
Pain
Restless leg syndrome (RLS)
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Hypersomnolence = Excessive sleepiness.
A polysomnogram involves the use of electroencephalography
(EEG), electromyography (EMG), and electro-oculography
(EOG) to monitor stages of sleep and wakefulness during
nighttime sleep.
Sleep hygiene = Practices that a patient associates with
sleep.
Cataplexy is sudden muscle weakness during intense
emotions such as anger, sadness, or laughter; it can occur
at any time during the day.
Sleep paralysis is the feeling of being unable to move or
talk just before waking or falling asleep.
Insomnia
• Adjustment sleep disorder (acute
insomnia), Inadequate sleep hygiene,
Behavioral insomnia of childhood,
Insomnia caused by medical condition
Sleep apnea
• Primary central sleep apnea, Central sleep apnea
caused by medical condition, Obstructive sleep
apnea syndromes, Excessive daytime sleepiness
Narcolepsy
• Cataplexy, Sleep paralysis
Sleep deprivation
Parasomnias
• Emotional stress, Medications,
Environmental disturbances, Symptoms
• Somnambulism (sleepwalking), Night
terrors, Nightmares, Nocturnal enuresis
(bed-wetting), Body rocking, Bruxism
1.During rounds on the night shift, you note
that a patient stops breathing for 1 to 2
minutes several times during the shift. This
condition is known as
A. Cataplexy.
B. Insomnia.
C. Narcolepsy.
D. Sleep apnea.
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Rest contributes to:
◦ Mental relaxation
◦ Freedom from anxiety
◦ State of mental, physical, and spiritual activity
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Bed rest does not guarantee that a patient
will feel rested.
Neonates
Infants
16 hours a day
8 to 10 hours at night for a total
of 15 hours per day
Toddlers
Preschoolers
Total 12 hours a day
12 hours a night
School Age
Adolescents
9 to 10 hours
Get ~7½ hours
Young Adults
Middle and Older Adults
Get 6 to 8½ hours
Total number of hours declines
2. A 4-year-old pediatric patient resists
going to sleep. To assist this patient, the
best action to take would be
A. Adding a daytime nap.
B. Allowing the child to sleep longer in the
morning.
C. Maintaining the child’s home sleep
routine.
D. Offering the child a bedtime snack.
Physical illness
Drugs and substances
Lifestyle
Usual sleep patterns
Emotional stress
Environment
Hypertension, respiratory,
musculoskeletal, chronic
illness, GI, nausea
Work schedule, social
activities, routines
Worries, physical health,
death, losses
Hypnotics, diuretics,
narcotics, antidepressants,
alcohol, caffeine, betablockers, anticonvulsants
May be disrupted by social
activity or work schedule
Noise, routines
3. A patient suffers from sleep pattern
disturbance. To promote adequate sleep, the
most important nursing intervention is
A. Administering a sleep aid.
B. Synchronizing the medication, treatment, and
vital signs schedule.
C. Encouraging the patient to exercise
immediately before sleep.
D. Discussing with the patient the benefits of
beginning a long-term night-time medication
regimen.iok
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Anna is a 23-year-old nursing student
assigned to the nursing home for her
second semester in nursing school. She
has had experience in nursing homes,
having worked in one center as a nurse
assistant during the last two summers.
Anna’s assignment is to care for Mr.
Murphy over the next 4 weeks.
What factors could Anna consider when
preparing to care for Mr. Murphy?
Assessment
Diagnosis
Plannin
g
Implementati
on
Evaluation
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As Anna prepares to conduct an assessment of
Mr. Murphy, she knows it is important to
consider how sleep is altered in older adults.
Because they typically have less deep sleep and
more awakenings, it will be important to
consider what factors in the nursing home
disrupt sleep.
She has learned that his osteoarthritis pain is a
contributing factor to the sleep disturbances.
His immobility from the stroke adds discomfort.
Anna also plans to assess Mr. Murphy’s
medications carefully to determine whether any
drugs are adding to a sleep alteration.
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Sleep assessment
◦ Sources for sleep assessment = Patient, family
◦ Tools for sleep assessment
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Sleep history
◦ Description of sleeping problems, usual sleep
pattern, current life events, physical and
psychological illness, emotional and mental
status, bedtime routines, bedtime environment,
behaviors of sleep deprivation
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Assessment questions for Mr. Murphy:
◦ Please describe the nature of your sleep
problem.
◦ Do you awaken during the night?
◦ Can you rate the quality of last night’s sleep?
◦ Please describe your usual bedtime routine.
◦ Are you having any trouble that is contributing
to your sleep problem?
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Assess Mr. Murphy for signs of sleep
problems.
