pain management, sleep, and comfort › pdf › 8337_htb_21_textbk.pdf · chapter 21 / pain...

21Chapter

OBJECTIVES• Describe your responsibility forreporting pain

• Describe what you might seewhen a resident is in pain

• List five side effects of painmedications

• Describe five complementaryor alternative measures to helpmanage pain

• List ways to promote comfortand sleep

MEDICAL TERMS• Acupuncture — a medicaltherapy that originated inancient China

• Endorphins — naturalmorphine-like substancesreleased by the brain duringexercise, which can alter one’sfeeling of pain

380

PAIN MANAGEMENT, SLEEP, AND COMFORT To feel good, we need to get enough sleep,be physically comfortable, and be free from pain. Health care is now focusing more on these three factors. If aresident is in pain, they are not comfortable. Their sleep and activities will be disrupted. This will affect thequality of their life. In many health care settings, including long term care facilities, pain is thought of as thefifth vital sign. This means that residents are asked about pain when they are admitted and then routinely.Their pain is assessed at least weekly and whenever their condition changes. Thinking of pain as a vital sign—along with temperature, pulse, respiration, and blood pressure—reminds staff to ask residents often about theirpain. This is important because residents do not always mention their pain if they are not asked.How residents perceive and respond to pain is influenced by their cultural or religious background and

beliefs. Your own beliefs also affect how you think residents should respond to pain. As a nurse assistant caringfor residents who are in pain, you must evaluate your own attitudes about pain. How you react to a residentwhen they report pain may affect the quality of their life. Your reporting of a resident’s pain may make thedifference in whether it is managed or not. Pain management is a key part of your residents’ care. Studies show that unrelieved pain can affect healing

and rehabilitation. Pain also affects socialization, ambulation, length of stay in a nursing home, and overallwell-being. In addition, pain can create problems with the resident’s immune system and other body systems.This means pain can affect how the body fights infection. This can cause further deterioration in the resident’shealth.In this chapter you will learn about pain management. You have an important role in communicating informa-

tion about the resident’s pain. You will learn what you can do to help a resident with chronic pain. You willlearn about different measures to relieve pain, increase the resident’s comfort, and promote sleep (Fig. 21-1).

“The hot compress really

relieved my joint pain, and

I was able to sleep so much

better.”

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Have you ever thought that someone did not believewhat you were saying? Did you try to convince theperson to believe you? Imagine that you are in pain

and are trying to convince your caregivers—who have thecapability to relieve your pain—that you are feeling pain.What if they do not believe you? How would that makeyou feel? Would you be able to trust them? Could you havea positive relationship with them? What would your qualityof life be like?

PAINIn the past, pain was often viewed as a symptom of some-thing else, another condition or disease. Health care pro-fessionals often ignored the pain and focused only ontreating the underlying cause. But in today’s health care,pain should never be ignored. Pain is recognized as a dev-astating health problem. Health care professionals todayfocus on finding better ways to treat pain. More researchis also being done today to find new ways to help managepain and bring relief.Pain cannot be measured like temperature or pulse. Pain

is whatever the resident says it is. Pain is what the residentfeels. You must accept what a resident says about the painthey feel and its severity. Report their pain the same way asthey tell you it makes them feel. You cannot interpret some-one else’s pain yourself. Believe what the resident says. Consider this: You see a resident walking down the hall

laughing. Because they are laughing, you do not believethey really are in pain, so you do not report their com-plaint of pain. Now consider a different resident whoreports to you that they experience pain when they walk.

You see this resident crying and holding onto the railing inthe hall as they walk.Would you think differently about these two residents’

pain? Can you be sure one is in pain and the other is not?Would one of them receive pain treatment because youreported it, while the other would not because you didnot report their pain? What you report can determinewhether residents are treated properly. You must not try tojudge their pain. Remember: you cannot know what theyactually feel inside. It is your responsibility to report what-ever the resident states, regardless of whether you believethem or not.Sometimes residents need pain medications around the

clock. That means they must receive the medication onschedule. This is the best way to treat their pain even if thenurse must wake them up in the middle of the night. Youmay think that waking the resident is not a good thing.But if the resident’s pain increases because they missed adose of medication, it may then become difficult to controltheir pain.

