Chapter 15 comfort - Shandong Universitycourse.sdu.edu.cn/G2S/eWebEditor/uploadfile/2012112520223964…  · Web viewoncept of Comfort. Comfort is a mental state of physical and psychological

Chapter 6 Comfort and Safety

Comfort and safety are the central concept of the nursing art. These are the basic human needs and that concerns many aspects, such as physiology, psychology, society and environment.

Section 1 Concepts

C oncept of Comfort Comfort is a mental state of physical and psychological health, no pain, and no anxiety

and relaxing at ease, it is a kind of high-individualized sense. Each individual has different physiological, psychological, social, mental and cultural background, so they vary in explanation and experience of comfort. The highest level of comfort is a healthy state that physiological and psychological needs are all met. People show mental equivalence, full of energy, feeling of safety and complete relaxation.

I nfluencing Factors of Comfort Physical Factors

These factors include sensation and perceptions of the body. Poor individual hygiene, inappropriate posture and position, local pressure and friction, and disease can all affect the comfort level of individual.Psychological Factors

This means internal consciousness, which includes the need of respect, sexual desire and understanding of life meaning. If people are anxious or fearful, they have never been given care and respect, or they confront with pressure, their level of comfort will decrease.Social Environmental Factors

It is shown in the relationships among individual, family and society. If people lack in support system or they have impaired role adaptation, their comfort will be affected.Physical Environmental

Factors It means all the external things around one person. Poor ventilation, unfamiliar environment, strange smell, noise and disturbance are such factors that can influence comfort.

P rinciples to Promote Comfort Discomfort can be decreased at the greatest extent when people focus on preventionGetting rid of the causes is the thorough way to resolve discomfortReinforcement of observation and psychological support

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On account of different influencing factors to different people, methods to promote comfort vary largely. Nurses must analyze the reasons of discomfort first, and then they can plan nursing interventions that are in accordance with the situation. There’re many methods to choose, such as maintaining the ward clean, keeping clients in appropriate posture and position, and remaining body clean for the clients.

SectionⅡ Client’s lying Position

T ype of Client ’ s lying Position Active lying position

According to their desires or habits, clients lie in most comfortable and easily position. It is commonly occur when disease is mild, pre-operation or recovering clients.

Passive lying positionClients could not be able to change lying position and be placed in the position others

have given them. It is commonly occur in coma, extremely weak clients.Compelled lying position

Clients have abilities to change lying position with awareness, however, lie in some certain position in order to reduce pains or due to treatment. For example, clients with cardiopulmonary diseases lie in sitting position.

Client ’ s lying Position Supine position

On the supine position, the client lies flat on the back with the head and shoulders slightly elevated with pillow unless contraindicated. The pillow under the head and upper shoulders may not be allowed following a spinal anesthetic or surgery on the spinal vertebrae. The body areas in need of attention when in the supine position are the feet, elbow, and neck. Pillows are almost always used to support the head to tilt it forward so that the person’s vision is improved. This causes flexion of the cervical spine. The feet will fall into a planter flexion position unless support is provided. Elbow protector may need to be applied on a restless client to relieve pressure in that area. Supine position may be changed to 3 special forms based on special purpose of positioning.Supine position without pillow Placement:

The client lies flat on the back without pillow under head. The client’s head turns to one side and arms are at sides of the body place the pillow at the head of the bed. Use:

This position is appropriate for the coma client or client who is still unconscious after general anesthesia. It prevents vomit obstructing respiratory tract. Removing pillow under the head of the client may prevent decreased encephalic pressure and headache for clients after intravertebral anesthesia or spinal puncture. Shock position

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when the client is on shock condition, place the client in the shock position by laying the client on the back, elevating the head and chest about 10-20 degrees to facilitate client’s ventilation and reduce hypoxia, and elevating the lower extremities about 20-30 degrees to promote return of venous blood to increase cardiac output.Supine position with knees flexed

The clients lies flat in the back with lower flexed and rotated outward. It is used in abdominal examination urinary catheterization, or perineum rinse.

Lateral position Placement:

In the lateral (side-lying) position, the person lies on one side of the body. Flexing the top hip and knee and placing the leg in front of the body creates a wider, triangular vase of support and achieves greater stability. The greater the flexion of the top hip and knee, the greater the stability and balance in this position. This flexion reduces lordosis and promotes good back alignment. For this reason, the lateral is good for resting and sleeping clients. The lateral position helps to relieve pressure on the sacrum and heels in people who is for much of the day or who are confined to bed and rest in fowler’s or Doral recumbent positions much of the time. In the lateral position, most of the body’s weight is borne by the lateral aspect of the lower scapula, the lateral aspect of the ileum, and the greater trichinae of the femur people who have sensory or motor deficits on one side of the body usually fid that lying on the uninvolved side is more comfortable.

Use:changing position to prevent ulcers pressure; enema, anal examination, and gastro scope examination.Gluteal intramuscular injection

Fowler’s Position Placement:

The semi-sitting position is called Fowler’s position and calls for the head of the bed to be elevated 45 to 60 degrees. This position is often used to promote cardiac and respiratory functioning because abdominal organs drop in this position and thereby provide maximal space in the thoracic cavity. This is also the position of choice for eating, conversation, vision, and urinary and intestinal elimination. Variations of Fowler’s position, the head of the bed are elevated 30 degrees. In the high Fowler’s position, the head of bed is elevated 60 degrees. In Fowler’s position, the buttocks bear the main weight of the body. Other skin areas require assessment and massage include the heels, the sacrum, and the scapulae. The arms and feet need particular attention when the client is in a semi-sitting position. Unless properly supported, the arms fall to the bed and pull on the shoulders, and the feet fall into a foot \strop position. Supportive devices may be necessary, including pillows supporting the upper back and bead, the elbows and wrist joints, the lower back the thighs, the ankles, and a footboard.Use:a. dyspnea caused by cardiopulmonary diseases.b. postoperative period of face or neck operations; c.post-operative stage of operations on pelvis or inflammatory diseases of abdominal and pelvis organs; d.recovery stage of sickness.

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Orthopneic position Placement:

The client sits either in bed or on the side of the bed side of the bed with an over bed table across the lap. Use:

severe dyspnea caused by heart failure, hydro pericardium, and asthma. This position facilitates respiration by allowing maximum chest expansion. It is particularly helpful to clients who have problems exhaling, because they can press the lower part of the chest against the edge of the over-bed table.

Prone position Placement:

the client lies in the abdomen with the head turned to one side. The body is straightened out in the prone position because the shoulders, head, and neck are in an erect position, the arms are easily placed in correct alignment with the shoulder girdle, the hips are extended, and the knees can be prevented from flexing or hyper extending. When clients on bed rest use this position periodically, it helps to prevent flexion contractures of the hips and knees. However, the pull of gravity on the trunk when the client lies prone produces a marked lordosis. This position is thus contraindicated for people with spinal problems. The pull of gravity on the feet may result in planter flexion unless the legs and feet are positioned carefully. Placing a pillow under the lower legs permits dorsiflexion of the ankles and some knee flexion, which promotes relaxation.Use:a. back and waist examination or cholangiography; b. clients who can not lie on back such as after spinal operation or having wounds on back. waist, or buttocks. c. abdominal pain caused by gastrointestinal pneumatosis.

Trendelenburg’s position Placement:

The client lies on the back. Pillow is removed and placed at the head of bed to prevent injury to client’s head vertically. Elevate feet of bed about 15-30cm. The client feels discomfort when lying in this position, so do not keep the client on this position for a long period of time. It can not be used for clients with intracranial hypertension.use:a. postural drainage of pulmonary secretions; b. duodenal drainage; c. premature rupture of fetal membrane; d. Skeletal traction through calcaneus or tibial tubercle.

