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Whatever the experiencing person says it is, existing whenever the person says it does.

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Pain

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it is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

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International Association for the study of Pain

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is protective. Sudden onset <3 months/diminished overtime as the duration occurs. Has a cause (surgery, labor) short duration. Protective function limited tissue damage and emotional response (warning/signal). Fight/flight response (HR increases, anxiety, sweating, muscle tension, grimacing, moaning, guarding)

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Acute Pain

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Persistent, come and goes, gradual, lasts >6 months, sudden, can be disproportion to the objective findings (what you see). Not knowing the cause of the pain. Affects ADLs, loss of job, social isolation, sexual dysfunction

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Chronic Pain

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Fatigue, insomnia, anorexia, weight loss, apathy (lack of interest), hopelessness, anger, and social isolation. Physical and mental exhaustion. Can be accompanied by anxiety and depression, even suicide. Often the symptoms are not clearly known.

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Effects of Chronic Pain

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SENSORY (perception, culture that is going to influence pain, education, coping strategies), PHYSICOLOGIC (transmission, genetics, family history of pain, how family treats pain, bodies reaction to stimuli), AFFECTIVE (emotional response to pain experience, can affect the quality and life), BEHAVIORAL (responses,facial expression, socially withdrawn, what is being used for relaxation, self medicating???), COGNITIVE (beliefs attitudes)

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Dimension of Pain

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Arthritis, lower back pain, HA, peripheral neuropathy

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Examples of Chronic Pain

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Assess pain experience of the client. Develop realistic goals Initiate pain relief measures; distraction, massage, cold/heat application. Initiate independent nursing interventions. Evaluate intervention and communicate appropriateness. Reduce fear and anxiety. Prevent pain.

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Nurses role in chronic pain management

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Gather and document data. Collaborative decisions with patient and other health care providers. Consider pain the 6th vital sign. Subjective/objective/PQRST The impact that the pain has on the client to function ADLs (shower, room, fixing own meals, changing, grooming).

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Nursing Assessment of Chronic Pain

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Patient's experience and self report is essential

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Subjective behavior for chronic pain

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onset, duration, associated symptoms, factors increasing or relieving, pattern, location, intensity, quality.

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Characteristics of chronic pain

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Provocation and palliation (what causes pain? what makes it worse or better?) Quality and Quantity (What does it fell like? Dull, sharp, stabbing, burning, numbing) Region and Radiation (Where is the pain? does it spread?) Severity and Scale (Does it interfere with activities? How does the pain rate on a severity scale of 1 to 10?) Timing and Type of Onset (When did it begin? How often does it occur? How long does it lasts? Is it sudden or gradual?)

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PQRST Assessment

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May not be able to see pan. Vital sign changes uncommon with chronic pain. Yelling, grimacing, moaning, crying, guarding the painful area, remaining immobile. Include family, but also what the nurse is observing.

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Objective behavior for chronic pain

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Not Part of aging, does not dull sensitivity to pain (common physical problem is osteoarthritis, low back pain, previous fractures), potential to reduce mobility. High prevalence of cognitive, sensory perceptual and motor problems can interfere with communication of pain. Does not mean patient does't have pain. Older adults often use "aching, soreness or discomfort" May not report pain for feeling of a burden or a complainer.

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Aging and Perception of Pain

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Decreased muscle mass, increased body fat and decreased percentage of body water. Decreased or poor appetite (low protein/serum albumin which increases toxicity to a drug) Decreased liver and renal function results in decreased metabolism and excretion of drugs (increases side effects of drugs) Thinning skin and loss of elasticity affect the absorption rate of topical analgesics.

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Factors influencing pain in older adults

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Client will: Report that the pain management regimen achieves comfort-functioning goal without the occurrence of adverse effects.

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Goals for chronic Pain

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Acetaminophen (most common used) ASA and other salicylates NSAIDs- GI bleeding and platelet disfunction

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Non-narcotic Analgesics for Chronic Pain (Transduction Phase)

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Opioid: Hydrocodone, morphine, oxycodone, codeine, hydromorphone.

