Pain Management, Comfort, Rest, and Sleep. The Meaning of Comfort Comfort – To give strength and hope, to cheer, and to ease the grief or trouble of another.

Pain Management, Comfort, Rest, and Sleep

The Meaning of Comfort

• Comfort– To give strength and hope, to cheer, and to

ease the grief or trouble of another• One of the greatest challenges for the nurse is

to provide comfort to the patient• Promoting physical comfort is a vital part of

the role of a nurse.

Comfort and well-being can be promoted with eye contact and gentle touch.

Providing Comfort• Lack of comfort can be the result of many factors and

can take many forms such as:– Anxiety Nausea– Depression Pain– Diarrhea Powerlessness– Dyspnea Urinary Retention– Fatigue Incontinence– Fear Hypoxia– Headache

Providing Comfort

• The nurse should pursue methods to assist the patient in achieving relief from discomfort.– Actively listen – Recognize non-verbal discomfort signals – Be diligent in your efforts– If interventions are not successful, pursue alternative

interventions

Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in the

US.

Nature of Pain

• A complex, abstract, personal subjective experience

Nature of Pain

• Per the American Pain Society and the International Association for the Study of Pain:– “An unpleasant sensory and emotional experience

associated with actual or potential tissue damage or described in terms of such damage.

Nature of Pain -unpleasant sensation -noxious stimulation of the sensory nerve endings -warning system to the body -actual or potential tissue damage -sign of inflammation and/or infection -diagnosis of many disorders and conditions -no tissue damage, such as the pain of grief

• Interpretation and significance of the pain • Individual’s learned experiences • Psychosocial and cultural factors.• Expert is the person who is bearing the pain: • -location -intensity• -quality -pattern • Degree of pain relief obtained from therapy.

Pain is Multifaceted

Psychological factors that influencethe perception of pain

• Increased Pain– Sadness, Depression– Fatigue– Anger– Discomfort– Insomnia– Anxiety– Fear

• Decreased Pain– Happiness– Rest– Diversion– Relief of symptoms– Sleep– Sympathy– Understanding

Nature of Pain

• Nursing goal – empower the patient to be an active

partner in reporting information about the pain• Pain history – patient’s description– optimal pain management.

Nursing Assessment of Pt. Pain

Obtain a baseline perspective In the past, failed efforts to control the pain plan future therapy. Complete a physical examination Persistent pain consider:

-physiologic cause is not always obvious or identifiable

Types of Pain Acute Pain

Intense and of short duration -comes on quickly -very definite symptoms -can be quite intense -heal in a relatively brief period of time. Autonomic response -Sympathetic Nervous System

Floods the body with epinephrine— mediator for “fight or flight” response

Acute Injury

Chronic Pain• Generally characterized a pain lasting longer than

6 months• Continuous or intermittent• Can be intense• Chronic pain does not serve as a warning of tissue

damage in process but rather signals the fact of its having occurred.

• Changes in the behavior of the patient• Development of fear-avoidance strategies• Precursor of chronic disability

Chronic Pain

•Fundamental mechanisms sustaining the pain has become independent of the initial injury or damage

-difficult to treat -very frustrating for patient and health providers. -chronic low self-esteem -change in social identity -changes in role and social interaction -fatigue -sleep disturbance -depression/suicidal ideation Syndrome of Chronic Pain

Chronic Pain

• Treating chronic pain– identify source [although it may be unknown]– referral to Pain Management Specialist as soon as possible – requires a multidisciplinary approach

• Referred Pain: Felt at a site other than the injured organ or part of the body

Nociceptor

• A peripheral nerve organ or mechanism for the reception and transmission of painful or injurious stimuli

Peripheral Nociceptors

• Unspecialized cell endings -free endings -detect chemical substances released from damaged tissue. -skin, muscle, joints, and some visceral tissues

Theories of Pain Transmission

• Gate Control Theory – Small diameter nerve fibers carry pain stimuli through a gate mechanism– Larger diameter nerve fibers go through the same gate– If other cutaneous stimuli besides pain are transmitted,

the “gate” through which the pain impulse must travel is temporarily “blocked” by the other stimuli.