Dorsal elevated position Placement:

the client lies on supine position. The feet of the head of bed are elevated about 15-30cm with raised block. The elevated height may be chosen based on the condition of the client.use: a. skull traction for clients with fracture of cervical spine; b. lessening intracranial pressure and preventing cerebral edema;

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c. post-operative period of craniocerebral operations.Knee-chest position

Placement:The client is on his knees, bends forward and places his two calves in bed and separates

them a little. Have the client place his/her shoulder and chest in bed, and suspend abdomen in air, and elevate hips. Client’s head turns to one side and arms are flexed and placed beside his/her head. Client’s weight is supported by his/her knees and shoulders.Use:a. anal and rectal examination or sigmoidoscope examination and treatment; b correction malpositions or retroversion of uterus;c facilitating involution of uterus.

Lithotomy position Placement:

The client lies on the examination table with supine position. Have the client move his/her body and buttocks are caudal to the table brink. The legs are flexed at hips and placed on leg carriages. Arms are place beside body or crossed on chest. Use:

Lithotomy position can be used in the examination, treatment, or operation on perineum and anus, such as cystoscope examination, obstetrics/gynecological examination, and vaginal lavage. It is also used during childbirth.

M oving and turning clients in bed Although healthy people usually take for granted that they can change body position and

go from one place to another with little effort, ill people may have difficulty moving even in bed. How much assistance clients require depends on their own ability to move and their health status. In general, nurses should be sensitive to both the need of people to function independently and their need for assistance to both the need of people to move, correct body mechanics need to be employed so that the nurse is not injured. Correct body alignment for the client must also be maintained so that undue stress is not placed on the musculoskeletal system.

Moving a client up in bed Client who have slid down in bed from the fowler’s position or been pulled down by

traction need assistance to move up in bed. The client should be encouraged to accomplish this movement independently whenever health permits.

Purpose To maintain good body alignment and promote comfort when clients who have slid

down in bed from the Fowler’s position or been pulled down by traction EquipmentOverhead trapeze bar if available Procedures

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Steps Rationale and key points

1.Explain the procedure to the client 2.Adjust the bed to flat position if the

client can tolerate it. Lower the side rail nearest the nurse

3.Remove the pillow and place it at the head of the bed, and put all tube and transfusion equipments in proper position.

4.If able to assist, have the client flex the knees with feet flat on the bed

5.Assist the client to grasp the overhead trapeze bar or head of the bed. If the client is unable to assist, fold the client’s arm across the chest.

6.The nurse flexes knees and hips with feet spread and position one foot slightly forward. Place one arm under the client’s neck and shoulders and another arm under client’s upper thighs.

7.Tighten abdominal and gluteal muscles. Assume the position to move the client.

8.The nurse shifts her weight from the back leg to the front leg. If possible, the client should push with legs and assist movement upward by grasping the trapeze or the head of the bed.

9.Assist the client to a comfortable position in the center of the bed. Reposition the pillow. Raise the side rail and adjust the bed position

10.Wash hands 11.If two nurses perform this procedure,

they stand on opposite sides of the bed. They may move a client up in bed by interlocking their arms under the client’s shoulders and thighs and lifting as described previously

·This facilitates cooperation of the client·This facilitates moving the client upward and

minimizes strain of the nurse

·This protects the client’s head from striking the top of the bed

·The client is prepared to push upward by using a major muscle group

·It provides assistance and reduces friction

·This position places the nurse in a stable position. ·The placement of the arms supports and evenly

distributes the weight of the client

·These muscles stabilize the pelvis before the lifting maneuver

·The rocking motion uses the nurse’s weight to counteract the client’s weight when moving the client up in bed

·This ensures the client’s safety

Turning a client to a lateral position Movement to a lateral position may be necessary when changing the client’s bed linen or

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when repositioning the client. Purposes a.Change position to promote comfort and prevent complications of immobility b.Prepare for nursing care such as changing sheet or skin careIndications a.Clients have altered consciousness levels b.Immobilized clients, such as hemiplegia, paralysis, and paraplegia c.Clients who are too weak to move their body EquipmentsPillowsProcedures

Steps Rationale and key points

1.Explain the procedure to the client 2.Stand on the side of the bed opposite to the

side that the client will face after being turned. The nurse stands close to the client’s chest

3.Place the client’s arms across the chest. and put all tube and transfusion equipments in proper position.

4.The nurse inclines the trunk forward from the hips and flexes hips, knees. Assume a board stance with one foot forward and weight placed upon this forward leg

5.Turning the clientone-person method(1)Move the client in segments(from head to feet) to the side of the bed opposite the client will face when turned(2)Place one hand on the client’s near hip and the other hand on the client’s near shoulder(3)The nurse tightens gluteal, abdominal, leg, and arm muscles; rocks weight from the backward to the forward foot and rolls client onto the side of the body opposite the nurseTwo-person method(1)Two nurses stand on the same side of bed. One nurse places arms under client’s shoulder and waist, while another nurse places arms under client’s hips and knees. Two nurses lift client’s body to the near side of bed(2)Two nurses hold client shoulder, waist, hips, and knees respectively and roll client onto the side of the body opposite the nurses

·This facilitates cooperation of the client ·To place the nurse’s center of gravity close the client’s

·This avoids friction and resistance to movement and prevents injury to the arm

·This lowers the center of gravity and widens the base of support

·This ensures that the client will be positioned safely in the center of the bed after turning·This position of hands supports the client at two heaviest parts the body, providing greater control in movement during rolling·This allows the nurse to use main muscles to act

·It is appropriate for clients who are heavy or in severe condition

·Two nurses’ performance should be cooperative, gentle, and stable

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6.Place pillows before chest, behind back, and between knees

7.Record time of turning and the status of skin·To ensures the client’s comfort and stability

Clients with impaired nervous, skeletal, or muscular system functioning and increased weakness and fatigability often require help from the nurse to attain proper body alignment while in bed or sitting. Any position, correct or incorrect, can be detrimental if maintained for a prolonged period. Frequent change of position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures. Position changes also maintain muscle tone and stimulate postural reflexes. When the client is not able to move independently or assist with movie, the preferred method is to have two or more people move or turn the client. Appropriate assistance reduces the risk of muscle strain and body injury to both the client and the nurse.When positioning clients in bed, the nurse can do a number of things to ensure proper

alignment and promote client comfort and safety:a. Make sure the mattress is firm enough to fill in and support natural body curvatures. A

sagging mattress that is too soft used over a prolonged period can contribute to the development of hip flexion contractures and low back strain and pain. Beds Board made of plywood and placed beneath a sagging mattress are recommended for clients who have back problems or are prone to them. It is important in the home setting to inspect the mattress for support.

b. Ensure that the bed is clean and dry. Wrinkled or damp sheets increase the risk of pressure ulcer formation. Make sure extremities can move freely whenever possible. For example, the top bedclothes need to be loose enough for the client to move the feet.

c. Plan a systematic 24-hour schedule for position changes. Frequent position changes are essential to prevent pressure ulcers in immobilized clients. Such clients should be repositioned every 2 hours throughout the day and night and more frequently when there is a risk for skin breakdown. Schedule periods throughout the day during which the client assumes positions that provide full extension of the neck, hips, and knees to prevent flexion contractures of there joints.

d. Place support devices such as pillows in specific areas according to the client’s position. Use only those support devices needed to maintain alignment and to prevent stress on the client’s muscles and joints. It is not necessary to use too many devices for the person who is capable of movement. Common alignment problems that can be corrected with support devices include the following: flexion of the neck; internal rotation of the shoulder; adduction of the shoulder; flexion of the wrist; anterior convexity of the lumbar spine; external rotation of the hips; hyperextension of the knees; plantar flexion of the ankle.

e. Avoid placing one body part, particularly one with bony prominence, directly on the top of another body part. Excessive pressure can damage veins and predispose the client to thrombus formation. Pressure against the political space may damage nerves and blood vessels in this area.

f. Always elicit information from the client to determine which position is most comfortable

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and appropriate. Seeking information from the client about what feels best is a useful guide when aligning persons and is an essential aspect of evaluating the effectiveness of the intervention.

