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CONCEPT:
Comfort
Concept Definition
A state of physical ease
Comfort Concept: Objectives
• Explain the concept of comfort (including
definition, antecedents, and attributes).
• Analyze conditions which place a patient at risk
for impaired comfort.
• Identify when impaired comfort is developing or
has developed.
• Discuss exemplars of common disruptions of
patient comfort. (Pain)
• Apply the nursing process (including
collaborative interventions) for individuals
experiencing comfort imbalance.
Positive Consequences
• Social interactions
• Perform ADL’s
• Adapt to stressors
• Calm demeanor
Sub-Concepts of Comfort
•Neuropathic pain
•Chronic and Acute pain
•Theory of pain control
•Nociceptive Pain
•Mixed Pain Syndromes
Neuropathic Pain
•“Neuropathic pain results from the abnormal
processing of sensory input by the nervous
system as a result of damage to the brain,
spinal cord, or peripheral nerve”.
•Neuropathic pain is pathologic.
•Postherpetic neuralgia, diabetic neuropathy,
phantom pain, and post stroke pain syndrome
•Burning, sharp, or shooting
Acute and Chronic Pain
•Acute pain-usually short lived
•Chronic pain-cancer, osteoarthritis, pain from
an underlying medical condition, may last a
lifetime
•Acute and Chronic pain combination
Pain Control
•Pharmacologic Strategies
• Oral medications
• Intravenous medications
• Epidural analgesia
• Patient-controlled analgesia
• Local anesthesia
Federal Drug Classification Schedules
With the Controlled Substances Act of 1970, a major
illegal substance control campaign began. Americans
have witnessed a corresponding shift of resources and
public attention onto the growing problem of
substance abuse and its effects on society.
• Schedule I
(a) The drug or other substance has a high potential
for abuse.
(b) The drug or other substance has no currently
accepted medical use in treatment in the United
States.
(c) There is a lack of accepted safety for use of the
drug or other substance under medical supervision.
Federal Drug Classification Schedules
• Schedule II
(a) The drug or other substance has a high potential
for abuse.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States or a currently accepted medical use with
severe restrictions.
(c) Abuse of the drug or other substances may lead
to severe psychological or physical dependence.
Federal Drug Classification Schedules
• Schedule III
(a) The drug or other substance has a potential for
abuse less than the drugs or other substances in
schedules I and II.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(c) Abuse of the drug or other substance may lead to
moderate or low physical dependence or high
psychological dependence.
Federal Drug Classification Schedules
• Schedule IV
(a) The drug or other substance has a low potential
for abuse relative to the drugs or other substances in
schedule III.
(b) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(c) Abuse of the drug or other substance may lead to
limited physical dependence or psychological
dependence relative to the drugs or other substances
in schedule III.
Federal Drug Classification Schedules
• Schedule V
(A) The drug or other substance has a low potential
for abuse relative to the drugs or other substances in
schedule IV.
(B) The drug or other substance has a currently
accepted medical use in treatment in the United
States.
(C) Abuse of the drug or other substance may lead to
limited physical dependence or psychological
dependence relative to the drugs or other substances
in schedule IV.
Implementing:
Pharmacologic Interventions
• Opioids (narcotics)
• Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS)
• Co-analgesic drugs
• WHO 3-step analgesic ladder
WHO Ladder Step
• Step 1
• For clients with mild pain (1 - 3 on a 0 - 10 scale)
• Use nonopioid analgesics (with or without a coanalgesic)
WHO Ladder Step (cont’d)
• Step 2
• For client with mild pain that persists or increases
• Pain is moderate (4 - 6 on a 0 - 10 scale)
• Use of a weak opioid (e.g., codeine, tramadol, pentazocine) or a
combination of opioid and nonopioid medicine (oxycodone with
acetaminophen, hydrocodone with ibuprofen)
WHO Ladder Step (cont’d)
• Step 3
• Client with moderate pain that persists or increases or with severe pain
• Pain is severe (7 - 10 on a 0 - 10 scale)
• Strong opioids (e.g., morphine, hydromorphone, fentanyl)
The WHO three-step analgesic ladder. From Cancer Pain Relief, 2nd
ed., by World Health Organization, 1996, Geneva: Author. © Copyright
World Health Organization (WHO). All rights reserved.
