Sleep & Pain
Brain Structures Essential to Sleep:
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Hypothalamus: commands nerve cells, affecting sleep and arousal
o Control center for the autonomic motor system
o Responsible for releasing hormones and regulating the body’s
temperature
o Signals are sent to relax muscles and to prevent individuals from
physically acting upon dreams
o Sleep-promoting cells produce gamma-aminobutyric acid (GABA) –
reduces the activity of the arousal centers
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Suprachiasmatic Nucleus (inside hypothalamus): controls behavioral rhythm
directly from the eyes through light exposure
o Assists in regulation of the circadian rhythm
o Patients with a damaged SCN can experience an erratic sleep cycle since
they are not able to regulate their circadian rhythm during light-dark cycles
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Brain stem: controls shift between wake and sleep; pons and medulla oblongata
influence rapid eye movement (REM)
o Sends signals to the hypothalamus, which controls the shift between wake
and sleep
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Thalamus: blocks out external distractions during sleep; transmits images,
sounds, and sensations during REM sleep
o Primary function – process sensory information and regulate sleep
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Pineal Gland: manufactures melatonin – a natural substance that helps the body
prepare for sleep
Know culture considerations and cultural characteristics regarding Sleep
BOX 43.10
CULTURAL ASPECTS OF CARE
Co-sleeping/Bed-sharing