Screening for Pain

Most facilities have pain assessment tools that residentscan use to rate their pain. A number scale is often used foradults. You ask the resident, “If zero is no pain and 10 isthe worst pain possible, what is your pain right now?” Itmay be easier for some residents, especially residents whodo not speak English, to use a visual pain scale like theone shown in Figure 21-2, next page. Other scales may beused for residents with impaired cognitive ability. A resi-dent’s pain should be assessed at least weekly and when-ever their condition changes. Let the charge nurse knowhow much pain the resident is experiencing so that amore detailed pain assessment can be performed.The charge nurse, along with other members of the

interdisciplinary team, may assess the resident’s pain.Residents are asked about the following pain qualities:• The location of their pain• What their pain feels like, using terms such as:- “achy” - “throbbing” - “sore” - “burning”

CHAPTER 21 / PAIN MANAGEMENT, SLEEP, AND COMFORT 381

Fig. 21-1 — Comfort measures such as fluffing pillows help relieve pain,increase the resident’s comfort, and promote sleep.

Pain — bodily sensation that causes suffering and distress


382 CHAPTER 21 / PAIN MANAGEMENT, SLEEP, AND COMFORT

- “pins and needles” - “knife-like” - “shooting” - “crampy” - “pressure” - “discomfort”

• When the pain started• Whether the pain is always there or if it comes and goes• What makes the pain worse or better• How the pain affects their walking, eating, sleeping, andmood

The interdisciplinary team uses all this information tocreate a plan to help relieve the resident’s pain.Pain management is the responsibility of the whole

team. The charge nurse may ask you to report when theresident complains of pain or to observe how the residentresponds after being given a pain medication. The physi-cian or another member of the interdisciplinary team mayprescribe complementary (nonmedical) or alternative ther-apies for pain relief. These may include the application ofheat or cold. The charge nurse will explain your responsi-bilities with these therapies. Later in this chapter you willlearn strategies for pain relief that can be administeredalong with medications or instead of them.You have a key role helping the interdisciplinary team

assess a resident’s pain. Listen carefully to how the resi-dent defines their pain. The charge nurse or other healthcare professional evaluates the resident’s pain, but youshould report any other signs or nonverbal cues to painthat you see in the resident or that they tell you about.Encourage residents to talk openly about their pain. They

should understand that pain is not a normal part of aging.They should never be made to feel they should hide theirpain. Pain can be managed, and they have the right to paintreatment.In some situations, a resident may try to hide their pain

because their culture or religion encourages that. Alwaysrespect the resident’s cultural and religious views whileyou work with the team to address the pain. Rememberthat it is crucial to report their pain so that it can be treat-ed appropriately.

Understanding Pain

The severe pain from some forms of cancer has led healthcare professionals to improve our understanding of painand how to manage it. Pain used to be defined in threecategories: (1) acute pain, such as caused by a sprain,strain, infection, inflammation, or surgical procedure; (2)chronic pain, such as caused by arthritis; and (3) malignantpain, such as in cancer. More recently, pain research defines pain in relation to

different forms of nervous system damage. This approachhelps the interdisciplinary team more effectively treat resi-dents’ pain. Certain medications or alternative strategiesfor comfort and pain relief work better with one kind ofpain than with another. In this way, the team can use thebest pain management strategies for the resident’s specifickind of pain. Your role in pain management is to always report infor-

mation about the resident accurately and in a timely man-ner, and to perform other strategies as directed.

Common Resident Concerns About Pain

Some residents have certain beliefs about pain and itstreatment. These beliefs may interfere with reporting theirpain and good pain management. Table 21-1 lists commonmisconceptions or beliefs about pain as well as the facts.Be aware of these misconceptions and beliefs. Whenappropriate, talk about them with your residents.

Reporting Pain Accurately

Pain is very subjective. In Chapter 8, DocumentationPrinciples and Procedures, you learned that subjectiveinformation is what the resident tells you. For example, aresident may tell you that they could not sleep all nightbecause they had pain in their hip. You must report thissubjective information exactly as the resident stated it. In

0

NoPain

MildPain

ModeratePain

SeverePain

VerySevere

WorstPossible

2 4 6 8 91 3 5 7 10

Fig. 21-2 — Example of a tool a resident can use to rate their pain.

