Transcript Comfort ppt 2x

CONCEPT:
Comfort
Concept Definition
A state of physical ease
Comfort Concept: Objectives
• Explain the concept of comfort (including
definition, antecedents, and attributes).
• Analyze conditions which place a patient at risk
for impaired comfort.
• Identify when impaired comfort is developing or
has developed.
• Discuss exemplars of common disruptions of
patient comfort. (Pain)
• Apply the nursing process (including
collaborative interventions) for individuals
experiencing comfort imbalance.
Positive Consequences
• Social interactions
• Perform ADL’s
• Adapt to stressors
• Calm demeanor
Sub-Concepts of Comfort
•Neuropathic pain
•Chronic and Acute pain
•Theory of pain control
•Nociceptive Pain
•Mixed Pain Syndromes
Pain is….
•Whatever the experiencing person says it is
whenever he or she is experiencing it
•A personal and private experience
•An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage.
•A subjective experience
Pain is described in
terms of….
•Duration
•Location
•Etiology
•Chronic vs. Acute
Components of Pain
Components of Pain
• Behavioral (Voluntary) Responses
• Moving away from painful stimuli
• Grimacing, moaning, and crying
• Restlessness
• Protecting the painful area and refusing to
move
Components of Pain
• Physiologic (Involuntary) Responses
• Typical Sympathetic Responses When Pain Is
Moderate and Superficial
• Increased blood pressure*
• Increased pulse and respiratory rates*
• Pupil dilation
• Muscle tension and rigidity
• Pallor (peripheral vasoconstriction)
• Increased adrenalin output
• Increased blood glucose
Components of Pain
• Typical Parasympathetic Responses When Pain Is
Severe and Deep
• Nausea and vomiting
• Fainting or unconsciousness
• Decreased blood pressure
• Decreased pulse rate
• Prostration (prone position)
• Rapid and irregular breathing
Components of Pain
Affective (Psychological)
Responses
• Exaggerated weeping and
restlessness
• Withdrawal
• Stoicism
• Anxiety
• Depression
• Fear
• Anger
• Anorexia
• Fatigue
• Hopelessness
• Powerlessness*
• An increase in vital signs
may occur briefly in
acute pain but may not
occur with chronic pain
Types of pain include:
• Deep somatic
• Originates in the skin,
muscle or bone or
connective tissue
• Visceral
• Pain arising from organs
• Radiating
• spreading outward
• pain that starts in one area
and spreads until a larger
area hurts
• Referred
• Appear to arise in different areas
to other parts of the body
• Cardiac may be felt in shoulder
• Intractable pain
• Pain not relieved by ordinary
medical, surgical, and nursing
measures.
• Often chronic and persistent and
can be psychogenic in nature.
Neuropathic Pain
• “Neuropathic pain results from the abnormal processing
of sensory input by the nervous system as a result of
damage to the brain, spinal cord, or peripheral nerve”.
• Typically chronic
• Described as burning, electric shock, and/or tingling,
dull and aching
• Diabetic peripheral neuropathy
• Phantom limb pain
• Carpal tunnel syndrome
• Multiple sclerosis
• Spinal cord injury
Nociceptive Pain
•“Refers to the normal functioning of
physiologic systems that leads to the
perception of noxious stimuli (tissue injury) as
being painful”
•Normal pain transmission
•Surgery, trauma, burns, and tumor growth
•Aching, cramping, or throbbing
• Giddens, J. F. (2013). Concepts for nursing practice. Pain
(pp. 270-279). St. Louis, Mo: Mosby.
Terminology Associated
with Pain
•“ Pain Threshold”
• Least amount of stimuli that is needed for a
person to label a sensation as pain
•“ Pain Sensation”
• a somatic sensation of acute discomfort;
•“ Pain Tolerance”
• Maximum amount and duration of pain that an
individual is willing to endure
Steps in the Pain Process
•Nociception
•Transduction
•Transmission
•Perception
•Modulation
Steps in the Pain Process
•Transduction
•Specialized pain receptors or
nocioreceptors can be excited by
mechanical, chemical or thermal
stimuli (action potential)
Steps in the Pain Process
•Transmission
•Transmission of pain, travels from the
peripheral nerve fibers to the spinal cord
•Substance P serves as a neurotransmitter
enhancing the movement of impulses
across the nerve synapse
•Creating an action potential (Na+ moves in
K+ moves out of the cell)
Figure 46- 2 Substance P assists the transmission of impulses across the synapse from the primary afferent neuron
to a second-order neuron in the spinothalamic tract.