Nonopioid Analgesics
Warnings:
• Acetaminophen
•
•
•
(potentially lethal drug with taken in overdose amounts. Can
cause hepatic toxicity)
NSAIDs
• cardiovascular risk (thrombotic events, myocardial
infarction, and stroke
• Do not use perioperative of coronary artery bypass graft
surgery)
Nonopioid Analgesics
NSAIDs-cont.
gastrointestinal (increased risk of bleeding,
ulceration, and perforation of the stomach
and or intestines).
Nonopioid Analgesics
• NSAID-includes aspirin, cyclo-oxygenase-2
inhibitors(Celebrex), Ibuprofen (Motrin, Advil)
Aleve, many others.
• commonly used for management of pain associated
with arthritis because of the antiinflammatory and
analgesic effects
• Acetaminophen-(Tylenol)most widely used
nonopioid analgesic
• most commonly used for fever and mild to moderate
pain.
• Tramadol Hydrochloride-Ultram
Nonopioids/NSAIDS
• Vary little in analgesic potency but do vary in anti-inflammatory
effects, metabolism, excretion, and side effects
• Have a ceiling effect
• Increasing a dose beyond an upper limit, provides no greater analgesia
• They do not produce tolerance or physical dependence
• Many are available without prescription
Nonopioids/NSAIDS
• Narrow therapeutic index
• Not much margin for safety between the dose that produces a desired
effect and the dose that may produce a toxic even lethal effect
• Most common side effect GI
• Effective for mild to moderate pain
• Often used in conjunction with opioid because they allow for
effective pain relief using lower opioid doses
• Examples are acetaminophen, ibuprofen, aspirin,
naproxen
Opioids (Narcotics)
• Full agonists
• Produce their effects by binding to receptors in the CNS causing
inhibition of the transmission of nociceptive input from the
periphery to the spinal cord
• Bind tightly to mu receptors, producing maximum pain
inhibition
• No ceiling on analgesia
• Dosage can be steadily increased to relieve pain
• No maximum daily dose limit
• E.g., morphine, oxycodone, hydromorphone
Opioid Drugs
• Alleviate moderate to severe pain
• Potential for adverse effects-nausea,
vomiting, sedation, mental clouding,
respiratory depression, subacute overdose,
and dry mouth.
• Contraindications-drug allergy and severe
asthma.
Chemical Classification of Opioids
Chemical Category
Meperidine-like drugs
Opioid Drugs
Meperidine, Fentanyl,
Remifentanil, Sufentanil,
Alfentanil
Methadone-like drugs
Methadone, Propoxyphene
Morphine-like drugs
Morphine, Heroin,
Hydromorphone,
Oxymorphone,
Levorphanol, Codeine,
Hydrocodone, oxycodone
Other
Tramadol
Pain Control
•
Nonpharmacologic Strategies
• Massage
• Splinting
• Relaxation and guided imagery
• Distraction
• TENS
• Counterirritation
• Nutrition
• Physical Therapy
Pain Theory-Pattern Specificity Theory
• Von Frey (1895)
• Certain pain receptors are stimulated by specific
stimuli
• Does not take into account tolerance to pain
• Does not taken into account psychological
components of pain
Smith, S. F., Duell, D. J., & Martin, B. C. (2012).Clinical nursing
skills (8th ed.) Retrieved from Skyscape.
Pain Theory-Pattern Theory
• Goldschneider (1920)
• Pain originates in the dorsal horn of the spinal cord
• Specific pain sensory reacts with intense receptor
stimulation
• Does not taken into account psychological
components of pain
Smith, S. F., Duell, D. J., & Martin, B. C. (2012).Clinical nursing
skills (8th ed.) Retrieved from Skyscape.
Pain Theory-Pattern Gate-Control
Theory
• Melzack
• Transmission of neurologic impulses
• Gate mechanisms along the spinal cord control the
transmission of pain
• If the gate is open the pain impulse is experienced
• If the gate is closed the pain impulse is not experienced
• Smith, S. F., Duell, D. J., & Martin, B. C. (2012).Clinical nursing skills
(8th ed.) Retrieved from Skyscape.
Nociceptive Pain
•“Refers to the normal functioning of
physiologic systems that leads to the
perception of noxious stimuli (tissue injury) as
being painful”
•Normal pain transmission
•Surgery, trauma, burns, and tumor growth
•Aching, cramping, or throbbing
• Giddens, J. F. (2013). Concepts for nursing practice. Pain
(pp. 270-279). St. Louis, Mo: Mosby.
