COMFORT AND SLEEP

OLEH:
Ns. Lilik Supriati, M.Kep
The experience of pain and the quality of
rest and sleep are both factors that can
have a significant impact on a clents
health

Both are personal experiences that can

affect all other aspect of individuals
health, including physical, mental,
effectiveness coping mechanisms
Concepts Associated with Pain
Pain threshold - amount of stimulation
required before feeling pain
Pain perception - point at which a person
first becomes aware of pain
Pain rection - response to pain (physiologic
and behavioral)
Pain Tolerance _ maximum amount of pain an
individual is willing to endure
definition
continued

" Universal experience

" Highly subjective
" Defense mechanism
_Pain is whatever the experiencing person
says it is, existing whenever the person
says it does
McCaffery & Pasero, 1999
The experience of pain
Three systems interact usually to
produce pain:
1. sensory - discriminative
2. motivational - affective
3. cognitive - evaluative
 Sensory - discriminative system processes
information about the strength, intensity,
quality and temporal and spatial aspects
of pain

Motivational - affective system

determines the individuals approach-
avoidance behaviours
 3. Cognitive - evaluative system overlies the
individuals learned behaviour concerning
the experience of pain. It may block,
modulate, or enhance the perception of pain
Physiology of pain
Injured tissue

stimulate nociceptor and CNS

Change in cells within the spinal cord afferent and

efferent pain pathways

Physiological responses
Physiology of Pain Perception
Nociceptors_ pain receptors that receive
& transmit impulses Location: most
body tissues Most abundant: skin,
periosteum joint surfaces, arterial walls
Absent in: lungs, brain
 Nociceptors stimulated by

1. Damage to cells _ mechanical, thermal

chemical
2. Release of chemical substances
_Bradykinin, histamine & substance P
(activate nociceptors)
3. Vasodilators increase capillary
permeability and constrict smooth
muscle
4. Neurotramsmitters such as
prostaglandins sensitivity to the effects
of Bradykinin
5. Histamine released with substance P
neurotransmitter
Type of nociceptor
1. A delta
5-30 m/s
Small diameter (2-5 microns)
Thinly myelinated
Mediated sharp pain
Type of nociceptor
2. C fibers
0,5-2 m/s
Veri small diameter axons (0,5-1micron)
Unmyelinated axons
Mediated dull pain
Injury responses
The Pain Process
Transduction activation of pain
receptors
Transmission conduction along
pathways (A-delta and C-delta fibers)
Modulation initiation of the protective
reflex response
Perception of pain awareness of the
characteristics of pain
ENDOGENOUS OPIOIDS

Bind with opiate receptor sites (CNS)

neuro receptors, pain transmission
(inhibit neurotransmitters)
3 groups of opioids Morphine-like
Enkephalins
Endorphins in happy people
Dynorphins in depression
substances found in Pituitary
Hypothalamus & Brain
Endogenous Opioids (cont.)
Acupuncture,TENS Unit,Placebos

stimulate release of opioids

Ceases to function with chronic pain

Types of Pain

1. Acute _ up to 6 months duration

2. Chronic _ 6 months or longer
limits normal functioning
3. Radiating _ perceived at source and
extends to nearby tissue
4. Referred _ pain felt in a part of body that
is considerably removed from cause
continued
5. Intractable _ resistant to relief _no
response to treatment
6. Phantom _ pain perception in a missing
part
7. Psychogenic _ no evidence of nerve or
tissue damage Originates in the mind
8. Visceral _ pain from abd., thorax, or
cranium caused by ischemia,muscle
spasm, or stretching
continued.

9. Somatic _ pain from skin, muscles,joints

sharp, burning
10. Neuropathic _ pain from peripheral or
CNS disturbance, Shooting,
stabbing(tikaman)
Stressors of Pain Experience
Culture
Ethnic variables
Family, gender, and age variables
Religious beliefs
Environment and support people
Anxiety and other stressors
Past pain experience
 Comparison of Acute and
Chronic pain

Acute Chronic
Mild to severe Mild to severe
Sympathetic n.s. Parasympathetic n.s.
response: response:
pulse rate resp. rate vital signs normal
B.P. Diaphoresis Dilated dry, warm skin
pupils pupils normal or dilated
Related to tissue injury; Continues beyond
resolves (berubah) with healing
healing
Continued.....
Akut Kronis

