SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
COLLEGE OF NURSING
NCM 3N - FUNDAMENTALS OF NURSING
COMFORT, PAIN MANAGEMENT, REST and SLEEP
INTRODUCTION:
The experience of pain and the quality of rest and sleep are both factors that can have a
significant impact on the client’s health. Both are personal experiences that can affect all other
aspects of an individual’s health including physical well-being, mental status and effectiveness of the
coping mechanisms.
An individual who is generally at peace with herself and with the environment is said to be
comfortable. Discomforts can result from both psychological and physical stimuli. Of all the signs and
symptoms of illness, pain is perhaps the most common form of discomfort. People who have pain
experience varying degrees of distress, from the mild feeling of discomfort to an acute feeling of
agony that obliterates all other sensations. The patient who is uncomfortable because of pain may
appear restless, pale, tense or may have sleepless nights as well as anxiety.
This discussion will explore the nature of pin, the importance of rest and sleep and the nursing
care that will help clients maintain their optimal health when the presence of pain or disturbances in
rest and sleep patterns threaten to compromise their health status.
PAIN – a sensation of physical or mental hurt or suffering that causes distress or agony to the one
experiencing it.
• It is whatever the patient says it is
• It exists whenever the patient says it is
• It is subjective in nature, only the person experiencing it may describe it
• It is protective because it provides warning signal for tissue injury. It helps minimize
injury and is often a protective injury – prevention mechanism.
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
Theories of Pain
1. Pattern Theory – it states that pain is perceived whenever the stimulus is intense enough.
2. Specificity Theory – it states that there are specific nerve receptors for particular stimuli e.g.
nociceptors for noxious stimuli; thermoreceptors for heat or cold; mechanoreceptors for
pressure, pulling or tearing sensation; chemoreceptors for chemicals.
3. Gate control Theory – it conceptualizes that there is a gate in the spinal cord called substantia
gelatinosa. When the gate is open, pain stimulus is transmitted, thus, pain is perceived. When
the gate is closed, pain stimulus is blocked, thus, no pain is perceived. This theory was
introduced by Wall and Melzack.
4. Affect Theory – it avers that pain is emotional. The intensity of pain perceived depends on the
value of organ affected to the individual.
5. Parallel Processing Model – it believes that the physiologic or neurologic deciphering of the
pain sensation and the cognitive emotional properties occur along different nerve fibers.
Factors influencing the Pain experience
1. Age 7. Religious beliefs
2. Sex 8. Expected response
3. Childhood 9. Setting
4. Cultural Background 10. Diagnosis
5. Psychological factors 11. Physical, Mental health
6. Previous experience 12. Knowledge/ understanding
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PAASCU
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
Pain threshold – the amount of pain stimulation a person requires before feeling pain. Generally
fairly uniform among people.
Pain Tolerance – the maximum amount and duration of pain that an individual is willing to endure.
Varies greatly among people.
Pain perception – the actual feeling of pain
Bradykinin – universal stimulus for pain
Hyperalgesia – excessive sensitivity to pain.
Physiology of Pain
Stimuli Nerve Fibers (Nociceptors)
A-Delta fibers C- fibers
(large, Myelinated) ( small, unmyelinated )
• Conduct impulses rapidly • Conduct impulses slowly
• Sharp, pricking pain • Dull, aching burning sensation
• Superficial somatic pain • Deep somatic and visceral pain
Spinal cord
( Substantia Gelatinosa )
Thalamus
( Center for awareness of pain)
Cerebral Cortex
(Center for interpretation of pain
Response
n
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
Types of responses to Pain
1. Involuntary Responses
a. Physiologic responses – are mediated by the autonomic nervous system. If the
pain is mild to moderate, it is manifested by sympathetic response stimulation. If
the pain is severe it is manifested by parasympathetic response stimulation.
2. Voluntary Response
a. Behavioral responses - Crying, moaning, grimacing, tossing in bed, splinting the
painful area, assuming fetal position.
b. Emotional responses – depression, withdrawal, social isolation
Three Stages of Pain Responses
1. Activation – begins with the perception of pain. The body assumes a fight or flight reaction
initiated by the sympathetic nervous system.
2. Rebound – the pain experienced is intense but brief. The parasympathetic nervous system
dominates
3. Adaptation – this may be due to endorphins counteracting the pain. This occurs when the
pain last for many hours or days.
