Promoting Comfort: Moving Beyond Pain Management Tara Foote RN, BSN, OCN Objectives Identify several nonpharmacological interventions to promote patient comfort Understand the importance of nursing presence in alleviating suffering Learn to apply nursing theory to positively impact quality of life and comfort Understand how to engage the interdisciplinary team to provide holistic comfort measures to patients in distress or discomfort Managing pain is far more than the giving of pain medication. Nurses demonstrate compassion as they listen to the patient’s description of pain, validate its presence and importance, and offer their commitment to relieving the pain. (Ferrel & Coyle, 2008) Pain Basics: A Brief Review Pain Definitions “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” (Agency for Health Care Policy and Research, 1994) “What the patient says it is, existing whenever he or she says it does.” (Institute for Clinical Systems Improvement, 2008) Types of Pain Nocioceptive Pain: nerve fibers within bodily tissues perceive noxious stimuli, usually responds to NSAID and narcotic medication and has a brief duration Somatic pain arises from damage to bodily tissues and is usually well-localized (e.g. I cut my arm) Visceral pain is mediated by stretch receptors and is usually poorly localized, deep, dull, and cramping (e.g. uterine cramping, gas pain, liver pain) Musculoskelatal pain arises from the bones and associated structures, tending to be inflammatory-type pain (e.g. tendonitis, twisted Types of Pain Neuropathic pain: arises from abnormal neural activity secondary to disease, injury or dysfunction of the nervous system Can be further subdivided into sympathetically mediated pain, peripheral neuropathic pain or central pain (arising from the CNS) Sensory experience ranges from sharp, shooting, burning pain to numbness and tingling Tends to respond better to anticonvulsant, antispasmodic and antidepressant medications than narcotics and NSAIDS alone Acute vs. Chronic Pain Serves as a warning that something is wrong Response to actual bone or tissue injury Generally viewed as a time-limited experience Responds to traditional pain medications (NSAIDS, narcotics) Has no apparent biological value Persists beyond the time required for the body to heal Worsens and intensifies over time Requires multifaceted approach to achieve pain Pain Assessment OLDCART O = Onset L = Location D = Duration C = Characteristics A = Aggravating factors R = Relieving factors T = Treatment Pain Assessment The ABCDE acronym A = Ask about pain regularly. Assess pain systematically. B = Believe patients’ reports of pain and what relieves it C = Choose pain control options appropriate for the patient, family, and setting. D = Deliver interventions in a timely, logical, and coordinated fashion. E = Empower patients and their families. Enable them to control their course to the greatest extent possible. Sometimes Medication Just Isn’t Enough Pain vs. Suffering Suffering Defined Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity (Cassell, 1982) A state of anguish in one who bears pain, injury, or loss (Copp, 1974) Suffering can be looked at in physical, personal, family, and spiritual aspects Physical Suffering Not all physical suffering is caused by pain, and not all pain is identified by the patient as physical suffering. Assess the following sources: physical discomfort that patients don’t identify as pain (aching, pressure, spasm, cramping, numbness, tingling) discomfort or distress from immobility sleeplessness chills or fever declining functional ability and increasing dependence on others changes in appearance skin problems (itching, inflammation, wounds) odors from bodily fluids or wounds Personal and Family Suffering How much are you suffering because of loss of enjoyment of life? How much are you suffering because of your feelings for and relationships with family and friends? How much are you suffering because of your concern for your loved ones? How much are you suffering because of fear of the future? How much are you suffering because of unfinished business? Spiritual Suffering Can also be viewed as existential suffering or the search for meaning, hope or connection with oneself, others or a higher power. How much are you suffering relative to your ability to interact with your spiritual tradition? How much are you suffering relative to your ability to find strength in your belief system? How much are you suffering relative to your feelings about your personal sources of inner strength? Ten Tenets of Suffering It is a loss of control, creating insecurity. Suffering people often feel helpless, trapped, and unable to escape their circumstances. Suffering is often associated with loss. It may be loss of a relationship or some aspect of self, or loss of some aspect of the physical body. The loss may only be evident in the mind of the sufferer, but leaves the person feeling diminished and broken. Suffering