Section Ⅲ Client’s Safety

Safety is the most urgent basic human need when the physiological needs have been met. It

is often defined as freedom from psychological and physical injury. For an individual, health care that is provided in a safe manner and a safe community environment are essential elements for his/her survival. And it is especially important for people with diseases. When people have diseases, they often become weak, thus tend to have high risk of injury in daily living, such as fall, infection. When the nurses use the nursing process and incorporate critical thinking safety of the client and the environment, as well as plan and implement appropriately to maintain a safe environment. Therefore, the nurse is not only a provider of safe acute, restorative, and continuing care, but also an active participant in health promotion.

S afety Related Factors Sensuous Function

As a necessary ability, well-sensuous function helps people realizing the surrounding, recognizing and judging the safety of self-activities. Any paresthesia will be prone to hurt by preventing individuals from distinguishing existed or potential dangerous factors around them.

AgeAge is related to the Individual’s ability of perception and comprehension

thereby it affects the individual’s self-protective behavior takes correspondingly. Current Health Condition

Accident will happen and hurt individuals unexpectedly in unhealthy condition. For example, clients are at risk for injury from fall when they are weak and activity-restricted. When illness gets serious and affects the consciousness, the clients are easier to be hurt as losing self-protective ability. Hypoimmunity clients likely infected. Anxiety and other unhealthy emotions may result in injury as scatterbrain can not predict the latent dangerous.

Extent of Familiar with SurroundingIndividuals can communicate with others in the environment they know well and

acquire information, helps and increase the sense of security sequentially. The psychology reaction such as anxiety, fear, scare and sense of unsafe may occur when individuals in a strange environment.

Diagnosis and Treatment MeasuresSome special diagnosis and treatment measures may comprise unsafe factors

when they are using for assisting diagnosis, illness treatment and improving healing. For instance, diversified invasion in diagnostic tests and treatment, surgical

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procedures etc cause the skin lesion and potential infection and so on.

Unsafe F actors and P recaution s in Hospital Physical Injuries and Precautions

Mechanical injuries Fall, collision are common.

Precautions:a. Use bedside rail restraints and protective device according to the situation to

prevent from falling for clients who are restless, unconsciousness or infants and young children.

b. Assist clients that are elder, weakness, hemiplegia, and prolonged bedrest when they get out of bed. Providing assistant device or helping them walking and keep the balance.

c. Keep the daily articles at the bedside and easy reach of clients to avoid falling.d.To avoid falling, make the floors clear, dry and move over the roadblocks or

instruments temporarily unused. Do not put sundries around the alleyway, stairway and exit.

e.Provide handrails in corridor, bathroom and toilet for clients safety.f. Provide the call light or other summoning device in bathroom and toilet for helping

by clients.g.To prevent clients from injury himself (herself) or others and place the instrument in

suitable area in psychotic ward.In a word, nurse must be alert to the possible unsafe factors in surroundings,

and provide appropriate management. Stab by glass and sharp instrument is common mechanical injury to the hospital working staff. Therefore, to provide the special container for broken glass or sharp instruments such as needles, blades, etc, and classify these things to reduce the damage. Thermal injuries

Scald by hot-water bag and thermos, frostbite by ice bag and refrigerated bag, burn by all kinds of physical therapy lamp and radio knife, or burn by flammable & explosive articles such as oxygen, aether, and other liquefied gas are common.

Precautions:a.Nurse should notice to the chief complaint of clients and observe the changes of

local skin when applying heat and cold application devices under the strict operation rules. Any discomfort should be timely handled.

b.Reinforcing the administration of the flammable & explosive articles and fireproofing education, making the fireproofing measures, and becoming familiar with the location and use of fire extinguishers.

c. Checking and maintaining electrocircuit and all kinds of electric apparatus in the hospital periodically. Taking safety examination to the electric apparatus taken by clients (such as radio, electric shaver etc.) before using, Carrying on the electric-safety education to clients.

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Pressure Injuries Pressure sores due to long-term pressure, baric injuries by inappropriate

hyperbaric oxygen therapy etc. (see related chapters).Radioactive Injuries

Caused by inappropriate management during diagnosis and treatment, radioactive dermatitis and ulceration are common, death may occur when it is serious.

Precautions:a.Lead aprons and gloves are used by working staff as protection from radioactive

source when carrying on X-ray or other radioactive diagnosis and treatment.b.Control the radioactive time and dosage accurately.c.Lessen unnecessary body exposure and keep the sign in radioactive field.d.Educating clients to keep the skin of radioactive field clean and dry, avoiding to

clean forcibly, using soap, and scratch.Chemical Injuries and Precautions

Chemical injuries follow by inappropriate or wrong medication. It is necessary for nurses to possess the pharmacology knowledge and execute medication administration strictly. Implementing ‘Three Check-ups’ and ‘Seven Verifications’ seriously, noticing the matching contradiction of medicine and observing the reaction after using, interpreting related knowledge to clients and their family members at one time.

Biologic Injuries and PrecautionsBiologic injuries include the damage to human body caused by microorganisms

and insects. Pathogenic microorganisims cause many diseases after invaded human body and threaten individual’s health directly. Nurses should execute the disinfection & isolation system strictly and observe the principle of aseptic technique, reinforce and perfect diversified nursing measures.

Insects biting not only disturb clients but trigger allergic injuries and even communicate diseases, Thus to extinguish insects and take precautions are very important.

Psychological Injuries and Precautions The client’s cognation and attitude to disease and medical staff’s behavior or

manner to client are all factors that affect the psychological health and may cause psychological injuries. To establish a sound nurse-client relationship and lay the groundwork for trust by high quality nursing. Helping clients build up a harmonious relationship with others, Educating clients the knowledge related to disease and supporting them face to difficulty in optimistic attitude.

Injuries caused by Medical Staff and Precautions Injuries include psychological or physical damage to clients result in inadvertent

speaking and behavior of medical staff. For example, inappropriate diction during talking may lead to emotional fluctuation to clients, nursing accident caused by irresponsibility, negligence in working as a painful experience to clients (even endanger their lives). Hospital infection may occur by inappropriate working methods. It is important to medical staff to keep a fine service manner by reinforcing

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ideaistic & moral education, enhancing their quality comprehensively,. Making related measure of extinguishing accident will be avoided effectively and protected clients in safety.

The measures Protect Clients in SafetyUse of Protective Device

Protective devices are all kinds of instruments that applying to restrain client’s activity of body or some parts of body and to maintain the safety and treatment effect.

