Module 5A Comfort PowerPoint

Comfort Unit 5 Module 5A Jill Huffman, MSNed, RN Learning Outcomes ● Collaborate with the interprofessional team to provide high-quality care for patients with fibromyalgia. ● Use clinical judgement to plan care for the patient with fibromyalgia. ● Discuss alternative t...

Comfort Unit 5 Module 5A Jill Huffman, MSNed, RN Learning Outcomes ● Collaborate with the interprofessional team to provide high-quality care for patients with fibromyalgia. ● Use clinical judgement to plan care for the patient with fibromyalgia. ● Discuss alternative therapies that can be used to manage chronic pain across the lifespan. ● Apply knowledge of anatomy, physiology, pathophysiology, and psychosocial needs of patients and family at end of life to plan care across the lifespan. Learning Resources • Ignatavicius, D. (2021). pp. 72-73, 1005-1006, & Chapter 8. • Perry & Hockenberry (2023). Chapter 30 • ATI RN Adult Medical Surgical Nursing 11.0 – Chapters 4 & p. 581 • ATI Fundamentals for Nursing 10.0 – Chapters 36, 41, & 42. • ATI Engage Fundamentals: (Review) • Foundational concepts for Nursing Practice - Complementary and Integrative Health • Physiological Concepts for Nursing Practice - Pain; End of Life • Websites: • https://medlineplus.gov/complementaryandintegrativemedicine.html • https://www.cdc.gov/arthritis/basics/fibromyalgia.htm Pain • Defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. • Subjective - Pain is what the patient says it is • Self reporting is always the most reliable indication of pain. • Considered the fifth vital sign • Use a focused data tool to collect data about the pain (OLDCARTS or PQRST) • Perception of pain is individualized Pain in Children • Young Infant • Loud cry • Rigid body • Expressions of pain • Older Infant • Loud cry • Deliberate withdrawal from pain • Facial expression of pain • Toddler • Loud cry or screaming • Verbal expression of pain • Thrashing of extremities • Attempt to push away or avoid stimulus • Clinging to significant person • Request physical comfort • School-Age Child • Stalling behavior • Muscular rigidity • Same behaviors as the toddler • Adolescent • More verbal expressions of pain with less protest • Muscle tension with body control Types of Pain ● Acute pain - temporary, has a sudden onset, and is easily localized. ○ as the injured area heals the pain goes away ○ ex: pain from surgery ● Chronic pain - aka persistent pain - lasts for more than 3 months ○ gradual onset and may or may not have a cause ○ ex: fibromyalgia and cancer ● Nociceptive pain - result of actual or potential tissue damage or inflammation. ○ Somatic pain - pain that arises from the skin and musculoskeletal structures ■ described as sharp throbbing, dull, aching, cramping ○ Visceral pain - pain that arises from organs ■ described as deep cramping or pressure, sharp, stabbing ● Neuropathic pain - result of damage or dysfunction of the nervous system ○ distinctive descriptors include: burning, shooting, tingling, feeling pins and needles Effects of Unrelieved Pain ● Acute pain can turn into chronic pain if left untreated ● Interferes with personal relationships ● Performance of ADL’s ● Emotional and financial burdens ● Depression/anxiety ● Hopelessness/fear/anger/insomnia ● Vital signs - pulse and B/P may be lower due to the body adapting ● Decreased gastric motility ● Decreased immunity ● Slower healing ● Poor quality of life ● Increased risk of suicidal idealation Assessment ● It is important to understand how the pain is affecting your patient at that time. ● Use an approved pain assessment scale and use the same one every time for the patient. ● Perform a complete assessment including: ○ Onset ○ Location ○ Duration (constant or intermittent) ○ Characteristics (burning, stinging, sharp, dull) ○ Aggravating and Alleviating factors (what makes it better/worse) ○ Radiation ○ Timing (does it hurt all the time, only at night, comes and goes) ○ Severity Treatment ● Pain is so complex that it takes different approaches to control it. ● Drug therapy ○ Multimodal analgesia- allows for lower doses of each medication and decreases the side effects ○ Routes of administration ○ Around the clock dosing ○ Patient-Controlled analgesia (PCA) ○ Three analgesic groups: ■ Nonopioid analgesics - acetaminophen and NSAIDs ■ Opioid analgesics - Fentanyl, Oxycodone, Methadone, Hydromorphone, Codeine, Tramadol ■ Adjuvant analgesics - anticonvulsants and antidepressants Treatment ● Nonpharmacologic management ○ Physical or Occupational Therapy ○ Aquatherapy ○ Acupuncture ○ Low-impact exercise ○ Application of heat, cold, or pressure ○ Therapeutic massage ○ Vibration ○ Transcutaneous electrical nerve stimulation (TENS) ● Cognitive-Behavior modalities ○ Relaxation breathing ○ Modifying the environment ○ Repositioning ○ music ○ Pleasant conversation ○ Laughter or humor Other Considerations ● Remember that being able to sleep does not mean that pain does not exist. ● Physical dependence is a response that occurs with repeated use of an opioid for several days. Not the same as addition. Normal response to regular opioid use. ● Tolerance occurs with regular use of a opioid and results in a decrease in the effectiveness of the medication. ● Opioid addiction is a chronic neurologic and biologic disease. Characterized by impaired control over drug use, compulsive use, continued use despite risk or actual harm, and craving. ● Pseudoaddiction is a mistaken diagnosis of addictive disease. When pain is not well controlled the patient may manifest symptoms suggestive of addictive disease. Fibromyalgia Syndrome • A chronic syndrome of unknown origin that causes pain in the muscles, bones, and/or joints • Associated with soft tissue tenderness at multiple characteristic sites. • Contributes to poor sleep, headaches, altered thought processes, and stiffness or muscle aches • Affects approximately 4 million people • 80% to 90% of those diagnosed are women • Most common in 20 -50 yr. olds although it can be diagnosed in children and older adults • Not considered life-threatening and does not cause permanent damage • Often seen in patients who also have rheumatic conditions such as RA and lupus Clinical Manifestations of Fibromyalgia • Frequent complaints of generalized achiness in areas such as the neck and lower back • Stiffness that is worse in the morning • Difficulty sleeping • Headaches • Tingling or numbness in hands and feet • Painful menstrual periods • Cognitive difficulties • Anxiety and/or depression Symptoms aggravated by cold or humid weather, physical or mental fatigue, excessive physical activity, anxiety or stress What Do Patients Say about Living with Fibromyalgia? Videos: https://youtu.be/4hpc1hHqqSg https://youtu.be/9t0xKhT1kPs Assessment Findings for Fibromyalgia ● Perform a complete pain assessment and include information on history of muscle pain, tension, migraine headaches, premenstrual tension, jaw pain, excessive fatigue, anxiety, and depression ● Ask about abnormal sensations such as numbness, tingling, feeling like insects are crawling on or under the skin ● Assess the patient for increased forgetfulness and confusion ● Ask the patient if they have noted periodic limb movements especially at night or a persistent need to move the lower extremities ● Obtain a history of sleep patterns ● Ask about the patient’s ability to complete ADL tasks Diagnostic Tests ● No specific laboratory or radiographic test is used in the diagnosis of fibromyalgia ● Diagnosis can take years and requires elimination of other potential conditions ● Criteria used to confirm a diagnosis of fibromyalgia syndrome includes the widespread pain index (WPI) ● CBC, Renal Function Panel, and ESR are normal in patients with Fibromyalgia ● Sleep study may be performed to rule out sleep disturbances such as apnea Medical Management ● There is no cure for fibromyalgia ● Primary treatment includes patient education, emotional support, and reassurance ● Antidepressants, anticonvulsants, muscle relaxants, and analgesics are used in symptom management ● Acetaminophen and NSAIDS are beneficial in the management of mild to moderate pain. ● Opioids are avoided to prevent the risk of tolerance and addiction Medications for Fibromyalgia ● Amitriptyline - Diminishes local pain and stiffness; improves sleep pattern ● cyclobenzaprine - Diminishes local pain, improves sleep pattern, and decreases number of tender points ● clonazepam - Decreased symptoms of constant leg movement, especially at night ● acetaminophen, NSAIDS, and tramadol - Used together or given alone for management of moderate to severe pain ● Pregabalin - An anticonvulsant that decreases pain severity and improves fatigue, sleep, and physical functioning ● tizanidine - Improves sleep and physical functioning ● sodium oxybate - Improves deep sleep and growth hormone