Steps in the Process of Pain
•Transmission
•From here they are diverted to the thalamus
where they are sorted out and sent on to the
cerebral cortex.
•This is where you get the message that it
hurts.
Steps in the Pain Process
•Perception
• When the patient becomes conscious of the
pain
• The psychosocial context of the situation and
the meaning of the pain based on past
experiences shapes the behavioral response
• There can be associated emotional feelings of
anxiety, fear, or pleasure (as in a good hurt or
runners high from a hard workout).
Steps in the Pain Process
•Modulation
• Occurs when neurons in the thalamus and brainstem
send signals back down to the dorsal horn of the
spinal cord
• The descending fibers release substances such as
endogenous opioids, serotonin, and norepinephrine
which can inhibit the ascending noxious impulses in
the dorsal horn
•Primary afferent fibers terminate in
the dorsal horn of the spinal cord
2
3
1
4
Fig. 10-1. Nocioceptive pain originates when the tissue is injured. 1, Transduction occurs when there is
release of chemical mediators. 2, Transmission involves the conduct of the action potential from the
periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3,
Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back
down the spinal cord to modify incoming impulses.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Acute and Chronic Pain
•Acute pain-usually short lived
•Chronic pain-cancer, osteoarthritis, pain from
an underlying medical condition, may last a
lifetime
•Acute and Chronic pain combination
CLASSIFICATIONS
• Acute Pain
• Chronic Pain
• Rapid onset
• Mild to severe
• Subsides upon healing
• Protective-reflects potential
or present tissue damage
• It should end once healing
occurs
• CNS response:
•  Vital signs
• Diaphoresis
• Dilated pupils
• i.e. sore throat, surgery, cut
• May be limited,
persistent or intermittent
and last beyond healing
• normal function
• Mild to severe
• Periods of remission and
exacerbations
• Parasympathetic NS
response:
• VS normal
• Warm, dry skin
• Pupils normal or dilated
Gate Control Theory
•Is a theory originated by Melzack and Wall in
1965.
•Not unanimously accepted
•Pain treatment is currently based on what
part of the pain transmission process it
effects
Gate Control Theory
• It describes the transmission of painful stimuli and
recognizes a relation between pain and emotions
• The theory states that certain nerve fibers, those of
small diameter, conduct excitatory pain stimuli
toward the brain, but nerve fibers of a large
diameter appear to inhibit the transmission of pain
impulses from the spinal cord to the brain
• There is a gating mechanism that is believed by some
to be located in substantia gelatinosa cells in the
dorsal horn of the spinal cord
Gate Control Theory
•The exciting and inhibiting signals at the
gate in the spinal cord determine the
impulses that eventually reach the brain
•Thus, only a limited amount of sensory
information can be processed by the
nervous system at any given moment
•When too much information is sent through,
certain cells in the spinal column interrupt
the signal as if closing a gate.
Gate Control Theory
• If something stimulates impulses in the large
nerves the gate is closed and pain can then not be
perceived.
• CLOSING THE PAIN GATE:
• Stimulation of touch fibers
• Touching, stroking, massage, vibration
• Endogenous opioids - Produced in CNS - Modulate
pain transmission & perception
• Analgesics – e.g. Endorphins, Acupuncture
Gate Control Theory
• The brain can also influence the gating
mechanism
• Past experiences and learned behaviors, which
are interpreted by the brain, regulate or adjust
the eventual behavioral responses to pain
• Thus, the gating mechanism appears to be
influenced by the amount of activity in large
and small afferent fibers in addition to nerve
impulses that descend from the brain
A schematic illustration of the gate control
theory
A-delta fibers when
activated) excites the
substantia gelatinosa
and facilitates opening
the gates transmitting
messages of pain to
the thalamus
A beta
Large diameter
fibers carrying non
pain (inhibitory
effect)
Send messages of
warmth touch, or
cold
CLINICAL APPLICATION OF GATE
CONTROL THEORY
• Stop nociceptor firing by treating the
underlying cause
• Nursing measures such as massage, heat, cold
or TENS to a painful lower back area, stimulate
large nerve fibers to close the gate, thus
blocking pain impulses
• Address patient’s mood (reduce fear, anxiety,
anger)
• Address patient’s goals (provide education and
anticipatory guidance)
Mixed Pain Syndromes
• “Unique with multiple underlying and poorly
understood mechanisms”
• Fibromyalgia, some low back pain, and myofascial
pain
• Patients may have a combination of nociceptive and
neuropathic pain
• For example, a patient may have nociceptive pain as
a result of tumor growth and also report radiating
sharp and shooting neuropathic pain if the tumor is
pressing against a nerve plexus
• Giddens, J. F. (2013). Concepts for nursing practice. Pain
(pp. 270-279). St. Louis, Mo: Mosby.