◆Objectives:a.To protect children, high-fever, phrenitis, coma and restless clients from falling,

collision, scratch and other accidents caused by weakness and unconsciousness. Keep clients in safety.

b.Ensure that the treatment and nursing process carry through smoothly.◆Preparation:

a. Assessment and Explanation Clients Assessmenta)Identify client’s age, state of illness, present level of consciousness, vital sign and

extremities mobility, skin breakdown and circulation impairment.b)Evaluate the degree of client’s understanding, accepting and cooperating to usage

of protective device and client’s abnormal psychological reactions such as uneasiness, restless, resistant and so on. To avoid accident (self-hurting, collision etc.) happen.

Explanation Explaining the variety, duration, method, attention and cooperation main-points of using protective device.

b.Clients and (or) Family members Preparation Clients and (or) Family members understand the importance, safety, attention and cooperation main-points of using protective device.c.Self-preparation of nurses:To be dressed neatly, nail-trimmed, hand-washing and mask-wearing.d.Equipment Preparation: To prepare bedside rail restraints, restraints, cotton padding, and overbed cradle according demands.e. Environment Preparation Space around every bed unit is roomy, moving over bedside chairs and desks.

◆Protective Devices:a. Bedside rail restraint: Using for protect clients from falling.a) Multi-functional bed rail restraint:

Inserted in foot of the bed commonly and inserted into all sides of the bed while using. They can be put under the client’s back and carry on closed chest cardiac massage when it is necessary.b) Semiautomatic bed rail restraint:

Inserted in all sides of the bed and may uprising and descending while using.c) Wooden bed rail restraint:

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Fix the bed rail restraint in all sides of bed steadily with an active door open in the middle, and opened while using.b. Restraint Using to the restless clients for restrict their body or extremities and protect them from self-hurting and falling. a) Broad Bandages: Used for fixing wrist and ankle. When using broad bandages as

a restraint, place cotton pad over and wrap restraint around the wrist or ankle. Tighten the bandages securely and assure the extremities are fixed well with adequate circulation. Fasten bandages under the bed frame then.

b)Shoulder Restraint: Used for fixing shoulder and restricting clients to sit up. Shoulder restraint is made by broad cloth with 8cm wide and 120cm in length. One end of it made into a wristband. Put the wristbands into client’s two shoulders and place cotton pads under the axillary regions while using. Ties of two wristbands knotted and fixed in front of the chest, then hitch the wider and longer ties to the head of bed. Place the pillow in horizontal position when needed. The sheet folded into strip can be used as a shoulder restraint.

c) Knee Restraint: Use for fixing knee and restricting the activity of legs. Knee restraint is made by broad cloth with 10cm wide and 250cm in length. In the middle of wider tie, two double-ended webbings are fixed and 15cm apart. Place the knee restraint on double knees and put a cotton pad between them, each of two webbings are trussed up a knee and then hitch the two ends of wider ties firmly on bed frame. A sheet can also use as a restraint.

d) Nylon Buckle Restraint: Used for fixing wrist, upper arm, ankle, and knee. It is safety, easy washing and sterilizing.And operation is also simple and convenient. The restraint is made by broad cloth and nylon buckles. Place restraint and cotton padding on the area of knee with appropriate degree of tightness, then tighten buckles and tie the restraint firmly on bed frame.

c. Overbed Cradle Mostly used for the clients of extremities paralysis. Protecting them from pressure of the quilt and uncomfortable or footdrop. It is also employed to keep warm when adopting exposure method by the burn clients. To place the overbed cradle over the parts of body which should be free of pressure and cover the quilt on it while needed.

◆Points for Attention:a. Identify the appropriate applying situation of the protective device and maintain

the client’s self-esteem. Explain the purpose, main points of the operation and attention to clients and their family members before using. Do not use it unless necessary.

b. Protective device just suitable for short-term using. Be careful about client’s lying position, keep the extremities and joints in functional position and assist client change his (her) position regularly.

c. Place a pad under the restraint while using, Fixing with appropriate degree of tightness and loosing regularly. To observe ending circulation of the restricted parts and give timely management when existed abnormal situation. Providing local massage and improving the circulation if needed.

d. Recording the purpose, time of using and loosing, observing result and nursing

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consideration.e. Evaluation about the protective device at any time followed by:a) To content the basic demand of body, clients are safe, comfortable, having no

complications and accidents like circulation impairment, skin breakdown, fall, collision and so on.

b) Clients and family members understand the purpose of using the protective device and accept it with cooperative manner.

c) Providing tests, treatment and nursing measurement smoothly.

◆Health Education:a.Explain to clients and family members the purpose of employing protective device is the available measurement for keeping clients in safety and assuring treatment and nursing process that provided.b.Protective device just use in short-term, Cooperation of clients and family members is vital and necessary. Sound communication between medical staff and clients will content client’s physical & psychic demands and avoid nervousness, anxiety and dread.

Section Ⅳ Pain Management

The worst discomfort is pain. Nearly everyone has experienced some type or degree of it, but it is one of the least understood. Pain is one of the most commonly occurring and important symptoms and signs in clinical nursing. It can be the major reason in hindering recover from illness. To provide comfort for clients, the nurses should learn the knowledge about pain and effective comfort measures to promote the recovering process of patients.

Concept of painThe International Association for the Study of Pain(IASP,1979)defined it as “an

unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

C haracters of Pain Pain indicate that there’re some stimulus infringed upon individual’s integrality.

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Viewing pain in a positive angle, it is also a protective physiological mechanism to the body. For example, when a person feels pain because his hands are on a fire, he’ll move hands away at once certainly to avoid his hands burned. On the other hand, if a client is unable to feel sensation, the nurse should look out of pain-inducing injuries.Pain is not just a single sensation with physical, behavior and emotional reaction.

Pain is not just a single sensation caused by a specific stimulus. It is subjective and highly individualized. The nature of stimulus for pain may be physical and/or mental, so damage may be done to actual tissues or to a person’s ego. Pain can make people tired and consume their energy. It can affect personal relationships and influence a person’s confidence of life. Though some types of pain have predictable signs and symptoms, we cannot measure pain objectively. The only thing that the nurse can do to assess pain is to observe the clients’ words and behavior, for the client is the only one who can tell what the pain is like. And the responsibility for the nurses is to believe its existence and find measures to decrease or eliminate it.Pain is an uncomfortable experience mixed with physical and psychological.

C lassification of pain We often speak of three types of pain: acute, chronic (often named chronic nonmalignant or

chronic benign), and cancer pain. Acute Pain

Acute Pain usually happens after acute injury, disease, or surgical intervention. It has a rapid onset and the intensity (mild to severe) varies. The lasting time of it is brief, usually less than 6 months. It can disappear with or without treatment after a damaged area heals. So the health team members often treat acute pain aggressively and the client’s expectation of the elimination of it is also earnest. However, if the nurse does not provide quick relief or the acute pain, conflict between nurse and client may arise.

Another reason for the conflict is that the client focuses all interests on pain relief because acute pain seriously threatens a client’s recovery, which may delay the client’s rehabilitation and prolong his/her hospitalization. At this time, the nurse’s efforts at teaching and motivating the client toward self-care may often be useless. So one of the priorities in the client’s care should be pain relief. Only when the pain is relieved, the client and health care team can direct full attention toward recovery.

Chronic Pain The characteristics of chronic pain are prolonged, varying in intensity, and lasting longer

than 6 months. Many of this type of pain are chronic non-malignant pain, such as arthritis, low back pain, myofascial pain, headache, and peripheral neuropathy. They are caused by non-life-threatening factors, which are often unknown. Fatigue, insomnia, anorexia, weigh loss, depression, hopelessness, and anger are symptoms of chronic pain. But they are not often shown overtly and the patient usually suffers physical and mental exhaustion.