– The brain does not have the capacity to acknowledge the pain impulse when it is interpreting the other stimuli.

– When gates are open, pain impulses flow freely.

Gate Control TheoryPain – Gate Theory cont. - The “gate” is shut by stimulating nerves responsible for carrying the

touch signal bombardment of sensory impulses

-Enables the relief of pain through massage techniques, rubbing, and application of hot and cold packs

- The gate mechanism is shut by stimulating the release of endorphins – Chemicals released by the body in response

to pain stimuli

Endorphins

• Natural supply of morphine-like substances– neurotransmitters that activate opiate receptors– Stress and pain activate endorphins analgesia • Certain endorphins attach to opioid receptors in the

brain preventing release of neurotransmitters inhibition of the transmission of pain impulse

Endorphins

• People who have less pain than others from a similar injury have been found to have higher endorphin levels.

• Acupuncture, TENS unit and placebos are believed to cause the release of endorphins.

Older Adult Considerations• Changes in drug absorption, distribution,

metabolism and elimination– affect the plasma levels/analgesic drug levels– drug absorption may be altered– increased gastric pH and decreased gastric motility– distribution of drugs may change– decrease in lean body mass or plasma proteins and albumin level secondary to

chronic illness and poor nutrition.

Older Adult Considerations

• Hepatic blood flow, renal blood flow and glomerular filtration rate are decreased

• Elimination of drugs may change as renal and hepatic clearance decreases.

• Management of acute pain in the elderly involves: -careful “titration” of analgesic doses -assessing patients frequently for inadequate pain control and for adverse side effects

Age and Pain Control

• Psycho-social issues in the elderly r/t pain:– Misconceptions• pain perception decreases with age• elderly cannot tolerate opioids

– Inadequate assessment• difficult in patients with cognitive impairment,

dementia, aphasia

Age and Pain Control• Psycho-social issues in the elderly r/t pain: (cont.)

– Lack of education• fear of addiction (patient, health care giver)• patient expects to have pain• patient unfamiliar/unwilling to use equipment:

e.g. PCA• may be as simple as HOH or needs repetitive

instructions

Analgesic options in the elderly

• Pharmacologic options – use around the clock dosing– start with low dose (25% to 50% of usual adult

dose), titrate up slowly– use adjuncts (acetaminophen or NSAID) for opioid

sparing effect– patient monitoring for sedation, respiratory

depression

Analgesic Options in the Elderly

Nonpharmacologic Options -heat or cold

-massage -exercise -transcutaneous electrical nerve stimulation (TENS). -Cognitive-behavioral techniques -education/instruction -relaxation -imagery -music -biofeedback

Pediatric Pain

• Just because you can’t talk, doesn’t mean you don’t have pain– Crying – Restlessness or agitation – Thrashing – Stiffened arms and legs – Increases in heart rate and blood pressure – Ask the mother !!!!!

Pediatric Pain• Developmental Effects of Unrelieved Pain– Increased behavioral/physiologic responses – Altered temperaments– Somatization –psychological needs are expressed

in physical symptoms– More distress behaviors– Altered development of the pain conduction

system– Stress disorders, addictive behavior and anxiety

states– Lowered pain threshold

Pain“ The Fifth Vital Sign”

• American Pain Society recommendation’s goal is to ensure pain is treated with the same zeal as any changes in pulse, temperature, blood pressure, and respirations would receive.

• A strategy to increase accountability for pain control

Pain “The Fifth Vital Sign”

• Pain Assessment– Ask patients about their pain– Accept and respect what they say– Use Nursing Process • Assess• Diagnose and Plan• Implement• Evaluate

50% of people who suffer moderate to severe pain will continue to suffer because nurses fail to assess pain.