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Narcotic Analgesics for Chronic Pain (Transmission Phase) binds to receptors in the CNS

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Antidepressants (alovel, amynotriptoline) Anticonvulsants (neurontin, gabapantin) Anti-inflammatory (corticosteroids for bone cancer) Local anesthetics (temporary loss by inhibiting nerve conduction to pain)

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Pharmacologic agents that may help control chronic pain

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Transcutaneous electrical Nerve stimulation (TENS), spiritual care, biofeedback (mind-body technique connected to electrical sensors to help lower HR, muscle relaxation), acupuncture (massage therapy), herbal therapy, PT/OT, pain, and palliative care.

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Collaboractive intervention for chronic pain management

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Massage, distraction, exercise, relaxation and guided imagery, heat/cold therapy, controlling painful stimuli in the client's environment, and assist client to maximize function with ADLs.

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Nursing Interventions for Chronic Pain Management

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Did not do a thorough assessment. Inadequate skills to assess and treat pain, does not believe the patient, lack of time, expertise, and perceived importance of pain assessments, false concepts of addition and tolerance. Own Biases

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Why do many nurses under-treat a client's pain?

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Not being aware of or oriented to time, place, and self. Altered mental state characterized by decreased mental alertness and attention deficit. Can result from delirium, dementia, and depression

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Confusion

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abnormal mental state, in which the individual experiences reduced attentiveness, alertness ability to comprehend the environment

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Mental confusion

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Abrupt onset of perceptual (ability to become aware of something through senses) disturbances (trauma, infections UTI, metabolic disorders ELECTROLYTES, hypoxemia, medications/alcohol, cardiovascular disease. Reversible with treatment. Short duration, fluctuating course.

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Acute Confusion (Delirium)

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Cholinergic deficiency, elevated brain dopamine function, increased and decreased serotonin function, and cytokines are also believed to paly a role.

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Neurotransmitter with links to delirium

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Injury to nervous tissue (hypoxemia, hypoglycemia). Action of toxin or chemical agents and neuronal cells prucing a dysfunction causing high levels of cortisol increasing delirium (drugs/medications such as anticholinergic medications, steroids, anesthesia, ambien) Disinhibition and overactivity of a depressed brain center (Trauma, infection or surgery in individuals with dementia place them at risk for delirium; UTIs and PNA).

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3 probably pathophysiologic mechanisms

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Orientation: Person, place, time, situation Memory: distant, recent, immediate Presence of anxiety, agitation, fear Presence of hallucinations, delusions Identify factors that may precipitate acute confusion such as hypoxia, hypotension, toxins, medications, electrolyte imbalance, untreated pain, hospitalization. sudden cognitive impairment.

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Nursing Assessment of Delirium

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UTI may present as a cognitive impairment secondary to delirium.

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Assessment Alert

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Acute confusion r/t age (>65 yrs old) alcohol, drug abuse, fluctuation of sleep cycle, severe pain Risk for acute confusion r/t (no s/sx looking at risk factors). it hasn't occurred yes. Intervention in the risk for diagnosis: based on the risk factors to prevent the acute confusion. EXPECTED OUTCOME(S): client will: Regain and maintain usual reality orientation by (date) Verbalize understanding of cause and risk factors of confusion. Initiate lifestyle or behavior changes to prevent or minimize recurrence of problems (or reduce risk of confusion)

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Nursing Diagnosis: Acute Confusion

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Assist with treatment of underlying problem (drug intoxication (stop med if induced), infectious process (ATB), hypoxemia, biochemical imbalances, pain management).

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Collaborative Interventions for Delirium

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When it is a new findings must action quick to find reversible causes. Notify MD immediately!! Orient client to surroundings, staff, activities. Maintain a calm and safe environment to prevent over stimulation and protect from harm (dim lights, reduce noise levels, avoid restraints). Encourage use of glasses, hearing aids, interdisciplinary team, avoid poly-pharmacy. Protein diet to increase protein intake d/t med toxicity if not enough protein/albumin in the body.

