Trisha Economidis, MS, ARNP Lake-Sumter Community College Fall, 2012 Sleep Quiz How many Americans suffer from sleep disorders? A. 100,000 B. 1 million C. 50-70 million How many sleep disorders have been identified? A. 10 B. 50 C. 90 Who has a greater incidence of insomnia? A. Men B. Women For women, sleep disturbances are often related to hormonal hallmarks (menstruation, pregnancy, menopause). A. True B. False Sleep patterns of the older adult include which of the following: (Select all that apply) A. Need more sleep than younger adults B. Take longer to fall asleep than younger adults C. Awake more frequently and stay awake longer than younger adults D. Frequent awakening is often due to physical discomfort and nocturia Physiology of sleep Biorhythms – Biological Controlled within the body Environmental Circadian rhythm- Biorhythm Day-night 24 hour clock Types of sleep Non-Rem REM (Rapid Eye Movement) Occurs in 90-100 minute cycles Sleep Cycle Factors Affecting Rest & Sleep Comfort Anxiety Environment Factors Affecting Rest and Sleep Lifestyle Work Exercise Travel Diet Drugs Medications Average Sleep Requirements Table 33-1 Page 814 Alterations in Sleep patterns Dyssomnias Dyssomnias Insomnia Sleep-wake Schedule Restless Leg Syndrome Sleep Deprivation Hypersomnia Narcolepsy Dyssomnias Sleep Apnea- airway occlusion Hypercapnia and hypoxemia May have increased heart rate, increased bp S/S: excessive sleepiness, fatigue, snoring, nocturia Diagnosis: Made by sleep study Untreated can lead to : Hypertension Dysrhythmias Angina MI Stroke Mood swings Impotence Personality changes Sleep Apnea Obstructive Sleep Apnea – caused by occlusion of the airway during sleep. TX: CPAP – Continuous Positive Air Pressure Central Sleep Apnea – Dysfunction in central respiratory control Mixed Apnea – combination of Obstructive and Central Sleep Apneas CPAP Altered Sleep Patterns Parasomnias Sleepwalking (Somnambulism) Occurs during Stage 3-4 of sleep Sleep talking Bruxism-teeth grinding or clenching Night Terrors Nocturnal Enuresis What is the Risk? Sleep Hygiene Practices Assessment of Sleep Patterns and rituals Relaxation Eliminate stressful situations before bed Muscle relaxation Activities that relax rather than stimulate Warm bath Sleep Hygiene Environment Adjust light, noise, temp to promote sleep Use bedroom for sleep & sex only Go to bed at same time each night Help client to understand what things can affect sleep patterns Pharmacologic Interventions for Sleep Be aware of potential side effects and possible dependency issues Shouldn’t mix with alcohol and most are not recommended for long-term use Pharmacologic Interventions Non-benzodiazepines: Ambien, Sonata, Lunesta Benzodiazepines: Valium, Ativan, Klonopin, Xanax Caution: Hazardous in elderly; must use cautiously in children; can cause ADDICTION Pharmacologic Interventions, cont. Barbiturates: sedative/hypnotic/anticonvulsants; Seconal, Luminal, Nembutal Tricyclic Antidepressants: major side effect is drowsiness. Elavil, Tofranil OTC Sleep aids Antihistamines Herbal remedies Melatonin Nutrition Impact on Sleep No large fatty meals before sleep L-tryptophan increases sleep (milk & cheese) Protein – increases alertness (not a good before bed snack) Carbohydrates promote sleep crackers, bread, cereal Nursing Diagnoses for Sleep Sleep Deprivation: Occurs over long periods of time and symptoms more severe (confusion, even psychosis) Disturbed Sleep Pattern: time limited sleep pattern. Ex.: related to hospitalization – can be treated by nursing therapy A patient is diagnosed with narcolepsy. The nurse’s primary intervention should address the patient’s: A. Inability to provide self-care B. Impaired thought processes C. Potential for injury D. Excessive fatigue Correct Answer: C Narcolepsy is excessive sleepiness in the daytime that can cause a person to fall asleep uncontrollably at inappropriate times (sleep attach) and result in physical harm to self or others The nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which is the most common intervention that the nurse should plan to discuss with this patient? A. Encouraging sleeping in the supine position B. Using devices that support airway patency C. Positioning two pillows under the head D. Administering sedatives Answer: B. A continuous positive airway pressure (CPAP) mask worn over the nose when sleeping keeps the upper airway patent through continuous positive airway pressure. Which is the most important nursing intervention that supports a patient’s ability to sleep in the hospital setting? A. Providing an extra blanket B. Limiting unnecessary noise on the unit C. Shutting off