Pain “The Fifth Vital Sign”

Unrelieved pain has harmful physical effects Increased oxygen demand Respiratory and cardiac function stressed Decreased gastrointestinal motility Confusion Depressed immune response Anxiety, depression and irritability Inability to enjoy life

Delaying analgesia until pain is severe has no benefits

JCAHO Standards for Pain Control

• Joint Commission on Accreditation of Healthcare Organization– http://www.jointcommission.org/

– Our Mission: To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.

JCAHO Standards for Pain Control

• Under the new JCAHO standards– Health care providers -knowledgeable about pain assessment and management– Facilities -develop policies and procedures -appropriate use of analgesics and other pain control therapies.

• Key Concepts– Patients have the right to: -appropriate assessment. -be treated for pain or referred for treatment. -be assessed and regularly reassessed. -be taught effective pain management. -be taught that pain management is a part of

treatment.

JACHO Standard of Care

JACHO Standard of Care

Patients have the right to: (cont.)-be involved in making care decisions.

-routine and PRN analgesics are to be administered as ordered. -continuing care based on the patient’s need at the time of discharge, including the need for pain management

Nursing Assessment of Pain

• Subjective Data collection:– Obtain accurate information from the patient• “pt. c/o pain” provides no useful data• Assess all characteristics of pain• Obtain socio-cultural information

– Encourage patients to use their own words• Quote the patient as needed

Nursing Assessment of Pain

• Subjective Data Collection (cont.)– Validated pain scale. -use the same pain scale = the one the patient chooses.– Document so that all involved in the patient’s care have a clear understanding of the pain problem.

Pain History

• Critical Elements of the Pain History– How the pain developed – Description of the pain – Location of the pain and any spread – The pattern of the pain over time – The patient’s pre-morbid and current levels of

function and impairment (how does the pain interfere with activity?)

– What aggravates or relieves pain – Previously attempted treatments

Nursing Assessment of Pain

• Objective DataCarefully observe the patient for:• Tachycardia• ↑ rate and depth of breathing• Diaphoresis• ↑ BP• Pallor; dilated pupils• Increased muscle tension

Nursing Assessment of Pain

• If the pain is chronic or less severe, observe for:– Changes in facial expression– Frowning, gritting teeth– Clenched fists– Withdrawal or c/o– Pacing– Wanting constant attention or to be left alone

Nursing Interventions

• Comfort measures/pain control.– Tighten wrinkled bed linens.– Reposition drainage tubes or other objects on which patient is lying. – Place warm blankets for coldness.– Loosen constricting bandages.– Change moist dressings.

Nursing Interventions• Comfort Measures cont.– Check tape to prevent pulling on skin.– Position patient in anatomic alignment.– Check temperature of hot or cold applications,

including bath water.– Lift, not pull, patient up in bed; handle

gently.– Position patient correctly on bedpan.– Avoid exposing skin or mucous membranes

to irritants.

Nursing Interventions• Other Comfort Measures:– Prevent urinary retention by ensuring patency of

Foley catheter.– Prevent constipation by encouraging appropriate

fluid intake, diet, and exercise and by administering prescribed stool softeners.

– Just saying “I believe that you are in pain and I will assist you in whatever way I can to relieve your pain”

It’s as easy as ABCDE !

› Ask about pain regularly. Assess pain systematically. › Believe the patient and family in their reports of pain

and what relieves it. › Choose pain control options appropriate for the patient,

family and setting. › Deliver intervention in timely, logical and coordinated

fashion. › Empower patients and their family. Enable them to

control their course to the greatest extent possible

Unrelieved Pain

Erodes the patient’s quality of life. About 50 million Americans (1 in 5) report persistent or intermittent pain annually.

Unrelieved Pain: -Public Health Problem

Estimated to cost billions of dollars in direct and indirect expenses.

Improved knowledge and practice of principles of pain assessment and management.