The WHO three-step analgesic ladder. From Cancer Pain Relief, 2nd ed.,
by World Health Organization, 1996, Geneva: Author. © Copyright World
Health Organization (WHO). All rights reserved.
WHO LADDER
•Step 1
•For patients with mild pain (1 - 3 on a 0 10 scale)
•Use nonopioid analgesics (with or
without a coanalgesic)
WHO LADDER CON’T
•Step 2
•For patients with mild pain that persists or
increases
•Pain is moderate (4 - 6 on a 0 - 10 scale)
•Use of a weak opioid (e.g., codeine,
tramadol, pentazocine) or a combination of
opioid and nonopioid medicine (oxycodone
with acetaminophen, hydrocodone with
ibuprofen
WHO LADDER CON’T
•Step 3
•patient with moderate pain that persists or
increases or with severe pain
•Pain is severe (7 - 10 on a 0 - 10 scale)
•Strong opioids (e.g., morphine,
hydromorphone, fentanyl)
Antecedents for Comfort
•Effective circulatory system
•Intact neurological/sensory system
•Absence of noxious stimuli
•Able to discern comfort from discomfort
Attributes for Comfort
•Reports being comfortable
•Indicates pain scale of zero
•Relaxed facial expression and body
posture
•Vital signs within the normal limits for
baseline
What are Common Misconceptions about pain?
• Many patient misconceptions interfere with the
patient’s ability to communicate pain
• The doctor has ordered pain-relieving medication for
me, which I will be given routinely.
• If I ask for something for my pain, I may become
addicted to the medication.
• Sometimes it is better to put up with the pain than
to deal with the side effects of the pain medication
• I should somehow be able to control my pain
Common Misconceptions
• It is immature to talk about pain
• It is better to wait until the pain gets really bad
before asking for help
• If I take the medication now for moderate pain, it
won’t relieve severe pain later on
• I don’t want to bother anyone—I know how busy
they are.
• It’s natural for me to have pain after surgery. After a
few days, I should notice it lessening.
How will knowing the Antecendents affect
your Nursing Assessment?
-use of open ended questions
-use of pain scale
-ability to assess patient’s comfort level (i.e.,
nonverbals, ability to do ADL’s, etc.)
-ability to assess patient’s ability to
distinguish between comfort and discomfort
Interrelated Concepts
•
•
•
•
Mobility
Sensory perception
Mood and affect
Functional ability
Risk Factors
•If a patient is able to respond and has all of the
antecedents then customary pain assessment
can be completed by the nurse.
•If the patient is “nonverbal” (i.e, infants,
toddlers, cognitively impaired, etc.) they will
be unable to report pain using the customary
pain assessment methods and tools (Giddens,
np).
Comfort Imbalance-Assessment
How does the nurse know when there is an
imbalance in comfort?
•Comprehensive History
•Physical & Psychological
•Diagnostic Test(s)
•P
• provoking; onset and duration
Assessment
•Q
• Pain history
• Quality, stabbing, sharp, burning
• Vital signs
•R
• Radiation, does it go anywhere?
• Pain scale
•S
• PQRST
• Symptoms, severity, intensity
• Reassessment • T
• Timing, triggers is it intermittent,
continuous, what makes it worse?
• Add…..
• location of pain,
• alleviating and relieving factors,
• effect of pain on function and quality
of life
Numeric Rating Scale
The Numeric Rating Scale (NRS-11) is an 11–point scale for patient self-reporting of pain. It is
for adults and children 10 years old or older.[33]
Rating
0
Pain Level
No Pain
1 – 3 Mild Pain (nagging, annoying, interfering little with ADLs)
4 – 6 Moderate Pain (interferes significantly with ADLs)
7 – 10 Severe Pain (disabling; unable to perform ADLs)
Color Intensity Scale
Physical & Psychological
• Anxiety
• Fear
• Hopelessness
• Sleeplessness
• Reports of pain
• Decrease in cognitive
function
• Mental confusion
• Altered temperament
• Restlessness
• Dilated pupil
• Increased heart rate
• Perspiration
• Muscle spasm
• Increased blood pressure
• Grimacing
• Moaning
• Crying
• Protecting the painful area
decreased movement
Diagnostic Test(s)
•Vital Signs
• Pain Scale
•Laboratory studies
•Diagnostic studies
Exercise
•Write a scenario/assessment using the PQRST
method and add location and alleviating or
relieving factors.
