0133427269 Module03 Comfort LectureOutline

Module 3 Comfort  The Concept of Comfort Comfort ( nursing definition ( the immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, social, and environmental) much more than the absence of pain For client in crisis ( nurse most immediate source of comfort for all contexts Comfort provides healing counteracts stress allows body, mind, spirit to enter into process of recovery, rehabilitation restores sense of self and self-esteem Normal presentation of comfort Comfort ( all needs met in Maslows hierarchy of needs Subjectively ( client may express feeling of contentment, ease Objectively ( nurse may note vital signs within normal limits, expression of calmness in facial appearance Comfort is subjective ( must understand normal for that client Lifespan considerations Infants do perceive pain Determining cause of infants pain can be difficult Assessment of pain in older adults can be challenging Some older adults do not report pain and sleep disorders Those with cognitive disorders may be unable to report pain Ethnicity Some ethnic groups are more likely than others to report pain Nurses must be culturally competent and ensure adequate comfort for all clients Alterations to comfort Alterations and manifestations Pain Simple opposite of comfort is pain ( unpleasant sensory, emotional experience associated with actual or potential tissue damage, or described as such damage Subjective response to physical and psychological stressors Plays protective role ( warning of potentially threatening conditions Referred to as the fifth vital sign Joint Commission ( standards that identify relief of pain as a client right Each individual pain event ( distinct, personal experience influenced by physiological, psychological, cognitive, sociocultural, spiritual factors Pain whatever individual experiencing it says it is, existing when individual says it does Holistic nursing care ( Only the individual affected can experience pain ( has a personal meaning If client says he/she has pain, client is in pain Pain has physical, emotional, cognitive, sociocultural and spiritual dimensions Pain affects the whole body, usually negatively Pain may serve as a response to and a warning of actual or potential trauma Described in terms of location, intensity, etiology, duration (see Exemplar 3.1) Duration Acute pain ( lasts only through expected recovery period Chronic pain ( prolonged, recurring/persisting over 6 months or longer, interferes with functioning Nursing diagnosis of chronic pain to be mild to severe, constant or recurring, without an anticipated or predictable end, lasting for longer than 6 months Categories differentiating chronic cancer pain from chronic nonmalignant pain problematic Cancer pain ( may result from direct effects of disease and treatment, or may be unrelated to disease End-of-life care ( nursing care provided to client who is dying, near death Dying clients, families need nurse ( educate, support, guide, advocate Informed understanding of clients values, wishes, goals ( allows nurse to attend to physical, emotional, psychosocial, spiritual needs Death ( natural part of life Assisting client to die comfortably, with dignity, provides benefits of nursing care ( Attention to pain and symptom control Relief of psychosocial distress Coordinated care across settings, communication between healthcare providers Preparation of the client and family for death Clarification and communication of goals of treatment and values Support, education during decision making ( benefits, burdens of treatment Nurses must be confident of clinical skills, aware of ethical, spiritual, legal issues End-of-life care ( team approach ( referrals, teaching comforting interventions Each dying client brings special challenges Fatigue May be product of insufficient sleep, overexertion, illness, side effect of medication Lack of energy and motivation, may or may not be accompanied by drowsiness Causes may include Anemia Sleep disorders Depression or grief Pregnancy Respiratory disorders Hypothyroidism Use of alcohol or drugs May result from course of normal events, single occurrence of enormous impact Acute fatigue ( normally resolves with rest, resolution of underlying cause Chronic fatigue ( may not resolve as easily Chronic fatigue syndrome ( complex disorder in which symptoms of unrelenting fatigue, associated symptoms cannot be explained for 6 months or longer Fibromyalgia Chronic disorder ( widespread musculoskeletal pain, fatigue, multiple tender points Tender points ( tenderness in precise areas ( neck, spine, shoulders, hips May have sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety Considered problem of abnormal central nervous system functioning Sleeprest disorders Sleep is basic human need ( universal biologic process common to all Require sleep for many reasons ( important factor in quality of life Hypersomnia ( client obtains sufficient sleep at night, cannot stay awake in day Narcolepsy ( experience sleep attacks or excessive daytime sleepiness Sleep apnea ( frequent short breathing pauses during sleep Insufficient sleep Parasomnias ( behaviors that may interfere with sleep, may occur during sleep Genetic considerations and nonmodifiable risk factors Genetics ( major role in a number of diseases associated with discomfort Amyotrophic lateral sclerosis Marfan syndrome Sickle cell disease Genetic mutations can also cause Sleep disturbances Depression Anxiety Case Study Part 1 ( April Daves, 34-year-old black woman, was in a severe motor vehicle accident 6 months ago CONCEPTS RELATED TO COMFORT ( see chart on p. 143 ALTERATIONS AND THERAPIES (see chart on p. 144 Prevention Prevention of discomfort begins with the client Personal preferences, lifestyle habits, and culture are factors Nurses provide education to prevent chronic disease Lifestyle habits that cause discomfort include Poor nutrition Poor sleep hygiene Smoking Excessive alcohol intake Illicit drug use Heavy lifting at work Long hours at work Repetitive movement Team sports and extreme sports Assessment Nursing assessment (see COMFORT ASSESSMENT on p. 147 History ( determine level of discomfort, extent affecting ADLs See ASSESSMENT INTERVIEW on p. 148 Length of time problem has persisted Times of day, activities during or following which the problem becomes worse Nature and duration of clients sleep Effect of the clients discomfort on other family members Nature of clients support network Clients eating habits, including types of food, portion sizes, times of day Physical exam Palpate painful areas for presence