ASSESSING THE CLIENT'S NEED FOR PAIN MANAGEMENT

Pain is a highly complex phenomenon. Plato described pain as an emotion and not a sensation; Hippocrates
believed that pain was the result of a lack of balance in terms of the body's fluids. Neither Hippocrates nor Plato
believes that the brain played any role in terms of pain. Other thinkers and philosophers prior to the Renaissance
believed that pain was a punishment from god. It was Descartes who introduced the notion that pain is
transmitted along the nerves to the brain where the pain is perceived by the person.
Some of the more current theories relating to pain and the evolution of thought relating to pain, the nature of pain,
and the client's response to pain are described below.
• The Specificity Theory of Pain: The Specificity Theory of Moritz Schiff in the 1850s described pain as a
sensation that was different from all the other senses in that pain had its own specific nervous system
pathways from the spinal cord that traveled to the brain. According to this theory, there are no
psychological responses to pain.
• Intensive Theory: This theory of pain debunked the Specificity Theory and it is based on the belief that pain
is an emotional state, rather than a sensory phenomenon. Pain occurs with an intense stimulus such as
intense heat and pressure.
• The Peripheral Pattern Theory: The Peripheral Pattern Theory of pain, which is often referred to simply as
the Pattern Theory of pain, was proposed by Sinclair and Weddell during the 1950s. Pain, according to this
theory, is transmitted by nerve endings in the skin when an intense stimulus is applied. This theory also
does not recognize the psychological aspects of pain as we know it today.
• The Neuromatrix Theory of Pain: This theory of pain supports the fact that pain is a dynamic and
multidimensional process with physical, behavioral, perceptual, psychological and social responses and one
that can only be described by the person who is experiencing it. The four parts of the nervous system
according to the Neuromatrix Theory of pain components of the nervous system, according to this theory,
consist of the body self neuromatrix, cyclical processing, the sentient neural hub which produces the
client's awareness, and the patterns of movement.
• Gate Control Theory: Melzack and Wall are credited with the Gate Control Theory of pain. Pain, according
to this theory, is a combination of sensory, cognitive, affective and psychological responses to a painful
stimulus. Pain is transmitted by rapidly transmitting nerve fibers, slowly transmitting nerve fibers, small
and large nerve fibers along the dorsal horn of the spinal cord and its substantia gelatinosa. The substantia
gelatinosa is the "gate" that facilitates or blocks the transmission of pain. Some of the factors that open
this "gate" and create pain include the person's level of anxiety and their paucity of endorphins. Some of
the factors that close this "gate" are the lack of anxiety, adequate levels of endorphins and the person's
belief that the pain can be managed and controlled.

The pain process consists of four phases which, in correct sequential order are transduction, transmission,
modulation and perception.
Pain can be described in a number of different ways. Pain can be acute and chronic; it can also be described as
nociceptive, neuropathic, superficial, deep, somatic, radicular, referred, visceral, localized, diffuse, and mild,
moderate, and severe.
• Acute Pain: Simply defined, acute pain is pain that lasts less than 3 months; it has a rapid onset, it is
typically localized, it is accompanied with sympathetic nervous system responses such as pupil dilation,
diaphoresis, and increases in terms of the client's blood pressure, pulse rate and adrenal hormone
secretion as well as other signs and symptoms such as anxiety, muscular tension and tightness, all of which
can increase the severity and the duration of the pain.Acute pain is most often self-limiting and
manageable with sound pain management interventions. Acute pain is a predictable, physiological warning
that something is wrong.
• Chronic Pain: In contrast to acute pain, chronic pain is long lasting pain that can continue for extended
periods of time, it is more difficult for the client to describe, it is less definable than acute pain, it is more
difficult for the nurse to assess, it can be continuous or intermittent and it is also often difficult to treat
than acute pain. For example, some pain, like malignant pain, is sometimes intractable. Chronic pain is
typically not associated with vital sign changes as they are associated with acute pain because the body has
somewhat adjusted to it; but, chronic pain is associated with physical, emotional, psychological and
behavioral changes such as distress, depression, anorexia, insomnia, fatigue, and withdrawal.
• Neuropathic Pain: This pain is typically described by the client as a burning and sharp pain.Neuropathic
pain can occur as the result of damage to the nervous system; central neuropathic pain occurs as the result
 of damage to the central nervous system; and peripheral neuropathic pain occurs as the result of damage
to the peripheral nervous system. Spinal cord injury pain is an example of central neuropathic pain and
examples of peripheral neuropathic pain include the pain associated with phantom pain and peripheral
neuropathy secondary to diabetes.
• Nocicetive Pain: Nocicetive pain includes both somatic pain and radicular pain which include deep
abdominal pain and the pain resulting from a herniated spinal disk, respectively.
• Superficial Pain: Superficial pain is body surface pain.
• Deep Pain: Deep pain is pain that it is deep inside of the body.
• Somatic Pain: Somatic pain, which is a type of nocicetive pain, occurs as the result of injuries to the skin,
bone, muscle, connective tissues and joints.
• Visceral Pain: Visceral pain, which is also a type of nocicetive pain, is pain that originates in and around the
organs of the body.
• Radicular Pain: Radicular pain is pain that radiates to the lower extremities with transmission that occurs
along the spinal nerve.
• Referred Pain: Referred pain spreads to an area of the body which is not the source of the pain.
• Diffused Pain: Diffuse pain is widespread pain.
• Localized Pain: Localized pain is pain that is restricted to one identifiable area.
Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a subjective
experience that cannot be scientifically proven to be or not be present. Current research clearly supports the fact
that the client's subjective complaints of pain are far more accurate than other indicators of pain, such as the
client's vital signs and behavioral changes such as crying and guarding the area of the body affected by the pain.

