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The Nursing Process for Comfort

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1. Assessment 2. Diagnosing 3. Outcome Identification 4. Implementing 5. Evaluating

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What is the fifth VS?

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Assessing for Pain

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Nurses Responsibility

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1. explore the pain experience through the EYES of the client 2. Pt. have the right to appropriate assessment and management

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Possible Barriers in Pain Assessment

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1. The nurse is the authority of the pt. pain (BIASES OF NURSE) -> nurses overestimate or underestimate the pain experience and withhold medication 2. Visible signs accompanying pain can verify it's existence and severity (lack of pain expression does NOT mean lack of pain) 3. Cognitively impaired older clients who are unable to use pain scales (want to use appropriate rating scale and give time)

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Client's self report of pain

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SINGLE MOST RELIABLE INDICATOR of the existence and intensity of pain and any related discomfort

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Components of pain assessment (characteristics)

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1. location 2. duration 3. intensity 4. quality 5. chronicity 6. AG factors 7. alleviating factors 8. physiologic indicators 9. behavioral responses 10. effects of pain on ADLs

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Location

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Ask to tell or point to all areas of discomfort - "where is the pain located?" -document on a body diagram (as a useful baseline of the pain should change) -use anatomical landmarks and descriptive terminology ex) pain is localized in the right upper abdominal quad

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Duration

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"when did the pain begin?" "how long has it lasted?" "does it occur at the same time each day?" "how often does it reoccur?"

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Intensity

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*most subjective and most useful characteristic for reporting pain* -Pain scales

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types of pain scales

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-verbal descriptive scale (VDS)-> none/uncomfortable/horrible/agonizing -numerical rating scale (NRS) -> rate pain from scale of 0-10 -visual analog scale (VAS) -> a straight line, representing a continuum of intensity (no pain _____________________ unbearable pain) -numerical rating scale -universal pain assessment tool -WILDA

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numerical rating scale

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no pain: 0-1 mild pain: 2-3 moderate pain: 4-6 severe pain: 7-9 pain as bad as it can be: 10

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values of "pain scales" to measure pain

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-easy to use -not time consuming -descriptive scales are useful in assessing severity in pain & evaluating changes in clients condition -pain scale CANNOT be used to compare the pain of one client to that of another

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wrong baker faces

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pain rating scale -use for 3yrs and older

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FLACC

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f:face l:legs a:activity c:cry c:consolability -use for children 2months - 7yrs of age -used for cognitively impaired adults and children (non responsive)

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PainAD

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-pain scale -use for pt with dementia

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WILDA

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w: words to describe pain I: intensity (0-10) l: location d: duration a: aggravating/alleviating factors -how does pain affect -are you experiencing any other symptoms -things to check: VS, PMH, knowledge of pain, use of noninvasive techniques

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Oucher Scale

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ethnically specific options -ages 3-12 yrs

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method for assessing pain

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1. pt self report 2. report of family member 3. nonverbal indicators 4. physiologic measures

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Quality

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-no common vocal for description of pain -> "in your own words, how would you describe the pain?" (crushing, throbbing, sharp or dull, pricking, burning, aching) -some commonly used terms: 1. crushing or vise-like = MI 2. sharp or stabbing = surgical incision 3. burning = neuropathic pain

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chronocity

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(chronology) -pattern to pain-> have pt keep journal

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Aggravating factors

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-events or conditions that precipitate or aggravate pain -actions that cause a painful response

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Alleviating factors

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-does the client have a useful method of relieving pain? -range of muscular activities, verbal methods (praying and cursing), concentration exercises help reduce intensity of oncoming pain -get identification of practitioners whose services are being used

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Associated factors

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N, HA, dizziness, urge to urinate, constipation, restlessness

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Physiologic Responses

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onset of acute pain -HR, RR, BP increase -palpation or manipulation of the site may increase pain -cues (posturing or guarding of the area may occur) -physical exhaustion if unrelieved

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Behavioral indicators of effects of pain

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1. vocalizations (may be involuntary) 2. facial expressions 3. body movement 4. social interaction

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Influence of Pain on DA

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-assessment of daily activities reveals the extent of disability and adjustments necessary to help in self-care routines 1. sleep interruptions? 2. normal hygiene? 3. sexual relations? 4. ability to work? 5. daily chores? 6. social activities? 5. neurological functions?