Client appears restless Client appears

and anxious depressed and
Client reports pain withdrawn
Client exhibits behavior Client often does not
indicative of pain: mention pain unless
crying (kecuali kalau) asked
rubbing area Pain behavior often
holding area absent
Behavioral sign associated
with pain
- bodily movement: withdrwal,rigidity
- state system: change in sleep/wake
cycles, change in activity level
- facial expressions
 Gate Control Theory
Relationship between pain and emotions
Peripheral nerve fibers carry impulses to
spinal cord
Pain input can be modified at the cord before
transmission to the brain
Synapses in the dorsal horn act as gates that
con be opened or closed to painful impulses
Small and large diameter nerve fibers conduct
and inhibit pain stimuli
Gating mechanism determine impulses that
reach the brain
Gate Control Theory
Small fiber
Gate Control Theory
Large fiber
 Gate Control Theory

small fibers carry pain impulses and

open the gate" Mylenated nerve fibers

large fibers that can be stimulated by

heat, cold, or touch and cause gates to
close
The gate is open to nerve impulses from NOCICEPTORS and the pain
is felt
Touch receptors in skin are larger A-delta nerves
Carry impulses quicker to brain and get through gate blocking the pain
Nocceptors
 Assessments of Pain
Source _ Client
1. Pain History (how is pain expressed,past
intervention and respon)
2. Subjective (PQRST)
a. Location
b. Intensity _ pain scale, face scale
c. Quality _ describe
d.Pattern (onset, duration,
consistency)
e.Precipitation/contributing stressors
f. Alleviating/aggravating means
 Lanjutan pengkajian nyeri
3. Objective
a. Position assumed
b. Behavioral / physiologic response
c. Vital signs _ acute vs. chronic
4. Effect on ADL_s
5. Coping Resources
6. Daily Pain Diary
7. Present regiment/effectiveness
 Nursing Diagnoses
" Pain
" Knowledge deficit
" Risk for Injury
Planning
" Focus is to eliminate, modify or prevent pain
" Nurse must develop a trusting relationship
" Prevention is better than dealing with the pain
" Believe the client, accept the client response to
pain
" Listen to the client
 Goals
" Client will verbalize a decrease in pain from
8 to less than 4
" Client will identify three methods to reduce
pain
" Client will use two methods of alternative
pain relief
 Nonpharmacologic Pain Relief
Measures
Cutaneous stimulation
Distraction
Acupuncture
Humor
Hypnosis
Music
Biofeedback
Imagery
Therapeutic touch
Relaxation
 Implementations for Pain
1. Individualized approach
2. Control painful stimuli _ tighten linens _
reposition (comfort measures)
3. Decrease disturbing stimuli - lights
4. Cutaneous Stimulation _ close gate,
stimulates large fiber impulses
a. Backrub (liniments / ointments)
b. Massage
d. Heat _
e. TENS
Lanjutan implementasi
5. Distractions
6. Relaxation (breathing, meditation, Yoga)
7. Nontraditional modalities:
a. Guided imagery
b. Therapeutic Touch
c. Acupuncture / pressure
8. Analgesics
9. Hypnosis
Documentation
Evaluation

" Were goals met???

Rest and Sleep
Objectives
Identify the characteristics of NREM and
REM sleep
Identify the four stages of NREM sleep
Describe variations in sleep patterns
throughout the life span
Identify factors that affect normal sleep
Describe common sleep disorders
 Objectives
Identify the components of a sleep
pattern assessment
Develop nursing diagnosis,
outcomes, and nursing interventions
related to sleep problems
Describe interventions that promote
normal sleep
 definition

Rest
Refers to a state of relaxation and calmness,
both mental & physical.
Sleep
Refers to a state of altered conciousness
during which an individual experiences
fluctuations in level of
conciousness,minimal physical activity,and
a general slowing of the bodys
physiological processes
Stages of Sleep
NREM-Non-REM sleep
Stage I- very light sleep (drowsy-relaxed), can
be easily awakened
Stage II- body process continue to slow,
Stage III-heart and respiratory rate are slower
Stage IV-signals the deepest sleep
REM-Rapid eye Movement : rapid eye movement,
heart & RR irregular and often higher, 80% dreams
occur
Sleep Cycles
NREM (pass the four stages in 1hour)
Sleeper passes from Stage I NREM through stages II
and III to Stage IV in about 20-30 min.
Stages are followed by Stage III and II, and then REM
The duration of a sleep cycle is generally between 70-
90 minutes, and the sleeper will pass through 4-6 sleep
cycles during sleep period of 7 to 8 hours.
Normal Sleep Patterns and Requirements

Newborns- sleep 16 to 18 hours a day, usually

seven sleep periods.
Infants- sleep 22 hours a day,20-30% REM
sleep.
Toddlers- 10-12 hours a day, 20-30% REM
sleep.
Preschoolers- 11-12 hours of sleep per night
School Aged children- 8-12 hours at night.
CONTINUED.......