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Nursing Interventions for Delirium/Acute Confusion

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Dysfunction/loss of memory. Gradual onset decline IRREVERSIBLE chronic progressive. Agitation, delusion, hallucination. Consistent impairments (ADLs) Memory loss and language skills are impaired to be able to diagnose dementia. Most common; Alzheimer disease, and vascular disorders (stroke). Can have a Dx of dementia and Alzheimer disease. Thoughts of suicide in early stages.

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Chronic confusion (Dementia)

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Most common Progressive, irreversible. Everyone is susceptible. Affects the cells of the cerebral cortex; affects language, memory, calculation, learned movements, sensory recognition and motor function.

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Alzheimer's Disease

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Amyloid plaques (cluster of insoluble deposits of proteins beta amyloid affects the non nerve cells; develops in areas of the brain for memory and cognition. Language and reasoning. Neurofibrillary tangles abnormal collection of twisted protein threads inside nerve cells, main component is TAU involved in providing support for the cellular structure. Loss of connection between neurons (cell death). Areas of the brain tissue are damaged/death and some messages do not transmit, causing the symptoms of the disease. Brain begins to shrink.

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3 characteristics of Alzheimer's Disease

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Genetic factors, Cellular; Theory of aging- free radicals damage neurons leading to inflammation which results in loss of function. Cardiovascular disease- risk factors for heart disease. Epidemiologic factors; brain activities decreases the process of AD, and lifestyle factors may also decrease AD.

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Risk factors for Alzheimers

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Early stage 2-4 years, Middle Stage 2-12 years, and Final stage can last up to a year.

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Stages of Alzheimer's Disease

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2-4 years. Forgetfulness, disinterest in environment, poor work performance.

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Early stages of AD

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2-12 years Progressive cognitive losses, irritability, wandering at night, cannot remember where person was going.

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Middle stage

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Can last up to a year Does not recognize family, incontinent, death from aspiration pneumonia because person cannot control secretions. Cannot perform ADLs, become unresponsive and require total care.

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Final Stage

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Most common in ID cognitive changes. Indicate early changes in cognition relating to the cortical function of the brain. Evaluates orientation, attention, recall and language. Scores below 24/30 are indicative of cognitive changes. Very important for client to cooperate for accurate data.

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Nursing Assessment in Chronic Confusion: Mini mental status Examination

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Paranoia, delusions, hallucinations, harming self, hitting others, inappropriate sexual remarks/activity, insomnia, repeated questioning, throwing things, uncooperative behavior, undressing, wandering, yelling or screaming.

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Behavioral symptoms in Alzheimer's Patietns

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is a dementia assessment: Orientation (what is the time, date, place), registration (3 unrelated objects and then ask to repeat after said to the person), attention and calculation (ask to count backwards from 100 by 7 or spell the word WORLD backwards), recall (3 objects), and language (wrist watch and ask a person what it is, also use a pencil, write a sentence/copy a design).

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Mini-Mental state examination (MMSE)

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Mini-Cog Assessment and Confusion Assessment Method (CAM)

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Cognitive Assessment Tools

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3 minutes to administer Can be used during routine visits or hospitalizations Less stressful to the patient Not influenced by education, culture, or language

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Mini-Cog Assessment

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Used in the ER 1. Acute onset and fluctuating course 2. Inattention, destructibility 3. Disorganized thinking, illogical or unclear ideas 4. Alteration in consciousness.

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Confusion Assessment Method (CAM) Diagnostic Algorithm

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The presence of both features 1 and 2, plus EITHER features 3 or 4.

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What does the diagnosis of delirium requires?

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Used mostly in Emergency Departments

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Confusion Assessment Method (CAM)

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Confusion, Acute or Chronic r/t Memory, impaired r/t Thought processes, disturbed r/t self-care deficit (bathing/dressing/toileting) r/t Risk for injury r/t Caregiver Role strain r/t tired, angry, self neglection. risk for stress overload r/t

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Nursing Diagnoses for Disturbances in Cognition

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Client will: Remain safe and free from harm by (date). Function at highest level of cognitive ability. Performs self care activities with assistance as needed (want them to maintain the functions that they have). Family/Significant others will: Verbalize understanding of disease process, prognosis, and clients needs. Maintain personal, emotional, and physical health of themselves. Identify resources to assist with coping with long-term effects of situation (support groups).