Sleep patterns, bedtime routines, sleep aids, and sleep arrangements are
components of cultural practices related to the use of space and interaction
distances
Know the characteristics of each (NREM and REM) of the stages of sleep - Use
Potter & Perry
There are two sleep phases:
 nonrapid eye movement (NREM) sleep and
 rapid eye movement (REM) sleep (Box 43.1).
 In the classical definition of NREM sleep, people progress through four stages during a
typical 90-minute sleep cycle.
 The American Academy of Sleep Medicine defines three stages in NREM sleep,
combining stages 3 and 4.
 The quality of sleep from stage 1 through stage 3 becomes increasingly deep. Lighter
sleep is characteristic of stages 1 and 2, when a person is more easily arousable. Stage
3 (formerly stages 3 and 4) involves a deeper sleep called slow-wave sleep, from which
a person is more difficult to arouse.
 REM sleep is the phase at the end of each 90-minute sleep cycle. During REM
sleep there is increased brain activity associated with rapid eye movements and
muscle atonia.
Brain wave frequencies and amplitudes can be detected using an electroencephalogram
(EEG) – a measurement of the brain’s electrical activity.
 Stages of sleep are defined based on a patients brain wave frequencies and amplitudes,
together with eye and body movements and changes in vital signs
Stages of the Sleep Cycle
NREM sleep (75% of night)
N1 (formerly stage 1)
• Stage of lightest level of sleep, lasting a few minutes.
• Decreased physiological activity begins with gradual fall in vital signs and metabolism.
• Sensory stimuli such as noise easily arouse sleeper.
• If awakened, person feels as though daydreaming has occurred.
 Alpha waves = frequency range 8-12 hertz
 Beta waves = frequency range 12-30 hertz
 When a person becomes drowsy and closes their eyes, the alpha waves dominate over
the beta waves
 Breathing is normal
 Skeletal muscle tone is present
 Can last 1-5 minutes and is approx. 5% of total sleep cycle
N2 (formerly stage 2)
• Stage of sound sleep during which relaxation progresses.
• Arousal is still relatively easy.
• Brain and muscle activity continue to slow.
 Sleep spindles or K-complex electrical waveforms that trigger the superior temporal gyri,
anterior cingulate, insular cortices, and the thalamus
 HR and body temp decrease
 1st sleep cycle lasts approx. 25 minutes; however, it becomes progressively longer with
each successive sleep cycle
 Consumes approx. 50% of a total sleep cycle
 # of cycles INCREASE with aging
N3 (formerly stages 3 and 4)
• Called slow-wave sleep.
• Deepest stage of sleep.
• Sleeper is difficult to arouse and rarely moves.
• Brain and muscle activity are significantly decreased.
• Vital signs are lower than during waking hours.
 Consists of delta electrical brain waves, which are slower frequency, higher-amplitude
signals
 If awoken in stage three, pts may have mental cloudiness for 30-60 minutes
 Immune system strengthens
 Muscles, tissues, and bones repair and regenerate
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# of cyles DECLINE with aging
Can last up to 40 minutes
REM sleep (25% of night)
• Vivid, full-color dreaming occurs.
• Stage usually begins about 90 minutes after sleep has begun.
• Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and
respiratory rates, and increased or fluctuating blood pressure.
• Loss of skeletal muscle tone occurs.
• Gastric secretions increase.
• It is very difficult to arouse sleeper.
• Duration of REM sleep increases with each cycle and averages 20 minutes.
 Looks like an awake cycle on an EEG; however, the skeletal muscles remain atonic
(loss of muscle tone)
 Pts breathing is irregular and erratic, and their heart rate may be elevated.
 Typically begins 90 minutes after falling asleep
 Initial cyle lasts 10 minutes and will become longer as the night progresses
 Can last up to 1 hour
Know components of a sleep assessment – What Questions to ask
Do you feel rested?
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Sleep and rest are not the same
Rest can be anything that helps a person feel relaxed
Bed rest does not guarantee a person will feel rested
Sleep assessment
Usually patients are the best resource for describing sleep problems
 Bed partners – can reveal helpful info about patterns
Tools for sleep assessment - subjective
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Epworth Sleepiness Scale
o contains eight questions about the likeliness of a patient being sleepy during
certain activities (e.g., watching television, reading, sitting and talking with
someone)
o on a scale of 0 (would never doze or sleep) to 3 (high chance of dozing or
sleeping).
o 0 to 5 = lower normal daytime sleepiness
o 6 to 10 = higher than normal daytime sleepiness
o 11 or 12 = mild EDS
o 13 to 15 = moderate EDS
o 16 to 24 = severe EDS
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Pittsburgh Sleep Quality Index: assesses sleep quality and patterns
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Visual Analog Scale
o Draw a straight horizontal line 100 mm (4 inches) long
o Opposing statements such as “best night’s sleep” and “worst night’s sleep” are at
opposite ends of the line
o Ask patients to place a mark on the horizontal line at the point corresponding to
their perceptions of the previous night’s sleep
o Measuring the distances of the mark along the line in millimeters offers a
numerical value for satisfaction with sleep
o Use the scale repeatedly to show change over time
o Useful to assess an individual patient, not to compare patients.
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Numeric Scale
o 0-to-10 sleep rating
o Ask individuals to separately rate the quantity and quality of their sleep on the
scale
o Instruct them to indicate with a number between 0 and 10 their sleep quantity
and then their quality of sleep, with 0 being the worst sleep and 10 being the
best.
Sleep history
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When you suspect a patient has a sleep problem, assess the quality and
characteristics of sleep in greater depth by asking the patient to describe the
problem.
This includes:
o recent changes in sleep patterns
o sleep symptoms experienced during waking hours
o the use of prescribed or over-the-counter sleep medications
o diet and intake of substances such as caffeine or alcohol that influence sleep
o recent life events that have affected the patient’s mental and emotional status.
Description of sleeping problems
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When a patient has a persistent or what appears to be a serious sleep problem – more
detailed assessment
Open-ended questions: help a patient describe a problem more fully
A general description of the problem followed by more focused questions
To begin, you need to understand:
o the nature of the sleep problem
o signs and symptoms
o onset and duration
o severity
o predisposing factors or causes
o the overall effect on the patient
Ask specific questions related to the sleep problem (Box 43.5).
BOX 43.5
Nursing Assessment Questions
Nature of the problem
• Describe the type of sleep problem you’re having.
• Why do you think you are not getting enough sleep?
• Describe a recent night’s sleep. Is this similar to your usual sleep? How is this sleep different
from your usual sleep?
Signs and symptoms
• Do you have difficulty falling asleep, staying asleep, or waking up?
• Have you been told that you snore loudly?
• Do you have headaches when awakening?
Onset and duration of signs and symptoms
• When did you notice the problem?
• What do you do to relieve the symptom?
• How long has this problem lasted?
Severity
• How long does it take you to fall asleep?
• How often during the week do you have trouble falling asleep?
• On average, how many hours of sleep a night did you get this week?
• How does this compare to your usual amount of sleep?
• What do you do when you awaken during the night or too early in the morning?
Predisposing factors
• What do you do just before you go to bed?
• Have you recently had any changes at work or at home?
• How is your mood? Have you noticed any changes recently?
• Which medications or recreational drugs do you take on a regular basis?
• Are you taking any new prescriptions or over-the-counter medications?
• Do you eat food (spicy or greasy foods) or drink substances (alcohol or caffeinated beverages)
that affect your sleep?
• Do you have a physical illness that affects your sleep?
• Does anyone in your family have a history of sleep problems?
Effect on patient
• How has the loss of sleep affected you?
• Do you feel excessively sleepy or irritable or have trouble concentrating during waking hours?
• Do you have trouble staying awake? Have you fallen asleep at the wrong times (e.g., while
driving, sitting quietly in a meeting)?
Proper questioning helps to determine the type of sleep disturbance and the nature of the
problem.
Box 43.6 provides examples of additional questions for you to ask a patient when you suspect
specific sleep disorders.
The STOP-BANG sleep assessment tool is a reliable evidence-based tool used to screen for
OSA and is frequently used in preanesthesia and/or preoperative assessments (see Chapter
50). The questions help to select specific sleep therapies and the best time for implementation.
BOX 43.6
Questions to Ask to Assess for Specific Sleep Disorders
Impaired sleep
• How easily do you fall asleep?
• Do you fall asleep and have difficulty staying asleep? How many times do you awaken? Do
you awaken at the same time?
• What time do you awaken in the morning? What causes you to awaken early?
• What do you do to prepare for sleep? To improve your sleep?
• What do you think about as you try to fall asleep?
• How often do you have trouble sleeping?
Sleep apnea
• Do you snore loudly? Does anyone else in your family snore loudly?
• Has anyone ever told you that you often stop breathing for short periods during sleep?
(Spouse or bed partner/roommate may report this.)
• Do you experience headaches after awakening?
• Do you have difficulty staying awake during the day?
Narcolepsy
• Do you fall asleep at the wrong times? (Friends or relatives may report this.)
• Do you have episodes of losing muscle control or falling to the floor?
• Have you ever had the feeling of being unable to move or talk just before waking or falling
asleep?
• Do you have vivid, lifelike dreams when going to sleep or awakening?
Sleep-wake log
 1 to 4 weeks
 The patient completes the sleep-wake log daily to provide information on day-to-day
variations in sleep-wake patterns over extended periods
 Entries in the log often include 24-hour information about various waking and sleeping
health behaviors such as:
o physical activities
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o
o
o
o
o
o
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mealtimes
type and amount of intake (alcohol and caffeine)
time and length of daytime naps
evening and bedtime routines
the time the patient tries to fall asleep
nighttime awakenings
the time of morning awakening
A partner helps record the estimated times the patient falls asleep or awakens. Although
the log is helpful, the patient needs to be motivated to participate in its completion.
Usual sleep pattern
Normal sleep: difficult to define because individuals vary in their perception of adequate quantity
and quality of sleep
 it is important to have patients describe their usual sleep pattern to determine the
significance of the changes caused by a sleep disorder
 Knowing a patient’s usual, preferred sleep pattern allows you to try to match sleeping
conditions in the health care setting with those in the home
 Ask the following questions to determine a patient’s sleep pattern:
1. What time do you usually get in bed each night?
2. How much time does it usually take to fall asleep? Do you do anything special to help you fall
asleep?
3. How many times do you wake up during the night? What do you think is the cause?
4. What time do you typically wake up in the morning?
Physical and psychological illness
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Determine any preexisting health problems that interfere with sleep
o Chronic diseases such as chronic obstructive pulmonary disease (COPD)
o painful disorders such as arthritis interfere with sleep
Assess the patient’s medication history
o including a description of over-the-counter and prescribed drugs
o Assess individuals for polypharmacy, especially older adults, because
polypharmacy can cause sleep problems
A history of psychiatric problems also makes a difference
o For example, a patient who is living with bipolar disorder sleeps more when
depressed than when manic
o A patient who is depressed often experiences an inadequate amount of
fragmented sleep
If a patient takes medications to aid sleep, gather information about the type and amount
of medication and the frequency of its use
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Assess the patient’s daily caffeine intake.
If a patient has recently undergone surgery with general anesthesia, expect that patient
to experience some sleep disturbance
o Patients usually awaken frequently during the first night after surgery and receive little
deep or REM sleep
o Depending on the type of anesthesia, it takes several days to months for a normal sleep
cycle to return.
Current life events
In your assessment learn whether the patient is experiencing any changes in lifestyle that
disrupt sleep
o A person’s occupation often offers a clue to the nature of the sleep problem
o Changes in job responsibilities, rotating shifts, or long hours contribute to a sleep
disturbance
o Questions about social activities, recent travel, or mealtime schedules help clarify the
assessment.
Emotional and mental status
A patient’s emotions and mental status affect the ability to sleep
o For example, a patient who is experiencing anxiety, emotional stress related to illness, or
situational crises such as loss of job or a loved one often experiences insomnia
o Ask whether the individual is a caregiver because caregiver stress, physical strain, and
irregular schedules of caregivers often contribute to sleep disruption
o When a sleep disturbance is related to an emotional problem, the key is to treat the
primary problem; its resolution often improves sleep
o Patients with mental illnesses may need mild sedation for adequate rest
 Assess the effectiveness of any medication and its effect on daytime function.
Bedtime routines
Ask patients what they do to prepare for sleep
 For example, some patients drink a glass of milk, take a sleeping pill, eat a snack, or
watch television
 Assess habits that are beneficial compared with those that disturb sleep
 For example, watching television promotes sleep for one person, whereas it stimulates
another to stay awake
 Sometimes pointing out that a habit is interfering with sleep helps patients find ways to
change or eliminate habits that are disrupting sleep.
Bedtime environment
During assessment ask the patient to describe preferred bedroom conditions, including
preferences for lighting in the room, music or television in the background, or needing to have
the door open versus closed
 Include questions about the presence of electronic devices in the bedroom (e.g.,
phones, televisions), all of which have small lights that remain on or have a light that
blinks when the battery is low
 Patients are often surprised by how many of these devices are in the sleeping
environment.
Behaviors of sleep deprivation
 Observe for behaviors such as irritability, disorientation (similar to a drunken state),
frequent yawning, and slurred speech
 If sleep deprivation has lasted a long time, psychotic behavior such as delusions and
paranoia sometimes develops
o For example, a patient reports seeing strange objects or colors in the room or
acts afraid when the nurse enters the room.
Know how sleep or lack thereof affects the client physiologically and
psychologically
Physiological Benefits of Sleep and Rest
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Necessary for developing and maintaining new pathways for learning and memorization
Without adequate sleep, it becomes challenging to concentrate and respond to the
various stimuli present in the environment
The brain and cells (neurons) continue to communicate with each other during sleep to
assist in removing the toxins that build up in the brain while the individual is awake
Essential physiological function that is necessary to support physical and mental health
During sleep, the body repairs muscles, tissues, and bones and strengthens immune
system
Prevents weight gain by decreasing production of ghrelin (the hunger hormone) and
leptin (the decreasing-hunger hormone)
Helps reduce the risk of type 2 diabetes by decreasing the release of cortisol (the stress
hormone) – increased levels of cortisol make it difficult for insulin to move sugar into
cells
Improves reaction time, hand-eye coordination, strength, and power
Sleep Deprivation
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Occurs when a patient does not meet the body’s biological sleep requirements
Total – caused by losing a night of sleep or by staying awake for 24 hours or for a
lengthy period
Partial – occurs when sleep hours have been decreased; can progress into chronic
sleep deprivation state
Selective – purposely strips someone of a cycle of sleep
Even losing 1 hour of sleep over multiple nights could have harmful cognitive effects
Cognitive effects may not be visible to a patient, resulting in obesity and poorly
controlled blood sugars in patients with type 2 diabetes
May also induce depression, anxiety and further sleeping difficulties
Menopause is a common cause of sleep disturbances – approx. 46-48% report sleeping
difficulties (38% for perimenopausal women)
BOX 43.3
Sleep-Deprivation Symptoms
Physiological Symptoms
• Ptosis, blurred vision
• Fine-motor clumsiness
• Decreased reflexes
• Slowed response time
• Decreased reasoning and judgment
• Decreased auditory and visual alertness
• Cardiac arrhythmias
Psychological Symptoms
• Confused and disoriented
• Increased sensitivity to pain
• Irritable, withdrawn, apathetic
• Agitated
• Hyperactive
• Decreased motivation
• Excessive sleepiness
Sleep deprivation occurs when a client does not meet the body's biological sleep
requirements. Sleep deprivation can affect higher order cognitive projects, impair
judgment, decrease response time, and trigger seizure disorders, migraines, and tension
headaches.
Functions of sleep
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Sleep restores biological processes
During NREM stage 3 sleep, the body releases human growth hormone for the repair
and renewal of epithelial and specialized cells such as brain cells
REM sleep appears to be important for early brain development, cognition, and memory
o Researchers associate REM sleep with changes in the brain, including cerebral
blood flow and increased cortical activity
o In addition, there is increased oxygen consumption and epinephrine release
o These changes are associated with memory storage and learning.
Sleep deprivation: affects immune function, metabolism, nitrogen balance, and protein
catabolism
o A loss of REM sleep often leads to confusion and suspicion
o Prolonged sleep loss alters various body functions (e.g., mood, motor
performance, memory, equilibrium)
o Individuals with sleep problems are also more likely to have chronic diseases
such as hypertension, cardiovascular disease, diabetes mellitus, obesity, and
depression
o In addition, they may experience poorer quality of life and productivity
o Millions of health care dollars are spent on indirect costs related to sleep
deprivation, such as motor vehicle and industrial accidents, litigation, property
damage, hospitalization, medical errors, and death.
Dreams
Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more
vivid and elaborate, and some believe that they are functionally important to learning, memory
processing, and adaptation to stress.
Complications of sleep disorders - know characteristics of each sleep disorder,
i.e., S/S, common, similarities and differences, safety issues related, nursing
diagnosis and nursing interventions related to them, evaluate outcomes, what to
expect for treatment
Insomnia
Insomnia = a more chronic condition vs. sleep deprivation
 A symptom patients experience when they have chronic difficulty in falling
asleep, frequent awakenings from sleep, and/or a short sleep or nonrestorative
sleep.
 Most common sleep-related complaint (up to 30% of adults) and more common
in women and older adults
 Commonly experienced by individuals diagnosed with depression
o Acute = lasts a few days (personal/situational stressors)
o Chronic = lasts a month or more
o Intermittent = recurring but gets a few days of sleep in between
Define: Insomnia is an ongoing inability to sleep despite having the opportunity to do
so.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment: is symptomatic
o including improved sleep-hygiene measures
o biofeedback
o cognitive techniques
o relaxation techniques
o Behavioral and cognitive therapies have few adverse effects and show evidence
of sustained improvement in sleep over time
Sleep Apnea
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Lack of air flow through the nose and mouth for periods of 10 seconds to 1-2
minutes
More than 5 breathing cessations lasting longer than 10 seconds per hour
during sleep
Results in decreased arterial oxygen saturation levels
Can be a single disorder or a mix of Central and Obstructive Sleep Apnea
o Central: CNS dysfunction in the respiratory control center of the brain that
fails to trigger breathing during sleep, and nasal airflow and chest wall
movement cease.
o Obstructive: Structures in the mouth and throat relax during sleep and
occlude the upper airway
Obstructive Sleep Apnea (OSA)
 Most common form of sleep apnea
 Upper airway becomes partially or completely blocked, and nasal airflow
diminishes (hypopnea) or stops (apnea)
 Person tries to breathe because chest and abdominal wall movements continue
(loud snoring sounds)
 Person becomes sufficiently hypoxic and must awaken to breathe
 Diagnosed using polysomnography – documents HR, BP, breathing,
oxyhemoglobin saturation, brain wave patterns, body movements, and snoring
patterns
 Common obstructions noted: inactive tongue, enlarged tonsils, and obesity
 Structural abnormalities – deviated septum, nasal polyps, narrow lower jaw, or
enlarged tonsils predispose a person to OSA
 Obesity and hypertension are major factors
 Smoking, increased age (older than 65), heart failure, alcohol, sleeping on back,
nasopharyngeal structural abnormalities, large neck circumferences, and
menopause are all increased risks for OSA
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Symptoms include EDS, fatigue, morning headaches, irritability, depression,
difficulty concentrating, and decrease in sex drive
Causes a serious decline in arterial oxygen saturation level
Patients are at risk for cardiac dysrhythmias, right heart failure, pulmonary
hypertension, angina attacks, stroke, and hypertension
Treatment options: lifestyle changes (weight-reduction program for obesity),
improved sleep hygiene, BiPAP, CPAP, surgery, and oral repositioning devices
for the jaw and tongue
Treatment includes therapy for underlying cardiac or respiratory complications
and any emotional problems that occur as a result of the disorder
Central Sleep Apnea (CSA)
 Involves dysfunction in the respiratory control center of the brain
 The impulse to breathe fails temporarily, and nasal airflow and chest wall
movement cease
 Oxygen saturation of the blood falls
 Common in patients with brainstem injury, stroke, obesity, muscular dystrophy,
and encephalitis
 Less than 10% of sleep apnea is predominantly central in origin
 Tend to awaken during sleep and therefore complain of insomnia and EDS
 Mild and intermittent snoring might be present
 Common causes are opioid overdose and heart failure
Define: Apnea is a condition in which there is an absence of inspiratory airflow for a
minimum of 10 seconds.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define: Hypopnea is associated with a decrease in oxygen saturation and lasts 10
seconds or longer.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define: Obstructive sleep apnea (OSA) is related to the recurrent episodes of upper
airway collapse and obstruction while sleeping combined with waking from sleep.
Safety: at risk for certain complications while in hospital
o Surgery and anesthesia disrupt normal sleep patterns
o After surgery patients reach deep levels of REM sleep – causes muscle
relaxation that leads to OSA
o Patients with OSA who are given opioid analgesics after surgery have an
increased risk of developing airway obstruction because the medications
suppress normal arousal mechanisms
o These patients often need ventilator support in the postoperative period because
of increased risk of respiratory complications
o Monitor airway, oxygen saturation, respiratory rate and depth, and breath sounds
frequently after surgery
o Notify provider immediately if patient is difficult to arouse or having trouble
breathing
Nursing diagnosis: The STOP-BANG sleep assessment tool is a reliable evidencebased tool used to screen for OSA and is frequently used in preanesthesia and/or
preoperative assessments
Interventions:
o Recommend lifestyle changes
o Teach patient to elevate HOB and use a side or prone position for sleep
 Use pillows to prevent a supine position
Outcomes:
Treatment:
Narcolepsy
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A dysfunction of the processes that regulate sleep and wake states
EDS is the most common complaint associated
During the day a person feels an overwhelming wave of sleepiness and falls asleep
REM sleep occurs within 15 minutes of falling asleep
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Often happens at inappropriate times and increase risk for injury
Symptom of narcolepsy type 1 – Cataplexy = sudden muscle weakness during intense
emotions such as anger, sadness, or laughter. Usually lasts only a few seconds but if
attack is severe, pt loses voluntary muscle control and falls to the floor
Patients with type 1 – lack hypocretin (a hormone responsible for maintaining alertness;
produced in the hypothalamus)
Type 2 = without cataplexy
Often has vivid dreams that occur as they are falling asleep – difficult to distinguish from
reality
Sleep paralysis is another symptom
Typically symptoms first appear in adolescence (often confused with EDS that teens
experience or laziness)
Treated with stimulants or wakefulness-promoting agents – modafinil, armodafinil,
methylfinidate, or sodium oxybate (only partially increase wakefulness and reduce sleep
attacks)
Also treated with antidepressants that suppress cataplexy and other REM-related
symptoms
Management methods: brief daytime naps no longer than 20 minutes (strategically
timing naps if possible), following a regular exercise program, practicing good sleep
habits, avoiding shifts in sleep, eating light meals high in protein, deep breathing,
chewing gum and taking vitamins
Avoid factors that increase drowsiness – alcohol, heavy meals, exhausting activities,
long-distance driving, and long periods of sitting in hot, stuffy rooms
Define: Narcolepsy is a chronic sleep condition characterized by sudden sleepiness and
sudden periods of sleep.
Safety: patients who experience EDS can fall asleep while sitting up in a chair or
wheelchair – position so that they do not fall out of chair if they fall asleep
 Elevate feet on a ottoman or small bench
 Pillow placed in lap offers some support
 If patient wants to lead over an over the bed table, ensure table is locked and
secure
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Hypersomnia
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Underlying cause is often unknown – some cases result from a dysfunctional ANS,
trauma to the CNS, and possibly genetic factors
Define: Hypersomnia is a disorder of excessive daytime fatigue without improvement
after more sleep lasting at least 3 months
Safety: increased risk for accident or injury related to sleepiness
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Restless Leg Syndrome (RLS)
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Cause is unknown but can occur with iron or vitamin deficiencies and other medical
conditions such as multiple sclerosis
Tends to run in families – could be an inherited syndrome
Avoiding caffeine, nicotine, and alcohol may help control symptoms
Define: Restless leg syndrome (RLS), also called Willis-Ekbom disease, is an
uncontrollable urge to move the legs during sleep.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Nursing Diagnoses
 Sleep deprivation – can be temporary due to special circumstances
 Insomnia – a more chronic condition
 Adequate sleep
 Fatigue
 Impaired sleep
 Impaired alertness
 Sleep deprivation
Nursing Interventions
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Promoting bedtime routines – same hour for bedtime, snack, or quiet activity
o Used consistently helps young children avoid delaying sleep
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Promoting safety – for any patients prone to confusion or falls, safety is critical
o Night light
o Beds set lower to the floor
o Remove clutter
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Promoting comfort – sleepwalkers are unaware of their surroundings and are
slow to react, increasing the risk for falls. Do not startle sleepwalkers but instead
gently awaken them and lead them back to bed
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Establishing periods of rest and sleep – in the home, it helps to encourage
patients to stay physically active during the day so they are more likely to sleep
at night
o Increasing daytime activity lessens problems with falling asleep
o Also limit television and computer work right before bedtime
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Stress reduction – the inability to sleep because of emotional stress also makes
a person feel irritable and tense. When patients are emotionally upset,
encourage them to try not to force sleep. Otherwise, insomnia frequently
develops, and soon bedtime is associated with the inability to relax.
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Preschoolers have bedtime fears (fear of the dark or strange noises), awaken
during the night, or have nightmares
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Bedtime snacks – some people enjoy bedtime snacks, whereas others cannot
sleep after eating.
o A dairy product such as warm milk or cocoa that contains L-tryptophan is
often helpful in promoting sleep
o A full meal before bedtime often causes GI upset and interferes with the
ability to fall asleep
o Warn patients against drinking or eating foods with caffeine before
bedtime
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Pharmacological approaches
o Several other herbal products assist in sleep:
 Valerian – effective in mild insomnia and RLS; affects the release of
neurotransmitters and produces very mild sedation
 Kava – helps promote sleep in patients with anxiety; should be
used cautiously because of its potential toxic effects on the liver
 Chamomile – an herbal tea; has a mild sedative effect that may be
beneficial in promoting sleep
o Hypnotics: medications that induce sleep
o Sedatives: medications that produce calming or soothing effect
o Benzodiazepines and benzodiazepine-like drugs: common classifications
of drugs used to treat sleep problems
o Regular use of any sleep medication often leads to tolerance and
withdrawal
o Side effects could be extreme grogginess
o Benzodiazepines can lead to falls in older patients
Know sleep issues specific to the adult and the older adult
Adults: Sleep Patterns
 Adults (20-35 yrs) spend 2-5% of their sleep time in stage 1
 45-55% in stage 2
 10-20% in stage 3
 20-25% in REM
 Cycles occur approx. 4-5 times while person is sleeping
BOX 43.8
FOCUS ON OLDER ADULTS
Older adults
Sleeping difficulties increase with age
o Approximately 40% of older adults report problems with sleep
o Older adults spend more time in stage 1 and less time in stages 3 and 4 (NREM
sleep)
o some older adults have almost no NREM stage 4 or deep sleep
o Episodes of REM sleep tend to shorten
o Older adults experience fewer episodes of deep sleep and more episodes of lighter
sleep
o They tend to awaken more often during the night, and it takes more time for them
to fall asleep
o To compensate they increase the number of naps taken during the day
o Older adults often experience excessive daytime sleepiness, which can lead to
decreased physical abilities and falls.
o
o
o
o
o
Older adults who have a chronic illness often experience sleep disturbances
For example, an older adult with arthritis frequently has difficulty sleeping because of
painful joints
Changes in sleep patterns are often caused by changes in the CNS that affect the
regulation of sleep
Many older adults with insomnia have co-morbid mental health or medical conditions,
take medications that disrupt sleep patterns, or use drugs or alcohol
Sensory impairment reduces an older person’s sensitivity to time cues that maintain
circadian rhythms.
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Older adults (65+) have a decrease in stage 3 cycles and increase in stage 2
Wake up more frequently and take longer to fall asleep
This pattern may cause them to stay in bed longer, leading to other health issues such
as worsening of musculoskeletal weakness, arthritis, and pulmonary disorders
Decreased stage 3 & 4 sleep cycles could contribute to immune system weakening and
decrease in skeletal muscle
Recommended hours of sleep for older adults = 7-8 hours
Know practices that hinder sleep and practices that promote sleep
Promoting Sleep
Sleep-wake pattern
• Maintain a regular bedtime and wake-up schedule
• Eliminate naps unless they are a routine part of the schedule
• If naps are taken, limit to 30 minutes and time them early in the day
• Go to bed when sleepy
• Use warm bath and relaxation techniques
• If unable to sleep in 15 to 30 minutes, do a relaxing activity such as reading
• Avoid stimulating activities such as exercise or watching television before bedtime
Environment
• Sleep where you sleep best.
• Keep noise to a minimum; use soft music to mask it if necessary.
• Use night-light and keep path to bathroom free of obstacles.
• Set room temperature to preference; use socks to promote warmth.
• Listen to relaxing music
• Sit in natural sunlight upon awakening if possible
Medications
• Use sedatives and hypnotics with caution as last resort and then only short term if
necessary
• Adjust medications being taken for other conditions and assess for drug interactions
that may cause insomnia or excessive daytime sleepiness
Diet
• Limit caffeine and nicotine in late afternoon and evening
• Avoid large meals and alcohol close to bedtime
• Consume carbohydrates or milk as a light snack before bedtime
• Decrease fluids 2 to 4 hours before sleep
Physiological/illness factors
• Elevate head of bed and provide extra pillows as preferred.
• Use analgesics 30 minutes before bed to ease aches and pains.
• Use therapeutics to control symptoms of chronic conditions as prescribed
Nursing Interventions (P&P)
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Focus on controlling factors in the environment that disrupt sleep, relieving physiological
or psychological disruptions to sleep, and providing for uninterrupted rest and sleep
periods for patients
Close curtains for patients who share a room
Dim lights in hospital nursing unit at night
Provide ear plugs or eye mask to reduce noise or light stimulation
Provide personal hygiene before bedtime – warm bath or shower can be relaxing
o Bedridden patients – offer to wash face and hands
o Brush teeth
o Cleanse perineal or anal area thoroughly for incontinent patients
Have patients void before bedtime
Help position off any potential pressure sites
Remove irritating stimuli:
o Change or remove any moist dressings
o Reposition drainage tubing
o Reapply wrinkled thromboembolic hose
o Change tape on NG tube
Patients who are diaphoretic benefit from a cool bath and dry clothes or linens
Avoid waking for nonessential tasks – schedule assessments, treatments, procedures,
and routines during awake times
o Stable patients – do not wake to check vital signs unless ordered
o Unless therapeutic blood level of a drug is essential – give meds during waking
hours
Always try to provide 2-3 hours of uninterrupted sleep at night
Become the patients advocate to promote optimal sleep
o Postponing or rescheduling family visits
o Questioning the frequency of certain procedures
Assist in reducing stress
o Therapeutic communication
o Take time to sit and talk to patients having trouble falling asleep
o Provide comfort measure (back rubs to relax)
o If sedative is indicated, confer with provider to be sure the lowest dose is used
initially
o Discontinue sedative as soon as possible to prevent dependence that disrupts
normal sleep cycle
Maintain activity
o Long-term care – serve meals in resident dining area, keep residents involved in
planned social activities, natural sunlight 2 hours a day
o Regular exercise – keeps people active and stimulated
Limit daytime napping to 30 minutes or less – short naps taken midafternoon
increase alertness and cognitive ability
Patients with dementia – shorten activities and visits to conserve energy level
Control sleep disturbances
o Pt w/ respiratory abnormalities – sleeps with 2 pillows or semi-sitting position to
ease effort to breathe; take prescribed bronchodilators before sleep to prevent
airway obstruction
o Hiatal hernia - eat small meals several hours before bedtime to prevent burning
sensation from gastric reflux; sleep in semi-sitting position
o Time medications to relieve pain, nausea, or other recurrent symptoms so that
drug takes effect at bedtime
o
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BOX 43.12
Control of Noise in the Hospital
• Close doors to patients’ room when possible.
• Keep doors to work areas on unit closed when in use.
• Reduce volume of nearby telephone and paging equipment.
• Wear rubber-soled shoes. Avoid clogs.
• Turn off bedside oxygen and other equipment that is not in use.
• Turn down alarms and beeps on bedside monitoring equipment.
• Turn off room television and radio unless patient prefers soft music.
• Avoid abrupt loud noise such as flushing a toilet or moving a bed.
• Keep necessary conversations at low levels, particularly at night.
• Designate a time during the day for “quiet time” for patients
Promoting Sleep (notes)
 Avoid stimulants, such as caffeine, alcohol, and nicotine at least four to six hours before
bedtime.