Mixed Pain Syndromes
•“Unique with multiple underlying and poorly
understood mechanisms”
•Fibromyalgia, some low back pain, and
myofascial pain
• Giddens, J. F. (2013). Concepts for nursing practice. Pain
(pp. 270-279). St. Louis, Mo: Mosby.
Antecedents for Comfort
•Effective circulatory system
•Able to discern from comfort to discomfort
•Without noxious stimuli
•Intact neurological/sensory system
How will knowing the Antecendents affect
your Nursing Assessment?
-use of open ended questions
-use of pain scale
-ability to assess patient’s comfort level
-ability to assess patient’s ability to distinguish
between comfort and discomfort
Risk Factors
•All populations with increased risk for older
adults, neonates, and persons unable to
report pain.
Comfort Imbalance-Assessment
How does the nurse know when there is an
imbalance in comfort?
•Comprehensive History
•Physical & Psychological
•Diagnostic Test(s)
Comprehensive History
•Assessment of comfort/discomfort
•triggers,
•location of pain,
•numeric rating scale,
•intensity of pain,
•quality of pain,
•onset and duration of pain,
•alleviating and relieving factors,
•effect of pain on function and quality of life
Assessment
•Location(s) of pain:
•Intensity:
•Quality:
•Onset and duration:
•Alleviating and relieving factors:
•Effect of pain on function and quality of life:
•Comfort-function (pain) goal
•Pain history
•Vital signs
Measurement of Comfort
• Pain assessment:
• COMFORT Scale
• CRIES Pain Scale
• FLACC Scale
• Wong-Baker Faces Pain Rating Scale
• 0-10 Numeric Rating Scale
• Checklist of Nonverbal Indicators
• Oucher Pain Scale
• FPS-R (Faces Pain Scale, Revised)
• Payen Behavioral Pain Scale
Monahan, Neighbors, & Green (2011) found the
following:
• Select a Pain Intensity Rating Scale appropriate to
patient and use it consistently to ensure
comparability of assessments
• Numeric rating scales (NRSs) of 0 (no pain) to 10
(worst possible pain) and descriptive scales (no pain,
mild pain, moderate pain, severe pain, very severe
pain, worst possible pain) are used commonly to
assess intensity in adults who are cognitively intact
Monahan, Neighbors, & Green (2011) found the
following:
• The Faces pain scale (Kim and Buschmann, 2006) is an
alternative that may best meet the needs of older adults
(Taylor and Herr, 2001)
• The Pain Assessment in Advanced Dementia (PAINAD)
scale based on vocalizations, facial grimacing, bracing,
rubbing, and restlessness has a pain intensity rating that
can be converted to a numeric equivalent (D'Arcy, 2007)
• The Payen Behavioral Pain scale (BPS) contains an
assessment of compliance with ventilation and is used
for critically ill, intubated patients (D'Arcy, 2007).(p. 14)
Numeric Rating Scale
The Numeric Rating Scale (NRS-11) is an 11–point scale for patient self-reporting of pain. It is
for adults and children 10 years old or older.[33]
Rating
0
Pain Level
No Pain
1 – 3 Mild Pain (nagging, annoying, interfering little with ADLs)
4 – 6 Moderate Pain (interferes significantly with ADLs)
7 – 10 Severe Pain (disabling; unable to perform ADLs)
Physical & Psychological
•,
Physical & Psychological
• Anxiety
• Fear
• Hopelessness
• Sleeplessness
• Reports of pain
• Decrease in cognitive
function
• Mental confusion
• Altered temperament
• Restlessness
• Dilated pupil
• Increased heart rate
• Perspiration
• Muscle spasm
• Increased blood pressure
• Grimacing
• Moaning
• Crying
• Protecting the painful area
decreased movement
Diagnostic Test(s)
•Vital Signs
• Pain Scale
•Laboratory studies
•Diagnostic studies
Clinical Management
•Primary Prevention (health promotion, disease
prevention)
• Patient education to include:
• Assessment of discomfort
• Pain identification
• Pain relief measures
• Pain relief measures may include analgesics,
relaxation techniques, guided imagery, proper body
alignment, thermal measures, and mind –body
therapies (Giddens, J. F. 2013,p. 275)
Clinical Management con’t.