Though the injured area has been healed long ago, the pain may still exist and may not respond to treatment. The unpredictability of chronic non-malignant pain often makes the client frustrated and frequently leads to psychological and physical disability, which will cause problems such as loss of a job, inability to perform simple daily activities, sexual

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dysfunction, and social isolation from family and friends. It is also challenging for the health care workers to treat such pain though there are many remedies for them to choose to use, such as pharmacological remedy, exercise and biofeedback. The nurse must maintain confidence when a relief measure fails and also should not provide false hope for a remedy to the client.

Cancer Pain Cancer pain is caused by tumor progression and its related pathology, invasive

procedures, toxicities of treatment, infections, and physical limitation. It doesn’t happen in every cancer patient. The quality of it can be chronic and/or acute, nociceptive and/or neuropathic. And its site can be at the actual site of the tumor or distant to the tumor, which is called referred pain.

M echanism of Pain Currently, there are two main mechanism of pain, which are neuro-regulation and gate-

control theory.Neuro-regulation

Neuro-regulators, or substances that has effect on the transmission of nerve stimuli, are one of important factors in the pain experience. These substances exist in nociceptor, at nerve terminals within the dorsal horn of the spinal cord, and at receptor sites within the spino-thalamic tract They can be divided into two groups: neurotransmitters and neuro-modulators. Neurotransmitters convey electrical impulses through the synaptic cleft between two nerve fibers, which include substance P, serotonin and prostaglandins. Neuro-modulators modify neuron activity and adjust or vary the transmission of pain stimuli and don’t transfer a nerve signal through a synapse directly. They are believed to act indirectly by increasing or decreasing the effects of particular neurotransmitters. Endorphins, dynorphins and brady-kinin are neuro-modulator. Pharmacological therapy for pain is largely concerned with the influence of medications selected on neuro-regulators.

Gate-Control Theory of Pain It is known that there is no specific pain centre in the nervous system. Melzack and

Wall’s gate-control theory (1965 ) thinks that pain impulses can be regulated or even blocked by fating mechanisms in the central nervous systems. Gating mechanisms exist in substantia gelatinosa cells within the dorsal horn of the spinal cord, thalamus, and limbic system. If people know how to influence these gates, nurses for pain management may gain a useful conceptual framework. As indicated in this theory, pain impulses can pass through when a gate is open and may be blocked when a gate is closed. So, how to close the gate is the focus of pain-relief interviews.

The gating process is regulated through a balance of activity from sensory neurons and descending control fibers from the brain. When A-delta and C neurons work dominantly, they release substance P to help impulses transmitted through the gating mechanisms. And the patient feels pain. On the contrary, when mechanoreceptor, thicker, faster A-beta neurons work mainly, they release inhibiting neurotransmitters to close gating mechanisms. Thus the patient perceives no pain. The massage can stimulate mechanoreceptors. Even if pain impulses go upward to the brain, there may be higher cortical centers in the brain to modify

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pain perception. Endogenous opiates such as endorphins, which are natural painkillers of the body, can be released by descending neural pathways. They may close gating mechanisms through inhibiting the release of substance P. The ways to release endorphins include distraction, counseling, and exercise.

Perception is the point at which a person is aware of pain. Pain stimuli travel through the spinal cord to the thalamus and midbrain. At thalamus, the pain message is transmitted to various areas of the brain, which include the somato-sensory cortex and association cortex ( both in the parietal lobe ), the frontal lobe, and the limbic system. The somato-sensory cortex discriminates the location and intensity of pain, and the association cortex determines the feeling of the pain. It is believed that within the limbic system there are cells of controlling emotion, particularly anxiety. Therefore, the limbic system may play an active role in the process of pain’s emotional reaction. At the end of nerve transmission, a person perceives the sensation of pain for the work of higher brain centers.

When a person becomes aware of pain, a complex reaction unfolds. T he perception of pain is the result of the interaction among psychological and cognitive factors and neuro-physiological ones. It gives awareness and meaning to pain to make people react. The reaction to pain includes physiological and behavioral responses.

R eactions to pain Reactions to pain include physiological responses and behavioral responses.

Physiological Responses When pain impulses travel up the spinal cord to the brain stem and thalamus, it stimulates the autonomic nervous system, which is a part of the stress response. Low to moderate intensity pain and superficial pain may cause the fight-or-flight reaction of the general adaptation syndrome. The results of stimuli to the sympathetic branch of the autonomic nervous system are physiological responses. If the nature of pain is continuous, severe, or deep, typically involving the visceral organs (e. g., a myocardial infarction or colic from gallbladder or renal stones), then the parasympathetic nervous system works. If physiological responses to pain last for a long time, they could do serious harm to an individual. Except the pain is severe and traumatic, which may cause shock, most people can reach a level of adaptation in which physical signs return to normal. So, pain will not always leads to physical signs.

Physiological Reactions to Pain

Response Cause or EffectSympathetic StimulationBronchial tubes dilate and respiratory rate increasesHeart rate increasePeripheral vasoconstriction (pallor, blood pressure elevates)Blood glucose level increases Diaphoresis

Make oxygen intake increased

Provides more oxygen transportBlood pressure elevates through blood supply shifts from periphery and viscera to brain and skeletal musclesProvides increased energyTo control body temperature during stressPreparation of muscles action

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Muscle tension increasesPupils dilates Gastrointestinal motility decreasesParasympathetic Stimulation+

Pallor Muscle tensionHeart rate and blood pressure decreaseBreath rapidly, irregularly

Nausea and vomitingWeakness or exhaustion

Provides better vision Store energy for more immediate activity

Leads to blood supply shift away from peripheryResults from fatigueCaused by vagal stimulationResult in body defenses failure when there’s prolonged stress of pain End in return of gastrointestinal functionCaused by expenditure of physical energy

Behavioral ResponsesIf pain experienced is left untreated or unrelieved, it can significantly alter the quality of

a person’s life.Pain can do harm to physical and psychological well-being. If clients believe expression

of pain will inconvenience others or signal loss of self-control, they may choose not to express it. So, some clients will endure severe pain without assistance. The nurse must encourage such a client to express pain and accept pain-relieving measures, such as avoiding seriously curtail activity or nutritional intake. Contrastively, other clients may seek pain relief even before it occurs. The ability of clients’ pain tolerance significantly influences the nurse’s perceptions of their discomfort degree. Clenching the teeth, holding the painful part, bent posture, and grimaces are typical body movements and facial expressions indicating pain. Other pain expression are crying or moaning, restless, or making frequent requests of the nurse. The nurse should know what the meaning of them is. However, for those who lack of pain expression (e.g., a confused client), the nurse should pay more attention to them and help them to communicate the pain response effectively.

Along with transmission of pain stimuli, the body can adjust or vary pain perception. After the pain stimuli travel through nerve fibers in the spino-thalamic tract to the midbrain, some regions in the midbrain are stimulated to send stimuli back to the dorsal horn of the spinal cord through the descending pain system, which can inhibit transmission of painful stimuli by releasing neuro-regulators.

The final processes in nociception are modulation, in which the pain impulses are inhibited or changed. During this period, neurons descending from the brain stem to the dorsal horn of the spinal cord release substances such as serotonin, nor-epinephrine, and endogenous opiates (endorphins and enkephalins ) which can inhibit the transmission of pain and help produce an analgesic effect. When people are stressful or do excessive exercise, the release of endorphins increase so to raise their pain threshold. Because the amount of circulating substances varies largely among individuals, the pain response will also be different.