Anxiety
Ineffective
breathing
pattern
Acute
confusion
Compromised
family coping
Ineffective
coping
Insomnia
Fatigue
Sleep
deprivation
Readiness for
enhanced sleep
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Nursing diagnosis: insomnia
◦ Related to excessive environmental stimuli
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Goal
◦ Mr. Murphy will attain a sense of restfulness
after sleep in 1 month.
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Goals and outcomes example
◦ Goal: The patient will control environmental
sources disrupting sleep within 1 month.
◦ Outcomes:
 Patient will identify factors in the immediate home
environment that disrupt sleep in 2 weeks.
 Patient will report having a discussion with family
members about environmental barriers to sleep in
2 weeks.
 Patient will report changes made in the bedroom to
promote sleep within 4 weeks.
 Patient will report having fewer than two
awakenings per night within 4 weeks.
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Health promotion
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Environmental controls
Promoting bedtime routines
Promoting safety
Promoting comfort
Establishing periods of rest and sleep
Stress reduction
Bedtime snacks
Pharmacological approaches
Discourage daytime
napping.
Bright light in the morning
helps maintain a 24-hour
circadian cycle.
Daytime napping interferes with
sleeping,
Have an egg-crate-type
mattress placed over his
normal mattress.
Increasing comfort of sleeping
position, enhancing relaxation
will promote sleep.
Encourage Mr. Murphy to
decrease his fluids 2 to 4
hours before sleep.
Decreases the number of times
the patient awakens to urinate.
Arrange for Mr. Murphy to
have a CD player and
headphones when he goes
to sleep.
Soothing music blocks out
sounds from the environment
and promotes relaxation.
Sit next to the window 30 to
60 minutes each morning.
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Acute care
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Environmental controls
Promoting comfort
Establishing periods of rest and sleep
Promoting safety
Stress reduction
Restorative or continuing care
◦ Promoting comfort
◦ Controlling physiological disturbances
◦ Pharmacological approaches
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Anna asked Mr. Murphy to use a rating scale for
the quality of his sleep at the end of each week.
After 1 week, Mr. Murphy rates his night sleep
at a 6 out of 10; after 2 weeks, an 8 out of 10.
Anna asked Mrs. Murphy to evaluate her
perceptions of Mr. Murphy’s level of fatigue. She
says he is more alert, awake, and talkative
during her visits.
Anna asked Mr. Murphy at the end of 4 weeks to
keep a record for a week of the length of time
he estimates he is sleeping.
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Patient outcomes
◦ Determine whether expected outcomes have
been met.
 Are you able to fall asleep within 20 minutes of
getting into bed?
 Describe how well you sleep when you exercise.
 Does the use of quiet music at bedtime help you to
relax?
 Do you feel rested when you wake up?
Chapter 43
Pain Management
Involves physical, emotional, and cognitive
components
Results from physical and/or mental
stimulus
Reduces quality of life
Not measurable objectively
Subjective and highly individualized
component
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Cellular damage by thermal, mechanical,
or chemical stimuli causes release of
neurotransmitters.
◦ Prostaglandins, bradykinin, potassium,
histamine, substance P
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Neurotransmitters surround the pain
fibers, spreading the pain message and
causing an inflammatory response.
Nerve impulse travel along afferent
(sensory) nerve fibers to the spinal cord.
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Pain impulses ascend the spinal cord to
the thalamus, which transmits information
to higher brain centers that perceive pain.
Two types of sensory nerve fibers:
◦ Fast myelinated A-delta fibers: send sharp,
localized, distinct sensations
◦ Slow, small, unmyelinated C fibers: send poorly
localized, burning, persistent pain
Transduction
Conversion of
stimulus into
electrical energy
Transmission
Sending of impulse
across a sensory
pain nerve fiber
(nociceptor)
Perception
Modulation
The patient’s
Inhibition of pain/
experience of pain release of inhibitory
neurotransmitters
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Gate-control theory of pain (Melzack and
Wall)
◦ Pain has emotional and cognitive components,
in addition to a physical sensation.
◦ Gating mechanisms in the central nervous
system (CNS) regulate or block pain impulses.
◦ Pain impulses pass through when a gate is open
and are blocked when a gate is closed.
◦ Closing the gate is the basis for
nonpharmacological pain relief interventions.
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Mrs. Ellis is a 70-year-old African American
woman with hypertension, diabetes, and
rheumatoid arthritis. Her current health
priority is the discomfort and disability
associated with her rheumatoid arthritis.
Arthritis has severely deformed her hands and
feet. The pain in her feet is so severe that she
often walks only short distances. The pain
interferes with sleep and reduces her energy
both physically and emotionally. As a result,
she does not leave home often.