Adolescents- 8-10 hours of sleep

Young adults- 7-8 hours may require
less
Middle Aged Adults- 6-8 hours per
night
Older Adults- 6 hours
 Factors Affecting Sleep
Age- One of the most important factors
affecting persons sleep and rest periods.
Illness- causing pain or physical distress
can result in sleep problems.
Environment-Noise level
Fatigue- more tired shorter the first
(REM) sleep
Lifestyle-Shift work
Continued
Emotional Stress
Alcohol and Stimulants
Diet
Motivation
Medications
Common Sleep Disorders

Primary Sleep disorders- those in

which the persons sleep problem is
the main disorder.
Secondary Sleep disorder- sleep
disturbance caused by another clinical
disorder, such as thyroid dysfunction,
depression , or alcoholism.
Primary Sleep Disorders
Insomnia- most common sleep disorder,
inability to obtain an adequate amount or
quality of sleep.
Hypersomnia- Opposite of insomnia,
excessive sleep, especially daytime.
Narcolepsy- Sudden wave of
overwhelming sleepiness that occurs
during the day. Referred to as sleep
attack
 Continued
Sleep Apnea- periodic cessation of breathing
during sleep.chracterized by pauses in breathing
of 30 to 60 second during sleep.
Parasomnias- Behavior that may interfere with
sleep. (somnambulism (sleep walking), sleep
talking, Nocturnal enuresis, nocturnal erections,
bruxism (teeth grinding)).
Sleep Deprivation- prolonged disturbance results
in decreases amount, quality, consistency of
sleep. Can result from age, prologed hospitalization,
drug and substance use, illness, and frequent
changes in the life style.
Assessment of Sleep
Assessment relative to a clients sleep
includes a sleep history, sleep diary, a
physical examination, and a review of
diagnostic studies.
 Sleep History
Usual sleeping pattern, specifically
sleeping and waking times, hours of
undisturbed sleep, etc.
Bedtime rituals
Use of sleep medications
Sleep environment
Changes in sleep pattern
Sleep Diary
Written record to be much more precise
Total number of sleep hours a day
Activities performed 2-3 hours before sleep
Bedtime rituals
Any worries that may affect clients sleep
Factors that client believes to be positive or
negative towards sleep
Physical Examination

Observation of clients facial appearance,

behavior, and energy level.
Darkened areas around the eyes,
puffy/bengkak eyelids, reddened conjunctiva,
glazed/lapisan or dull appearing eyes (lesu).
Irritability, yawning/menguap, slumped
posture/lunglai, hand tremor, rubbing of eyes,
confusion, fatigued, lethargic, etc
Planning

Major goal for clients with sleep disturbances

is to maintain a sleeping pattern that provides
sufficient energy for daily activities.
Interventions include- guided imagery,
therapeutic message, progressive muscle
relaxation, uninterrupted sleep periods
Implementation

Nursing interventions to enhance the

quantity and quality of sleep involve
largely non-pharmacologic measures
 Continued
Client teaching
Individuals need to learn the importance of
rest and sleep in maintaining active and
productive lifestyles.
Supporting bedtime rituals
Many are accustomed to rituals or pre-sleep
routines and if altered can affect sleep.
Creating Restful Environment
 Continued
Promoting Comfort and Relaxation
Assist client with hygienic routines
Offer back message
Administer analgesics 30 min before sleep
Enhancing Sleep with Medications
Nurse responsible for making decisions
with the client about when to administer
sedative hypnotics.
 Reducing Environmental
Distractions in Hospitals
Close window curtains if street lights
shine through
Close curtains between client in
semiprivate and larger rooms
Reduce or eliminate overhead lighting:
provide night light at the bedside or in
the bathroom
Close the door of the clients room
 Continue
Perform only essential noisy activities
during sleeping hours
Ensure that all carts wheels are well
oiled
Wear rubber soled shoes
Keep required staff conversations at low
levels: conduct nursing reports or other
discussions in a separate area away
from clients rooms
Thank you....