“Hi, Dr. Martin. I have this burning (quality) pain in the
upper left side (location) of my abdomen. It started a
couple of days (timing) ago after I ate pizza (provoking
factor). I took some Maalox and it felt a little better
(relieving factor). But I’m getting worried because
yesterday I threw up and there was some blood
(associated symptom). The pain gets pretty severe at
times (severity). So much so, that I almost double over
with the pain. Sometimes the pain goes across my
abdomen (radiation). What do you think I should do?”
Pain Control - Pharmacologic
•Oral medications
•Intravenous medications
•Epidural analgesia
•Patient-controlled analgesia
•Local anesthesia
Federal Drug Classification Schedules
With the Controlled Substances Act of 1970, a major
illegal substance control campaign began. Americans
have witnessed a corresponding shift of resources and
public attention onto the growing problem of
substance abuse and its effects on society.
• Schedule I
(a) The drug or other substance has a high potential
for abuse.
(b) The drug or other substance has no currently
accepted medical use in treatment in the United
States.
(c) There is a lack of accepted safety for use of the
drug or other substance under medical supervision.
Federal Drug Classification Schedules
• Schedule II
(a) The drug or other substance has a high potential
for abuse.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States or a currently accepted medical use with
severe restrictions.
(c) Abuse of the drug or other substances may lead
to severe psychological or physical dependence.
Federal Drug Classification Schedules
• Schedule III
(a) The drug or other substance has a potential for
abuse less than the drugs or other substances in
schedules I and II.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(c) Abuse of the drug or other substance may lead to
moderate or low physical dependence or high
psychological dependence.
Federal Drug Classification Schedules
• Schedule IV
(a) The drug or other substance has a low potential
for abuse relative to the drugs or other substances in
schedule III.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(c) Abuse of the drug or other substance may lead to
limited physical dependence or psychological
dependence relative to the drugs or other substances
in schedule III.
Federal Drug Classification Schedules
• Schedule V
(A) The drug or other substance has a low potential
for abuse relative to the drugs or other substances in
schedule IV.
(B) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(C) Abuse of the drug or other substance may lead to
limited physical dependence or psychological
dependence relative to the drugs or other substances
in schedule IV.
Analgesic Drugs
• Nonopioid Analgesics
• Opioid Drugs
NONOPIOIDS/NSAIDS
• Prostaglandins are lipid compounds that initiate inflammatory
responses that increase tissue swelling and pain at the site of
injury (Vadivelu, Whitney, & Sinatra, 2009).
• They form when the enzyme phospholipase breaks down
phospholipids into arachidonic acid.
• In turn, the enzyme cyclo-oxygenase (COX) acts on the
arachidonic acid to produce prostaglandins (pg. 218 Brunner
Fig. 12-2).
• COX-1 and COX-2 are isoenzymes of COX and play an important
role in producing the effects of the nonopioid analgesic agents,
which include the nonsteroidal anti-inflammatory drugs
(NSAIDs) and acetaminophen.
• NSAIDs produce pain relief primarily by blocking the formation
of prostaglandins in the periphery
NONOPIOIDS/NSAIDS
• Vary little in analgesic potency but do vary in antiinflammatory effects, metabolism, excretion, and side
effects
• Have a ceiling effect
• Increasing a dose beyond an upper limit, provides no
greater analgesia
• Effective for mild to moderate pain
• Often used in conjunction with opioid because they allow
for effective pain relief using lower opioid doses
• Examples are acetaminophen, ibuprofen, aspirin,
naproxen
Nonopioid Analgesics
• NSAID-includes aspirin, cyclo-oxygenase-2 (COX2)
inhibitors(Celebrex), Ibuprofen (Motrin, Advil)
Aleve, many others.
• commonly used for management of pain associated
with arthritis because of the antiinflammatory and
analgesic effects
• Acetaminophen-(Tylenol)most widely used
nonopioid analgesic
• most commonly used for fever and mild to moderate
pain.