Remove unnecessary light and noise.
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Establish a bedtime routine, such as taking a warm shower or bath.
 Keep room dark, quiet, and at a comfortable, cold temperature.
 Go to bed only when tired.
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If no sleep in 20 minutes, go to another room and read or listen to music.
 Turn the clock away from view.
 Go to bed and wake up at same time each day.
 Keep naps short and before 3 p.m.
 Complete exercise at least three hours before going to bed.
 Remove work items and televisions from bedroom when possible.
 The bedroom should be for sleep and sexual activity only.
Know circadian rhythm
Circadian rhythms
o People experience cyclical rhythms as part of their everyday lives
o The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or
circadian rhythm (derived from Latin: circa, “about,” and dies, “day”)
o The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control
the rhythm of the sleep-wake cycle and coordinate this cycle with other circadian
rhythms
o Circadian rhythms influence the pattern of major biological and behavioral functions
o The predictable changing of body temperature, heart rate, blood pressure, hormone
secretion, sensory acuity, and mood depend on the maintenance of the 24-hour
circadian cycle.
o Factors such as light, temperature, social activities, and work routines affect circadian
rhythms and daily sleep-wake cycles
o All people have biological clocks that synchronize their sleep cycles
o This explains why some people fall asleep at 8 p.m., whereas others go to bed at
midnight or early in the morning
o Different people also function best at different times of the day.
o Health care agencies or extended-care centers usually do not adapt care to an
individual’s sleep-wake cycle preferences
o Typical hospital routines interrupt sleep or prevent patients from falling asleep at
their usual time
o Poor quality of sleep results when a person’s sleep-wake cycle changes
o Reversals in the sleep-wake cycle, such as when a person who is normally awake
during the day falls asleep during the day, sometimes indicate a serious illness.
o
o
o
The biological rhythm of sleep frequently becomes synchronized with other body
functions
o For example, changes in body temperature correlate with sleep patterns.
o Normally, body temperature peaks in the afternoon, decreases gradually, and
drops sharply after a person falls asleep
When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other
physiological functions usually change as well
o For example, a new nurse who starts working the night shift experiences a
decreased appetite and loses weight
o Anxiety, restlessness, irritability, and impaired judgment are other common
symptoms of sleep cycle disturbances
Failure to maintain an individual’s usual sleep-wake cycle negatively influences a
patient’s overall health.
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Internal process that controls the sleep-wake cycle
Occurs approx. every 24 hours
Regulates a pt’s biological clock and causes them to be sleepy at night and wake
on their own in the morning
Synchronizes with environmental cues such as light and temperature; however
the body will maintain circadian rhythms without prompts
Sleep-Wake Homeostasis
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Assists the body to remember to sleep after a given time
Regulates the level of sleep according to the amount of sleep deprivation a pt is
experiencing
Affected by factors such as lighting in the room, medications, caffeine, foods,
sleep environment, and stress
Know non-pharmacological interventions for sleep
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Massage: assists in relaxation of muscles, improvement of circulation, and fatigue
o Contraindications – patients with burns, wounds, and on blood thinners (warfarin)
Guided imagery, mindfulness, meditation, and music therapy
Assist with complementary alternative therapies (CAT) – silently repeating mantras,
practice restful breathing, visualize restful images
Yoga – reduce stress, decrease pain, and improve overall health
Educate on good sleep habits (sleep meds should not be used for an extended period of
time)
Assist with selecting seep-promoting interventions by having patients keep a diary of
sleep habits; helps identify and analyze sleep-related problems
Collaboratively (w/ patient) develop a plan of care tailored to patient’s lifestyle and living
arrangements (increases likelihood that pt will follow plan)
Evaluate through follow-up calls and appointments
Keep in mind priorities related to benzodiazepines
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Benzodiazepines cause relaxation, antianxiety, and hypnotic effects by
facilitating the action of neurons in CNS that suppress responsiveness to
stimulation (decreases levels of arousal)
Short-acting benzodiazepines (oxazepam, lorazepam, or temazepam) at lowest
possible dose for short-term treatment of insomnia are recommended
Initial doses are small, and increments are added gradually, based on patient
response, for a limited time
Warn patients not to take more than prescribed dose, especially if medication
seems to become less effective after initial use
Use of benzodiazepines in older adults is potentially dangerous because of the
tendency of the drugs to remain active in the body for a longer time
o As a result, also cause respiratory depression; next-day sedation;
amnesia; rebound insomnia; and impaired motor-functioning and
coordination
o Leads to an increased risk of falls
o If older adult patients who were recently continent, ambulatory, and alert
become incontinent or confused and/or demonstrate impaired mobility, the
use of benzodiazepines need to be considered as possible cause
Low-dose trazodone (serotonin antagonist and reuptake inhibitor (SARI)
antidepressant) often used as an alternative to benzodiazepines, especially in
older adult patients
Rebound insomnia is a common problem after stopping benzodiazepines
(regular use leads to tolerance and withdrawals)
Consider alternative approaches before administering
o Immediately administering a sleep med at first complaint can do more
harm than good
o Routine monitoring of patient response to sleep meds is important
Understand all drugs for sleep and their potential side effects, safety issues
related, nursing diagnosis and nursing interventions related to them, evaluate
outcomes, when to expect them to be prescribed
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Benzodiazepines (GABA agonists): alprazolam, clonazepam, and lorazepam
o Can cause drowsiness, relax muscles, lessen anxiety, and cause
retrograde amnesia
o Should be used cautiously in older adults patients with decreased liver
and kidney function
o May develop physical dependence (not recommended for long-term use)
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Nonbenzodiazepine hypnotics: zolpidem, zaleplon, and eszopiclone (z-drugs)
o Most commonly prescribed sleep medications
o Can cause adverse effects – gastric discomfort, hallucinations, and
memory loss
o Have the potential to be abused since higher doses can induce stimulation
and euphoria
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Melatonin (controlled-release)
o First-line medication recommended for older adults
o Cost-effective, non-habit forming, and has few adverse effects