F actors Influencing Pain

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There are numerous factors that influence an individual’s pain experience. If the nurse can considers all factors that affect the client in pain, she/he will make more effective and holistic approaches to assess and relieve the pain.

individual’s factorsAge

Age is an important factor that influences pain. The extent of individual’s sensitivity to pain varies in age. The infants are less sensitive to pain than the adults. Along with the increase of the age, the sensitivity of pain increases, too. But in the older adult, the sensitivity of pain decreases with the aging. So, nurses must provide different pain relief measure to different age people with pain, especially the infants and the older adults. The nurses should pay attention to their specialty and individual variety.Gender

In general, men and women do not differ significantly in their responses to pain. It is uncertain whether gender along is a factor in the expression of pain But in some place, the culture does influence on gender and there is difference between the choices of medications for men and women by health care providers. So, nurses should be aware of their own biases of pain management.

Culture Cultural beliefs and values can affect how individuals react to pain and express pain. For

example, if the culture in which the client lives encourages tolerance and praises highly on bravery, the clients in pain are more likely to endure the pain and don’t express it. Nurses should explore the impact of the culture on the pain of the client and communicate effectively with the client and the family to make appropriate pain relief process.Individual’s pain experience

Any pain caused by single stimuli is influenced by individual’s previous similar pain experience. If a person has had plentiful experience of pain without relief, the client will feel anxiety or even fear when the client first experiences some kind of pain, the ability to cope may be impaired. The nurses caring such client should explain the pain and receiving methods of it to the client.

The meaning of pain that a client keeps affects the client’s pain experience and the extent to adapt to it. For example, the pain perceived by a woman in labor is differently from that of a cancer patient. And it is also different if a client regards the pain experiencing as a threat, loss, punishment, or challenge.Attention

The degree of attention that a client pays to pain can influence pain perception. When the client focuses all attention on one another thing, the perception of pain may be decreased or even disappear. Various pain-relief interventions such as relaxation, guided imagery, music remedy and massage are based on the principle.Emotion

Emotion can modify the pain response of a client. Positive emotion may decrease pain, but negative emotion can increase the perception of pain. For example, anxiety and pain may formulate a vicious circle and happiness or satisfaction can make a positive effect on pain. Though given the same painful stimuli, the perception of pain is varied under different emotion. Nurses should encourage the positive emotion when contacting with the patient.

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FatigueFatigue heightens the perception of pain and decreases the tolerance of pain. It is

especially evident in the patient with long-term chronic illness. Pain is often experienced less after a good rest, otherwise the perception of pain will increase.Individual’s difference

Coping style can influence the patient’s ability to deal with pain. If people have internal local of control, they will think their environments and the outcome of events, such as pain, are in the control of themselves. In contrast, the people with external loci o control will depend on other factors in their environments, such as nurses, to control their pain. The coping style varies in people. Nurses must make clear what the client’s coping resources are and bring them into the care plan to support the client or relieve the pain.Family and Social Support

People in pain often depend on family members or close friends for support, assistance, or protection. People will feel less lonely or fear. And they will decrease the perception of pain if accompanied by family members or relatives when experiencing pain. It is especially important for children that the parents can accompany them when they feel pain.

Nurse’s Knowledge, Attitudes, and BeliefsThe reasons that nurses can play a unique role in caring for clients with pain are the

nurses take care of the patients in their most vulnerable state and can observe the impact that pain has on many aspects of the clients’ life. So the trust between clients and nurses is very important for their effective communication. In this section factors influencing pain are also explored.

In the view of traditional medical model of illness, which suggests that physical problems result from physical causes, the nurses may not believe the clients are painful unless they have objective organic dysfunction. The medical care members often stereotype pain sufferers as complainers or difficult clients when no obvious source of pain can be found.

Besides the situations above, the assumptions about the extent of the client’ pain, influenced by biases based on their culture, education, and experience, lead to ineffective pain management by misconceptions about pain, too. Common biases and misconceptions about pain include that drug abusers and alcoholics may overreact to discomforts, the pain of people with minor illnesses is less than that with severe physical alteration, regular analgesics administration will cause drug addiction, tissue damage amount in an injury can accurately reflect the intensity of pain, health care personnel are the best authorities to evaluate the client’s pain nature, psychogenic pain is false, the nature of chronic pain is psychological, and people should expect pain experienced in a hospital.

To exactly help a client with pain, the nurse must view the experience at the client’s angle and avoid personal prejudices or misconceptions. At the same time, the nurse should become an active, knowledgeable observer of a client in pain to make a more objective analysis of the pain experience so to make more effective pain relief measures.

Pain Assessment At the phase of pain assessment, it is of important significance to obtain objective data

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from the client about the pain, observe the behavioral response carefully, analyze the data and decide the baseline of the client’s pain. On the basis of a factual, timely, accurate pain assessment, nurse will be able to make correct nursing diagnosis, choose appropriate interventions and evaluate the response (outcomes) of the interventions accurately. The core of this complex activity is to explore the pain experience through the eyes of the client.

When assessing clients with chronic pain, it is best to focus on affective, cognitive, and behavioral dimensions of the pain experience, its history and context. And the assessment of function level should be assessed, because complete pain relief may not be achieved. There’s an effective way to manage pain that called ABCDE：A. Ask clients about pain regularly and assess pain systematically. B. Believe the client and family’s pain report and their relieving methods. C. Choose appropriate pain-control options for the client, family, and setting. D. Deliver interventions timely, logically, and corporately. E. Empower client and their families to control their pain course to greatest possible extent.

And when the nurses do assessment, many possible errors should be avoided by using the right tools and methods. Common sources for pain assessment mistakes include the bias of nurse, vague or unclear assessment questions causing unreliable assessment data, use of pain assessment tools without proved reliability and validity among identical clients, pain information from client aren’t complete, pertinent, and accurate, and cognitively impaired older clients aren’t able to use pain scales.

AspectsClient’s Expression of Pain

The expression of pain varies in people and it’s often influenced by the perception of the nurse. For example, if the clients notice that the nurses doubt the existence about their pain, they may report little information about their pain experience or will minimize the communication. So the nurses must be aware of the verbal and nonverbal ways about the pain expression of the clients, especially the nonverbal ways of the clients who are children, developmentally delayed, psychotic, critically ill, dementia, and can not speak. The nurses should know that grimacing, splinting one body part, and unusual posturing are common nonverbal expressions of pain.

Because pain is a subjective feeling, the single most reliable indicator of the existence and intensity of pain and any related discomfort is the client’s self-report of pain. Nurses may use instruments to quantify the extent and degree of pain.

Onset and Duration The onset, duration, and sequence of pain can be determined by asking the client. It is

often easier to assess the onset of sudden and severe pain that of gradual, mild discomfort. The significance of knowing the time cycle of pain is to make it possible that the nurse can intervene before the pain occurs or worsens.

Implications of Pain Assessment for Nursing InterventionsAssessment Criteria Nursing Interventions

Onset and duration Administer analgesics to make its peak action occurs at the time that pain is most acute (e.g. ,during dressing change or exercise therapy)

Location Position client off affected area. Use local treatments(e.g. ,elastic

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bandage and splinting) over painful site directlyIntensity Modify or revise interventions according to the effect of one

intervention Precipitation or aggravating factors

Avoid activities causing or aggravating pain and send these messages to client or family

Relief measures Use measures that client is used to, safe and appropriate, including some nonpharmacological interventions

LocationTo assess pain location, the nurse can document the sites on a baby diagram that are told

or pointed by the client. Classified by location, pain may be superficial or cutaneous, deep or visceral, or referred or radiating.