of edema, location Lifespan and cultural considerations Age and developmental stage affect ability to describe pain and discomfort Culture plays a role in how clients perceive and report pain See LIFESPAN CONSIDERATIONS on p. 149 Diagnostic tests May be ordered to determine underlying cause of pain X-rays ( determine physical injury WBC ( identify infection Hemoglobin and hematocrit ( anemia Polysomnographies ( diagnose sleep disorders Case Study Part 2 ( Ms. Daves is awaken by severe pain and calls 911 Interventions and therapies Initial interventions ( identifying sources of discomfort Independent interventions Sleep hygiene ( interventions used to promote sleep Bedtime rituals, presleep routines that are conducive to comfort and relaxation Encourage maintenance of a restful environment Promote comfort and relaxation to help client fall, stay asleep Provide loose-fitting nightwear Assist clients with hygienic routines Make sure bed linen is smooth, clean, dry Assist or encourage client to void before bedtime Offer to provide back massage before sleep Position dependent clients appropriately to aid muscle relaxation, provide supportive devices to protect pressure areas Schedule medications, especially diuretics, to prevent nocturnal awakenings For clients who have pain, administer analgesics 30 minutes before sleep Hospitalized clients ( scheduling, administering analgesics, supportive environment Hypnotics may be prescribed depending on type of sleep problem Caution with older adults Bedtime rituals for institutionalized clients Assist client to reduce environmental distractions See Box 31 MINIMIZING ENVIRONMENTAL STIMULI IN THE HOSPITAL SETTING, p. 150 Take into consideration individual circadian rhythms Psychosocial well-being Laughter Helps relieve pain and reduce stress Helps boost immunity and improve mood Positive attitude Helps to ease distress Can decrease depression and stress Can increase cardiovascular health Interaction with family and friends Relaxation therapy Breathing exercises Muscle relaxation Imagery Movement techniques Collaborative interventions Pharmacologic therapy See MEDICATIONS PAIN on p. 151 See MEDICATIONS SLEEP on p. 151 Nonpharmacologic therapy Complementary and alternative therapies Review The Concept of Comfort Relate Link the concepts Ready Go to companion skills manual Refer Go to Student Nursing Resources Reflect Case Study, Part 3 ( Ms. Daves is successfully managing her fibromyalgia Exemplar 3.1 Acute and Chronic Pain Overview Pain ( unpleasant, highly personal experience, may be imperceptible to others while consuming all parts of an individuals life Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is whatever the individual says it is, existing whenever the individual says it does Describing pain Location Classifications of pain based on where it is in the body may be useful Radiation ( spreading or extending to other areas Referred ( appearing to arise in different areas of the body Intensity Categorizing ( mild, moderate, severe Underlying physiology ( somatic, visceral, neuropathic Standard 010 scale 13 mild pain 46 moderate pain 710 severe pain Quality Quality of pain varies depending on clients pain perception, vocabulary, personality, and culture Superficial pain may be described as Itchy Tingling Tender Sensitive Deep pain may be described as Stabbing Burning Shooting Radiating Throbbing Heavy Pathophysiology and etiology Pain ( triggered by peripheral nervous system Nociceptors send a signal along the sensory neurons to the spinal cord ( signal is transmitted to brain for interpretation Brain sends signal back to site of pain causing body to respond to painful stimuli See Table 3-1 TYPES OF PAIN STIMULI, p. 153 Pain theories Specificity theory ( pain is a specific sensation that uses sensory neurons separate from other sensations such as heat and touch Peripheral pattern theory ( all sensory nerve fiber endings are the same, and pan is felt only when the fibers are intensely stimulated brain deciphers differences in signals Gate control theory ( stimulation of small-diameter (pain) fibers causes gates to open stimulation of large-diameter (heat, cold) fibers causes gates to close Amount of activity of small vs large fibers controls perception of pain Most widely accepted theory Etiology Nociceptive pain ( experienced when intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care Cut, broken bone Healing occurs ( pain goes away Neuropathic ( experienced by people who have damaged, malfunctioning nerves Abnormal from illness Injury Types of pain Acute pain ( has a sudden onset, is usually temporary, localized Somatic pain ( from nerve receptors originating in skin or close to surface of body Visceral pain ( from body organs, dull, poorly localized( low number of nociceptors Viscera sensitive to stretching, inflammation, ischemia Cramping, intermittent, colicky pain Referred pain ( pain perceived in area distant from the site of the stimuli See Figure 34 REFERRED PAIN, p. 155 Chronic pain ( prolonged pain, usually lasting longer than 6 months Does not always have a known cause Can range from mild to severe Physiological adaptation of vital signs may occur ( hormonal stress responses Chronic pain subdivided into three categories Chronic recurrent acute pain ( intense episodes interspersed with pain-free episodes, e.g., migraine headache Chronic intractable pain ( pain that is always present although intensity varies, e.g., lower back pain Chronic progressive pain ( pain associated with a chronic condition that worsens over time, e.g., cancer or rheumatoid arthritis Breakthrough pain ( pain that exceeds baseline treated or untreated pain Sudden flare, temporary, often debilitating (adjust dose, timing of analgesia Incident pain ( predictable, caused by activity, such as coughing, changing positions Central pain ( caused by damage to nerves in CNS due to stroke, MS, Parkinsons, or trauma May occur shortly after injury, or may be delayed by weeks or years Dysfunction of spinothalmic tract causes abnormal temperature and pain sensation Clients may experience constant pain as well as pain paroxysms, evoked pain, or allodynia described as burning, pins and needles, aching, or lacerating Phantom pain ( occurs in missing limb following amputation Described as shooting, stabbing, squeezing, stabbing, or burning Psychogenic pain ( associated with psychological factors Experienced in absence of any diagnosed physiological cause or event Emotional needs may prompt pain ( pain is real ( leads to physiological changes such as muscle tension ( produces