OTC meds: doxylamine, succinate, and diphenhydramine
o Can help sleep but encourage to discuss options with provider before
resorting to these
o Can cause daytime drowsiness, dry mouth, visual disturbance, difficulty
urinating, and constipation
When pharmacologic therapy is necessary, a sleep specialist should evaluate patients
for sleep apnea or chronic lung disease with nocturnal hypoxia before a sedative is
prescribed. Ensure safety by monitoring for adverse effects and practicing rights of
medication administration.
Melatonin
Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and
promote sleep. It is a popular nutritional supplement that is found to be helpful in improving
sleep efficiency and decreasing nighttime awakenings. The recommended dose is 0.3 to 3 mg
taken 2 hours before bedtime. Older adults who have decreased levels of melatonin find it
beneficial as a sleep aid. Short-term use of melatonin has been found to be safe, with mild,
infrequent side effects of nausea, headache, and dizziness. A melatonin receptor agonist, such
as ramelteon or tasimelteon, is well tolerated and appears to be effective in improving sleep by
improving the circadian rhythm and shortening the time needed for sleep onset. It is safe for
long- and short-term use, particularly in older adults. Common side effects include diarrhea,
drowsiness, tiredness and dizziness.
Several other herbal products help in sleep:
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Valerian has been shown to be effective in mild insomnia by reducing the time to fall
asleep and improving quality of sleep. Typically, individuals who use valerian do not
experience morning grogginess.
Lavender essential oil may improve sleep quality
Passionflower (maypop) has mild sedative effects and is used as a natural sleep aid
Chamomile, an herbal tea, has a mild sedative effect that may be beneficial in
promoting sleep
Caution patients about the dosage and use of herbal compounds because the U.S. Food and
Drug Administration (FDA) does not regulate them. Herbal compounds may interact with
prescribed medications, and patients need to avoid using these together
The use of nonprescription sleeping medications is not recommended. Patients need to learn
the risks of such drugs. Over the long term these drugs lead to further sleep disruption, even
when they initially seemed effective. Caution older adults about using over-the-counter
antihistamines because of their long duration of action, which can cause confusion,
constipation, urinary retention, and an increased risk of falls. Help patients use behavioral and
proper sleep-hygiene measures to establish sleep patterns that do not require the use of drugs.
The liberal use of drugs to manage insomnia is quite common in American culture. CNS
stimulants such as amphetamines, caffeine, nicotine, terbutaline, theophylline, and modafinil
need to be used sparingly and under medical management. In addition, withdrawal from CNS
depressants such as alcohol, barbiturates, tricyclic antidepressants (amitriptyline, imipramine,
and doxepin), and triazolam causes insomnia. Consult with pharmacists and health care
providers about managing doses.
Medications that induce sleep are called hypnotics.
Sedatives are medications that produce a calming or soothing effect
A patient who takes sleep medications needs to know about their proper use and their risks and
possible side effects. Long-term use of antianxiety, sedative, or hypnotic agents disrupts sleep
and leads to more serious problems. The FDA requires that the product labels of all sleep
medications contain safety information related to the potential adverse effects of severe allergic
reactions; severe facial swelling; and complex sleep behaviors such as sleep-driving, making
phone calls, and preparing and eating food while asleep.
Benzodiazepines and benzodiazepine-like drugs are commonly used to treat sleep problems
and are intended for short-term use.
The benzodiazepine-like drugs are the treatment of choice for insomnia because of improved
efficacy and safety of use. Experts recommend a low dose of a short-acting medication such
as zolpidem for short-term use (no longer than 2 to 3 weeks). These drugs cause fewer
problems with dependence and abuse and fewer rebound insomnia and hangover effects than
benzodiazepines.
The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the
action of neurons in the CNS that suppress responsiveness to stimulation, thereby decreasing
levels of arousal.
 Short-acting benzodiazepines (e.g., oxazepam, lorazepam, or temazepam) at the lowest
possible dose for short-term treatment of insomnia are recommended.
 Initial doses are small, and increments are added gradually, based on patient response,
for a limited time.
 Warn patients not to take more than the prescribed dose, especially if the medication
seems to become less effective after initial use.
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The use of benzodiazepines in older adults is potentially dangerous because of the
tendency of the drugs to remain active in the body for a longer time. As a result, they
also cause respiratory depression; next-day sedation; amnesia; rebound insomnia; and
impaired motor functioning and coordination, which leads to an increased risk of falls.
If older patients who were recently continent, ambulatory, and alert become incontinent
or confused and/or demonstrate impaired mobility, consider the use of benzodiazepines
as a possible cause.
Administer benzodiazepines cautiously to children under 12 years of age. These medications
are contraindicated in infants less than 6 months old. Patients who are pregnant need to avoid
them because their use is associated with risk of congenital anomalies. Mothers who are
breastfeeding do not receive the drugs because they are excreted in breast milk. Raise these
issues with patients’ health care providers if you are concerned about the safety of a prescribed
medication.
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) antidepressant often
used in patients with depression or anxiety and insomnia. The most common side effects are
daytime grogginess and orthostatic hypotension. Low-dose trazodone is often used as an
alternative to benzodiazepines, especially in older patients.
Regular use of any sleep medication often leads to tolerance and withdrawal. Rebound
insomnia is a problem after stopping a medication, particularly the benzodiazepines.
Immediately administering a sleeping medication when a hospitalized patient is unable to sleep
does the patient more harm than good. Consider alternative approaches to promote sleep first.
Routine monitoring of patient response to sleeping medications is important.
Box 43.4
Drugs and Their Effects on Sleep
Hypnotics
 Interfere with reaching deeper sleep stages
 Provide only temporary (1-week) increase in quantity of sleep
 Eventually cause “hangover” during day – excess drowsiness, confusion, decreased