Nursing Interventions

Treated aggressively Nurse’s role in pain management is important Advocate for the patient -clarifying concerns -answering questions -supplying information the patient needs to

make decisions about care -supporting the patient’s decisions.

Analgesics• Goal: effective pain relief without causing loss of

consciousness• Selection of proper analgesic– Effectiveness of the agent– Duration of action– Desired duration of therapy– Ability to cause drug interactions– Hypersensitivity of the client– Available routes of drug administration

Placebo Effect

• Occurs when a person responds to the medication (or other treatment) because of an expectation that the medication (or treatment) will work rather than because it actually does so.

• American Pain Association recommends that facilities have policies in place prohibiting the use of placebos– Educational programs should be conducted for nurses

and other healthcare providers about effective pain management

– Ethics committee should assist in developing and disseminating these policies

Placebo Effect

Factors that influence the placebo effect include: -characteristics of the placebo -pill looks genuine -believe that it contains medicine -larger sized pills suggest a stronger dose than smaller pills -two pills appears more potent than swallowing just one -injections have a more powerful effect than pills.

Noninvasive Pain Relief Techniques

• Advantages– - some self control over the treatment of pain– - inexpensive and easy to perform– - low risk and few side effects

Noninvasive Pain Relief Techniques

• Transcutaneous Electrical Nerve Stimulation (TENS)

• A special device transmits low-voltageelectrical impulses through electrodes on the skin to an area of the body that is in pain

• Considered safe • Electrical current that is too intense or use

incorrectly can burn or irritate the skin.

Noninvasive Pain Relief Techniques

–Distraction• Turns attention to something other than the

pain. -"take their minds off" the pain.

–Relaxation• Reduces tension in the muscles.

–Other: guided imagery, biofeedback, meditation, and hypnosis– See P. 399 FON Table 16-1

Invasive Approach to PainManagement

• Invasive = Anything that enters the body• Risks are high• Examples invasive procedures/risks:– Nerve blocks• Complications• Pneumothorax, hemorrhage, infection , paresis,

paralysis, bowel or bladder dysfunction – Epidural analgesics• unexpected and unusual side effects, pedal edema

and excessive perspiration.

Invasive Approach to PainManagement

• Examples cont.

– Neurosurgical procedures Infection

– Acupuncture -fainting, -local hematoma -pneumothorax -convulsions -local infections -hepatitis B-bacterial endocarditis -contact dermatitis -nerve damage

Medication for Pain Management

• Nonopioids– NSAIDS and Acetaminophen– frequently used, widely available– headache, mild to moderate pain– over the counter (OTC), inexpensive– ceiling effect – doses higher than the recommended dose will not produce greater pain relief, but can cause toxicity.– no physical dependence

NSAIDS

• Aspirin:– Most widely used – Oldest and cheapest– Reduce inflammation and pain – inhibits the synthesis of prostaglandin– Reduce fever • stimulating the hypothalamus • peripheral blood vessel dilation • increase sweating/promotes heat loss.

NSAIDS

• Aspirin (cont.)

• Adverse Reactions› Irritation of the GI tract -gastric ulceration/hemorrhage› Nausea /vomiting, thirst› Interfere with blood clotting› Interferes with Ibuprofen if taken concurrently› Could cause Respiratory Alkalosis from respiratory

center stimulation (hyperventilation)

NSAIDS

• Aspirin (cont.)

– High doses -CNS over-stimulation -tinnitus and/or hearing loss -confusion, impaired vision– Children with viral infections (cold or chicken pox) -Risk for Reye’s Syndrome

if take aspirin

NSAIDS

• Acetaminophen• OTC• -over 200 types of pain relievers and cold remedies• maximal therapeutic dose is 4 Gram per day. • -inhibiting prostaglandin synthesis in the central and peripheral nervous system• -inhibition of the synthesis or actions of other substances that sensitize pain receptors to stimulation.