The PQRST method is a useful way for nurses to assess pain:

P: Precipitation: What precipitated the pain symptoms? What things precipitate an increase in the amount of
pain and what things precipitate a relief from the pain?
Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or stabbing?
R: Region: Where is the pain? What region or area is painful? Does the pain travel and radiate to another area
of the body like the jaw and your leg?
S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being minimal pain and
10 as the most intense pain? What other symptoms are you experiencing in addition to the pain?
T: Triggers and Timing: What triggers and starts your pain? What triggers make the pain worse and more
severe? When did the pain begin? Tell me about the timing of the pain. How long does the pain last? How often
does the pain appear?
The quality of pain as sharp, burning, etc. is also described by the client as the nurse is assessing the client's pain.
At times, the quality of the pain can suggest its cause. For example, cramping may indicate that the source of the
pain is musculoskeletal in terms of its origin. The standardized McGill Pain Questionnaire has a large number of
these quality of pain descriptors including descriptors like unbearable, hot, and pricking needle like pain.
Behavioral signs and symptoms associated with pain can include insomnia, anorexia, muscular tension, rigidity,
a narrow focus of attention and crying. Some of the objective physiological signs and symptoms of pain include
like increased blood pressure, diaphoresis, tachycardia, adrenal hormone secretion and dilation of the pupils.
The signs and symptoms are assessed for by the nurse, particularly when the client, such as an infant, is not
able to provide the nurse with full subjective data which describes their pain.
Observational behavioral pain assessment scales for the pediatric population are used among children less than
three years of age. Some of these standardized pediatric pain scales include the FACES Pain Scale, the neonatal
CRIES Pain Scale, Toddler Preschooler Postoperative Pain Scale (TPPPS), the Neonatal Infant Pain Scale (NIPS),
the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), the Faces Legs
Activity Cry Consolability Pain Scale (FLACC), the Visual Analog Scale (VASobs) the Observation Scale of Behavioral
Distress (OSBD), the COMFORT Pain Scale and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with
toddlers.
At the current time, most nurses use a pain scale from 0 to 10 along the scale with 0 being the absence of pain
and 10 being the worst possible level of pain for adults who are cognitively aware and other tools like faces
pain assessment scale with adult clients who are affected with the lack of cognitive abilities, such as those who
are demented or in a lethargic state of consciousness..
The consequences of uncontrolled pain are severe and they adversely affect the client's quality of life. Many
clients, like the population at large, have misconceptions about pain and pain management. Some of these
misconceptions include:
• The belief that pain is inevitable and a normal part of illness.
• Addiction occurs when a client takes narcotic analgesics.
• Neonates and infants do not feel pain.
• Clients who have a past personal history of a substance related abuse should not be given any narcotic
analgesics
None of the above statements are true.
RECOGNIZING DIFFERENCES IN THE CLIENTS' PERCEPTIONS AND RESPONSES TO PAIN
Like all other things, clients vary in terms of their perceptions of pain and their responses to pain. Some of the
factors that impact on the clients' perceptions of and responses to pain include:
• Social factors including one's support systems
• Ethnic factors and values
• Cultural factors and values
• Level of development
• Economic factors
• The individual client's personal definition of pain and its meaning
• The client's past experiences with pain
• Level of fatigue
• Genetic factors
• Levels of fear and anxiety
• Level of cognitive functioning