energy
Sometimes worsen sleep apnea in older adults
Benzodiazepines
 Alter REM sleep
 Increase sleep time
 Increase daytime sleepiness
Opiates
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Suppress REM sleep
Cause increased daytime drowsiness
Anticonvulsants
 Decrease REM sleep time
 Cause daytime drowsiness
Antidepressants and Stimulants
 Suppress REM sleep
 Decrease total sleep time
Alcohol
 Speeds onset of sleep
 Reduces REM sleep
 Awakens person during night and causes difficulty returning to sleep
Caffeine
 Prevents person from falling asleep
 Causes person to awaken during night
 Interferes with REM sleep
Nicotine
 Decreases total sleep time
 Decreases REM sleep time
 Causes awakening from sleep
 Causes difficulty staying asleep
Diuretics
 Nighttime awakenings caused by nocturia
Beta-Adrenergic Blockers
 Cause nightmares
 Cause insomnia
 Cause awakening from sleep
SLEEP SUMMARY (ATI)
• Sleep is an essential physiological function that is necessary to support physical and mental
health. While sleeping, the body goes through several processes to rebuild, strengthen, retain
memory, and improve mood and concentration. While asleep, the body repairs muscles,
tissue, bones, and strengthens the immune system.
• Understanding sleep cycles, sleep patterns, common sleep disorders, and age-related
requirements will help nurses reduce sleep deprivation and sensory overload and promote a
healthy night’s sleep for their clients.
• Sleep patterns are different for infants, young and middle adults, and older adults. Changes in
sleep patterns associated with aging include lighter sleep, fewer dreams, and frequent
waking.
• Sleep deprivation has been shown to affect higher-order cognitive processes, impair
judgment, decrease response time, and trigger seizure disorders, migraines, and tension
headaches.
• Sleep promotion requires education, lifestyle changes, a calm environment, rituals, relaxation,
and comfort. Many factors can affect the sleep cycle.
• Overstimulation of one or more of the body’s senses quickly leads to sensory overload.
Nurses play an integral role in forming a plan of care to minimize sensory overload factors.
• Sleep disorders interfere with the quality of sleep. Insomnia, sleep apnea, narcolepsy, and
hypersomnolence are common sleep disorders that create poor sleep patterns, which can
lead to constant fatigue and increased physical and mental health problems.
• Sleeplessness causes many clients to visit their providers each year. Many interventions will
rely on lifestyle changes, but it may also become necessary to use pharmacologic therapy for
some clients.
• Clients require proper rest and sleep to heal and recover. During a hospital stay, stress, pain,
fear, procedures, adverse effects from medications, and the environment can inhibit restful
sleep.
• The nurse–client plan of care focuses on ensuring the client’s comfort, being respectful of the
client’s cultural and spiritual beliefs and practices, and incorporating these factors into the
care plan whenever feasible. A thorough history and assessment, including assessing for
adequate pain management, should be performed to guide the choice of interventions. Being
attentive to their needs, focusing on their concerns, and evaluating the relationship will help
nurses gain their clients’ trust.
• Strategies to control lights, noise level, visitors’ timing, vital signs, and procedures should be
incorporated into the plan of care for hospitalized clients. Providing ongoing assessments,
support, and education can also promote a healthy sleep lifestyle.
 Promoting comfort necessitates easing clients’ mental and physical distress. Permitting
clients to feel in control and make informed choices concerning their care supports their
development of positivity and confidence. Comfort means valuing clients, assuring their
safety, and having a positive connection.
PAIN
o
o
o
o
o
o
o
o
o
o
o
Not only subjective – also linked to both physical and emotional-psychological
experiences of individuals
Can be caused by actual stimuli or anticipated
Pain = “an unpleasant sensory and emotional experience associated with, or resembling
that associated with, actual or potential tissue damage” (ATI)
Pain threshold = point at which a stimulis causes client to perceive pain
Pain tolerance = how much of a stimulus client is willing to accept
Document patients description of pain (subjective), physiological responses –
hypertension, diaphoresis (objective), and/or behavioral responses (guarding, facial
grimacing)
Not adhering to standards of care for pain management can lead to a charge
of malpractice, defined as a negligent act that has been performed by a professional or
trained individual—in this case, a nurse. Negligence is defined as failing to perform in a
manner that a reasonable and prudent person would perform.
To monitor the client’s objective pain, the nurse can collect objective data such as vital
signs, physical assessment findings, laboratory tests and imaging reports, and any other
diagnostic information the provider has prescribed.
Subjective indicators of pain: pain scale score, along with quantity and quality of pain
Objective indicators of pain: grimacing, guarding, crying
Types of Pain
Acute:
 Less than 6 months
 Protective (lets you know something is wrong)
 Temporary
 Self-limiting (pt knows that end is in sight)
 Has a direct cause
 Examples: pain that results from tissue damage caused by trauma or injury, incisional
pain from surgery, and pain from environmental factors such as heat or cold.
 Resolves with tissue healing
 Can lead to chronic pain if not relieved
 Intervention: treat underlying cause
 Physiological response: sympathetic nervous system – fight or flight responses
(tachycardia, hypertension, anxiety, diaphoresis, muscle tension)
Chronic:
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Not protective
Recurring
Last longer than 6 months – persisting beyond tissue healing
Does not usually alter vital signs
Psychosocial implications – depression, fatigue, decreased level of functioning (may
lead to a disability)
Can be malignant or nonmalignant (cancer/non-cancer pain)
Examples: arthritis, back pain, headaches
Can be both physically and emotionally debilitating
Management aims at symptomatic relief – pain does not always respond to interventions
Administer long-acting or controlled-release opioid analgesics (including the transdermal
route)
Pain meds can be given around the clock for pain control rather than PRN
Idiopathic pain = form of chronic pain without a known cause, or pain that exceeds
typical pain levels associated with patient’s condition
Nociceptive:
 Arises from damage to or inflammation of tissue
o Noxious stimulus that triggers the pain receptors called nociceptors and causes
pain
 Throbbing, aching, and localized
 Typically responds to opioids and non-opioid medications
 Types: cutaneous, somatic, visceral
o Cutaneous – skin or subcutaneous tissue
o Somatic – bones, joints, muscles, skin, or connective tissues
o Visceral – internal organs (stomach or intestines); can be referred to pain in
other body locations; can radiate
 Examples: back pain, broken rib
Neuropathic:
 Nerve pain
 Phantom limb pain
 Pain below the level of a spinal cord injury
 Diabetic neuropathy
 Intense, shooting, burning, “pins and needles”
 Pain responds to adjuvant medication
o Antidepressants
o Antispasmodic agents
o Skeletal muscle relaxants
 Topical medications can provide relief for peripheral neuropathic pain
 Examples: Trigeminal neuralgia
 Sciatic pain
 Below the knee amputation
Cancer Pain:
 Nociceptive location of the tumor or neuropathic, arising from abnormal or damaged pain
nerves related to chemotherapy
 Referred pain = patient sense pain distant from the site of tumor
o Always completely assess reports of new pain by a patient with existing pain
 Fentanyl patch: effective pain relief for cancer
Nursing Process and Pain
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AAPIE
Assessment, Analysis, Planning, Implementation, and Evaluation
Pain management needs to be systematic
Consider patients quality of life for pain management
Clinical guidelines available to manage pain:
o American Pain Society
o Sigma Theta Tau
o National Guidelines Clearinghouse
ABCDE
Ask
Believe
Choose
Deliver
Empower
Pain Scales (used in goals and outcomes)
Numeric
 Pain rating from 0-10; patient asked to rate pain
 Slight pain = 1-3
 Moderate pain = 4-6
 Severe pain = 7-10
Nonverbal Pain Scale (NVPS)
 5 categories: *FAGPR*
o Face
o Activity (movement)
o Guarding
o Physiological (vital signs)
o Respiratory
 Designed for patients who are unable to verbalize their pain scale
 Used in burn units and critical care units
o Severity of illness
o Sedation
o Mechanical ventilation
Visual Analog Scale (VAS)
 Vertical or horizontal single line
 One end representing no pain and the other the worst pain imaginable

Patient points along the line that represents the intensity of the pain
CRIES Scale
 Crying
 Requires O2 for SaO2 less than 95%
 Increased vital signs (BP and HR)
 Expression
 Sleeplessness
 For infants 38 weeks gestation or older
FLACC Scale
o
o
o
o
o
o
Face, Legs, Activity, Cry, Consolability
Used with children ages 2 months-7 years
Clients who are cognitively disabled
Observe for 1-5 minutes if awake
Give numeric score of 0-2 for each behavior
Total score ranges from 0-10
Know culture considerations and cultural characteristics regarding Pain
 Wong-Baker FACES® Pain Rating Scale, to assess
 Assess a patient’s health literacy
 Recognize variations in subjective responses to pain. Undertreatment, overtreatment, or
lack of trust in the health care provider might occur if members of the health care team
are unaware of the cultural norms associated with pain and pain expression, since pain
is subjective
 May under report due to culture or religious beliefs about pain
 Use knowledge of biological variations of pain. Significant differences in drug
metabolism, dosing requirements, therapeutic response, and adverse effects occur in
cultural groups.
 Check your own biases
Adults and older adults can experience pain that is more prevalent and unique to their particular
age. Clients in their 30s, 40s, and 50s have more complaints of headaches, abdominal and
back pain, and temporomandibular problems than any other age group.
As age increases, pain seems to increase in conjunction with neuropathic conditions, as well as
for joint and lower extremity conditions. As a client ages, the likelihood of experiencing chronic
pain conditions also increases. Chronic conditions such as arthritis, diabetes, and diseases of
the heart, liver, kidney, and lung are all likely to cause pain. Many clients live with more than
one chronic condition and experience pain on a daily basis. A national health trends study of
adults older than age 65 found that nearly 53% reported bothersome pain during the previous
month. Research suggests that pain tolerance does not change significantly as a person ages.
According to Fillingim, research has not yielded consistent results related to the severity,
impact, or intensity of pain with greater age; therefore, the nurse cannot assume that these
aspects of pain decrease with age. Indeed, older adult clients can experience pain more and
longer than younger adult clients.
Clients with cognitive impairment or communication challenges (e.g., expressive aphasia)
require careful nursing assessment. These clients may not report pain effectively, so the nurse
should look for behaviors that suggest pain is present, such as guarding, grimacing,
restlessness, and other behavioral changes.
Assessment and treatment of pain can be more challenging when clients are members of
cultural and ethnic groups with which the nurse is not familiar. Nurses will frequently encounter
clients from a variety of ethnic backgrounds, cultural variances, socioeconomic status, literacy
levels, and religious preferences. Language barriers can also exist. It is the nurse’s
responsibility to be cognizant and respectful of these differences. To provide culturally sensitive
care, the nurse must understand that such differences may influence the way in which clients
react to and report their pain. Also, these influences can lead a nurse to underestimate, and
therefore undertreat, the client’s pain.
Along with differing attitudes about pain itself, barriers can exist regarding the treatment of pain.
Many cultures hold differing beliefs about opioids and, therefore, are not comfortable receiving
them. As opioids remain one of the leading pharmacological treatments for pain, the nurse may
need to provide education to clients and family members on the advantages of having pain
relieved through the administrations of opioids. Alternative therapies such as medicinal herbs,
acupuncture, and cupping can be helpful when caring for clients. Clients should be allowed to
utilize traditional practices as long as they are not harmful to the client.
If a language barrier exists, it is important for the nurse to utilize translators to enhance
communication with the client. When assessing pain in such cases, use of the Wong-Baker
FACES Scale, Numeric Rating Scale, and Visual Analog Scale can probably facilitate the most
accurate description of the client’s pain. As with other clients, the nurse should pay attention to
nonverbal manifestations to develop an accurate assessment of the client’s pain. It is important
for the nurse to be aware of cultural differences and meet the challenges they may present. The
goal of providing compassionate care and improving a client’s quality of life by relieving their
pain remains the same, regardless of the client’s cultural or religious beliefs.
12. Know components of a pain assessment – What Questions to ask
The nurse uses subjective indicators to assess the client’s pain by asking questions about the
characteristics of their pain
Location: use anatomical terminology and landmarks to describe location (superficial, deep,
referred, or radiating)
o Where is your pain?
o Does is radiate anywhere else?
o *Ask patient to point to the location*
Timing: onset, duration, frequency
o When did it start?
o How long does it last?
o How often does it occur?
o
Is it constant or intermittent?
Quantity: intensity, strength, and severity are “measures” of the pain
o *Use a pain intensity scale (visual analog, description, or number rating scales) to
measure pain, monitor pain, and evaluate the effectiveness of interventions
o How much pain do you have now?
o What is the worst/best the pain has been?
o Rate your pain on a scale of 0-10
Quality: refers to how the pain feels – sharp, dull, aching, burning, stabbing, pounding,
throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying,
torturing, nagging, annoying, intense, or unbearable
o What does the pain feel like?
o Is the pain throbbing, burning, or stabbing? *Give more than 2 choices*
Setting/Chronology: how the pain affects daily life or how activities of daily living (ADLs) affect
the pain
o Where are you when the symptoms occur?
o What are you doing when the symptoms occur?
o How does the pain affect your sleep?
o How does the pain affect your ability to work or interact with others?
Associated findings: fatigue, depression, nausea, anxiety
o What other symptoms do you have when feeling pain?
o Concomitant Symptoms of Pain = naturally accompanying or associated
o Nausea, headache, dizziness, urge to urinate, constipation, depression,
restlessness
Aggravating/relieving factors
o What makes the pain feel better?
o What makes the pain feel worse?
o Are you currently taking any prescription, herbal, or OTC medications?
Assessment/Data Collection
o
o
o
o
Pain is whatever the person experiencing it says it is, and it exists whenever the person
says it does. The patient’s report of pain is the most reliable diagnostic measure of pain
 Patient-centered care
Self-report using standardized pain scales is useful for patients over the age of 7 years
 Pain scales can include images, numbers, words, or other
intensity markers that allow the patient to select a pain level
 Specialized pain scales are available for use with younger children
or individuals who have difficulty communicating verbally
Assess and document pain (the 5th vital sign) frequently
Use a symptom analysis to obtain subjective data
o
Nurse is the patient advocate
 Empower the patient; show compassion and respect
PQRST or PQRRST– a detailed acute pain (current pain) assessment questionnaire