further pain Risk factors Internal and external environments Risk for enhanced perception of new pain ( effects of previous pain or decreased functional ability, psychosocial, emotional, spiritual, financial, cultural effects Specific factors contribute to risk for pain Risk factors related to inadequate pain relief include barriers from client and family Good clients never complain Pain is inevitable with aging, so older adults should not complain Strong medicine only comes in injectable form, do not want shots Side effects of pain medicine are worse than the pain itself Addiction to pain medicine is common Strong pain medicine should be used only for very severe pain Morphine is used only when the individual is dying Barriers from healthcare providers Healthcare professionals are better judges of pain than the client is Pain is often not seen as important as other indicators in the hospital Only opioids are effective in severe pain Opioids cause respiratory depression Fear of double effect (unintentionally causing harm when trying to do good) Confusion over addiction/tolerance/physical dependence General lack of education relating to pain assessment, treatment, pharmacology in basic and graduate education programs, especially regarding use of morphine and treatment of chronic versus acute pain Clinical manifestations Bodys response to pain complex process ( physiological and psychosocial aspects Pain fibers adapt very little ( become sensitized ( sensitization intensifies, prolongs, spreads pain Unrelieved pain has potentially harmful effect on individuals well-being Uncontrolled pain impairs immune function ( slows healing, increases susceptibility to infections, dermal ulcers Persistent severe pain changes nervous system ( incurable chronic pain syndromes 24 hours ( changes structure and function of nervous system Establishes new nerve growth ( develops reverberating loops Pain threshold lowered ( cells sensitized See CLINICAL MANIFESTATIONS AND THERAPIES Acute and Chronic Pain, p. 167 Lifespan and cultural considerations Each client has a unique set of factors that influences how they perceive pain Developmental stage Age, developmental stage ( variables that influence reaction to/expression of pain See Table 32 INFLUENCE OF AGE ON PAIN PERCEPTION AND BEHAVIOR, p. 158 Children and pain Children less able than adults to accurately describe pain Children as young as 3 can give a basic description of location and intensity of pain Physiological considerations Children have higher pulse and respiratory rates and lower blood pressure ( take into account when assessing for pain Normal sympathetic response not always present in children Children tend to experience pain more intensely at beginning of pain episode Pain brings anxiety and stress ( emotional comfort is vital Children may not realize they can ask for pain relieft Behavior responses to pain Common behavior responses to pain ( crying, grimacing Changes in behavior may indicate pain in nonverbal children Responses become more controlled as children get older See Table 3-2 INFLUENCE OF AGE ON PAIN PERCEPTION AND BEHAVIOR, p. 158 Children and pain memory Children develop pain memory that influences response to future pain May undergo sensitization that causes a lower pain tolerance, higher levels of stress, and an inability to cope with pain Pain memory also influenced by parents, family, peers Barriers to pediatric pain management Inadequate pain assessment Lack of knowledge for treating pain safely See Table 3-3 PAIN IN INFANTS AND CHILDREN COMMON MISCONCEPTIONS, p.159 Pain and adults Chronic pain ( widespread problem in adult population Women ( fibromyalgia, osteoarthritis Women have lower pain threshold and lower pain tolerance than men Men ( cluster headaches, coronary heart disease, gout, duodenal ulcer, pancreatic disease Pain and older adults Aging adults develop chronic conditions associated with pain See Box 3-3 DISORDERS LINKED TO PAIN IN OLDER ADULTS, p. 160 See Box 3-4 CHRONIC PAIN IN OLDER ADULTS, p. 160 Physiological changes that effect how pain is perceived Decreased cerebral blood flow Neuronal loss Decreased synthesis of neurotransmitters Decreased opioid receptors Changes in gastrointestinal and urinary systems cause decreased Drug absorption Metabolism Excretion Drug interactions are common ( increased pain and discomfort Barriers to effective pain management Healthcare providers may lack knowledge needed for assessment, diagnosis, and management of pain Older clients may have issues with Misconceptions about aging, pain, and medication Fear of drug effects Noncompliance Religious beliefs Financial barriers Comorbidities such as dementia Inadequate pain management Reduces quality of life Decreases ability to perform ADLs Increases dependence on others Effects of cultural and personal factors on pain Cultural and ethnic influences Stoic cultures ( rarely vocalize pain or show behavioral responses to pain Expressive cultures ( routinely moan or scream when in pain Despite variations, ethnic or cultural background does not affect the pain threshold Cultural background may affect methods of treatment for pain Nurses must approach all clients with cultural competence See FOCUS ON DIVERSITY AND CULTURE CULTURAL DIFFERENCES IN RESPONSE TO PAIN, p. 161 Meaning of pain Client may accept pain depending on circumstance, clients interpretation Pain of childbirth ( positive outcome Client with unrelenting chronic pain may suffer more intensely Affects body, mind, spirit, social relationships in undesirable way Environment and social support Strange environment can compound pain Children can be especially frightened in the hospital, intensifying pain response Family education related to assessment and management of pain can positively affect perceived quality of life for caregiver, client Expectations of significant others ( affect individuals perceptions, responses to pain Previous experience with pain ( alter a clients sensitivity to pain Collaboration Pain clinics ( multidisciplinary approach Diagnostic tests Pain assessment tools Laboratory tests to determine cause of pain, not to quantify pain Surgery Depending on etiology, surgery may be viable option For chronic pain, surgery is last resort ( procedures to disrupt pain conduction pathways Pharmacologic therapy Opioids ( narcotics Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDs) Coanalgesic drugs ( not classified as pain medications, used in conjunction See Box 35 CATEGORIES AND EXAMPLES OF ANALGESICS, p. 162 World Health Organization (WHO) three-step approach Mild pain ( step 1 ( nonopioid analgesics (with/without coanalgesic) Persists, moderate pain ( step 2 ( weak opioid, combination of opioid and nonopioid medicine, with/without coanalgesic Persists, severe pain ( step 3 ( strong opiates administered, titrated in around-the-clock scheduled doses until pain relieved or respiratory depression occurs When treating clients with multiple medications, always be aware of potential drug-drug interactions Nonopioids/NSAIDs Include acetaminophen and NSAIDs ( ibuprofen, aspirin NSAIDs ( Anti-inflammatory, analgesic, antipyretic effects Acetaminophen ( analgesic, antipyretic only Anti-inflammatory action ( interferes with cyclooxygenase (COX) chemical cascade activated by damaged tissue Second isoform (COX-2) found ( specific only for pain, inflammation Less GI bleeding, uncommon cardiovascular events ( pulled from market All prescription NSAIDs now have black box warnings of risks NSAIDs ( vary in anti-inflammatory properties, metabolism, excretion, side effects Ceiling effect ( once maximum analgesic benefit achieved, more drug will not produce more analgesia ( more toxicity may occur Narrow therapeutic index ( not much margin for safety between dose that produces desired effect, dose that may be toxic, lethal Clients taught to take NSAIDs with food, full glass of water, monitored Acetaminophen ( does not affect platelet function, rarely causes GI distress, kidney, skin, cardiovascular problems Hepatotoxicity with high dose, long-term use Hidden ingredient in many OTC remedies See Table 34 MISCONCEPTIONS ABOUT NONOPIOIDS, p. 164 See Table 36 OVERVIEW OF MEDICATIONS USED IN THE MANAGEMENT OF CHRONIC PAIN p. 172 Opioids ( drugs that act on one or more of the opioid receptors mu, delta, kappa Commonly called narcotics ( they are controlled substances Weak or partial agonists Weak agonists have low affinity for opioid receptors Partial agonists have high affinity but only a partial effect Both have a ceiling effect See Box 3-6 PREVENTION AND MANAGEMENT OF COMMON OPIOID SIDE EFFECTS, p. 165 Full agonists High affinity to mu receptor sites ( produce strong analgesic effect Examples are fentanyl, hydromorphone, methadone, morphine, oxycodone Do not have a ceiling effect May produce euphoria, respiratory depression, tolerance Mixed opioid analgesics ( two types Mixed agonistantagonist Act as an agonist at one opioid receptor (usually kappa) and as an antagonist at another (usually mu) Give only as first opioid Have a ceiling effect Opioids mixed with nonopioids More efficacious than either drug alone Allows lower doses, which decreases side effects Opioid side effects Respiratory depression ( most concerning Sedation ( may occur before respiratory depression ( assess baseline alertness, respiratory rate See Box 36 PREVENTION AND MANAGEMENT OF COMMON OPIOID SIDE EFFECTS, p. 165 See Box 37 PASERO OPIOID-INDUCED SEDATION SCALE (POSS), p. 166 Nausea/vomiting Urinary retention Blurred vision Sexual dysfunction Constipation Older adults particularly sensitive to analgesic properties of opioids ( may require less medication, less frequent intervals Start slow (2550 dose reduction) and go (titrate) slow Coanalgesics Have properties that may reduce pain alone or in combination with other analgesics, relieve other discomforts, potentiate effects of pain medications, reduce pain medication side effects Include antidepressants, anticonvulsants, antihypertensives, antipruritics, corticosteroids, and local anesthetics Appear to be beneficial for management of neuropathic pain Nonpharmacologic therapy Invasive therapies Nerve block ( chemical interruption of nerve pathway effected by injecting local anesthetic into the nerve Combination of long-acting local anesthetic and steroid injected adjacent to problem nerve Relief from anesthetic for several hours ( steroid effect after a day or two May be series of three injections ( no more than three per year in one area Permanent block ( uses alcohol or phenol, cryoanalgesia, or radioablation to destroy nerve tissue Complementary and alternative pain control Physical modalities Cutaneous stimulation Ice or heat Immobilization or therapeutic exercises Transcutaneous electrical nerve stimulation (TENS) Acupuncture Mindbody Guided imagery Cognitive-behavioral therapy Religious rituals Social support Family and friends Laughter Focusing on others Nursing process Assessment Client interview ( ask questions about Location Intensity Duration Quality Pain rating scales Numerical pain scales verbal descriptor scales Faces pain scales Observational or behavioral pain scale Visual assessment Observe clients behavior such as facial expression, body movement, posture Particularly important for neonates and infants Physical assessment Take vital signs Inspect for injuries or wounds Palpation can help pinpoint location of pain Diagnosis General diagnoses include Impaired Physical Mobility Fatigue Activity Intolerance Deficient Knowledge Anxiety For clients with acute pain Disturbed Sleep Pattern Risk for Infection Impaired Skin Integrity For clients with chronic Pain Insomnia Hopelessness Imbalanced Nutrition Social Isolation Self-Care Deficit For clients taking opioids Risk for Constipation Ineffective Breathing Pattern Fear Nausea Planning Client will report reduction in pain to allow for comfort Client will be able to contribute to self-care activities Client will obtain adequate relief from pain to allow for mobility Client will obtain adequate pain relief to allow for sleep Implementation Monitor manifestations of pain by taking vital signs, observing pupils, facial expressions, positions in bed, guarding of body parts, restlessness Communicate belief in clients pain by verbally acknowledging presence of pain, listening carefully to description of pain, acting to help client manage the pain Provide optimal pain relief with prescribed analgesics, determining preferred route of administration Client is part of decision-making process Around-the-clock administration provides better pain management Evaluate and monitor effects of analgesics, other pain-relieving measures teach family members/significant others to be alert for adverse reactions to pain medications Teach client and family nonpharmacologic methods of pain management, such as relaxation, distraction, cutaneous stimulation Help client with self-care, such as toileting, bathing, and oral care. Provide comfort measures, such as changing positions, back massage, oral care, skin care, changing bed linens Provide client and family teaching, make referrals if necessary to assist with coping, financial