NSAIDS

• Acetaminophen (cont.) • Reduces fever -acts on the heat-regulating center of the hypothalamus. -drug of choice to treat fever and flu-like symptoms in children.

NSAIDS

• Acetaminophen (cont.)

– Adverse Reaction• Skin rash, hypoglycemia, neutropenia • Acute overdose causes hepatic necrosis.• Long-term ingestion of large doses can result in

nephropathy• Give with caution to children younger than age 2• Not to be administer to children for more than 5 days or

to adults for more than 10 days• Keep track of daily acetaminophen intake including

combination drugs daily.

Nonselective NSAID

• Action:– anti-inflammatory – analgesic and antipyretic effects– inhibit prostaglandin synthesis by blocking

two enzymes known as cyclooxygenase-1 (Cox-1) and cyclooxygenase-2 (COX-2)– also known as: COX-1 and COX-2 Inhibitors

Membersof Nonselective NSAIDS

Indomethacin (Indocin) Ibuprofin (Motrin) Diclofenac (Cataflam and

Voltaren) Etodolac (Lodine) Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ketoprofen (Orudis, Oruvail) Ketorolac (Toradol)

Mefenamic Acid (Ponstel)

Meloxicam (Mobic) Nabumetone (Relafen) Naproxen (Naprosyn,

Aleve) Oxaprozin (Daypro) Piroxicam (Feldene) Sulindac (Clinoril)

Members of Selective NSAIDS

• Selectively block COX-2 enzymes, thereby inhibiting prostaglandin synthesis

• This produces the analgesic and anti-inflammatory effects without causing the adverse GI effects associated with COX-1 inhibition

Valdecoxib (Bextra) Celecoxib (Celebrex) Rofecoxib (Vioxx)

Off the market since 10/2004

Selective NSAIDS Adverse Reaction

Dyspepsia Nausea and Vomiting GI Ulcer (lesser degree with nonselective NSAIDS) Hypertension Fluid retention Peripheral edema Dizziness Headache Controlled clinical trials show that the COX-2 selective agents (Vioxx,

Celebrex, and Bextra) may be associated with an increased risk of serious cardiovascular events (heart attack and stroke) especially when they are used for long periods of time or in very high risk settings.

Risk for NSAID complications

Age greater than 60 History of peptic ulcer disease Previous intolerance to NSAIDs History of GI Hemorrhage High-dose NSAID therapy Long-term NSAID therapy Cigarette smoking History of alcoholism Multiple NSAID use Anticoagulation therapy Corticosteroid therapy Concomitant serious illness

Opioid Analgesics• Treat moderate to severe acute pain• A derivative of opium plant • Can obtain synthetic drug with similar properties• Mimics the body’s natural pain control mechanism• Affect the smooth muscles

› Affects contraction of the bladder and ureters› Slows intestinal peristalsis› Causes vasodilatation› Suppress the cough center of the brain› Constriction of the bronchial muscles

The Opioid Group of Drugs• Codeine• Fentanyl Citrate• Hydrocodone• Hydromorphone

hydrochloride (Dilaudid)• Levorphanol tartrate

(Levo-Dromoran) • Meperidine HCL

• Methadone HCL• Morphine Sulfacte• Oxycodone• Oxymorphone (Opana)• Propoxyphene• Remifentanil (Ultiva) • Sufentanil (Sufenta)

Opioid Analgesics

• Adverse Reaction*Most dangerous: potential to cause depression of vital

nervous system functionsEg. Decreased rate and depth of breathing

* Other adverse reactions:• Nausea and vomiting• Constipation• Hypotension• Pruritis• Miosis—Pinpoint Pupils

*May trigger asthmatic attacks in a susceptible patient*Flushing, orthostatic hypotension

Opioid Analgesics

– Adverse Reactions cont.› Myoclonus -higher opioid doses of Dilaudid. › Urinary retention › Sedation, confusion, euphoria, hallucinations, and

dizziness

› “The Toxicity Triad” Catastrophic respiratory depression Stupor or coma Pinpoint pupils