Used with permission, University of Colorado Health Sciences Center, Denver, Colorado.

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OBSERVATION

The resident’s facial expression

The resident’s physical movements

What you might hear

SIGNS OF PAIN

• Frown, wrinkled forehead• Furrowed brow• Grimace• Expression of fear• Expression of sadness• Tense muscles around the

mouth and eyes (Fig. 21-3)

• Restlessness, fidgeting,agitation

• Absence of movement, slowmovements

• Cautious movements,guarding, or bracing

• Rigidity, generalized tension• Rubbing a body part

• Groaning, moaning• Crying• Noisy breathing• Saying things like “Ouch!”

or “Don’t touch me”

TABLE 21-2SIGNS OF PAIN


Fig. 21-3 — A resident with a facial expression such as a frown,grimace, or expression of sadness may be in pain.

MISCONCEPTIONS ABOUT PAIN

“If I take too much painmedicine I will getaddicted.”

“Pain is inevitable as you get older—I just have to livewith it.”

“The nurses and nurseassistants are so busy—Idon’t want to bother themby asking for painmedication.”

“If my pain medicine doesn’twork as well as it used to, itmeans I am getting immuneor addicted to it.”

“It is better to save painmedicine for when the paingets really bad.”

“It’s easier to cope with thepain than with the sideeffects of pain medication,especially constipation.”

FACTS ABOUT PAIN

The risk of addiction is rare (lessthan one in 10,000 people) whenpain medications are taken forpain.

As you age, conditions that causepain become more common. Butpain is not normal. Good pain reliefis possible for all types of pain.

The nurses and nurse assistantswant to know about your pain. Thestaff want to provide the besttreatment possible.

Sometimes people get used to amedicine. This is called toler-ance–not addiction. If tolerancehappens, staff can increase thedose or change to a different painmedicine.

If a resident waits too long to takepain medicine, they may actuallyneed a stronger medicine or high-er dose. Taking pain medicine on aregular schedule may help preventpain.

Pain medicine, particularly nar-cotics, can cause constipation. Butconstipation can be prevented andtreated with stool softeners andlaxatives. Worries about sideeffects should not stop the residentfrom taking pain medicine for theirpain.

TABLE 21-1MISCONCEPTIONS ABOUT PAIN AND ITSTREATMENT

Used with permission, University of Colorado Health Sciences Center, Denver,Colorado. Development of pamphlet was supported by AHRQ grant U18-HS11093-3.



this case you would tell the charge nurse that the residentsaid they could not sleep all night because they had painin their hip. The charge nurse may ask you questions suchas: “Is the resident up now? Did they say they felt painwhen you helped them with their ADLs? Do they show anyother signs of pain?” Then you would tell the nurse whatyou observed, being careful to identify subjective andobjective information.Table 21-2, previous page, describes some common signs

of pain you may observe. But always remember thatregardless of what you observe or do not observe, pain iswhat the resident says it is.

Pain That Is Left Untreated

Each resident feels pain differently and responds in theirown way. You may hear someone say that one resident hasa “high pain threshold” while another has a “low thresh-old.” The reasons for such differences are very complexand not fully understood. Researchers believe that culturalinfluences, the brain’s release of endorphins, and previousexperiences with pain all may play a role in pain sensation,along with other individual factors.Regardless of differences among residents, pain that is

not relieved can lead to terrible problems. As mentionedearlier, the resident’s immune system is compromised byunrelieved pain. Pain also affects other body systems.Because of the constant effect of pain on the nervous sys-tem, even the lightest touch can cause a resident morepain. The charge nurse can give you more informationabout how the body is affected by unrelieved pain.A resident in pain is not happy. They cannot get comfort-

able and relax. They do not sleep well. They may feel thatthe quality of their life is poor. If a resident’s pain is notmanaged, the resident may experience some or all of thefollowing feelings:• Fear•Depression• Anxiety•Helplessness•Hopelessness•Distress•Decreased will to live

Pain Treatment

The most common treatment of pain is medication. Manydrugs are available today to treat residents’ pain. Typically,a combination of drugs is used to manage pain caused bycancer or chronic illness. The physician and other mem-bers of the team select what drugs to use. Your inputabout the resident’s experience is a key part of this deci-sion. The team must clearly understand what type of painthe resident is experiencing and other information aboutthe resident’s pain. In addition to communicating yourknowledge about the resident’s pain, you also are respon-sible for reporting any side effects, or undesired effects, ofthe pain medication on the resident. Box 21-1 lists somepossible side effects.