Acute/transient pain
Protective, identifiable,
short duration; limited
emotional response
Chronic/persistent
noncancer
Is not protective, has no
purpose, may or may not have
an identifiable cause
Chronic episodic
Cancer
Occurs sporadically over
an extended duration
Can be acute or chronic
Inferred pathological
Idiopathic
Musculoskeletal,
visceral, or neuropathic
Chronic pain without identifiable
physical or psychological cause
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Attitude of health care providers
◦ Malingerer or complainer
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Assumptions about patients in pain
◦ Biases based on culture, education, experiences
◦ Acknowledge pain through patient’s experiences
◦ Limit your ability to help the patient
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Physiological
◦ Age, fatigue, genes, neurological function
 Fatigue increases the perception of pain and can
cause problems with sleep and rest.
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Social
◦ Attention, previous experiences, family and
support groups, spiritual
◦ Spirituality includes active searching for
meaning in situations, with questions such as
“Why am I suffering?”
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Psychological
◦ Anxiety
◦ Coping style
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Pain tolerance
◦ The level of pain a person is willing to accept
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Cultural
◦ Meaning of pain
◦ Ethnicity
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Pain management needs to be systematic.
Pain management needs to consider the
patient’s quality of life.
Clinical guidelines are available to manage
pain:
◦ American Pain Society
◦ National Guideline Clearing House
(www.guideline.gov)
◦ Agency for Healthcare Research and Quality
(AHRQ)
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Patient’s expression of pain
Characteristics of pain
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Onset and duration
Location
Intensity
Quality
Pattern
Relief measures
Contributing symptoms
Effects of pain on the patient
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Effects of pain on the patient
◦ Behavioral effects
 Assess verbalization, vocal response, facial and body
movements, and social interaction.
 For patients unable to communicate pain, it is vital for
you to be alert for indicative behaviors.
◦ Influence on activities of daily living
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Physical deconditioning
Sleep disturbances
Sexual relationships
Ability to work (outside of and in the home)
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Jim is a 26-year-old nursing student
assigned to do home visits with the
community health nurse. Jim knows that
Mrs. Ellis has lived alone since her
husband’s death 6 years ago.
Jim conducts assessments, performs
procedures, and teaches health promotion
to a variety of patients. This is Jim's first
experience caring for a patient with severe
chronic pain.
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A: Ask about pain regularly. Assess pain
systematically.
B: Believe the patient and family in their report
of pain and what relieves it.
C: Choose pain control options appropriate for
the patient, family, and setting.
D: Deliver interventions in a timely, logical, and
coordinated fashion.
E: Empower patients and their families. Enable
them to control their course to the greatest
extent possible.
1. When a smiling and cooperative patient
complains of discomfort, nurses caring for this
patient often harbor misconceptions about the
patient's pain. Which of the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to
drug addiction.
D. Amount of pain is reflective of actual tissue
damage.
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When Jim enters Mrs. Ellis’ four-room
apartment, he finds the home in disarray. Mrs.
Ellis is sitting in a recliner in her living room,
with clothing on the floor and soiled dished on a
nearby table. She reports that the pain she has
been experiencing has made it very difficult to
use her hands and walk between rooms. She is
able to get to the bathroom, but it causes her to
become fatigued.
Her pain is constant and is localized in the
joints of her hands and knees.
Activity
intolerance
Anxiety
Ineffectiv
e coping
Hopelessness
Insomnia
Fear
Fatigue
Impaired
physical
mobility
Powerlessness Chronic
Impaired Spiritual
low selfsocial
distress
esteem interactio
n
Imbalanced nutrition: less than body
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Mrs. Ellis’ responses lead Jim to this
nursing diagnosis: chronic pain related to
joint inflammation.
Mrs. Ellis has rated the pain as a 3 on a
FACES Pain Scale of 0 to 10, with her most
severe pain as a 4.
She has been taking aspirin, but the pain
prevents her from falling asleep; if she
does sleep, she often reawakens.
She has difficulty standing and an
unsteady gait.
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Determine with the patient what the pain has
prevented the patient from doing.
Then agree on an acceptable level of pain that allows
return of function.
For example, for the goal, “The patient will achieve a
satisfactory level of pain relief within 24 hours,”
possible outcomes are as follows:
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Reports that pain is a 3 or less on a scale of 0 to 10
Identifies factors that intensify pain
Uses pain relief measures safely
Level of discomfort does not interfere with activities of daily
living (ADLs).