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Special populations

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-children -older adults -developmentally delayed or clients who are psychotic -critically ill -cognitively impaired pt -clients with dementia -non-english speakers

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Pain Assessment Tools for children

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-oucher (2 separate scales) -wrong baker faces -behavior indicators of pain

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Pain as a problem (d)

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pain (acute or chronic) related to... -fear -inadequate pain management

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pain as an etiology (d)

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-anxiety -ineffective coping -compromised health maintenance -ineffective health maintenance -fatigue -self care deficit -impaired physical mobility

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Outcome Identification/Planning (p)

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-pt will have decreased level of pain (3/10) within one hour -pt will identify 3 emotional factors that precipitate pain by the end of the shift

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Implementation (I)

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-be the patient advocate! -nurses role is to: 1. administer and monitor interventions ordered by physician for pain relief 2. independently use pain relief measurers that complement those prescribed by the physician

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CAM pain-relief interventions (non pharmacological)

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1. include cognitive behavioral and physical approaches 2. agency for health care policy and research (AHCPR) cite non pharmacological interventions as appropriate to clients when they: -find them to be appealing -express anxiety or fear -may benefit from avoiding or reducing drug therapies -are likely to experience and need to cope with a prolonged interval of post op pain -have incomplete pain relief after use of pharmacological interventions

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Distraction (I)

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-distraction directs a client's attention to something else and reduces awareness of pain -the reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input *w/ meaningful stimuli: can become unaware of pain *pleasurable stimuli: causes release of endorphins -most appropriate for short intense pain lasting a few minutes (while waiting for analgesia to work)

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Music

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effective distraction that produces an altered state of consciousness through sound, silence, space and time -to be therapeutic listen to for at least 15 minutes -decreases physiological pain, stress, and anxiety by diverting there person's attention away from pain and creating a relaxation response -should match client's mood

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Relaxation (I)

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relaxation: mental and physical freedom from tension or stress -relaxation techniques provide individuals with self-control when discomfort or pain occurs *reverses the physical and emotional stress of pain

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Guided Imagery (I)

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-client creates an image in the mind, concentrates on the image and gradually becomes less aware of pain -nurse coaches in formation of image and concentrating on sensory experience -client describes image -STOP if signs of agitation or restlessness occur

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Effective Relaxation

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-particiaption and cooperation are necessary -explain the technique in detail and describe common sensations -nurse is the coach, guiding through the exercise -environment should be free of noises -sit in a comfortable chair or lie in a bed -a light sheet or blanket for warmth = comfortable

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Effects of Relaxation

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-decreased pulse, BP, RR -decreased O2 consumption -decreased muscle tension -decreased metabolic rate -heightened global awareness -lack of attention to environmental stimuli -no voluntary change of position -sense of peace and well-being -deep, wakeful, restful period of alertness

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Progressive Relaxation

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-involves combination of controlled breathing exercises and series of contractions and relaxation of muscle groups -attention is paid to body and areas of tension are noted -success: when full relaxation is achieved -> pain perception and anxiety is lowered

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Cutaneous Stimulation (CS)

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-stimulation of the skin to relieve pain *touch and massage are sensory integration techniques that influence autonomic nervous system activity -massage -applying heat (dry & moist) -applying cold (dry & moist)

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Applying heat

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dry: hot water bags, electric heating pads, aquathermia pads, hot packs moist: sterile moist compress, sitz baths, warm soaks

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Applying cold

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dry: ice bags, cold packs, hypothermia blankets moist: cold compress

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Acupressure

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-based on asian theory that a life force in the form of energy, circulates throughout the body in well-defined cycles -acupressure opens congested energy pathways to promote a healthier state (takes about an hour) -nurse therapists apply pressure over particular points along pathways

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TENS

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transcutaneous electrical nerve stimulation -stimulation of skin with mild electric current passed through external electrodes -REQUIRES PHYSICIAN ORDER -consists of a battery powered transmitter, lead wire, electrodes (placed over or near the site of pain) -when client feels pain: transmitter is turned on, and a tingling sensation is created. -intensity and quality of skin stimulation may be adjusted -tingling sensation applied until pain relief occurs -useful: post surgical pain control and reduction of pain caused by post op procedures

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Self-Hypnosis

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-useful self-suggestion and images of relaxation and peace -helps to alter pain perception through the influence of positive suggestion

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Biofeedback

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-learns voluntary control over autonomic function such as HR, muscle tension -produces deep relaxation - effective for muscle tension and migraine HA (place electrodes externally over each temple) -requires extensive training (takes several weeks to learn)

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Meditation

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-person focuses on a single thought or sound -yoga is meditation with stretching exercises

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basic nursing interventions for controlling painful stimuli

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-tighten & smooth wrinkled bed linens -position tubing on which client is lying -loosen constricting bandages -change wet dressings and linens -position in anatomical alignment -check temp or hot or cold application -lift client up in bed -position correctly on bed pan -avoid exposing skin or mucous membranes to irritants -prevent urinary retention -prevent constipation with fluids, diet and exercise -remove or prevent painful stimuli -anticipate procedures' effects

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