APPLYING A KNOWLEDGE OF PATHOPHYSIOLOGY TO NON-PHARMACOLOGICAL

COMFORT/PALLIATIVE CARE INTERVENTIONS
some of the signs and symptoms associated with the end of life include those below. These signs and symptoms
and some possible non-pharmacological comfort and palliative care interventions are discussed below.
• Excessive sleeping: Excessive sleeping is more of a concern for the family members than it is for the client.
Family members should be instructed about the fact that excessive sleeping is a commonly occurring occurrence
at the end of life. They should also be taught about the importance of their mere presence and gentle touches
are comforting to the client even when they are sleeping.
• A decreased desire for food and fluids: Anorexia and a lack for fluid and food intake are common at the end of
life. Many clients elect to forgo tube feedings and intravenous fluids for fluid rehydration in their advance
directive so these choices must be supported.
• Incontinence of the bowels and bladder: The end of life is probably not the time to do bowel and bladder
training so the nurse must, instead, insure that the client is always clean and dry.
• Respiratory secretions congestion: Respiratory congestion results from the accumulation of respiratory
secretions in the airways. The pulmonary hygiene procedures discussed above such as coughing, deep breathing,
incentive spirometry, postural drainage, percussion, vibration and inspiratory respiratory exercises, in addition
to suctioning may be indicated for the relief of the respiratory congestion.
• Changes in respiratory patterns, including Cheyne-Stokes respirations: Cheyne-Stokes respirations are
characterized with deep and rapid breathing that is then followed with periods of apnea. Apnea is often
disturbing and upsetting to the client's family members, therefore, the nurse should explain the fact that
Cheyne-Stokes respirations are normal during the perideath period and that clients with Cheyne-Stokes
respirations report that these episodes did not cause them to experience any distress.
• Restlessness and agitation: Some clients at the end of life may experience agitation and restlessness. In addition
to insuring the safety of the client, the underlying cause of this agitation and restlessness must be identified and
treated if possible. For example, restlessness can occur as the result of hypernatremia, renal impairment, poor
hepatic function, blood pH changes and other causes. When the underlying cause cannot be determined and
treated, the client may be given an antipsychotic medication like haloperidol or an antianxiety agent like
lorazepam to correct restlessness and agitation.
• A lack of orientation: Nurses assess the clients' level of orientation to person, time and place. When a lack of
orientation occurs as the result of an identifiable and treatable cause like delirium, the underlying cause should
 be treated and corrected. When the cause of the lack of orientation is not identifiable and/or not treatable, the
client should be frequently oriented by the nurse and other members of the health care team.
• Body pallor and coolness: Pallor can result from a number of causes including anemia, a low blood glucose level
and exposure to cold. When correctable, treatable causes of this body pallor are identified, and then they should
be treated when the client at the end of life chooses to have these treatments.
• Social withdrawal: Many clients want to be alone at the end of life. Again, this choice should be supported and
upheld by the members of the health care team and the family.
• Vision like experiences: It appears that many clients at the end of life have vision like experiences of relatives
and friends that have predeceased the client. According to clients who have experienced these visions, they find
them comforting and with a lot of meaning. If, and when, clients and family members express concerns about
these visions and appearances, they should be told that these things commonly occur at the end of life for some
clients.
• Saying goodbyes to loved ones: Although saying goodbye to a loved one is a sad experience and often associated
with grief, saying goodbye allows the client and their loved ones to express their love, to ask for forgiveness and,
for family members, it is a time to tell the loved one that they have your permission to let go and leave when the
client is ready.
• Letting go: Letting go, ideally, occurs when the client has reached a level of acceptance about their own death.
This letting go facilitates the client to reconcile with others and tap into the spiritual dimension when this is
something that the client is connected to.
Nurses monitor the client's responses to non-pharmacological interventions in terms of the client's level of
comfort. As with pharmacological interventions, nonpharmacological interventions have expected outcomes like
a reported or observed decrease in the levels of pain and discomfort and increased levels of comfort as reported
by the patient or observed by the nurse.
In essence, the outcomes of palliative care interventions are evaluated in terms of whether or not the client and
family members have had their physical, psychological, emotional, religious, social and spiritual needs
effectively met, including the client's freedom from pain.