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Nonpharmacological pain relief
interventions
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Relaxation, guided imagery
Biofeedback
Distraction, music
Cutaneous stimulation
 Massage, transcutaneous electrical nerve
stimulation (TENS), heat, cold, acupressure
◦ Herbals
◦ Reducing pain perception
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Pharmacological pain relief
◦ Acute pain management
◦ Analgesics
 Nonopioids
 Opioids
 Adjuvants/co-analgesics
◦ Delivery systems
 Patient-controlled analgesia (PCA)
 Local/regional anesthesia
 Topical agents
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Jim discussed with Mrs. Ellis’ primary health
care provider the possibility of starting a
disease-modifying antirheumatic drug (DMARD),
a biological response modifier, a nonsteroidal
anti-inflammatory drug (NSAID), or an
analgesic.
Jim had Mrs. Ellis take analgesics approximately
30 minutes before ambulating, performing selfcare activities, or going to sleep. He instructed
her to take medication with a light snack or
meal and a full glass of water. During
instruction, he explained that the drug will
relieve the pain.
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Jim also suggested the following to Mrs.
Ellis:
◦ Place a sturdy stool in the shower stall and run
warm water continuously over joints of the
hands and feet.
◦ Apply moist, warm compresses to the joints of
the hands 3 times a day.
◦ Referral to a physical therapist to determine
possible use of a walker or other assistive device
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What are the rationales for these additional
measures?
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Nursing implications
◦ You maintain responsibility for providing
emotional support to patients receiving local or
regional anesthesia.
◦ After administration of a local anesthetic,
protect the patient from injury until full sensory
and motor function return.
◦ Nursing implications for managing epidural
analgesia are numerous.
◦ Nurses monitor IV sites, lines, and controllers.
2. A patient has just undergone an
appendectomy. When discussing with the
patient several pain relief interventions,
the most appropriate recommendation
would be
A. Adjunctive therapy.
B. Nonopioids.
C. NSAIDs.
D. PCA pain management.
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Cancer pain may be chronic or acute.
Breakthrough pain = A transient flare of
moderate to severe pain superimposed on
continuous or persistent pain.
Transdermal pain patches may be used.
WHO, World Health Organization.
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Physical dependence: A state of adaptation that is
manifested by a drug class–specific withdrawal syndrome
produced by abrupt cessation, rapid dose reduction,
decreasing blood level of the drug, and/or administration
of an antagonist
Addiction: A primary, chronic, neurobiological disease
with genetic, psychosocial, and environmental factors
influencing its development and manifestations
Drug tolerance: A state of adaptation in which exposure
to a drug induces changes that result in a diminution of
one or more effects of the drug over time
Placebos
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Pain centers, palliative care, and hospices
◦ Pain centers treat patients on an inpatient or
outpatient basis.
◦ The goal of palliative care is to learn how to live
life fully with an incurable condition.
◦ Hospices are programs for end-of-life care.
◦ The American Nurses Association (ANA)
supports aggressive treatment of pain and
suffering even if it hastens a patient’s death.
3. A postoperative patient is using PCA. You
will evaluate the effectiveness of the
medication when
A. You compare assessed pain w/baseline
pain.
B. Body language is incongruent with reports
of pain relief.
C. Family members report that pain has
subsided.
D. Vital signs have returned to baseline.
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What is the pain rating now? Over the past
period of time?
Which pain rating is acceptable to the
patient?
How do you recommend that the patient’s
treatment be changed to reduce the pain
rating?
Which professional reference can be used,
if needed, to support this
recommendation?
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When Jim observed Mrs. Ellis’ ability to
stand and walk from the living room to the
kitchen, she was able to ambulate with the
walker; her gait was slow but steady.
Mrs. Ellis reports that she has less
discomfort from bathing after using warm
water over her joints, although dressing is
still causing some discomfort when
manipulating buttons.
Mrs. Ellis rates her pain at a 2 after taking
the analgesic.
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Evaluation of pain is one of many nursing
responsibilities that require effective
critical thinking.
The patient’s response to pain may not be
obvious.
Evaluating the appropriateness of pain
medication will require nurses to evaluate
patients’ responses after administration.
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The patient is the only person who should
press the button to administer the pain
medication when PCA is used.
Monitor the patient for signs and symptoms of
oversedation and respiratory depression.
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Two weeks after his last visit, Jim returns
to evaluate Mrs. Ellis’ progress. She has
gone to see a nurse practitioner, who
prescribed an NSAID for her arthritic pain.
She has not filled the prescription and is
still taking her aspirin, but continues to
have some gastrointestinal irritation. Jim
gets the chance to observe Mrs. Ellis using
a warm compress on her hands and notes
that her gait is steadier.
Mrs. Ellis has spoken with her neighbor,
who has offered to help with shopping.