P – Palliative, Provocative factors or Precipitating Cause:
o What makes your pain worse?
o What makes it better?

Q – Quality
o Describe your pain for me

R – Relief measures (omitted in ATI)

R – Region (location)
o Show me where you hurt

S – Severity
o On a scale or 0-10, how bad is your pain now?
o What is the worst pain you have had in the past 24 hours?
o What is the average pain you have had in the past 24 hours?

T – Timing
o Do you have pain all of the time, only at certain times, or only on certain days?

U – What are you not able to do because of your pain?
o With whom do you live, and how do they help you when you have pain?
13. What indicates effective pain management?
Effective pain management will:
 Improve quality of life
 Increase physical comfort
 Promote early mobilization
 Facilitate return to baseline
 Decrease hospital and clinical visits
 Decrease length of stay
 Decrease health care costs
An indication of the success of a plan of care is determined through attainment of
outcomes. When complete pain relief is not achievable, reducing pain to a tolerable
level is a realistic outcome. For example, the following are possible outcomes:
• Reports that pain is at a tolerable level of 3 or less on a scale of 0 to 10
• Modifies activities that intensify pain
• Uses pain-relief measures safely
• Is able to complete ADLs independently (able to dress self)
Evaluate the patients’ perception of the effectiveness of interventions used to relieve
pain
 The pt helps decide the best time to attempt pain treatment
 The pt is the best judge of whether a pain-relief intervention works
 Family is also a valuable resource (if pt is unable to express discomfort)
 The pain intervention is viewed positively if pt is feeling an improvement in
participation in self-care or activities (physical therapy)
 Also ask about tolerance and overall relief obtained
 If pt states intervention is unhelpful or even aggravating the discomfort – stop
immediately and seek an alternative intervention
Behavioral Indicators of Pain:
 Vocalizing
 Facial Expressions
 Body Movement
 Social Interactions (or lack of)
Objective Indicators of Pain:
 Vital signs initially showing an elevation in BP, HR, and respiration (acute)
 Muscle tension or rigidity
 Pallor
 When pain becomes more severe, there is a decrease in BP and HR
 Nausea and vomiting
 Fainting
 Withdrawal to pain
 Grimacing
 Restlessness
 Guarding the area of pain
The final step of the nursing process is evaluation. The nurse should evaluate each intervention
undertaken to address the client’s pain—pharmacological and nonpharmacological—and record
the client’s response in the medical record. The nurse should be sure to choose an appropriate
pain assessment tool by considering the client’s age, culture, and ability to understand the scale
being utilized.
Nurses must remember that pain management is an ethical responsibility. Clients should have
individual pain interventions, and these interventions must be evaluated fully to determine their
effectiveness. Clients should also be participants in evaluating the effectiveness of pain
interventions. Keeping a pain diary or a pain log can be helpful for clients to determine if
medications or treatments are helping over time, and it may assist in reinforcing adherence to
the pain regimen. As discussed previously, evaluating pain in the context of cultural and
socioeconomic situations is crucial to effective pain management. Older clients may underreport pain and need careful assessment, intervention, and reassessment. Nurses must assess
and reassess continually after each treatment or intervention, keeping the client’s goals in mind
documenting their findings upon evaluation.
Safety
Nurses must keep client safety at the forefront of their minds. Nurses should educate
themselves as well as participate in any health care facility education offerings regarding safe
medication administration. All clients receiving pharmacological pain interventions require a
client-centered plan of care and frequent monitoring, including a complete baseline and ongoing
assessment of their respiratory rate, quality, and oxygen levels obtained by pulse oximetry, as
well as the level of sedation. The first hours after surgery, in particular, are the most problematic
for clients due to the many medications given for anesthesia and pain management. Although
the first 4 hours after release from the postanesthesia care unit (PACU) are the most critical,
close monitoring needs to occur for the first 24 hours following surgery. Newer modalities for
early identification of opioid-induced ventilatory impairment (OIVI)—another name for respiratory
depression—include using a combination of capnography (monitoring of carbon dioxide levels)
along with respiratory assessment and pulse oximetry to improve identification of OIVI.
Range Orders
Sometimes pain medications are prescribed with range orders. For example, the provider
prescription might read as follows:
Morphine 2 to 4 mg Q4Hours IV prn pain
In this instance, the nurse can give 2 mg, 3 mg, or 4 mg of morphine every 4 hours as needed
for pain. When selecting the dose, the nurse should consider whether the client has taken the
medication before, how much the client took, the effect, and any adverse effects. The nurse
should start with the lowest dose and then, if it is ineffective, may increase the dosage in
increments up to the maximum amount in the range order. Note that when the medication is first
administered, the client may report that the initial dosage has not been effective. The nurse
must be aware of how long the medication takes to reach its peak effect and not administer
another dose until that peak has been reached.
However, the nurse cannot split the dose to give 2 mg every 2 hours instead of 4 mg every 4
hours. While the math might seem equal, this is not how the dose was prescribed. In addition,
the nurse would then be prescribing—which is not operating within the nurse’s scope of
practice.
If clients still do not have what the nurse believes is adequate pain relief after the prescribed
medication is administered, the nurse should contact the provider for further prescriptions or
guidance in controlling pain. After administering the medication, it is important for the nurse to
perform an evaluation of the medication’s effectiveness and to document the dose, dosage
interval, and client response to the medication administered.
14. Understand all drugs for pain and their potential side effects, safety issues related,
nursing diagnosis and nursing interventions related to them, evaluate outcomes, when to
expect them to be prescribed Keep in mind priorities related to opioids
Pharmacological Interventions
 Parenteral route best for immediate, short-term relief of acute pain


o IM, IV, SQ
Oral route – better for chronic non-fluctuating pain
Analgesics
o Non-opioid
o Opioids
o Adjuvants
There are three types of analgesics:
1. Non-opioids

Acetaminophen (Tylenol)
o No more than 4g/day – for pts w/ a healthy liver
o Hepatotoxicity
o Monitor use of alcohol
o Make sure pt is aware of opioids that contain acetaminophen (hydrocodone
bitartrate 5 mg/acetaminophen 500 mg)

Non-steroidal Anti-Inflammatory Drugs (NSAIDS)
o Watch for bleeding
o GI upset

Salicylates (ASA)
o Monitor for tinnitus, vertigo, decreased hearing acuity (salicylism)



Appropriate for treating mild-moderate pain
Administer with food or antacids – prevent GI upset
Monitor for bleeding with long-term NSAID use
(2) Opioids (traditionally called narcotics)






Morphine sulfate - natural
Oxycodone – semi synthetic
Demerol
Dilaudid – semi synthetic
Fentanyl - synthetic
Codeine - natural
o
Appropriate for treating moderate-severe pain
 Post-operative, myocardial infarction, cancer
o
Nursing Implications for Opioid Administration:
 Identify high risk patients – older adults, patients who are opioid-naïve
 Titrate dose
 Monitor respiratory status
 RR is below 8/min and shallow or difficult to arouse – STOP opioid
and give antagonist naloxone
 Identify the cause of sedation
o
Essential to monitor and intervene for adverse effects of opioid use:

Sedation: monitor LOC and take safety precautions. Sedation usually
precedes respiratory depression

Respiratory depression: monitor RR prior to and following
administration of opioids (especially for patients who have had little
previous exposure to opioid medications)
 Initial treatment of respiratory depression and sedation is
generally a reduction in opioid dose
 If necessary, slowly administer diluted naloxone to reverse opioid
effects until patient can deep breathe with a RR of at least 8/min

Orthostatic Hypotension: advise patient to sit or lie down if
lightheadedness or dizziness occur
 Instruct to avoid sudden position changes by slowly moving from a
lying to a sitting or standing position
 Provide assistance with ambulation

Urinary retention:
 Monitor I&O
 Assess for distension
 Administer bethanechol
 Catheterize

Nausea/Vomiting:
 Administer antiemetics
 Advise patient to lie still and move slowly
 Eliminate odors

Constipation: use preventative approach
 Monitor bowel movements
 Fluids
 Fiber intake
 Exercise
 Stool softeners
 Stimulant laxatives
 Enemas
(3) Adjuvants or coanalgesics
 Enhance effects of non-opioids
 Help alleviate other manifestations that aggravate pain (depression, seizures,
inflammation)
 Useful for treating neuropathic pain
o
Anticonvulsants: carbamazepine, gabapentin
o
o
o
o
o
o
o
Antianxiety agents: diazepam, lorazepam
Tricyclic antidepressants: amitriptyline, nortriptyline
Anesthetics: infusional lidocaine
Antihistamine: hydroxyzine
Glucocorticosteroids: dexamethasone
Antiemetics: ondansetron
Biphosphates and Calcitonin: for bone pain
Patient-Controlled Analgesia (PCA)






A medication delivery system that allows patient to self-administer safe doses of opioids with
minimal risk of overdose
Small, frequent dosing ensures consistent plasma levels
Less lag time between identified need and delivery of medication
o Increases patients sense of control and can decrease the amount of medication they
need
Typical opioids for PCA delivery:
o Morphine
o Hydromorphone
o Fentanyl
Patient should let nurse know if using the pump does not control pain
The patient is the ONLY person who should be pushing PCA button
o Prevent inadvertent overdosing
Additional Pharmacological Pain Interventions