is an intensely personal experience. It encompasses a range of intense emotions including sadness, anguish, fear, abandonment, and despair. Suffering forces one to confront their own mortality. In the face of serious illness, some may fear death while others may yearn for death. Suffering often begs the question “Why?” Illness or loss may be seen as untimely or undeserved. People may seek meaning and answers for that which is unknowable. It is often associated with separation from the world. People may express intense loneliness and desire for connection with others while also feeling intense distress about dependency on others. Suffering can produce spiritual distress, feelings of hopelessness, self-reflection of lived experiences and what remains undone, and reevaluation of one’s relationship with a higher power. Although not synonymous with suffering, pain can produce psychological, spiritual and social distress. Pain which persists without meaning becomes suffering. Suffering occurs when individuals feel voiceless or unheard. How Can Nursing Theory Guide Us? Quality of Life Model by Betty Ferrell (1996) Quality of Life Model Physical Well Being Social Well Being Fatigue Sleep Disruption Function Nausea Appetite Constipation Aches/Pains Isolation Role Adjustment Financial Burden Roles/Relationships Affection/Sexual Function Leisure Activities Burden Employment Quality of Life Psychological Well Being Anxiety Depression Helplessness Difficulty Coping Fear Uselessness Concentration Control Distress Spiritual Well Being Meaning Uncertainty Hope Religiosity Transcendence Positive Change The Process of Pain Impacting Quality of Life Physical appetite function sleep fatigue Chemo (Immediate Cause) Physiologic Effects (Immediate Effect) PAIN Social isolation finances sexuality leisure (Patient Sypmtom) Spiritual Psychological anxiety depression helplessness concentration fear meaning hopeless uncertainty Suffer ing How Can Nursing Theory Guide Us? Comfort Theory by Katharine Kolcaba Comfort Theory Middle range nursing theory developed in the 1990’s for health practice, education and research drawn from nursing, medicine, psychology, psychiatry, ergonomics and English literature Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental). (Kolcaba & Fisher, 1996) Types of Comfort Relief: the state of having a discomfort mitigated or alleviated or having had a specific need met Ease: a state of calm or contentment or the absence of a specific discomfort Transcendence: the state in which one rises above one's problems or pain even when they cannot be eradicated or avoided Contexts of Comfort Physical: pertaining to bodily sensations and homeostatic mechanisms. Psychospiritual: pertaining to internal awareness of self, including esteem, concept, sexuality, and meaning in one's life; one's relationship to a higher order or being. Environmental: pertaining to external surroundings, conditions, and influences. Sociocultural: pertaining to interpersonal, family, and societal relationships. Also to family traditions, rituals, and religious practices. Types of Care Technical (maintains homeostasis) Coaching (relieve anxiety, plan for recovery) Comforting (unexpected things) -care for and strengthen -monitor & manage pain, nausea, dyspnea, etc. -prevent complications -administer medications -observe for side effects -reassure -educate -environmental interventions -provide hope -massage, touch, holding a hand -active listening -providing opportunities for life review -help plan for optimizing health -calm presence -encourage -creating a memorable connection Case Study 74 year old client in own home with 70 year old wife (Mr. & Mrs. Green). Recently, Mr. Green has had weight loss, nausea and abdominal pain. Mrs. Green is anxious when present at physical exam where Mr. Green is diagnosed with pancreatic cancer with liver metastases. Sociocultural Physical -pain -nausea -anorexia -jaundice Psychospiritual -anger -anxiety -questioning meaning -depression -many treatment options, side effects -financial distress -wife’s anxiety -body image, selfesteem Environmental -transportation issues -uncomfortable wait room -cold treatment rooms -bright lights -hallway noise Total Comfort Relief Ease (maintenance) Transcendence Physical Narcotic pain medication Anti-nausea medication Radiation to liver mets pain rated at goal able to eat without vomiting reduction in jaundice meets with dietician to develop nutritional plan reengages in leisure activities Psychospiritual Chaplain and social work consults Encourage Nursing presence and active listening adherence to plan patient reports less anxiety and more positive mood pt and wife participate in support groups find meaning in illness, renewed sense of faith Sociocultural Provide information on treatment options and side effects Enlist social work to assist with disability paperwork Include wife in teaching and care Provide soft hats after hair loss fully understands