› Demerol (Meperidine HCL) rarely used anymore because of neurotoxicity problems

Opioid Analgesics

• Pharmacokinetics– Administered by any route– Oral doses are absorbed readily– IV provides the most immediate reliable relief– transmucosal and intrathecal routes are fast acting– SQ and IM injections may have delayed absorption

Opioid-induced Constipation

• Due to:– delayed gastric emptying – slow bowel motility– decreases peristalsis– reduces secretions from the colonic mucosa– slow-moving, hard stool that is difficult to pass– ileus, fecal impaction, and obstruction.preventative bowel program

Constipation

• Treatment:– foods high in fiber

-fresh fruits/vegetables -whole grain breads/cereals, -unprocessed bran– Dietitian consult – drink plenty of liquids.– exercise as much as tolerated

Constipation

– Provide toilet or bedside commode – set aside time for sitting on the toilet or

commode, preferably after a meal.– Provide hot drink about half an hour before

planned time for a bowel movement.– bulk laxative such as Metamucil as ordered – Stool softeners– laxatives.

Tolerance and Addiction Addiction is a behavioral pattern of substance use

characterized by a compulsion to take the substance primarily to experience it’s psychic effects A socially unacceptable use of drugs or chemical substance for

non therapeutic purposes Involves a craving for and compulsive use of drugs

Tolerance -reduced effect from the use of a substance resulting from its repeated use over time. -greater amount of substance to produce the same result

Tolerance and Addiction Habituation -repeated substance use in which a person feels better when using the substance than when not using it.

Dependence - difficulty functioning unless under the influence of a drug or other chemical substance. - a person’s body adapts to the drug. If the drug is stopped

withdrawal symptoms which include: muscle aches, watery nose and eyes, irritability, sweating and diarrhea

Tolerance and Addiction • Tolerance and physiological dependence : -unusual with short-term postoperative use -psychological dependence and addiction are extremely unlikely after taking opiates for

acute pain (< 0.1%)

Tolerance and Addiction

• Finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle

Drug Classification

• Over-the-counter (OTC)• Prescription (controlled substance)– Schedule I—highest potential for abuse– Schedule II– Schedule III– Schedule IV– Schedule V—lowest potential for abuse

Controlled Substances

Schedule I and II drugs -kept separate from all other records of the handler

• Schedule III, IV, and V substances -kept in a "readily retrievable" form. -kept under double lock. -narcotic count done at every change of shift. -one nurse counts drugs and one nurse records

Controlled Substances

• Licensed nurse/CMA has med cart keys -responsibility to account for all narcotics removed from drawer during her shift.• “Lost” narcotic must be accounted for • MDs have tracking numbers they must put on all

narcotic prescriptions. • Pharmacist must have original prescriptions . . . No

copies, faxes, phone calls or emails.

Opioid Antagonist Have a greater attraction for opiate receptors than

opiods do Attach to opiate receptors but don’t stimulate

them Prevent opioid drugs from producing their effects

reversing sx/s of opioid drug depression of CNS Drugs:

Naloxone hydrochloride (Narcan) Naltrexone hydrochloride (Revia)

Used primarily in the management of alcohol and opoid dependence.

Opioid Antagonist

Side Effects Nausea and vomiting Hypertension, tachycardia Hyperventilation Muscle tremors

Drug Interactions None

Pharmokinetics Administered IM, SC or IV Metabolized by the liver and excreted by the kidneys

Adjuvant Analgesics

Adjuvant analgesics are drugs whose initial use was not for pain but rather for other conditions.

They are a diverse group of drugs that includes steroids, antidepressants, anticonvulsants and others.