Topical analgesics
o Creams, ointments, patches
Local anesthesia
o Local infiltration of an anesthetic medication to induce loss of sensation to a body
part
o Regional anesthesia
Perineural local anesthetic infusion
Epidural analgesia
o Regional
o Administered into epidural space
o Risk factors: bleeding, epidural hematomas (leading to ischemia of spinal cord),
unaddressed serious neurological complications
o Nursing Implications:
 Maintain responsibility for providing emotional support for patients
receiving local or regional anesthesia
 After administration of local anesthesia – protect patient from injury until
full sensory and motor function return
 Patient education
Nursing Knowledge

Diaphoresis is one of the early signs of withdrawal of opioids
o Occur between 6 and 12 hours



Late signs = Fever, nausea, and abdominal cramps
o 48-72 hours
If GI system is functioning – oral route is preferred for routine analgesics because of
lower cost and ease of administration
o Oral route is also less painful, less invasive than parenteral (IV, IM, SQ) or PCA
routes
o Transdermal route is slower and medication availability is limited compared to
oral form
Opioid pain meds can cause constipation and respiratory depression
o
Physical dependence: a state of adaption that is manifested by a drug class-specific
withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing
blood level of the drug, and/or administration of an antagonist
Addiction: a primary, chronic, neurobiological disease with genetic, psychosocial, and
environmental factors influencing its development and manifestations
Drug tolerance: a state of adaption in which exposure to a drug induces changes that
result in a diminution of one or more effects of the drug over time
Placebos
Herbal supplements may interact with prescribed analgesics and condition-specific
medications.
 Glucosamine and Chondroitin supplements may interact with the anticoagulant drug
warfarin and increase the risk of bleeding.
 It is important to ask patients to report to their health care provider any type of herbal or
dietary supplements taken to relieve pain (see Chapter 32).
BOX 44.13
Common Opioid Side Effects
Central nervous system (CNS) toxicity
• Thought and memory impairment
• Drowsiness, sedation, and sleep disturbance
• Confusion
• Hallucinations, potential for diminished psychomotor performance
• Delirium
• Depression
• Dizziness and seizures
Ocular
• Pupil constriction
Respiratory
• Bradypnea - <12/min
• Hypoventilation – shallow breathing
Cardiac
• Hypotension - < 90/60 mmHg
• Bradycardia - < 60 bpm
• Peripheral edema
Gastrointestinal
• Constipation
• Nausea and vomiting
• Delayed gastric emptying
Genitourinary
• Urinary retention
Endocrine
• Hormonal and sexual dysfunction
• Hypoglycemia - < 70 mg/dL —reported with tramadol and methadone
Skin
• Pruritus – itchy skin
Immunological
• Immune system impairment possible with chronic use
Musculoskeletal
• Muscle rigidity and contractions
• Osteoporosis
Pregnancy and breastfeeding
• When at all possible, avoid opioid use during pregnancy to prevent fetal risks
Tolerance
• Over time, increased doses needed to obtain analgesic effect
Withdrawal syndrome
• Rapid or sudden cessation or marked dose reduction may cause rhinitis, chills, pupil dilation,
diarrhea, “gooseflesh”
BOX 44.14
Patient Characteristics Associated with Higher Risk for Opioid-Related Adverse
Drug Events
• Snoring and sleep apnea or sleep-disordered breathing
• Morbid obesity with high risk of sleep apnea
• Older age
• Significant co-morbidities (cardiac, pulmonary, or major organ failure)
• No recent opioid use
• Increased opioid dose requirement
• Receiving other sedating medications (e.g., antihistamines, antipsychotics)
• Recent surgery, especially thoracic or upper abdominal
• Prolonged general anesthesia
• Smoker
Adjuvants
Coanalgesics or adjuvants are drugs originally developed to treat conditions other than pain but
that also have analgesic properties. For example, tricyclic antidepressants (e.g., nortriptyline),
anticonvulsants (e.g., gabapentin), and infusional lidocaine successfully treat chronic pain,
especially neuropathic pain. Corticosteroids relieve the pain from inflammation and bone
metastasis. Other examples of coanalgesics are bisphosphonates and calcitonin for bone pain.
Adjuvants have analgesic properties, enhance pain control, or relieve other symptoms
associated with neuropathic pain. You give adjuvants alone or with analgesics. Sedatives,
antianxiety agents, and muscle relaxants have no analgesic effect, although they may be
effective for their specific indications.
Know non- pharmacological interventions for pain
Non-pharmacological Pain Management Strategies





Reduction of pain stimuli in the environment
Elevation of edematous extremities
o To promote venous return and decrease swelling
Relaxation
o Meditation
o Yoga
o Progressive Muscle Relaxation
Ensure bed linens are clean and smooth
Position or change position
o Repositioning
o Supporting
o Padding bony prominences (coccyx, sacrum, heels, scapula)
Cutaneous Stimulation *hot/cold therapy in videos*
 Heat and cold therapy
 Touch
 Massage
 Acupuncture
 Acupressure
 Transcutaneous electronic stimulation (TENS) unit
o
o
o
Interruption of pain pathways
Cold = inflammation
Heat = increase blood flow and to reduce stiffness
Hot and Cold Therapy
o
o
o
Hot
o
o
o
o
Used for muscular pain relief or menstrual pain
Increase blood flow and reduce stiffness
Heating pad or hot water bottle
Always provide barrier for heating pad
Cold
o
o
o
Decrease swelling
inflammation
Icepacks, packages of frozen vegetables, cold washcloths
Both need to be applied for no longer than 20 minutes at a time and at
least a 20 minute break after usage
Massage and Acupressure
 Decrease pain scores
 Neuropathic pain
 Aromatherapy massage may incorporate essential oils
 After massage, have patient get up slowly to decrease risk of orthostatic hypertension
 Acupressure = stimulating subcutaneous tissues at specific points using the digits
Acupuncture
 For acute pain, chronic pain, and complex regional pain syndrome
 Inserting small sterile needles into the skin to minimize pain
 Points are believed to stimulate the CNS, releasing chemicals in the muscles, spinal
cord, and brain
o Causing biochemical changes to stimulate the body’s natural healing abilities and
promote physical well-being
TENS Unit
 Transcutaneous Electrical Nerve Stimulation (TENS)
 Sends low voltage electrical impulses to the skin over the painful areas
 Can be obtained without a prescription
Cognitive Strategies
 Cognitive Behavioral Therapy (CBT)
 Can be effective in managing chronic pain
 Requires ability to concentrate
 Patients learn how to manage negative thoughts and maladaptive behaviors
o Distraction
o Relaxation
o Imagery
o Music therapy
Evidence-based nonpharmacological therapies include acupuncture, massage, osteopathic and
chiropractic manipulation, cognitive-behavioral intervention, meditative movement and mindbody interventions, and dietary and self-management approaches to pain management
Distraction, prayer, mindfulness, relaxation, guided imagery, music, and biofeedback are
examples of therapies frequently initiated by nurses.
Physical therapies (e.g., applying hot or cold compresses, massage, exercise, transcutaneous
electrical nerve stimulation [TENS]) treat pain by improving physical function, altering
physiological responses, and reducing pain-related immobility. Complementary and alternative
medicine (CAM) therapies such as therapeutic touch and mindfulness meditation also help to
alleviate pain in some patients (see Chapter 32).
PAIN SUMMARY
• Pain is subjective and is whatever the client says it is.
• Acute pain lasts for the duration of an injury or damage to the body, until healing has taken
place. Chronic pain lasts longer than acute pain and for a more extended period than it should
for the injury or damage to the body. Cancer pain is now recognized as a separate pain, and
its treatment can be complex.
• Nociceptive pain either comes from the tissues or organs, or is referred pain. Neuropathic
pain comes from nerve damage or misfiring.
• The various types of pain are treated differently. Acute pain may be treated with oral,
intravenous, PCA, or epidural medications, while chronic pain may be treated with oral
medications. Nonpharmacological modalities may be beneficial for use in conjunction with
medications for acute and chronic pain and may be effective for pain relief used alone for
chronic pain.
• The nurse has legal, ethical, and moral obligations to the client as part of the overarching
concept that clients have the right to effective and safe pain management.
• Assessment of pain is complex and involves the use of pain rating scales (the nurse
determines the appropriate scale), consideration of influencing factors, and awareness of
diversity considerations including age, race, gender, culture, socioeconomic status, and
literacy level.
• The nurse advocates for the client and can assist the provider in determining and
implementing appropriate pharmacological and nonpharmacological interventions for the
client to address pain. A variety of modalities may be used, including some in conjunction with
others.
• The nurse and the client should be aware of and educated fully on whatever pain modalities
are utilized. The nurse has the responsibility to assure that all precautions are taken when
administering pain medications and treatments.
• Pain should always be evaluated as the last step of the nursing process. Reassessment is
needed if the client’s goals have not been achieved and when each treatment is completed.
 The nurse should document the results of the reassessment after pain medication
administration or interventions such as heat/cold application and relaxation techniques.
Aging – P&P Ch. 14, ATI Ch. 25
Vocabulary:
Presbycusis -age related hearing loss; loss of acuity for high-frequency tones
Anosmia -loss of sense of smell that happens with aging
Gerontology-the scientific study of old age, the process of aging, and the particular problems of old people
 Old age begins at 65
 Sensory decline is a normal aging phenomenon
 Chronic pain leads to depression and isolation in the older population
 Visual acuity declines with age
 Myths of gerontology:
o delirium, dementia, and depression commonly affect older people
o health declines with age
o intelligence declines with aging
o exercise will not improve muscle function in elderly
o older adults are not capable of making decisions about their care
Geriatrics-the branch of medicine or social science dealing with the health and care of old people.
Osteoporosis- Osteoporosis is a bone disease that develops when bone mineral density and
bone mass decreases, or when the structure and strength of bone changes. This can lead to a
decrease in bone strength that can increase the risk of fractures (broken bones).
Cataracts -A cataract is a cloudy area in the lens of your eye (the clear part of the eye that
helps to focus light). Around age 40, proteins in clear lens break down and clump together. The
clump forms cloudy part called a cataract.
 Cataracts are very common as you get older. In fact, more than half of all Americans age
80 or older either have cataracts or have had surgery to get rid of cataracts.
 Not noticed at first but over time can make make vision, blurry, hazy, or less colorful
 Can make everyday activities difficult
 Vision loss can eventually occur
Osteomalacia- describes a disorder of “bone softening” in adults that is usually due to
prolonged deficiency of vitamin D. This results in abnormal osteoid mineralization.
 Bones can break more easily
Know age related changes in the body
Keep in mind everything goes down if the question answer says up it is more than likely not one
of the answers….
ATI CH 25 read over it but just notice all the things go down mainly
Developmental Tasks for Older Adults