Classification of Pain by LocationLocation Characteristics Examples of Causes

Superficial or Cutaneous Pain

Pain is caused by skin stimulation Short duration, local and usually a sharp sensation

Needle stick, small cut or laceration

Deep Visceral Pain

Pain is caused by stimulation of internal organs

Diffuse, possible radiation in several directions, different duration (usually longer than superficial pain ), sharp, dull, or unique organ involved

Sensation of crushing (e.g. , angina pectoris ); burning (e.g. ,gastric ulcer)

Referred Pain

Common phenomenon in the visceral pain. Because many organs have no pain receptors themselves. Their sensory neurons go into the same spinal cord segment with other body part. When these organs are affected, pain is felt in unaffected areas

Separated from source of pain, and maybe any characteristic

Myocardial infarction, causing referred pain to jaw, left arm, and left shoulder; kidney stones may refer pain to groin

Radiating Pain

Sensation of pain extends from initial site of injury to another body part

Traveling down or along body part likely, possible intermittent or constant

Ruptured intravertebral disk has low back pain and pain radiating down leg from sciatic nerve irritation

IntensityTo assess the intensity of pain, nurses can ask the client to describe pain as mild,

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moderate, or severe. But there may be misunderstanding between nurses and clients. So it is more objective to use scales to assess the intensity of pain. There are three types of scales for adults and one for children that are often used in assessment of pain.

QualityWhen nurses assess the quality of pain, they can offer a list of descriptive terms, such as

pricking, burning and aching to the clients when they cannot describe the pain. Then the clients may choose more descriptive terms. Often people describe certain types of pain in the similar words. For example, crushing or viselike is frequently used to describe the pain associated with a myocardial infarction, whereas to describe the pain of a surgical incision, sharp and stabbing are often used.Pain pattern

Various pains can be precipitated or aggravated by certain activities or actions. For example, bending over or lifting objects usually aggravates the low back pain and radiation down the leg of a ruptured intravertebral disk patient. Thus, if nurses identify precipitating or aggravating factors of certain pain, they may plan interventions to prevent pain from occurring or worsening easily.Relief Measures

It is helpful to relieve the pain of client for the nurse to know the client’s effective way of relieving pain (such as changing position, eating, or applying heat or cold to the painful site) and express the willingness to try the measures in the pain management. This often makes the client comfortable and the most cooperative in implementation of the pain. So the self-relieving measures of the client should be included in the nursing assessment of pain.Concomitant symptoms

The symptoms that often occur with pain (e.g., nausea, headache, dizziness, urge to urinate, constipation, and restlessness) are called concomitant symptoms. Sometimes, they are as much a treatment priority as the pain itself. The significance to assess these symptoms is that certain types of pain have predictable accompanying symptoms. For example, the pain of a kidney stone often causes nausea and vomiting.Effects of Pain on the Client

Pain is a stressful event that can change a person’s lifestyle and affect psychological well-being. The nurse can identify the nature and existence of pain better by recognizing the effects that pain has on clients.a.Behavioral Effects To assess a client with pain, a verbal report of pain is a vital part of assessment. But when the client hasn’t the ability to communicate, vocalizations, facial expressions, body movements and social interaction of the client are to be assessed instead (Table 5-6). Sometimes, these behaviors may reflex the information of pain more authentically to provide useful clue for the nurse about the intensity or nature of the pain.b.Influence on Activities of Daily Living The influence on activities of daily living can be assessed by observing the changes in sleep, social activities and neurological function, and the abilities to perform basic hygiene, maintain normal sexual relations, or work productively. These assessments may reveal the extent of the client’s disability so to help the nurse to make judgment on the necessary to provide help in the client’s daily living and help the client participates in self-care training.

Behavioral Indicators of Effects of Pain

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Cl ien t

ExpectationsStudies have shown that people view pain as a “part of life” and would rather bear it

than take action to relieve it. It is often that the client has experience a pain for many hours or days before seeking health care assistance. Even though in hospital, they may expect and even accept a certain amount of pain. But they may expect that nurses will provide immediate pain relieving for they have suffered it for so Long a time.

MethodsCollect health history

The nursing health history is obtained when the nurse interviews the client. To collect data from an interview, the nurse should use communication skills to initiate the nurse-client relationship.Observation and physical examination

Nurse may identify client`s perception ,extend and position of pain, according to their face expressions or limb actions. For example: 1.still:clients keep on one position in which they are most comfortable, usually occur in limb pain or injure pain. 2. blind motions: some serious client distract their attention to pain by blind motion. 3. Protectful motions: a evasive reflect to pain. 4. typical actions or massage: usually used to release pains. Such as, press head with fingers when headache, massage abdomen when splanchnic bellyache.Pain assessment toolsa. VDS Verbal descriptor scale (VDS) is a line divided into three to five parts equally along the line. From one end to the other, the parts are ranked from “no pain” to “unbearable pain”. The clients are asked to choose one of the verbal descriptor that suits to their situations the most.

Aspects of effects Behavioral indicationVocalizations Clients moan

Clients cryClients gaspClients grunt

Facial Expressions Clients grimaceClients clench teethClients wrinkle forehead Clients close tightly or open widely the eyes or mouthClients bit lip

Body Movement Clients are restlessClients are immobilizedClients’ muscle tenseClients increase movements of hand and fingerClients pace activitiesClients do rhythmic or rubbing motionsBody parts move protectively

Social Interaction Clients avoid conversationClients focus merely on pain activitiesClients avoid social contactsClients’ attention span reduce

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b. NRS Numerical rating scale (NRS) is to use number instead of word as the graduation on the line. And in the scale, the pain is divided into eleven degrees from 0 to 10.0 represents no pain, and 10 means severe pain. This scale is especially useful to compare the pain intensity before and after therapeutic interventions.

c. VAS Visual analogue scale (VAS) is a line without dividing into sections. It represents a continuum of intensity, and has verbal descriptors at each end. One is “no pain”, and the other is “unbearable pain”. This scale is more sensitive than the two scales above, for it provides the client total freedom in identifying in the severity of pain.

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d. FES The face expressional scale (FES) is developed to assess pain in children. It consists of six cartoon faces ranged from a smiling face (“no pain”) to a final sad, tearful face (“worst pain”). It is suitable to use in children as young as 3 years of age.

Face 0 is very happy because he doesn't hurt at all.

Face 1 hurts just a little bit.

Face 2 hurts a little more.

Face 3 hurts even more.

Face 4 hurts a whole lot.

Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad.

e. World Health Organization(WHO) Pain Scale 0: absent of pain 1:mild pain2:moderate pain3:severe pain

f.Prince-Henry pain scale application to patients after thoracic operation.0: absent of pain1:caugh caused pain2: absent of pain when patient live in peaceful condition3: pain in peaceful condition and bearable4: severe pain in peaceful condition and unbearable

A good pain scale should be easy to use and not time consuming to complete. It is to be noticed that when nurses use the pain scales, they must select and consistently use one scale when assessing a client and not use them for comparison between clients.

P ain interventions

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Reduce or eliminate the reason of pain Remove the pain stimuli, reduce or eliminate the reason of pain. For example, first of

all, the pain caused by trauma needs stopping bleeding, dressing the wound or fixation according to the specific conditions. And there are also many interventions that the nurse can take to prevent the pain from happening. For example, the nurse can teach a patient how to breath deeply and cough effectively before he or she will perform a surgical operation in the chest or abdomen, which may help to avoid pulmonary infection.