• Tramadol Hydrochloride-Ultram
Nonopioid Analgesics
Warnings:
• Acetaminophen
• (potentially lethal drug if taken in overdose
amounts. Can cause hepatic toxicity, dose
3000mg/day)
• NSAIDs
• Cox2 inhibitors have a lower risk of GI bleeding, but
thought to significantly increase cardiovascular risk
(thrombotic events, myocardial infarction, and
stroke
• Do not use perioperative of coronary artery bypass
graft surgery)
•
Nonopioid Analgesics
NSAIDs-cont.
gastrointestinal (increased risk of bleeding,
ulceration, and perforation of the stomach
and or intestines).
Opioid Drugs
• Alleviate moderate to severe pain
• Potential for adverse effects-nausea,
vomiting, sedation, mental clouding,
respiratory depression, subacute overdose,
and dry mouth
• Contraindications-drug allergy and severe
asthma.
Opioid Drugs – Full Agonists
• Produce their effects by binding to receptors
• Three major classes of opioid receptor sites: mu, delta,
and kappa in the CNS causing inhibition of the
transmission of nociceptive input from the periphery to
the spinal cord
• produces maximum pain inhibition as well as unwanted
effects such as constipation, nausea, sedation, and
respiratory depression
• No ceiling on analgesia
• Dosage can be steadily increased to relieve pain
• No maximum daily dose limit
• E.g., morphine, oxycodone, hydromorphone
OPIOIDS FOR MODERATE PAIN
•
Opioid analgesics for moderate pain
• Codeine or hydrocodone, Tramadol
• Two to four times more potent than nonopioids
alone
• Most are a combination of a nonopioid with an
opioid
• These drugs have a ceiling effect due to the
nonopioid and a maximum daily dose limit
• Advantages: lowering the amount of any one
medication, reducing side effects
Chemical Classification of Opioids
Chemical Category
Meperidine-like drugs
Opioid Drugs
Meperidine, Fentanyl,
Remifentanil, Sufentanil,
Alfentanil
Methadone-like drugs
Methadone, Propoxyphene
Morphine-like drugs
Morphine, Heroin,
Hydromorphone,
Oxymorphone,
Levorphanol, Codeine,
Hydrocodone, oxycodone
Other
Tramadol
Pain Control - Nonpharmacologic
• Massage
• Splinting
• Relaxation and guided imagery
• Distraction
• TENS
• Counterirritation – many things from noxious
chemicals to sharp instruments provide the irritant
stimulus
Pain Control - Nonpharmacologic
• Nutrition
• Antioxidant may play a role in painful inflammatory
diseases (Green tea)
• It has been suggested that fasting followed by a
vegetarian diet can be useful to treat symptoms of
rheumatoid arthritis
• Essential fatty acids (omega 3 and omega 6) play a role in
the regulation of the immune system
• Physical Therapy
• Manual therapy to manipulate joints, provide pressure
on muscles, etc.
Exemplars
• Osteoarthritis
• Chronic pain
• Degenerative Disc Disease
• Chronic
• Pre-procedure pain
• Acute Pain
• Chronic Pain
• Post-operative Pain – Total Joint Arthroplasty
• Acute pain
• Procedural Pain (dressing change, wound care,
Physical therapy)
• Acute pain)
Osteoarthritis (DJD)
• OA is a noninflammatory degenerative disorder of
the joints
• It is the most common form of joint disease and is
routinely referred to as degenerative joint disease
• OA does not involve autoimmunity or inflammation.
• Another distinguishing characteristic of OA is that it is
limited to the affected joints; there are no systemic
symptoms associated with it
• By 40 years of age, 90% of the population has
degenerative joint changes in their weight-bearing
joints, even though clinical symptoms are usually
absent
Degenerative Disc Disease
•“Progressive degeneration is a normal
process of aging and results in the
intervertebral disks losing their elasticity ,
flexibility, and shock-absorbing capabilities”
(Dirksen, S. R., Lewis, S.L., Heitkemper, M.M., & Bucher, L.
2011, p. 364).
Osteoarthritis Degenerative Disc
Disease
•X-rays may show a narrowing of the joint
space; osteophyte formation; and dense,
thickened subchondral bone
Degenerative Disc Disease
•Nursing interventions:
•Assess location, onset, duration, and factors
that increase pain and or reduce pain
•Use a pain scale to assess pain
•Assess vital signs
•Assess for drug allergies
•Administer prescribed analgesics
•Provide rest , heat and or cold therapies
•Patient education about exercise and weight
control
Pre-procedure pain
•Potential pain and or actual pain prior to a
procedure
Pre-procedure pain
•Nursing interventions:
•Assess location, onset, duration, and factors
that increase pain and or reduce pain
•Use a pain scale to assess pain for
comparison to patients pain pre-procedure
and post procedure
•Assess vital signs
Pre-procedure pain
•Nursing interventions:
•Assess for drug allergies
•Treat pain or expected pain with analgesics
prior to procedure (before physical therapy,
before a dressing change)
•Provide patient education about requesting
pain medication, request prior to procedure,
understand action and effects of the
medication
Pre-procedure pain
• The pain reported by the patient is the
determining factor of pain control
• Pain must be assessed as often as every 2 hours
after major surgery
• The older patient is at risk for both
undertreatment and overtreatment of pain.