Delirium

NURSING INTERVENTIONS:
Physiological Support
Interventions
• Establish/maintain normal fluid and electrolyte balance.
• Establish/maintain normal nutrition.
• Establish/maintain normal body temperature.
• Establish/maintain normal sleep/wake patterns (treat with bright light for two hours in the early evening).
• Establish/maintain normal elimination patterns.
• Establish/maintain normal oxygenation (if clients experience low oxygen saturation treat with supplemental
oxygen).
• Establish/maintain normal blood glucose levels.
• Establish/maintain normal blood pressure.
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Minimize fatigue by planning care that allows for separate rest and activity periods.
• Increase activity and limit immobility.
• Provide exercise to combat the effects of immobility and to "burn off" excess energy.
• Decrease caffeine intake to help reduce agitation and restlessness.
• Manage client's discomfort/pain.
• Promptly identify and treat infections.

Communication
Interventions
• Use short, simple sentences.
• Speak slowly and clearly, pitching voice low to increase likelihood of being heard; do not act rushed, do not
shout.
• Identify self by name at each contact; call client by his/her preferred name.
• Repeat questions if needed, allowing adequate time for response.
• Point to objects or demonstrate desired actions.
• Tell clients what you want done - not what not to do.
• Listen to what the client says, observe behaviours and try to identify the message, emotion, or need that is being
communicated.
• Validation Therapy: technique tries to find the reason behind the expressed feeling.
• Resolution Therapy: attempts to understand and acknowledge the confused client's feelings.
• Use nonverbal communication alone or in combination with verbal messages.
• Educate the client (when not confused) and family.

Environment
Interventions
• Reality Orientation: offer orienting information as a normal part of daily care and activities.
Repeat information as necessary for the confused person.
Provide orienting information and explain the situation, unfamiliar equipment (e.g., monitors, intravenous lines,
oxygen delivery devices), the rules/ regulations, plan for care, and the need for safety measures.
• Remove unfamiliar equipment/devices as soon as possible.
• Provide call bell and be sure it is within reach. The client should understand its purpose and be able to use it.
• Use calendars and clocks to help orient client.
• Limit possible misinterpretations or altered perceptions which may occur due to pictures, alarms, decorations,
costumed figures, television, radio and call system.
• Work with client to correctly interpret his/her environment.
• Establish a consistent routine, use primary nursing and consistency in caregivers.
• Bring in items from the client's home, allow the client to wear his/her own clothes.
• Avoid room changes, especially at night. Put delirious, disruptive clients in a private room if at all possible.
• Create an environment that is as "hazard free" as possible.
• Provide adequate supervision of acutely confused/delirious clients.
• Avoid physical restraint whenever possible; use a sitter or have a family member stay with the client if safety is a
concern. If restraints must be used, use the least restrictive of these.
• Consider moving the client closer to the nurses' station.
• Environmental manipulations may be appropriate if many clients wander: wandering alarms, exit door alarms, or
painting lines on floor in front of exits or rooms you do not want the client to enter. Wandering can also be
managed through "collusion", walking with resident, then you or other staff, "invite" him/her to return to
ward/facility.
• Have a plan to deal with disruptive behaviour; keep your hands in sight; avoid "threatening" gestures or
movement; remove potentially harmful objects from client, room, and the caregiver's person. Bear in mind that
these episodes may not be remembered by clients. If they are remembered, often they are the cause of
embarrassment.

Sound and Light

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Interventions
• Keep the environment calm and quiet with adequate, but soft, indirect light and limit noise levels.
• Provide glasses and hearing aides to maximize sensory perception.
Consider the use of night lights to combat nighttime confusion.
• Use music which has an individual significance to the confused and agitated client to prevent the increase in or
decrease agitated behaviours.

Psychosocial
Interventions
• Encourage clients to be involved in, and to control, as much of their care as possible.
• Be sure to allow them to set their own limits, and do not force clients to do things they do not want to, as this is
likely to cause disruptive behaviours. Reminiscing can also help increase selfesteem.