In addition to pain medication, other therapies are usedto help manage residents’ pain (Fig. 21-4, next page).These therapies also help the resident be more comfort-able and sleep better. Complementary or alternative thera-pies often help the resident feel more in control. It is diffi-cult to feel in control when in pain. The choice of othertreatments or therapies depends in part on the resident’spreferences and cultural beliefs. The choice also dependson their ability to tolerate certain body positions, the expe-rience of the health care team, and other factors. Box 21-2describes some nondrug therapies that may be used tohelp relieve residents’ pain.

Endorphins – natural morphine-like substances released by the brainduring exercise, which can alter one’s feeling of pain

BOX 21-1. POSSIBLE SIDE EFFECTS OF PAIN MEDICATION

•Constipation•Diarrhea•Nausea and vomiting• Sleeping too much•Complaints of stomach pains• Rash•Confusion• Slowed respiratory rate•Dizziness when standing or changing position


Your role with nondrug therapies depends on yourexperience. The charge nurse or the physical therapist willtrain you in techniques used in your facility. The chargenurse and other team members decide what alternative orcomplementary therapies to use for each resident. Youmay be asked to report how effective the treatment is incomforting the resident or relieving pain.

If the physician prescribes heat or cold application, fol-low the guidelines on the use of heat or cold therapy inChapter 24.

PROMOTING COMFORT AND SLEEPResearch has shown that frequent sleep disturbances, suchas getting up to go to the bathroom, may affect the body’snatural pain inhibitors and cause more pain. This is espe-cially so with women. You are responsible for helping allresidents to feel comfortable and get enough sleep. Thetechniques listed in Box 21-2 can be used with all residentsto help promote comfort and sleep in addition to relievingpain. You can also help control the resident’s environmentin the following ways to help make them comfortable andto promote sleep:•Ask the resident about their room temperature. Be sure

the room it is not too hot or too cold. Remember thatwhat you consider a comfortable temperature yourselfmay be different from what the resident finds comfort-able. Be sure the resident has enough blankets nearbyso that they can pull up more covers if they get cold dur-ing the night. If residents cannot do this by themselves,be sure to check on them throughout the night.

• Limit noise at night. Do not not talk to others in theresident’s room or outside their door.

• Lower the lights in the hallways. Close the resident’sdoor if appropriate. Be sure to pull window shades andclose curtains so that outside lights do not shine in theresident’s window.

• Pay attention to any odors. Make every effort to emptybedpans, change soiled linens, and manage incontinencein a timely manner.

• Encourage residents to use the bathroom before goingto bed at night.

In addition to these guidelines, encourage the residentto rest during the day. This can simply mean quiet timereading or listening to music. Understanding how the resi-dent likes to relax and to prepare for sleep will help youknow what to do for the resident.


Fig. 21-4 — Exercise like stretching helps residents manage their pain.



BOX 21-2. NONDRUG THERAPIES FOR PAIN

•Heat/cold application involves using dry or moistheat or cold on a specific area to relieve pain orincrease the resident’s comfort.

•Vibration can be used to promote comfort or helprelieve pain. This form of electrical massage is appliedlightly or with pressure on various body areas.Different types of vibrating devices are available fordifferent parts of the body.

•Massage is a method of relaxation that can be used tohelp residents relax both physically and mentally. Athree-minute backrub using slow, rhythmic strokes is asafe and effective way to decrease pain and promoterelaxation.

•Acupuncture is an ancient Chinese healing method.The acupuncturist inserts very thin needles in specificbody sites. Acupuncture is said to allow energy to flowto or from areas that do not have enough energy orhave too much energy. Acupuncture is believed tohelp restore and regulate the body’s energy balance.

•Distraction is a technique used to direct a resident’sattention away from pain. With distraction, theresident deliberately focuses on something other thanthe pain and thus responds less to it (Fig. 21-5).Talking, books, movies, and social activities are alldistractions.

•Humor is an enjoyable and often effective form ofdistraction that can be used to get the resident’s mindoff their pain.