Administration Routes for Analgesics Oral

Optimal route, especially for chronic pain Convenient, flexible, and relatively steady blood levels Use as soon as the patient can tolerate oral intake For ambulatory surgical patients

Intravenous (IV) Route of choice after major surgery Bolus and continuous infusion

Intramuscular (IM) Unreliably absorbed Painful and traumatic May cause fibrosis of muscle and soft tissue

Administration Routes

Sublingual or buccal Place in the mouth, either under the tongue

(sublingual) or between the gum and the cheek (buccal) Eg. Nitroglycerin

Small, quick-dissolving tablets, sprays, lozenges, suckers or liquid suspensions

Extremely effective, because it bypasses the hepatic system

Not all medications can be prepared for sublingual or buccal administration

Administration Routes

• Skin Patches– used to relieve moderate to severe pain that occurs

constantly

• Rectal Suppositories– Good choice if oral route is unavailable and drug is

unavailable as sublingual.– Most drugs can be compounded in a pharmacy– Many clients reluctant to use this route

Patient-Controlled Analgesic Device.

• This drug delivery system allows patients to administer pain medications whenever needed.

• Analgesia is more effective when the patient in control of dosage.

• Patient must be alert, oriented, and able to follow simple directions.

• Epidural Analgesia– Insertion of an epidural catheter and the infusion

of opiates into the epidural space– Medication diffuses slowly from the epidural

space across the dura and arachnoid membranes into the cerebrospinal fluid

– Side effects• urinary retention, • postural hypotension, • pruritus, • nausea/vomiting, • respiratory depression

Epidural catheter

Food/Drug/Herb Interaction

-In China it is common for herbs to be combined with drugs -Herbs reduce the side effects of drugs and help them to perform their function better; – herb formula work more strongly and quickly

-more desirable result than either taken alone -little attention has been paid to adverse herb-drug interactions.

Sleep and Rest

Sleep and Rest

A patient at rest feels: – mentally relaxed– free from worry– physically calm – free from physical/mental exertion.

Sleep and Rest

• Sleep is:– A cyclical physiologic process that alternates with

longer periods of wakefulness. – A time for repair and recovery of body systems for

the next period of wakefulness.– Restorative : it restores a person’s energy and

feeling of well-being.

Sleep and Rest

• Sleep Cycle– Two Phases• Rapid eye movement (REM)• Nonrapid eye movement (NREM)

– NREM is further divided into four stages• Through which a sleeper progresses during a typical

sleeping cycle.

See Figure 16-7; p.411 FON

Sleep Deprivation Decreases in the amount,

quality, and consistency of sleep.

When sleep is interrupted or fragmented, changes in the normal sequence of sleep stages occur, and cycles cannot be completed.

Cumulative sleep deprivation developsSleep-wake cycles

across the life span.

Sleep deprivation is dangerous!! -sleep-deprived people tested by using a driving simulator or by performing a hand-eye coordination task -performed as badly as or worse than those who are intoxicated -magnifies alcohol's effects on the body -a fatigued person who drinks will become much more impaired than someone who is well-rested.

Sleep Deprivation

– Physiologic Signs and Symptoms• Hand tremors• Decreased reflexes• Slowed response time• Reduction in word memory• Decrease in reasoning and

judgment• Cardiac dysrhythmias

– Psychological Signs and Symptoms• Mood swings• Disorientation• Irritability• Decreased motivation• Fatigue• Sleepiness• Hyperexcitablity

Promoting Rest and Sleep

– Determine the patient’s usual rest and sleep patterns, decide whether they are sufficient, and note why the patient is not getting sufficient rest.

Promoting Rest and Sleep

– Limit interruptions during the night -delete night shift vitals -quiet environment -comfortable room temperature. -limit the number of visitors/duration of visits–Have patient ‘schedule’ visits times with

family -carry out all procedures within a given time frame.

Promoting Rest and Sleep

– Preparing the Patient for Sleep• Wash the patient’s back.• Gently massage the back.• Change the linens.• Make certain the patient is warm enough.• Offer a decaffeinated beverage such as milk.• Change soiled dressings.• Have the patient void.• Dim the lights and decrease the noise level.