Social Interaction
Interventions
• Encourage family and friends to visit, but visits work best when scheduled, and numbers of visitors and lengths
of visits should be limited so as not to overwhelm the client.
• Consider involving the client in programming so as to decrease his/her social isolation (physiotherapy and
occupational therapy may be potential options).

Other Interventions
Interventions
• Consult with a Nurse Specialist/Geriatrics or Psychiatry for severe disruptive behaviours, psychosis, or if
symptoms do not resolve in 48 hours.
• Provide reassurance to clients both during and after acute confusion/delirious episodes.
• Acknowledge client's feelings/fears.
• Allow clients to engage in activities that limit anxiety.
• Avoid demanding abstract thinking for delirious clients, keep tasks concrete.
• Limit choices, and offer decision-making only when clients are capable of making these judgments.

Behavioural Management Interventions (for disruptive behaviours seen as part of Acute Confusion
Interventions
Changing staffing patterns or altering care routine (including amount/type of touching).
• One to one supervision. • Pay attention to clients.

• Talk with/counsel clients; give verbal reprimands.

• Ignore.
• Removal of client from the situation; time out; seclusion/isolation. Reposition.
• Positive reinforcement of desired behaviours; removal of reinforcer of undesired behaviour.
• Restrict activities.
• Physical or chemical restraint as a last resort.

Cognitive and Attentional Limitation Interventions (for disruptive behaviours seen as part of Acute Confusion
Interventions
• Diversion can be used to distract the client from the disruptive behaviours that she/he is currently engaging in.
• Divide activities into small steps in order to simplify them and decrease likelihood of causing disruptive
behaviours.
• Determine what triggered or caused the disruptive behaviour, and try to prevent its occurrence.

Pharmaceutical Interventions
Interventions
• In general, limit use of medications (to the extent possible) in clients with acute confusion and disruptive
behaviours.
• Regularly evaluate each medication used and consider discontinuing. If this is not possible, use the minimal
number of medications in the lowest effective doses.
• Monitor for intended and adverse effects of medications.
• Treat pain in the delirious client; however, be alert for narcotic induced confusion and disruptive behaviours.
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• Avoid medicating clients to control wandering, as medications are likely to make them drowsy and light-headed,
increasing the risk for falls
• Be sure to monitor for side, untoward or paradoxical effect

CONFUSION
• Confusion is a symptom that makes you feel as if you can’t think clearly.
• You might feel disoriented and have a hard time focusing or making decisions.
• Confusion is also referred to as disorientation.
• In its extreme state, it’s referred to as delirium.
Nonpharmacological Interventions
Psychological and physical interventions can be seen as an adjunct to pharmacological therapies. Nonpharmacological
interventions may or may not be totally effective on their own as an analgesic, but their use is frequently beneficial for
the patients.
Choice of nonpharmacologic intervention is determined by (1) the nature of each case, (2) what works for a specific patient
and (3) the skills of the clinician. Nonpharmacologic interventions are relatively noninvasive, and may present less risk to
the patient than invasive or pharmacologic measures. They often are more time consuming for the patient and the nurse,
and they usually place the patient in a more active role. A nurse needs to consult the individual institutional/agency
policies and procedures about implementation of nonpharmacologic interventions and the need for physician's orders or
the necessity to involve a more skilled practitioner.