resources, and home care Community-based care Teaching of client and family includes Specific drugs to be taken ( frequency, potential side effects, possible drug interactions, special precautions to be taken How to take or administer drugs See Table 36 OVERVIEW OF MEDICATIONS USED IN THE MANAGEMENT OF PAIN, p. 172 Importance of taking pain medications before the pain becomes severe Explanation that the risk of addiction to pain medications is very small when they are used for pain relief and management Importance of scheduling periods of rest and sleep Suggest following resources Pain clinics Community support groups American Cancer Society American Pain Society Evaluation Assessing clients pain, questioning client to determine if adequate pain relief has been obtained Time for pain relief highly dependent on Route of analgesic administration Oral medications ( up to an hour IV medications ( within minutes Nonpharmacologic intervention Clients pain level before initiation of therapy Evaluate vital signs Objective data may validate/conflict with subjective data Review Acute and Chronic Pain Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 3.2 End-of-Life Care Overview End of life ( final weeks of life when death is imminent As advocates, nurses must ensure that clients are receiving the best possible care As guides, nurses must use communication and intuition to support clients and families through the dying process Pathophysiology and etiology Etiology Most Americans would prefer to die in own homes ( but 45 die in hospitals, 22 in long-term care facilities only 25 die at home Data from numerous studies indicate that families are not satisfied with the care their dying members received Clinical manifestations Signs of impending death include Increased confusion or disorientation Decreased food and liquid intake Changes in respiration Decreased body temperature and blood pressure Cyanosis Lose of bladder and bowel control Changes in muscle control Restlessness When death is inevitable, many clients and families choose palliative care See Box 3-9 EIGHT DOMAINS OF PALLIATIVE CARE, p. 175 Nursing considerations for end-of-life care All clients have the right to be treated with dignity See Box 310 THE DYING PERSONS BILL OF RIGHTS, p. 175 Legal and ethical issues Advance healthcare directives ( legal documents that allow an individual to plan for health care and/or financial affairs in the event of incapacity Living will ( provides written directions about life-prolonging procedures, provides instructions when individual can no longer communicate in a life-threatening situation Healthcare proxy ( individual who has been selected to make medical decisions when an individual is no longer able to make them for himself or herself Durable power of attorney ( document that can delegate the authority to make health, financial, and/or legal decisions on an individuals behalf Must be in writing Must state that designated individual authorized to make healthcare decisions Do-not-resuscitate orders (DNR) ( written by physician for client with terminal illness or near death Usually based on wishes of client and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest Comfort measures only order indicates no further life-sustaining interventions are necessary and that the goal of care is comfortable, dignified death Euthanasia ( painless, easy, gentle, or good death ( now commonly used to signify a killing prompted by some humanitarian motive Considered malpractice to participate in slow codes Natural death laws seek to preserve notion of voluntary versus involuntary euthanasia Voluntary ( withdraw life support knowing it will result in clients death Involuntary ( giving lethal dose of medication that will result in death Palliative and hospice care Palliative care Improves quality of life of clients, families facing life-threatening illness by preventing, assessing, treating pain and physical, psychosocial, spiritual problems Palliative care appropriate for some conditions that may be cured, but treatment failure is also a possibility Can take place across all settings Hospice care End-of-life care at home, long-term care settings, hospitals Defined as support and care for individuals in last phase of an incurable disease so that they may live as fully and comfortably as possible Added to Medicare program Clients, families often seek hospice care when a physician has determined that the client has 6 months or less to live ( client, family agree with care and comfort over aggressive medical intervention Supportive care provided to family, caregivers Lifespan and cultural considerations End-of-life care for children Children with life-limiting conditions should receive palliative care, even infants and young children ( comfort care, end-of-life decisions, bereavement support for families See Box 3-11 PRINCIPLES OF PEDIATRIC CARE See Box 3-12 IMPROVING PEDIATRIC PALLIATIVE AND END-OF-LIFE CARE Barriers to effective pediatric palliative care include Healthcare professionals lacking education and experience limited knowledge about caring for children with rare conditions Ineligibility for hospice care based on uncertainty of length of life Hospice programs lacking expertise in caring for children Financial barriers including poor or lacking reimbursement Miscommunication and differences in values based on culture or ethnicity Misconception that palliative care means that client can no longer receive curative care Advance care planning Should occur early in the disease process when the child is not in crisis Plan should be modified as necessary to meet needs Considerations for adolescents Adolescents should participate in any advance planning discussions Open, honest discussion with adolescent helps parents, healthcare team determine if adolescent understands implications of terminating curative therapy Ethical issues surrounding a childs death Withdrawing or withholding treatment Difficult and highly emotional for the parents Does not mean discontinuing care or abandoning child Cultural and religious considerations Cultural differences greatly influence what type of care a client or family desires at end of life Improvements in access to palliative care not reaching minority populations Less likely to receive appropriate pain management Spiritual and religious beliefs also shape the context of death for many individuals Collaboration Collaboration among healthcare providers is essential to providing quality care at end of life Pharmacologic therapy Pain Pain medications given at low doses initially and then gradually