treatment plan feels able to identify and manage sideeffects wife reports less anxiety Engages family and social support system in care plan wife starts volunteering with a group to knit hats Environmental Provide warm blankets Make office decor comfortable and patient friendly Arrange medical transport Provide headphones and eye pillows P pt feels comfortable in treatment spaces pt consistently arrives to clinic Pt’s church fundraises for new treatment chairs Pt uses guided imagery to create comfort during treatment Intervening Variables: factors unlikely to change and over which providers have little control (prognosis, financial situation, etc) Health seeking behaviors: behaviors the patient engages in that facilitate health or a peaceful death. They can be measurable outcomes that are either internal (healing, T-cell formation, oxygenation,) or external (observable behaviors such as working in therapy, shortened length of stay) Institutional Integrity: values, financial stability and wholeness of health care organizations at local, regional, state and national levels Best Policies: protocols and procedures developed by an institution for overall use after collecting evidence Putting It All Together: Using Nursing Presence and Communication to Provide Comfort Nonpharmacological Interventions heat/cold deep breathing repositioning elevation distraction music therapy prayer massage Cognitive-behavioral approaches: biofeedback, guided imagery, hypnosis, passive relaxation, progressive muscle relaxation Guided imagery is a gentle but powerful technique that focuses and directs the imagination to promote healing, relaxation, and pain and anxiety relief. Going through an entire exercise may be time-intensive but nurses can develop skills to enhance their practice or direct patients and caregivers to do exercises on their own. http://www.cancer.med.umich.edu/support/guided_imagery_podcasts_descriptions.sht ml http://www.innerhealthstudio.com/ Jill Lematta Learning Center CD’s and downloads available on line, at bookstores and libraries Social Work consult (may be able to provide resources) Nursing Process as Intervention Nursing was born out of the desire to provide comfort. As technology advances, we increasingly move to a “fixit” medical model focused on outcome more than process. Nurses can respond to suffering by Assessing sources of pain and suffering, such as shame, feelings of abandonment and isolation Diagnosing sources of suffering to identify those that can be relieved, witnessed or supported Intervening through presence, listening and communication that enables patient expression and by eliminating sources of suffering Evaluation to allow alterations in the plan of care and recognition of new problems to meet patients’ needs Presence Benner described skill acquisition of nurses as they progress from novice to expert “Presencing” is one of the eight competencies of the nurse’s helping role Behaviors of expert nurses are committed and involved, contributing to the patient’s personhood, meaning and dignity Expert nurses knew their “being” was sometimes more important than their doing Presence Defined (from Schaffer &Norlander, 2009) Being available with the wholeness of one’s being Encountering the patient as a unique human being in a unique situation and choosing to “spend” oneself on the patient’s behalf Intuitive knowing or sensing another’s needs for help and making self physically available to be present in a helping way A subject-to-subject interrelationship that honors the ever-changing reality of the other Key Elements of Nursing Presence Attentiveness: being in the moment focused on the patient’s message Accountability: doing the right thing, invested and committed Sensitivity: knowing the patient as a unique person Touching: massage, turning, positioning and teaching families to help Openness: willing to enter another’s experience bringing one’s authentic self Active Listening: hearing beneath the words to their meaning, using silence Acknowledging: life review, seeing the patient as still having Death is awful, demonic. If you think your task as comforter is to tell me that really, all things considered, it’s not so bad, you do not sit with me in my grief but place yourself off in the distance away from me. Over there, you are of no help. What I need to hear from you is that you recognize how painful it is. I need to hear from you that you are with me in my desperation. To comfort me, you have to come close. Come sit beside References Agency for Health Care Policy and Research. (1994). Management of cancer pain, clinical practice guideline number 6. Rockville, MD: U.S. Department of Health and Human Services. Cassell, E. (1982). From Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press. Copp, L. (1974). From Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press. Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. 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