• The nurse is responsible for assessment,
implementation, evaluation of a pain
management plan, and for teaching the patient
preoperatively how to communicate and report
pain (see Chapter 35 Taylor) so it is manageable
Pre-procedure pain
• Children can be introduced to an age-specific
pain scale preoperatively (Jacob, 2007)
• Teach the patient and family that medications to
relieve pain will be ordered by the physician and
administered by the nurse
• The physician may order pain medications to be
given on a regular basis or on an as-needed
(p.r.n.) basis
• If medication is ordered p.r.n., there is a time
restriction between doses (e.g., every 2 or 4
hours).
Pre-procedure pain
• If the medication does not control the pain or if
the patient has unpleasant side effects (such as
nausea and vomiting), a different medication can
be ordered
• There is little danger of addiction to pain
medications used in the postoperative
management of pain
• The use of relaxation techniques (e.g., deep
breathing, music, and guided imagery) enhances
the effects of pain medications (See the
accompanying Research in Nursing box- Taylor)
Pre-procedure pain
•Alternative methods of pain control that may
be used after surgery include:
• transcutaneous electrical nerve stimulation
(TENS)
• pressure-controlled pain pumps filled with local
anesthetics with soaker drains placed inside the
incision
• patient-controlled analgesia (PCA),
• patient-controlled epidural anesthesia
Pre-procedure pain
• Diagnostic studies
• to find the causative factor in pre-procedure pain
•Culture
• to identify the offending organism
•Platelet count• if any bleeding is present
•Vital signs
• assess for changes in vital signs and the
correlation to increased pain
P0st-procedure pain
• Assess pain frequently;
• Administer prescribed analgesics every 2 to
4 hours on a regular schedule during the
first 24 to 36 hours after surgery
• Reinforce preoperative teaching for pain
management
• Offer nonpharmacologic measures to
supplement medications: i.e., massage,
position changes, relaxation, guided
imagery, meditation, music.
painconsortium.nih.gov/pain
scales
• painconsortium.nih.gov/pain_scales/FLACCScale.pdf
• painconsortium.nih.gov/pain_scales/NumericRatingScale.pdf
• painconsortium.nih.gov/pain_scales/COMFORT_Scale.pdf
• painconsortium.nih.gov/pain_scales/CRIESPainScale.pdf
• painconsortium.nih.gov/pain_scales/Wong-Baker_Faces.pdf
• painconsortium.nih.gov/pain_scales/ChecklistofNonverbal.pdf
Resources
• http://www.oucher.org/the_scales.html
• http://consultgerirn.org/uploads/File/trythis/try_this
_d2.pdf
• http://www.iasppain.org/Content/NavigationMenu/GeneralResource
Links/FacesPainScaleRevised/default.htm
References
Ackley, B., & Ladwig, G. (n.d.). Nursing Diagnosis Handbook.
Retrieved from Skyscape.
Ankner, G. M. (2012). Clinical decision making: Case studies in
medical-surgical nursing (2nd ed.). Cengage Learning.
Giddens, J. F. (2013). Concepts for nursing practice. Pain (pp. 270- 279). St.
Louis, Mo: Mosby.
Lilley, L.L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the
nursing process (5th ed.). St. Louis, MO: Mosby/Elsevier
Lynn, P. (2011). Taylor’s clinical nursing skills: A nursing process
approach. Comfort (3rd ed., pp. 521-560). Philadelphia, PA:
Lippincott Williams & Wilkins.
References
Monahan, F. D. , Neighbors, M., & Green, C. J. (2011). Manual of
medical-surgical nursing (7th ed.). Maryland Heights, MO:
Elsevier/Mosby.
Smith, S. F., Duell, D. J., & Martin, B. C. (2012).Clinical nursing skills
(8th ed.) Retrieved from Skyscape.
Weber, J. (2010). Nurses’ handbook of health assessment (7th ed.).
Retrieved from Skyscape.
A state of physical ease