increased to provide adequate relief Tolerance and addiction are not issues at the end of life Other symptoms Relief should be provided for depression, anxiety, dyspnea, constipation, delirium, nausea, sleep disturbances, loss of skin integrity Goal is to give clients a high quality of life for the time they have left Nonpharmacologic therapy Feeding tubes Artificial nutrition and hydration (ANH) may be implemented with a feeding tube, may prolong life, but it does not improve quality of life or chance of recovery Withdrawing ANH for clients near death has ethical considerations Clients who die after ANH withdrawal do not experience feelings of hunger or thirst Applying moisture to the mouth and lips is often adequate to relieve dry mouth, regardless of hydration status Cardiopulmonary resuscitation Provides artificial ventilation and external cardiac compression to clients in respiratory and cardiac arrest Clients in hospitals and long-term care facilities have a lower chance of survival than any other group Clients with frail health are susceptible to damage during CPR For clients without a DNR, CPR must be administered by default Nursing process Assessment See CLINICAL MANFESTATIONS AND THERAPIES END-OF-LIFE CARE, p. 182 State of awareness Closed awareness ( client not made aware of impending death Mutual pretense ( client, family, healthcare personnel know that the prognosis is terminal but do not talk about it, make effort not to raise the subject Open awareness ( client and others know about impending death, feel comfortable discussing it, even though it is difficult Diagnosis Nursing diagnoses for clients nearing death may include Impaired Swallowing Functional Urinary Incontinence Bowel Incontinence Disturbed Sleep Pattern Risk for Ineffective Peripheral Tissue Perfusion Acute Confusion Death Anxiety Risk for Impaired Skin Integrity Acute Pain Nursing diagnoses for families members may include Hopelessness Caregiver Role Strain Compromised Family Coping Grieving Decisional Conflict Planning Maintain client comfort Support family members and loved ones as they grieve Maintain client hygiene Prevent complications such as pressure ulcers or loss of skin integrity Support and comfort client to reduce fear and anxiety related to death Implementation Interventions incorporate both physiological and psychological concerns Pain management is important Promote emotional well-being Death anxiety may stem from clients concern for self or others Anxiety may be experienced by family as well Interventions include methods to reduce suffering and loneliness Promote family coping Refer family members to local hospice provider, organizations for dying families Assist primary caregiver of the dying client at home to arrange for respite services Refer the family to resources for financial support as necessary Evaluation Clients comfort is maintained throughout the dying process Client is supported by nursing and/or family presence at time of death Family members are informed and prepared for clients dying process Review End-of-Life Care Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 3.3 Fatigue Overview Characterized by a lack of energy, motivation may be accompanied by drowsiness Perception of fatigue influenced by culture, capacity to carry out expected, required ADLs Usually relieved by adequate sleep and by treatment of the underlying condition causing the fatigue Pathophysiology and etiology Fatigue is associated with a decrease in the bodys energy reserves that affects all basic body functions Etiology Fatigue has many causes Anemia Depression or grief Medications Persistent pain Sleep disorders Hyper- or hypothyroidism Regular use of alcohol or drugs Chronic illness Acute fatigue ( variety of causes ( resolves on treatment of underlying cause Chronic fatigue ( from ongoing illness, condition, situation not quickly resolved Working mothers Illness ( side effect of medication Risk factors Acute or chronic illness Lifestyle factors ( alcohol abuse, excessive physical activity, lack of sleep Medications ( antihistamines, pain medications, heart medications Medical procedures ( surgery, chemotherapy Mood disorders ( depression, grief, stress Genetics ( individuals with alterations in the HPA axis and neurotransmitter signaling are more susceptible to fatigue Women are more susceptible to fatigue ( see Box 3-14 FATIGUE AND WOMEN ASSOCIATED CONDITIONS AND LIFESTYLE FACTORS, p. 186 Prevention Balanced diet Daily exercise Good sleep hygiene Avoiding alcohol, caffeine, tobacco Practicing good coping skills Counseling Clinical manifestations Most common symptoms Drowsiness Exhaustion Lack of motivation Physical symptoms Lethargy Muscle weakness Palpitations Dizziness Dyspnea on mild exertion Loss of appetite Slow movements Blurry vision Neurological symptoms Difficulty concentrating Impaired decision-making abilities Confusion Impaired coordination Slowed reflexes Chronic fatigue syndrome Also called myalgic encephalomyelitis Severe tiredness for more than 6 months that is not caused by a primary condition Accompanied by at least four of the following symptoms Malaise lasting longer than 24 hours after exercise Feeling unrefreshed after adequate sleep Forgetfulness Confusion Inability to concentrate Joint pain with no swelling Headaches not previously experienced Irritability Mild fever Muscle aches Muscle weakness Sore throat Sore lymph nodes Lifespan and cultural considerations Fatigue in children ( generally result of stress, illness, insufficient sleep, or poor nutrition Extremely common in older adults ( tends to increase with increasing age Common occurrence during pregnancy Culture fatigue or culture shock ( occurs when changing countries or cities Collaboration Simplest fatigues resolved with sufficient sleep Complicated etiology ( team to help resolve fatigue Diagnostic tests Ordered to determine underlying cause Sleep study may be ordered Surgery If fatigue is related to thyroid function, it may be removed surgically If fatigue is a sign of cancer, biopsy or removal of solid tumor may occur Pharmacologic therapy Interventions vary on root cause of fatigue Iron deficiency anemia ( erythropoietin Depression, sleep deprivation fatigue ( tricyclic antidepressant SSRIs ( improve sleep, decrease anxiety and pain Nonpharmacologic therapy Good sleep hygiene Mild to moderate exercise Cognitive-behavioral therapy Complementary and alternative medicine ( none are consistently supported by clinical studies Massage Acupuncture Relaxation techniques Herbal and dietary supplements Nursing process Assessment