Associated with varying degrees of change and loss
o Changes in health and physical strength
o Significant others/family, a sense of being useful, socialization, income, and
independent living
Coping with:
o Retirement and reduced or fixed income
o Residence change – maintaining satisfactory living arrangements
o Death of a spouse, children, siblings, friends
Adult children – redefining relationships (role reversal in later years)
Erikson: Integrity vs. Despair
Social-concept development
Body image changes
Social development remaining socially active to overcome isolation; maintaining sexual
health
Psychosocial Interventions
o
o
o
o
o
o
o
Therapeutic communication
Touch
Reality orientation
Validation therapy
Reminiscence therapy
Attending to physical appearance
Assistive devices (canes, walkers, hearing aids)
Cognitive Development
o Piaget: Formal Operations
o Many older adults main cognitive function – some decline in speed of
cognitive function vs. cognitive ability
o
Delirium: acute, temporary, and can have a physiological source (infection, sleep
deprivation, or pain)
o Or related to a change in surroundings (unfamiliar or new environment)
o Delirium is often the 1st manifestation of infection (UTI) in older adults
o
Dementia: chronic, progressive, and possibly with an unknown cause (alzheimer’s
disease, vascular dementia)
o
Depression: chronic, acute, or gradual onset (present for at least 6 weeks)
o Often due to loss of loved one, feelings of isolation, or chronic disease
o Geriatric Depression Scale – easy to use screening tool
Integumentary
 Loss of skin elasticity w/ fat loss in extremities
 Decreased skin turgor, subcutaneous fat, and connective tissue (dermis)
o Leads to wrinkles and dry, transparent skin
 Loss of subcutaneous fat
o Makes it more difficult for older adults to adjust to cold temperatures
 Thinning/graying of hair
o More sparse distribution
o Decreased facial hair in men, increased in women
 Glandular atrophy (oil, moisture, sweat glands)
 Thickening of fingernails and toenails
 Pigmentation changes
Cardiovascular/Pulmonary
 Decreased chest wall movement, vital capacity, and cilia
o Decreased cough reflex and ciliary activity
o Increases risk for respiratory infection
 Fewer alveoili
 Increased airway resistance
 Increased anterior-posterior chest diameter
 Thickening of blood vessel walls
 Reduced cardiac output
 Decreased peripheral circulation
 Increased BP
Neurologic
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Slower reaction time
Decreased touch, smell, and taste sensations
Decline in visual acuity
Decreased ability for eyes to adjust from light to dark
o Leads to night blindness – especially dangerous while driving
Inability to hear high-pitched sounds (prebycusis)
Reduced spatial awareness
Gastrointestinal
 Decreased production of saliva
 Decreased digestive enzymes, gastric secretions
 Gastric atrophy
 Decreased production of intrinsic factor and increased stomach pH
 Decreased intestinal motility
o Can lead to increased risk for constipation
 Increased dental problems – periodontal disease
 Hemorrhoids
 Rectal prolapse
Musculoskeletal
 Decreased height due to intervertebral disk changes
 Decreased muscle strength and tone
 Decalcification of bones
 Degeneration of joints
Genitourinary
 Decreased bladder capacity
 Prostate hypertrophy in males
 Decline in estrogen or testosterone production
 Atrophy of breast tissue in females
Endocrine
 Decline in triiodothyronine (T3) production
o Yet overall function remains effective
 Decreased sensitivity of tissue cells to insulin
Immune
 Decreased production of antibodies by B cells
 Decreased production of autoantibodies (antibodies against the host’s body) with
increased autoimmune response
 Decreased core body temperature
 Decreased T-cell function
 Decreased stress response
 Decreased response to immunizations
How you assess the older adult and use their functional status as a baseline
o Gerontological Nursing: involves the provision of care that addresses mutually
establishes goals for an older adult, the family, and health care team members
o Nursing assessment takes into account:
 The interrelation between physical and psychosocial aspects of
aging
 The effects of disease and disability on a patient’s current
functional status
 Tailoring the nursing assessment to an older person
Assessing the Needs of Older Adults

Physiological changes
o General survey – initial inspection may reveal some universal aging
changes

Integumentary system
o skin loses resilience and moisture

Head and neck
o Facial features may become more pronounced
o Visual and auditory impairments may be present
o Salivary secretion is reduced, and taste buds lose sensitivity

Thorax and lungs
o Respiratory muscle strength decreases
o Anteroposterior diameter of thorax increases

Heart and vascular system
o Decreased contractile strength of the myocardium results in decreased
cardiac output

Breasts
o Milk ducts of breasts replaced by fat, making breast tissue less firm
o Atrophy of glandular tissue coupled with more fat deposits results in
slightly smaller, less dense, less nodular breast

GI System and Abdomen
o Increase in amount of fatty tissue in trunk and abdomen
o GI functional changes: slowing of peristalsis, noted by auscultating
reduced bowel sounds, and alterations in secretions

Reproductive system
o Changes in the structure and function of the reproductive system occur as
a result of hormone alterations

Urinary system
o Prostate gland hypertrophy is frequently seen in older men
o Urinary incontinence is an abnormal and typically embarrassing condition
that is more common in women but may also occur in men

Musculoskeletal system
o Muscle fibers become smaller
o Bone density and bone mass decreases with age

Neurological system
o All voluntary reflexes are slower, and individuals often have less of an
ability to respond to multiple stimuli
Nutrition
o
o
o
o
o
o
o
o
o
o
o
GI alterations
Access to food
Low income
Impaired mobility
Depression or dementia
Social isolation (preparing meals for one, eating alone)
Medications – alter taste of food
Prescribed diets that are unappealing
Incontinence – causes person to limit fluid intake
Constipation
Metabolic rates and activity decline – decrease total caloric intake to maintain a
healthy weight
o Makes it even more important that calories consumed are of good nutritional
value
o Increase intake of Vitamin D, B12, E, folate, fiber, and calcium
o Increase fluid intake – minimize risk of dehydration and prevent constipation
o Low-dose vitamin along with mineral supplementation
o Limit sodium, fat, refined sugar, and alcohol intake
Improving Nutrition Intake
o Encourage patient to eat with others / socialization
o Ensure food is accessible during day and nutritional supplementation in between
meal times
o Provide meds/address other physical needs before meals to promote comfort
o Allow pt to wash hands and clean mouth before meals
o Avoid meal interruptions
o Make sure pt has glasses, dentures, or other assistive devices prior to meals
o Consult provider and dietitian about including client-preferred foods in prescribed
diet
o Promote physical activity to increase appetite – walking, ROM
Injury Prevention
o Bath rails, grab bars, and handrails on stairways
o Remove throw rugs
o Eliminate clutter from walkways and hallways
o Remove extension and phone cords from walkways and hallways
o Mobility aids (walkers, canes)
o Safe medication use
o Adequate lighting
o Wear eyeglasses and hearing aids if needed
o Prevent substance use disorders
o Avoid driving after drinks or substance use
o Wear seat belt
o Wear helmet – bike riding, skiing, and other activities that increase risk of head
injury
o Install smoke and carbon dioxide detectors
o Secure firearms in safe location
BOX 14.3
SPICES Tool for Overall Assessment of Older Adults
S: Sleep disorders
P: Problems with eating or feeding
I: Incontinence
C: Confusion
E: Evidence of falls
S: Skin breakdown
Use clinical judgment to conduct a more in-depth assessment when an older adult
demonstrates changes in any of these areas
BOX 14.4
Examples of Altered Presentation of Illnesses in Older Adults Occurring in
Various Health Care Settings
Hospital
• Confusion is not inevitable. Look for an acute illness, presence of fever, neurological
events, new medication, or the presence of risk factors for delirium.
• Many hospitalized older adults have chronic dehydration exacerbated by acute illness
• Not all older adults have fevers with infection. Symptoms instead include increased
respiratory rate, falls, incontinence, or confusion
Nursing center
• Health care providers often undertreat pain in older adults, especially those with
dementia. Look for nonverbal cues of pain presence, such as grimacing or resistance to
care
• Decline in functional ability (even a minor one such as the inability to sit upright in a
chair) is a signal of new illness.
• Residents with less muscle mass—both the frail and the obese—are at a much higher
risk for toxicity from protein-binding drugs such as phenytoin and warfarin
• New urinary and/or fecal incontinence is often a sign of the onset of a new illness.
Ambulatory care
• Fatigue or a decreased ability to do usual activities is often a sign of anemia, thyroid
problems, depression, or neurological or cardiac problems
• Severe gastrointestinal problems in older adults do not always present with the same
acute symptoms seen in younger patients. Ask about constipation, cramping
sensations, and changes in bowel habits.
• Older adults reporting increased dyspnea and confusion, especially those with a
cardiac history, need to go to the emergency department because these are the most
common manifestations of myocardial infarction in this population
• Depression is common among older adults with chronic illnesses. Watch for lack of
interest in former activities, significant personal losses, or changes in role or home life.
Home care
• Investigate all falls, focusing on balance, lower extremity strength, gait, and
neurological issues (e.g., loss of sensation).
• Monitor older adults with late-stage heart disease for loss of appetite as an early
symptom of impending heart failure
• Drug-drug and drug-food interactions in older patients who are seeing more than one
provider and taking multiple medications are common. Watch for signs of interactions.
What could change their functional status?
Functional changes
o Physical function is a dynamic process. It changes as individuals interact with their
environments.
o Functional status in older adults includes the day-to-day ADLs involving activities
within physical, psychological, cognitive, and social domains.
o A decline in function is often linked to illness or disease and the degree of chronicity.
o However, ultimately it is the complex relationship among all of these factors that
influences an older adult’s functional abilities and overall well-being.
o
o
o
o
Keep in mind that it may be difficult for older adults to accept the changes that occur in all
areas of their lives, which in turn have a profound effect on functional status.
Some deny the changes and continue to expect the same personal performance, regardless
of age. Conversely some overemphasize them and prematurely limit their activities and
involvement in life.
The fear of becoming dependent is overwhelming for an older adult who is experiencing
functional decline as a result of aging.
Educate older adults to promote understanding of age-related changes, appropriate lifestyle
adjustments, and effective coping. Factors that promote the highest level of function include
a healthy, well-balanced diet; paced and appropriate regular physical activity; regularly
scheduled visits with a health care provider; regular participation in meaningful activities;
use of stress-management techniques; and avoidance of alcohol, tobacco, or illicit drugs.
Functional status in older adults refers to the capacity for and the safe performance of
ADLs and instrumental ADLs (IADLs). It is a sensitive indicator of health or illness in the
older adult. ADLs (such as bathing, dressing, and toileting) and IADLs (such as the
ability to write a check, shop, prepare meals, or make phone calls) are essential to
independent living; therefore carefully assess whether an older adult performs these
tasks and how the illness either has changed or threatens to change the way these tasks
are completed.
Occupational and physical therapists are your best resources for a comprehensive assessment
of functional impairment. A sudden change in function, as evidenced by a decline or
change in an older adult’s ability to perform any one or a combination of ADLs, is often a
sign of either an acute illness (e.g., pneumonia, UTI, or electrolyte imbalance) or
worsening of a chronic problem (e.g., diabetes or cardiovascular disease). An online
collection of functional assessment tools used most commonly with older adults is available at
the website of the Hartford Institute for Geriatric Nursing, https://consultgeri.org/.
When you identify a decline in a patient’s functional status, focus your nursing interventions on
maintaining, restoring, and maximizing an older adult’s functional status to maintain
independence while preserving safety and dignity.
Nursing diagnosis and interventions related to the older adult maintaining
maximal functioning and Independence
Healthy People 2030 has an overarching goal to improve the health and well-being of
older adults. More specifically, Healthy People 2030 cites the following objectives for
older adults:
• General health (improve physical activity for older adults with physical or cognitive
health problems, reduce rate of pressure injuries during hospitalization, reduce hospital
admissions among older adults with diabetes)
• Dementias (improved awareness and prevention of hospitalizations)
• Foodborne illness (reduce infections caused by Listeria, reduce rate of hospital
admissions for urinary tract infections)
• Injury prevention (reduce fall-related deaths, reduce the proportion of older adults who
use inappropriate medications, reduce emergency department visits due to falls)
• Oral conditions (reduce the proportion of older adults with untreated root surface
decay, loss of all teeth, and moderate and severe periodontitis
• Osteoporosis (reduce hip fractures among older adults, increase screening for
osteoporosis, increase the proportion of older adults who get treated for osteoporosis
after fractures)
• Respiratory disease (reduce the rate of hospital admissions for pneumonia and
asthma)
• Sensory or communication disorders (reduce vision loss from age-related macular
degeneration)