•Secondary Prevention (screening and diagnosis,
occurs after health problem has arisen)
•The patient’s culture, past pain experiences,
and pertinent medical history such as
comorbidities, lab tests, and diagnostic tests
should all be considered for treatment of pain
(Giddens, J. F. 2013,p. 272)
Clinical Management con’t
•Tertiary Prevention
• follows occurrence and correction of healthcare
problem, aimed at
•Returning patient to the highest level of
function possible; rehabilitation
•Re-educate the patient about how to manage
and or prevent pain
Clinical Management con’t
•Educate the patient about how to learn to
modify his or her reaction to pain
•Rehabilitative efforts to encourage the
patient to follow analgesic schedule, physical
therapy, nutritional suggestions, and or other
pain relief strategies
Exemplars
• Osteoarthritis
• Chronic Pain
• Degenerative Joint Disease
• Neuropathic pain
• Post-operative pain
• Total joint arthroplasty (acute pain)
• Procedural pain
• Dressing changes
• Wound care
• PT after arthroplasty
• Acute pain
Pre-procedure pain
•Potential pain and or actual pain prior to a
procedure
Pre-procedure pain
•Nursing interventions:
•Assess location, onset, duration, and factors
that increase pain and or reduce pain
•Use a pain scale to assess pain for
comparison to patients pain pre-procedure
and post procedure
•Assess vital signs
Pre-procedure pain
•Nursing interventions:
•Assess for drug allergies
•Treat pain or expected pain with analgesics
prior to procedure (before physical therapy,
before a dressing change)
•Provide patient education about requesting
pain medication, request prior to procedure,
understand action and effects of the
medication
Pre-procedure pain
• Diagnostic studies
• to find the causative factor in pre-procedure pain
•Culture
• to identify the offending organism
•Platelet count• if any bleeding is present
•Vital signs
• assess for changes in vital signs and the
correlation to increased pain
Degenerative Disc Disease
•“Progressive degeneration is a normal
process of aging and results in the
intervertebral disks losing their elasticity ,
flexibility, and shock-absorbing capabilities”
(Dirksen, S. R., Lewis, S.L., Heitkemper, M.M., & Bucher, L.
2011, p. 364).
Degenerative Disc Disease
•Nursing interventions:
•Assess location, onset, duration, and factors
that increase pain and or reduce pain
•Use a pain scale to assess pain
•Assess vital signs
•Assess for drug allergies
•Administer prescribed analgesics
•Provide rest , heat and or cold therapies
•Patient education about exercise and weight
control
painconsortium.nih.gov/pain
scales
• painconsortium.nih.gov/pain_scales/FLACCScale.pdf
• painconsortium.nih.gov/pain_scales/NumericRatingScale.pdf
• painconsortium.nih.gov/pain_scales/COMFORT_Scale.pdf
• painconsortium.nih.gov/pain_scales/CRIESPainScale.pdf
• painconsortium.nih.gov/pain_scales/Wong-Baker_Faces.pdf
• painconsortium.nih.gov/pain_scales/ChecklistofNonverbal.pdf
Resources
• http://www.oucher.org/the_scales.html
• http://consultgerirn.org/uploads/File/trythis/try_this
_d2.pdf
• http://www.iasppain.org/Content/NavigationMenu/GeneralResource
Links/FacesPainScaleRevised/default.htm
References
Ackley, B., & Ladwig, G. (n.d.). Nursing Diagnosis Handbook.
Retrieved from Skyscape.
Ankner, G. M. (2012). Clinical decision making: Case studies in
medical-surgical nursing (2nd ed.). Cengage Learning.
Giddens, J. F. (2013). Concepts for nursing practice. Pain (pp. 270- 279). St.
Louis, Mo: Mosby.
Lilley, L.L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the
nursing process (5th ed.). St. Louis, MO: Mosby/Elsevier
Lynn, P. (2011). Taylor’s clinical nursing skills: A nursing process
approach. Comfort (3rd ed., pp. 521-560). Philadelphia, PA:
Lippincott Williams & Wilkins.
References
Monahan, F. D. , Neighbors, M., & Green, C. J. (2011). Manual of
medical-surgical nursing (7th ed.). Maryland Heights, MO:
Elsevier/Mosby.
Smith, S. F., Duell, D. J., & Martin, B. C. (2012).Clinical nursing skills
(8th ed.) Retrieved from Skyscape.
Weber, J. (2010). Nurses’ handbook of health assessment (7th ed.).
Retrieved from Skyscape.
A state of physical ease