History Are you feeling weak, tired, wiped out How long does it last Is there a pattern How does your fatigue affect your normal activities of daily living Is there a part of your body that feels more tired than another What medications are you taking Have you been taking any medications to help you sleep Do you feel anxious or depressed Do you have difficulty concentrating Do you have preexisting conditions Physical examination Vital signs Client mobility Hydration status Muscle strength, symmetry, and endurance Diagnosis Insomnia Sleep Deprivation Fatigue Activity Intolerance Readiness for Enhanced Coping Stress Overload Planning Client will be able to explain importance of bedtime rituals and good sleep hygiene and create a bedtime routine to promote rest Client will verbalize feelings of increased energy Client will optimize ability to perform ADLs Client will participate in mild exercise program Client will experience increased motivation Client will explain relationship of fatigue to a disease process and activity level Implementation Consider clients cultural, developmental needs regarding sleep rituals Promote effective coping Assess and support clients social support network, usual method of coping Encourage client involvement in making care decisions, setting goals Facilitate process of setting short- and long-term goals Evaluation Conducted at intervals from subjective and objective data to see if goals are being met If interventions are not effective, modify the therapy Review Fatigue Relate Link the Concepts and Exemplars Ready Go to the Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 3.4 Fibromyalgia Overview Chronic syndrome ( musculoskeletal pain, stiffness, fatigue, sleep disturbances, difficulty concentrating, multiple tender points Affects more than 10 million Americans, 75 to 90 are women between 20 and 50 years of age Pathophysiology and etiology Disorder of pain processing Hyperalgesia Allodynia Etiology Exact cause is unknown 70 of clients with fibromyalgia have no precipitating factor Causative factors ( infections, physical trauma, psychosocial stressors, vaccinations, chemical substances Risk factors Female 20 to 50 years of age Family history of fibromyalgia Having a psychiatric disorder such as ADHD or depression Having a medical disorder such as irritable bowel syndrome or rheumatoid arthritis Genetic abnormalities may predispose some individuals to fibromyalgia Prevention No known way to prevent fibromyalgia Maintaining health lifestyle ( best way to reduce risk Prompt diagnosis and treatment can reduce flare-ups Clinical manifestations Widespread pain Above and below waistline On right and left sides of the body Often localized to 18 tender points( See Figure 38 LOCATION OF 18 PAIRED TENDER POINTS IN FIBROMYALGIA, p. 191 Fatigue Likely the result of sleep disturbances, insomnia Other symptoms Mood disorders Cognitive dysfunction Headaches Numbness in hands and feet Irritable bowel syndrome Restless leg syndrome Painful menstrual periods Lifespan and cultural considerations Children and adolescents may develop juvenile primary fibromyalgia syndrome (JPFS) Most will continue to have symptoms into adulthood 35 - 40 will report no symptoms 3 4 years after diagnosis Collaboration Difficult to treat ( try combination of therapies to find treatment that provides relief Diagnostic tests Based on criteria set by American College of Rheumatology ( see Box 3-15 2010 FIBROMYALIGIA DIAGNOSTIC CRITERIA, p. 192 All diagnostic tests are negative for individuals with fibromyalgia Those with positive tests are evaluated for underlying cause of pain and fatigue Pharmacologic therapy Three drugs approved by FDA Duloxetine (Cymbalta) Milnacipran (Savella) Pregabalin (Lyrica) Other medications include Acetaminophen NSAIDS Tricyclic antidepressants Tramadol Nonpharmacologic therapy Aerobic exercise Strength training Aquatic exercise Cognitive-behavioral therapy Relaxation therapy Nursing process Focus of nursing care ( reduce pain, increase restorative sleep, improve physical function Assessment History Family history of fibromyalgia and other rheumatic disorders Physical assessment Testing tender points See Box 315 2010 DIAGNOSTIC CRITERIA, p. 192 Diagnosis Disturbed Sleep Pattern Readiness for Enhanced Sleep Fatigue Activity Intolerance Readiness for Enhanced Knowledge Hopelessness Anxiety Ineffective Coping Chronic Pain Planning Pain relief Fewer sleep disturbances Improve activity tolerance Balanced periods of exercise and rest Score on symptom severity scale will be less than 5 Implementation Nursing interventions Manage pain Education on pharmacologic and nonpharmacolgic methods Increase activity tolerance Assess current activity level and tolerance of that activity Encourage the client to establish priorities, include rest periods or naps when scheduling daily activities Encourage delegation of some responsibilities to family members Reduce fatigue Inquire about feelings of malaise and fatigue, particularly if fatigue not improved with rest Encourage verbalization of feelings about impact of disease and fatigue on lifestyle Encourage enjoyable but quiet activities, such as reading, listening to music Evaluation Client is able to reduce pain sufficiently to allow for periods of activity and sleep Client voices feelings related to chronic condition Client obtains adequate follow-up Client avoids use of narcotics or addictive substances to avoid substance addiction Review Fibromyalgia Relate Link the Concepts and Exemplars Ready Go to the Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 3.5 SleepRest Disorders Overview Sleep ( essential to normal physiological functioning Adults need 7 9 hours of sleep each night Pathophysiology and etiology Normal sleep patterns can be disrupted by several disorders Sleep loss Occurs when individuals receives fewer than 7 8 hours of sleep each night Major problem in the U.S. Insomnia Most common sleep disorder Individuals have trouble falling asleep or staying asleep May be primary disorder or secondary Acute ( one to several nights Chronic ( more than a month Sleep apnea Characterized by repetitive periods of complete or partial airway obstruction that cause five or more apneic events per hour Symptoms ( snoring is primary sign Types of sleep apnea Obstructive apnea ( structures of pharynx, oral cavity block the flow of air Central apnea ( defect in the respiratory center of the brain Mixed apnea ( combination Hypersomnia Client obtains sufficient sleep at night but suffers extreme daytime drowsiness Narcoplepsy ( severe form characterized