lights in the patient’s room D. Pulling curtains around the bed at night. Answer: B Noise is a serious deterrent to sleep in a hospital. The nurse should limit environmental noise (distributing fluids, providing treatments, rolling drug and linen carts) and staff communication noise. (Turning off the lights is unsafe. You may dim the lights or put a night light on to provide enough illumination for safe ambulation to the bathroom) What concept associated with sleep should the nurse consider to best plan nursing care for a hospitalized patient? A. People require eight hours of uninterrupted sleep to meet energy needs B. Frequency of nighttime awakenings decreases with age C. Fear can contribute to the need to stay awake. D. Bed rest decreases the need for sleep. Answer: C Fear of loss of control, the unknown, and potential death results in the struggle to stay awake, which interferes with the ability to relax sufficiently to fall asleep. Comfort/Pain True or False? The nurse is the best judge of a patient’s pain Answer: False Pain is SUBJECTIVE – only the client can judge the level and severity of pain TRUE OR FALSE? You should wait until pain has reached the maximum amount bearable before medicating. Answer: False Pain control/relief is much more effective when given when pain begins True or False? True pain always produces observable signs/symptoms such as grimacing or moaning Answer: False Many people are stoic when it comes to expressing pain. One’s culture may also have an impact on the expression of pain. True or False? If the patient doesn’t look like he’s in pain, it’s ok to withhold medications or decrease the dose. Answer: False Pain is a subjective experience. Only the patient knows how much pain he/she is experiencing. True or False? Clients taking pain medications will become addicted. Answer: False While it does happen, it is unlikely when analgesics are administered and monitored carefully So….What IS Pain? A sensation that HURTS A SUBJECTIVE experience An interference : a multi-dimensional experience and impact Protective Types or Origins of Pain Cutaneous - superficial Somatic - ligaments, joints, muscles Visceral – internal organs/body cavities Neuropathic – nerve pain Radiating – Starts at origin, but extends to other locations Referred – Pain felt distant to origin Phantom Phantom Duration of Pain Acute Pain - Sudden onset/short duration (up to 6 months) Chronic Pain –Has lasted 6 months or longer Intractable Pain – Chronic and very resistant to relief http://www.youtube.com/watch?v=Hs kbfhiVJro Quality of Pain What does it feel like? Sharp? Dull? Aching? Stabbing? Burning? Crushing? Tingling? Intensity or Severity of Pain How much does it hurt????? Pain Rating Scales imperative – Allows assessment of level of pain and effectiveness of interventions 0-10 scale Faces Pain Rating Scale Poker Chips - “pieces” of pain Faces Numeric . Assessment of Pain: The Who, What, When, Where, and How Who? The patient self-report is the most reliable indicator of pain What if it’s a child? The parent/caregiver knows the child best What? What the patient says AND Your observations which may include: Physiological responses: Acute pain - Increased blood pressure, pulse and respirations; dilated pupils, rapid speech Behavioral responses: Moaning, facial grimacing, crying, agitation, guarding, withdrawing from painful stimuli Psychological responses: Anxiety, depression, anger, fear, exhaustion, irritability When? On admission Before and after procedures or treatments With each assessment/vital signs When the patient is resting as well as during activity Before you give pain meds and 30 minutes after When the patient complains of pain Where? Where ever the patient is and whatever is going on? Resting in bed Ambulating Before, during, after procedures whether in the patient’s room or in another location How? Begin with a pain history Do you have pain now? When did the pain begin? (Onset) Where is the pain located? (Location) How do you rate your pain? (use a pain scale) (Intensity) How would you describe your pain? (Quality) How? (Pain History) How often do you have pain? (Frequency) What makes the pain better? (Alleviating Factors) What makes it worse? (Aggravating Factors) Do you have any other symptoms when you are experiencing pain, i.e. nausea/vomiting? (Associated Factors) How? (Pain History) Have you experienced this type of pain in the past? If so, how did you manage/cope with it? (History of Previous Pain Experience) Have you used any medications to treat the pain? If so, what have you used and was it effective? What, if any, alternative treatments have you used for