•Relaxation techniques are methods that help reduceanxiety, muscle tension, and pain. Such techniquesinclude meditation, music, massage, and deepbreathing (Fig. 21-6).

•Guided imagery is a healing technique that useswords and sometimes music to bring the body andmind to a relaxed and focused state.

•Animals provide relaxation and companionship andhelp distract a resident’s attention from pain.

Fig. 21-5 — Encouraging residents to participate in activities theyenjoy can help distract them from their pain.

Fig. 21-6 — Meditation can help residents relax and reduces theirpain.


IN THIS CHAPTER YOU LEARNED: •Your responsibility for reporting pain• Signs you might see when a resident is in pain• Common side effects of pain medications• Complementary or alternative measures to help managepain

• That hot and cold applications are used to decrease pain•Ways to promote comfort and sleep

SUMMARYIn this chapter you learned how important it is for a resi-dent to sleep well, be comfortable, and be free from pain.Your role of reporting the resident’s pain is critical, so thattreatments can be given to relieve their pain. In addition todrug therapy, many alternative measures can help promotesleep, make the resident comfortable, and relieve pain.

PULLING IT ALL TOGETHERYour responsibility to report information can makethe difference in how residents are treated. Considerthese examples:

Example 1. Mrs. Bailey is a resident newlyadmitted to your facility. She has Alzheimer’sdisease and can no longer safely care for her-self. At the end of your shift you report to thecharge nurse that she seemed irritable andstubborn. You do not report that she was hug-ging her knees and resisted releasing themwhen you tried to help her go to the bathroom,dining room, and her arts and crafts group.Example 2. At the end of your shift you

report to the charge nurse that Mrs. Bailey wasrocking in the bed and holding her kneeswhen you tried to help her with activities ofdaily living.

In example 1 you reported your opinion. In example 2 you reported the facts.Now think about what could happen in each situa-

tion. In the first example, your opinion could resultin the resident being labeled as difficult. In the sec-ond example, reporting the facts would prompt thecharge nurse to assess the resident. This assessmentis preferable, because it might discover that Mrs.Bailey has pain in her knees from an old injury.




1. What is considered the fifth vital sign?A. Pain.B. Anxiety.C. Hearing.D. Mental status.

2. How residents perceive and respond to painis influenced by: A. Their nutritional status.B. Sunlight.C. The clothing they are wearing at the time.D. Their cultural or religious background and beliefs.

3. How can you help a resident manage theirpain?A. Make the lights in their room as bright as possible.B. Report any signs or symptoms of pain to the charge

nurse.C. Offer them plenty of snacks and beverages between

meals.D. Turn the television up loud.

4. Why is it important to manage a resident’spain?A. Untreated pain makes residents sleepy.B. Untreated pain can cause Alzheimer’s disease.C. Untreated pain can lead to hypothermia.D. Untreated pain can put a resident at increased risk of

illness.

5. Mrs. Samuelle doesn’t ask for painmedication, even though she has chronicpain from arthritis in her hip. What is apossible reason for why she tolerates herpain?A. Her roommate never asks for pain medication.B. In her family, complaining about pain is a sign of

weakness.C. Staff in long term care facilities cannot administer pain

medication.D. Pain will make her immune system stronger.

6. If a resident tells you their knee hurts, butthey don’t show any signs of pain, youshould think they are:A. Disoriented.B. Telling you the truth.C. Addicted to pain medication.D. Just trying to get your attention.

7. A possible side effect of pain medication is:A. Sleeplessness.B. Constipation.C. Acute sensitivity to light.D. Increased respiratory rate.

8. The technique of distraction may include:A. Sneaking up on a resident to startle them.B. Watching a movie.C. Acupuncture.D. Taking a Sitz bath.

9. Which of these nondrug therapies can helpreduce painful swelling?A. Exercise.B. Vibration.C. Music therapy.D. Cold application.

10. How can you help residents sleep well atnight?A. Give each resident a sleeping pill.B. Limit noise and conversations in the hallway.C. Give each resident a glass of warm milk before bed.D. Never go into a resident’s room during the night.

CHECK WHAT YOU’VE LEARNED

(Answers to “Check What You’ve Learned” are in the Instructor’s Manual.)


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