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Expected Outcome for chronic confusion AD

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Cholinesterase inhibitors, NMDA receptor antagonist, Depression, Sleep disturbances, and Behavioral management.

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Management of Alzheimer's Disease Medications

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Work by slowing down the disease activity that breaks down a key neurotransmitter (acetylcholine). This allows acetylcholine more time to transmit the message. The drugs will either improve or stabilize cognitive decline. Can enhance functional abilities. MEDICATION: Cognex, Aricept (Denoxapil), Exelon mild to mod (patch/pill), Razadyne for mild to moderate AD. Vitamin E for antioxidant effects the free radicals helps prevent the plasma disease.

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Management of Alzheimer's disease: Cognitive Medications; Cholinesterase Inhibitors:

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Works by regulating the activity of glutamate a chemical messanger involved in learning and memory. Protects the brains cells against excess glutamate. The chemical messengers released in large amounts by cells damage by AD and other neurologic disorders. Attachment of the glutamate to the cell site will cause receptor sites will allow calcium to attach to the cells which will cause damage to the cell. Treatment for middle to late stages of AD. NAMENDA prevents this chain of events (helps patient remember faces)

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Management of Alzheimer's disease: Cognitive Medications; NMDA receptor antagonist

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Zoloft, Celexa, Tegretol, Depakene

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Management of Alzheimer's Disease: Medication for Depression

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Ambien (not being used as often because of the adverse affect)

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Management of Alzheimer's Disease: Medication for Sleep Disturbances

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Haldol, Risperdal, Zyprexa, Seroquel

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Management of Alzheimer's Disease: Medication for Behavioral Management

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Provide calm, safe environment. Provide physical and intellectual stimulation in accordance with the client's capabilities. Preserve the dignity of the human being. Simple directions, speak slowly because they are trying to process what the nurse is saying, lower voice. Don't argue with them. Don't ask WHY

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Nursing interventions for Chronic confusion

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Provide a private area, use distraction to avert disruptive behavior, use positive reinforcement, set limits for unacceptable behavior (hitting, yelling), Protect other residents from patient's behavior, assess cause of behavior (remove trigger, can have dementia and get delirium), avoid restraints.

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Nursing interventions for Socially Inappropriate Behavior

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is appropriate in early stages of dementia and for acute confusion.

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Reality Orientation

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Allow them to live in that satisfying happier time (memory newspapers). Do not reinforce false beliefs-be kind. Allow client to talk about the subject that is on their mind. Reality can be confirmed with social conversation, not with the orientation "drill" (don't ask them what day it is)

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Validation Therapy

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Keep lights on during evening hours, use night lights, keep stimulating activities (social gatherings, exercise) to a minimum in the evening. Avoid caffeine, encourage quiet activities in the evening; play soft, relaxing, soothing music, offer a familiar object for comfort. Goal: is to keep their nights and days straight. Open blinds during the day, try to keep same nurses during the day and night.

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Sundown syndrome

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Assess stressors ID coping strategies Respite Care Support Groups

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Nursing Intervention for Caregiver Support

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Often abrupt, occurs with life changes. Treatable illness Effects typically worse in the morning Impaired concentration and attention span May deny depression Disturbed sleep-wake (lost of appetite, not involved in play activity) cycle

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Depresson

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Low self-esteem Life changes (loss of spouse) Co-occurrence with medical conditions (stroke/heart disease).

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Factors of Depression

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Lethargy, agitation, weight loss

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Common physical complaints: of depression

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Encourage older client to seek medical attention, respite care services, support for caregiving role (pain support groups)

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Depression Intervention

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the ability and willingness to assume responsibility for one's action and to accept the consequences of one's behavior. "answerable to oneself and others for one's own actions"

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Accountability

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The specific accountability or liability associated with the performance of duties of a particular role. "The specific accountability or liability associated with the performance of duties of a particular role."

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Responsibility

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