Pharmacological Pain-Relief Interventions Pharmacological Interventions are one of the most common methods that are used to

relieve pain. The pharmacological agents that provide pain management all require a physician’s order to administer. What the nurses can do is to use and manage the medications, which is based on the nurses’ knowledge of pharmacology, the data of patient’s physical status and the understanding of medical therapy process.

There are many kinds of analgesics. The analgesics can’t be used at will before the doctor makes explicit diagnosis, which is to avoid covering the real signs and symptoms so to delay the treatment of the disease. For the clients who have chronic pain, the nurses should make clear the regular pattern of its occurrence and give medications before it happens, which may bring better pain-relief effect and need less dosage than giving medications after the pain has happened. And the nursing routine should be arranged during the period that the medication medications should be ceased immediately to avoid the occurrence of side effects and tolerance if being used for a long time. So an ideal analgesic should have these characteristics: rapid onset, prolonged effectiveness, effectiveness in all age-groups, oral and parenteral use, lack of severe side effects, nonaddicting nature, and inexpensive.Medication therapy of Cancer Pain

Currently, the three-grade analgesic ladder recommended by WHO is carried out popularly for the cancer pain management in clinic. The objective of this approach is to make rational utilization of drugs according to the extent of pain and the grade of analgesics. The principles of medication are using drugs from weak to strong effects, take orally, using timing and jointly, and individualizing the dosage. Most patients following this approach can relieve pain satisfactorily. This method includes three steps. The first step: focusing on patients with mild pain, nonopioid, antipyretics nanlygesics, and antiphlogistics drugs, such as aspirin, ibuprofen, and paracetamol are to be used. The second step: applying to patients with moderate pain. If the nonopioid is ineffective, weak opioid, such as anfendailyin, codeine, and tramadol can be used. The third step: being mainly used on patient with severe pain and acute cancer pain. And strong opioid is choosed, such as morphine, pathidine, and dihydroetorphine. Along this approach, adjuvants can be used alone or combining with analgesics. Adjuvants can decrease the dosage of the analgesics and its side effects. The common adjuvants include nonsteroidal antiinflammatory drugs, antianxiety agents, and antidepressants, such as aspirin, diazepam, and amitriptyline.

World Health Organization(WHO) Pain Ladder

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Patient-Controlled Analgesia PCA device (also named Patient-Controlled Analgesia), which is a drug delivery system

that are portable infusion pumps usually computerized), containing a chamber for a syringe or bag that delivers a small, preset does of medication and which can decrease the side effects by delivering small does of medications at short intervals and under the control of the clients themselves; epidural analgesia, which injects the medications, such as morphine or fentanyl, directly into the spinal epidural leision to increase the cerebrospinal fluid level of analgesics and gain action of long duration. Epidural analgesia is an effective therapy for the treatment of severe pain and carried out widely in medical setting.

Psychotherapy-- cognitive-behavioral interventionsThe goals of cognitive-behavioral interventions include changing clients’ perceptions of

pain, altering pain behavior, and providing clients with a greater sense of control.Distraction

The reticular activating system may inhibit painful stimuli when sufficient or excessive sensory input is received. So, the nurse can provide pleasurable stimuli for the client to make the client’s attention directing to something else, thus to reduce the awareness of pain and even increase tolerance. This is just the mechanism of distraction. And distraction is best suitable for short, intense pain that lasts a few minutes. a.Activity

Singing, praying, describing photos or picture aloud, listening to music, and playing games are methods of distraction.b.Music

Music is one effective distraction, which can decrease physiological pain, stress, and anxiety by diverting the person’s attention away from the pain and creating a relaxation response. Music that initially matches a person’s mood is usually best. In music therapy, classical, popular, and nontraditional music (music with no vocals, periods of silence) is often used. And the client must listen to the music at least 15 minutes to be therapeutic. Studies have shown that listening to music can be highly effective in reducing a client’s postoperative pain.c.Rhythmically massage

instruct clients focus eyes on one fixed spot, imagine object`s shape, color etc, meanwhile annularly massage pain spots.d.Deep breath

instruct clients breathe deeply in rhythm, inspire deeply via nose, expire slowly via

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mouth, then repeat again. Guided imagery

Guided imagery is to use the positive effect of a pleasant scene or experience imagery to make client gradually less aware of pain. For example, the nurse may describe a scene of green grass, the sounds of stream, and the fragrance of flowers. This may make client pay more attention to it and less attention to pain. When doing this, the nurse should sit closely enough needn’t to speak continuously. Otherwise, the exercise should be stopped and begin later when the client is more at ease.Relaxation

Affective-motivational and cognitive pain perception can be altered through relaxation and guided imagery. Relaxation is a state of mental and physical freedom from tension or stress. Successful relaxation can bring several physiological and behavioral changes, such as pulse, blood pressure, and respirations decrease, oxygen consumption drops, muscle tension falls, metabolic rate goes down, global awareness heightens, attention to environment stimuli descends, fell peaceful and well-being and alterness level increases. Meditation, yoga, Zen, guided imagery, and progressive relaxation exercises are relaxation techniques. These techniques can be used at any phase of health or illness except acute discomfort.

When doing relaxation, the environment should be very quiet and without irritating stimuli. The client must concentrate on it and cooperate with the nurse. And it is also important to keep the client in a comfortable body position. If the client sits， He/she should rest entire back against back of chair, place feet flat on floor, maintain legs separated, hang arms at both sides or rest them on chair arms, and at the same time, keep head aligned with spine. If lying position has been chosen, the client should use thin, small pillow under head, maintain head aligned with spine, place arms at sides without touching sides of body, and maintain legs separated with toes pointed slightly outward.

Progressive relaxation exercise is to contract and relax a series of muscle groups with controlled breathing exercise also need to be stopped and begin at another time whenever the client feels uncomfortable.

Other interventions Physical interventions

Cold and heat therapy, naprapathy, massageAcupuncture

According to the site of pain, different acupuncture point is select for acupressure to dredge the body blood vessels and mediate the body functions to reduce pain. It is generally believed that the mechanism of acupressure is the result of interaction and integration of the stimulation signals from pain site and the acupuncture point at the different levels of central nervous system. And in this process, it not only involves the participation of central nerves that are associated with pain relieving, but also includes the attention of the central neuromodulators, such as endorphins.Cutaneous Stimulation

Cutaneous stimulation is to stimulate the skin to relieve pain. It can reduce pain perception and muscle tension that might increase pain. The exact mechanism that cutaneous stimulation relieves pain is not clear. One explanation is that it causes release of endorphins, which can block the transmission of painful stimuli. Common examples of it are message,

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warm bath, ice bag, and transcutaneous electrical nerve stimulation (TENS). Some of them are very simple and can be used at home. But it needs to be noticed not to use them on sensitive skin areas (such as, burns, bruises, skin rashes, and inflammation) directly and the environment should be quiet to obtain satisfying effect.

Promote patient’s comfortNursing to make clients more comfortable is one important procedure coping with pain.

Help clients in appropriate posture, provide comfortable bed and environment including light, indoor temperature and humidity. In addition, explain steps to clients before nursing, do nursing after analgetic act, make sure clients could easily get necessary living products. These all can reduce clients` anxiety and suffering.

Health EducationIt is helpful for the clients to reduce discomfort and achieve a sense of control that the

nurse teaches them about the pain experience and associated discomfort. For children, relevant play may be a good type of teaching. There’re nonpharmacological and pharmacological interventions that can be used in this situation. But the nonpharmacological interventions are used the most, which includes acupressure and cognitive-behavioral approaches.

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