by daytime sleep attacks that last from a few seconds to several minutes Parasomnias Abnormal actions that take place during sleep Sleep-related eating disorders Somnambulism Night terrors Sleep paralysis Enuresis Sleep talking Bruxism Sex-somnia Dyssomnias Restless leg syndrome ( neurologic sensorimotor disorder characterized by an overwhelming urge to move legs when at rest Periodic limb movement disorder ( repetitive movements that occur every 20 40 seconds and manifest as muscle twitches and jerking movements, usually of the legs Etiology Many factors contribute to sleep disorders Physical factors Injury Ulcers Aging Excessive weight Medical factors Fibromyalgia Asthma Chronic pain Genetic polymorphisms Psychiatric factors Depression Anxiety Stress Environmental factors Alcohol Medications Extreme temperatures Risk factors Insomnia Older age Female gender Obstructive sleep apnea Male gender Smoking Obesity Large neck circumference Parasomnias Children more like to suffer from sleepwalking Alcohol and drug abuse contributes to night terrors in adults Restless leg syndrome Occurs more frequently with age and stress Occurs more frequently in individuals with chronic conditions such as kidney disease, diabetes, Parkinson disease Clinical manifestations Vary according to nature of disorder Sleepiness ( sleeplessness Fatigue Distractibility Irritability Morning headaches See CLINICAL MANIFESTATIONS AND THERAPIES SleepRest Disorders, p. 200 Lifespan and cultural considerations Adolescents and sleep Delay in melatonin release may cause delayed sleep phase syndrome Inability to fall asleep and wake up at desired time Pregnant women and sleep Often develop sleep disorders associated with physical discomfort and changing hormone levels May also be related to emotions and anxiety Restless leg syndrome and GERD may occur May develop sleep apnea, especially if obese Later in pregnancy, difficult to find comfortable position, and may have decreased lung capacity CPAP is safe and effective for pregnant women Older adults and sleep Sleep-rest disorders increase in prevalence with increasing age Chronic health problems cause sleep disturbances and vice versa Changes in sleep patterns include long periods of wakefulness, decreased total sleep time, reduced sleep efficiency, decreased time spent in stages 3 and 4 NREM and REM sleep Increased daytime napping Physiological changes may contribute ( changes in circulation, metabolism, body tissue density Older adults in long-term care facilities are at increased risk for sleep disorders Collaboration Collaborative healthcare team ( holistic approach Diagnostic studies Polysomnography (PSG) records biophysical changes during sleep Electroencephalogram (EEG) measures and records the brains electrical activity Surgery For clients with obstructive sleep apnea, surgery to remove the obstruction may be performed Tonsillectomy Adenoidectomy Pharmacologic therapy Sleep medications prescribed as needed Sedative-hypnotic medications ( general CNS depression, unnatural sleep Antianxiety medications ( decrease levels of arousal Antiparkinson drugs, opioids, and anticonvulsants are occasionally used Sleep medications vary in onset and duration of action, impair waking function Side effects may include headache, dizziness, residual drowsiness, somnolence, nausa Side effects put older adults at risk for injury during ambulation Regular use of sleep medication can lead to tolerance and rebound insomnia Drug, food, and herbal interactions with sleep aids can be problematic Abrupt cessation of barbiturate sedative-hypnotics ( withdrawal symptoms See Table 37 SELECTED MEDICATIONS USED FOR SLEEPREST DISORDERS, p. 198 Nonpharmacologic therapy Cognitive-behavioral therapy (CBT) Good sleep hygiene Physical exercise Relaxation techniquest For obstructive sleep apnea Weight loss, alcohol abstinence, avoiding supine position for sleep CPAP or BiPAP ( see CLIENT TEACHING CPAP and BiPAP MACHINES, p. 199 Complementary and alternative therapies Herbal, natural remedies Melatonin Herbs ( chamomile, valerian Nursing process Assessment Interviewing Sleep history ( subjective ( sleep partner may provide additional information Sleep assessment scales ( Epworth Sleepiness Scale Diagnosis Insomnia Sleep Deprivation Readiness for Enhanced Sleep Disturbed Sleep Pattern Fatigue Wandering related to somnambulism Ineffective Breathing Pattern related to sleep apnea Ineffective Coping Stress Overload Risk for Injury related to sedative-hypnotic effects Deficient Knowledge related to sleep hygiene Planning Maintain/develop sleeping pattern that provides sufficient energy for daily activities and improve quality, quantity of sleep Client will sleep through the night Client will use relaxation techniques 30 to 45 minutes before bedtime Client will maintain a consistent bedtime Client will use good sleep hygiene Client will reduce or remove environmental distractions in the bedroom The client will have sufficient energy for normal daily activities The client will report improved quality and quantity of sleep The clients spouse will report decreased snoring The clients spouse will report no apneic episodes Implementation Nursing interventions include the client, spouse or parents, and healthcare team Educating client about the factors associated with impaired sleep-rest patterns Instructing client in the proper use of assistive devices Teaching client about proper use of prescribed medications Teaching clients about good sleep hygiene Evaluation Data collection Observations of duration of clients sleep Questions about how client feels on awakening Observations of clients level of alertness during the day Explore reasons outcomes not achieved Were etiological factors correctly identified Has clients physical condition or medication therapy changed Did the client comply with instructions about establishing a regular sleepwake pattern Did the client avoid ingesting caffeine Did the client participate in stimulating daytime activities to avoid excessive daytime naps Were all possible measures taken to provide restful environment for the client Were the comfort and relaxation measures effective Review Sleep-Rest Disorders Relate Link the Concepts and Exemplars Ready Go to the Companion Skills Manual Refer Nursing Student Resources Reflect Case Study PAGE MERGEFORMAT 1 Y, dXiJ(x(I_TS1EZBmU/xYy5g/GMGeD3Vqq8K)fw9 xrxwrTZaGy8IjbRcXI u3KGnD1NIBs RuKV.ELM2fiVvlu8zH (W uV4(Tn 7_m-UBww_8(/0hFL)7iAs),Qg20ppf DU4p MDBJlC5 2FhsFYn3E6945Z5k8Fmw-dznZxJZp/P,)KQk5qpN8KGbe 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