levels and helps reduce pain and fatigue ● duloxetine hydrochloride - Reduces pain in patients with fibromyalgia with or without having symptoms of major depression Nursing Interventions ● Focuses on functional goals that enable the patient to live as normal a life as possible ● Interventions include: ○ education on disease process and management ○ exercise - non-impact such as swimming, walking, or stationary cycling ○ yoga ○ stretching ○ relaxation techniques ○ basic principles of good sleep hygiene ○ healthy diet Prognosis End of Life Care End of Life ● Part of the normal life cycle but also one of the most feared as it is considered a time of pain and suffering. ● The experience of dying does not need to be physically painful for the patient or emotionally agonizing for the family. ● Most people die after a long period of chronic illness with gradual deterioration until a significant decline preceding death. ● Many healthcare providers view death as a failure. These views can lead to a decrease in the quality of life for the patient End of Life Care ● In 1991 US congress passed the Patient Self-Determination Act (PSDA) which granted Americans the right to determine the medical care they wanted if they become incapacitated. This is accomplished by completing and advanced directive. ● Advance directives include: ○ Durable Power of Attorney for Healthcare ○ Living Will ○ Do-Not-Resuscitate (DNR) Hospice and Palliative Care ● Hospice ○ provides high-quality, compassionate care for people facing a life-limiting illness or injury. Holistic care ○ diagnosis of 6 months or less to live and agree to forgo curative treatment for their terminal illness ○ team-oriented approach providing medical care, pain management, emotional and spiritual support personalized to the patient and family ○ Medicare hospice benefit serves as a guide for hospice care ● Palliative care ○ care for people with life-threatening disease ○ patients can be in any stage of serious illness ○ works together with curative therapies and treatment that prolong life ○ care is not limited by specific time period ○ consultation visit by a primary healthcare provider who make recommendations Assessment Findings at the End of Life ● Physical: ○ Coolness of extremities (mottled or discolored skin) ○ Increased sleeping ○ Decreased food and fluid intake ○ Incontinence ○ Congestion and gurgling sounds ○ Breathing pattern changes (decreased respiratory rate ○ Disorientation ○ Restlessness ● Emotional: ○ Withdrawal ○ Vision-like experiences ○ Letting go ○ Saying goodbye Managing Symptoms of Distress ● The most common end-of-life symptoms that can cause the patient distress are: ○ Pain ○ Weakness ○ Breathlessness ○ Nausea and vomiting ○ Agitation and delirium ○ Seizures ● Pain is the symptom the dying patients fear the most. ○ use of nonopioid and opioid medications ○ request change of medication route as needed ○ be aware of organ failure (kidney or liver) which may affect the absorption and excretion of the medication Managing Symptoms of Distress ● Medical Marijuana ● Massage ● Music Therapy ● Guided Imagery ● Aromatherapy ● Therapeutic Touch ● Repositioning ● Indwelling Catheter ● Oxygen Therapy ● Palliative Sedation End of Life Care and Religious Beliefs ● Roman Catholic ○ encourage patient to receive Sacrament of the Sick, administered by a priest at any point during the illness. May be administered more than once. Not receiving the sacrament will not prevent them from entering heaven after death. ● Christians ○ believe in an afterlife of heaven or hell once the soul has left the body after death ● Judaism ○ encouraged to recite the confessional or the affirmation of faith called Shema . ○ Dying person should not be left alone. ○ Body should not left be unattended until the funeral (preferably within 24 hours) ○ Autopsies are not allowed by the Orthodox Jews except in special circumstances. ○ The body should not be embalmed, displayed, or cremated ● Islam ○ Death is seen as the beginning of a new and better life ○ God has prescribed an appointed time of death for everyone ○ Qur’an encourages humans to seek treatment and not to refuse treatment ○ Only Allah cures but can cure through the work of humans ○ At death eyelids are to be closed and the body covered ○ Rituals of bathings and wrapping the body in cloth must be performed by someone from the person’s mosque prior to moving or handling the body.