pain? Review: Assessing Pain How do we assess? Onset of symptoms Alleviating Factors Location Aggravating Factors Intensity Associated Factors Quality History of Previous Frequency Pain Experience How? Combine your pain history with your observations of: Physiological responses Behavioral responses Psychological responses Factors That May Affect Perception of Pain Age Child – may not recognize sensation of pain or may have paradoxical reaction Adolescent – may be expressed as “attitude,” anger, aggression Older adult – may have trouble verbalizing because of perception that pain is “normal” part of aging Factors that may Affect Pain Culture May impact level of pain one is willing to endure Need to use assessment tools that are culturally sensitive Perception of pain is impacted by age and culture. Analgesics Used for Pain 3 common groups of drugs used for pain management Opioids Nonopioids Adjuvants Pain Medications: Opioid Analgesics Work on pain by blocking receptors in the Central Nervous System Opioid Analgesics morphine sulfate methadone meperidine HCl (Demerol) hydromorphone (Dilaudid) Fentanyl oxycodone (Percocet) hydrocodone (Vicodin) Opioid Analgesics Indications/Uses: More effective for visceral pain Side/Adverse Effects: Respiratory depression N/V, constipation, drowsiness, pruritis (itching), dry mouth, difficulty urinating, tachy/bradycardias, hypotension Opioid Analgesics Nursing Considerations: Assess respiratory status frequently. If respiratory depression occurs, administer Narcan to reverse effects. Monitor blood pressure. Monitor for constipation and make appropriate interventions (pg 741) Treat other symptoms as indicated Nonopioid Analgesics Used to relieve mild to moderate pain, acute or chronic (also may relieve inflammation and fever) Acetaminophen (Tylenol) (minimal anti-inflammatory effect) NSAIDS (nonsteroidal anti-inflammatory drugs) aspirin ibuprofen (Motrin, Advil) naproxen (Aleve) Prescription NSAIDS: Celebrex, Voltaren, Indocin and others Side/Adverse Effects of Nonopioids Acetaminophen – Can cause liver toxicity especially in patients who consume alcohol or who have liver disease. Current recommendation: maximum of 3000 mg (3g) per day as of July, 2011 Aspirin – regular use can cause prolonged clotting time (bruise easily and bleed more) Other NSAIDS – gastric irritation and bleeding, use with caution in patients with impaired clotting and renal disease Nursing considerations for Nonopioids Tylenol – teaching regarding maximum daily dose. Importance of reporting overdose (liver damage occurs rapidly) NSAIDS – importance of taking with food. Use of enteric-coated pills if gastric irritation occurs. Monitor for gi bleeding. Be aware of the possibility for drug interactions. Adjuvant Medications Enhance the analgesic effect of opioids Anticonvulsants Antidepressants Sedatives Steroids Non-pharmacological Interventions for Pain Management(see pgs. 736738) Relaxation Guided imagery Distraction Therapeutic Touch Hypnosis Cutaneous Stimulation: TENS units, PENS units, Spinal Cord stimulator, Acupuncture, Acupressure, Massage, Heat/Cold Application, Contralateral stimulation A patient has a total abdominal hysterectomy for Stage 4 ovarian cancer. What should the nurse do first when on the second postoperative day this patient reports abdominal pain at level 5 on a 1 to 10 pain scale? A. Reposition the patient B. Offer a relaxing back rub C. Use distraction techniques D. Administer the prescribed analgesic. Answer: D Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision that require adequate pharmacological intervention to provide relief from pain A patient states, “The pain moves from my chest down my left arm.” Which characteristic of pain is associated with this statement? A. Pattern B. Duration C. Location D. Constancy Answer: C This is a description of referred pain, which is pain felt in a part of the body that is at a distance from the tissues causing the pain. Referred pain is related to location of pain. A patient has a history of severe chronic pain. Which is one of the most important guidelines associated with providing nursing care to this patient? A. Asking what is an acceptable level of pain B. Providing interventions that do not precipitate pain C. Determining the level of function that can be performed without pain D. Focusing on pain management intervention before pain becomes excessive Answer: D Administration of analgesics around the clock at regularly scheduled intervals or by long-acting controlled-release transdermal patches maintains therapeutic blood levels of analgesics, which limit pain at levels of comfort acceptable to patients.