Psychological Modalities
Distraction can be useful by changing the patient's attention to stimuli other than the pain sensation. It usually makes
pain more bearable (i.e., reduces pain intensity), though it does not eliminate the pain. Distraction topics need to be
interesting to the patient and consistent with the patient's energy level and ability to concentrate. The effect of distraction
can change with a change in the patient's pain. The presence of pain or the return of pain at the end of the distraction
technique is real and is an indicator only of how effective the distraction was in interfering with the pain perception. Types
of distraction include watching TV, listening to music, engaging in imagery, and visiting with friends and family; patients
automatically engage in these activities to reduce pain.
Controlled breathing increases oxygenation and improves the elimination of carbon dioxide. This is an extremely useful
technique for patients in labor and when transferring patients, for example, from bed to stretcher or from bed to chair.
Active listening, as a nursing intervention, conveys support of the patient and trust in the patient. It offers the patient
reassurance and allows the patient the opportunity to discuss other issues, which may be increasing the stress of
hospitalization or illness, such as financial concerns, childcare issues, or employment issues. Research indicates that stress
influences pain, so efforts to reduce stress may dramatically decrease pain.
Patient education, depending upon the patient's anxiety level, may or may not be beneficial for any given patient. Let the
questions the patient asks guide the amount and type of patient education. Patient education in pre- and postoperative
care, procedural events, and in discharge planning is beneficial when anxiety is reduced and pain, therefore, lessens.
Reinforce or modify pain control behaviors by observing patients to see what they do to reduce or control pain. Such
observation may provide important information for tailoring nursing interventions to a specific patient. Reinforce use of
a given activity if it is beneficial for the patient. Recommend modifications of the activity if it may be causing additional
problems. Patients often use techniques of rubbing, positioning, splinting, and limping to decrease their pain or to limit
the pain they may experience with a given activity.
Relaxation strategies are indicated in the presence of muscle tension. Patients can be trained to use relaxation strategies
relatively easily. No special equipment is required and the nurse does not need extensive training. There are different
styles of relaxation training, including progressive muscle relaxation, autogenic training, and biofeedback. Relaxation can
be as simple as a brief quieting response.
Consultants are resources for nurses as they consider nonpharmacologic interventions as adjuncts treatments of pain. If
necessary, there are many supportive services that can be obtained through the use of social workers, psychologists,
psychiatrists, massage therapists, biofeedback therapists, therapeutic touch practitioners, music therapists, and physical
therapists.

Physical Modalities
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Beds are often overlooked as a pain control strategy. Nurses often are in the position to recommend use of different
mattresses to physicians for improved patient comfort. Mattress options include fluidized, air, and foam overlays. Bedding
itself often can be wrinkled or irritating. Pillows can be used to stabilize a joint, to prevent deformity, and to help splint an
incision for improved coughing effort. A pillow, brought from home, can provide psychological comfort to some inpatients.
Massage can decrease muscle tension and can break the cycle of tension --> increased pain --> increased tension. Massage
may activate large diameter fibers, inhibit pain messages carried by smaller fibers, increase endorphins, and cause
decreased sensitivity to pain. Massage produces variable and unpredictable results, but there is usually a reduction in the
intensity of pain during massage and for a short period after. Unpredictable results may be associated with the presence
of hyperalgesia (exaggerated pain sensation) or allodynia (nonpainful stimulus perceived as painful, e.g., touch) and may
be contraindications for massage. Massage may change the character of the pain or may change the pain to a more
acceptable sensation. It can help bring about mental and physical relaxation, and it strengthens the nurse-patient
relationship. Massage can be incorporated into routine nursing care: apply lotion, give a back rub, or give a neck rub. More
sophisticated massage techniques can be learned.
Heat application helps to reduce striated muscle spasm, relax smooth muscles, reduce peristalsis, and reduce gastric
acidity. It causes vasodilation resulting in increased blood flow. Nurses can apply heat through the use of warm blankets,
electric heating pads, or moist hot packs, and by assisting the patient to shower or bathe.
Cold application can also reduce muscle spasm by reducing muscle spindle response. It causes vasoconstriction resulting
in reduction in bleeding and edema. It is felt to have a longer lasting effect than application of heat. Cold can decrease
inflammation and results in increased peristalsis of the stomach, small bowel, and colon. Nurses can use ice packs, ice
cubes, and cool wash clothes to apply cold therapy to patients.
Positioning is another simple strategy for pain control. Simply assisting a patient to change position in the bed or chair or
while ambulating can improve comfort. Additionally, appropriate body alignment and support of extremities can improve
patient comfort and outlook. Keeping items within reach also makes a patient more comfortable. Ensuring that the over-
bed table, the telephone, the nurse call button, and the PCA control button are all within a patient's reach not only
decreases repeat demands from the patient, but also decreases patient anxiety.
Exercise programs have been shown to reduce fatigue. The value of exercise is becoming known. Complete rest, even
following orthopedic injuries, is no longer advocated because of the potential for progressive shortening of muscle fibers,
muscle atrophy, and deterioration of bones and joints. Although exercise is most often the responsibility of a physical
therapist, nurses can assist their patients in active or passive range of motion and encourage general conditioning and
strengthening exercises. Some patients report an improvement in comfort when joints are kept active.
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