Classification of Pain
A. Types of Pain
1. Cutaneous or Superficial Pain – it occurs over the body surface or skin segment.
2. Somatic Pain – may be deep or superficial. It occurs in the skin, muscles or joints
3. Visceral Pain – it arises from stimulation of pain receptors in the abdominal cavity and
thorax
4. Referred Pain – the pain is perceived at an area other than the site of injury
PhilHealth Accredited
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
5. Intractable Pain – it is resistant to cure or relief.
6. Phantom Pain – is actual pain felt in a body part that is no longer present, eg, pain
experienced after amputation of limbs
7. Radiating Pain – it is felt at the source and extends to surrounding tissues
8. Psychogenic Pain – it is primarily due to emotional factors, with physiologic basis
9. Intermittent Pain – pain that stops and starts again
B. Location – this provides information on the organ affected. Eg. Epigastric area, RUQ, LLQ
C. Duration
1. Acute Pain – sudden onset, last for less than 6 months
2. Chronic pain – gradual onset, lasts for more than 6 months to years
D. Character / Quality – whatever description the client gives, accept it as is,
eg, pricking, dull, throbbing, stabbing
E. Intensity / Severity – use scale of 0 – 10;
0 – no pain; 1-3 mild pain; 4-6- moderate pain; 7-10- severe pain
F. Factors Relieve / Aggravate Pain – eg chest pain in angina can be relieved by rest or
nitroglycerine
G. Effects of ADL – eg – back pain in a client with herniated nucleus pulposus which can no
longer be relieved by medications may require surgery
Neurosurgery for Relief of Pain
1. Neurectomy - interrupts cranial or peripheral nerves by an incision
2. Rhizotomy – interruption of the anterior or posterior nerve root area close to the spinal cord .
3. Cordotomy or Spinothalamic Tractotomy – the surgical interruption of pain – conducting
pathways within the spinal cord. The incision is made in the anterolateral pathway opposite
the side on which the pain is located.
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
4. Tractotomy – surgical resection of the anterolateral pathway in the brainstem
5. Gyrectomy – removal of the postcentral gyrus ( part of the sensory cortex of the brain )
6. Hypophysectomy – destroying of the pituitary gland by injection with absolute alcohol.
Pain Modulation
Endogenous Oploids – chemical regulators that may modify pain
• Enkephalins – the inhibit the release of substance P, a neurotransmitter which enhances
transmission of pain impulses
• Endorphins – they are more potent than the enkephalins
• Dynorphins – they have analgesic effect, which is 50 times more potent than endorphins
Nursing Care of the Patient with Pain
1. Techniques that stimulate the skin ( enhance secretion of serotonin, a neurotransmitter that
block transmission of pain impulses )
• Therapeutic touch – energy is transmitted from one person to another
• Contralateral stimulation – stimulating the skin in an area opposite to the painful area.
• Vibration
• Heat and cold application
• Acupuncture / acupressure
• TENS ( transcutaneous electrical nerve stimulation)
2. Techniques that distract attention – to close the gate by acting on the thalamus.
• Staring
• Slow, rhythmic breathing
• Recite, sing
• Describe something in detail
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
• Listen to music
• Conversation
• Read, play games
• Busy oneself, (chores or hobbies )
• Favorite toy
3. Techniques that promote relaxation
• Conventional method
• Relax muscles
• Listen to music
• Guided imagery – use of images or fantasy to achieve specific health related goals
• Meditation, yoga, biofeedback
• Biofeedback is conscious control of the physiologic response under the control of
ANS ( Autonomic Nervous System ) eg, heart rate, BP, RR
• Autogenic Training – involves relaxation and physiologic control by a system of self-
suggestion in which the client repeats phrases to themselves
• Analgesic - administer analgesic at the start of pain. It is no longer effective when pain
reaches its peak.
• Placebo – a non- organic substance that satisfies the patient’s request for analgesic. It
requires physician’s order
PhilHealth Accredited
PAASCU
Accredited
Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
REST and SLEEP
Rest – diminished state of activity, calmness, relaxation without emotional stress;
freedom from anxiety
Sleep – a state of consciousness in which the individual’s perception and reaction to the environment
are decreased.
Physiology of Sleep
Reticular Activating System ( RAS ) – maintains a state of wakefulness and mediates stages of sleep.
Sleep is an active process involving the RAS and a dynamic interaction of neurotransmitters.
Serotonin is a major neurotransmitter associated with sleep. It is derived from its precursor
Tryptophan, a naturally occurring amino acid. It decreases activity of RAS, thereby inducing and
sustaining sleep. Other neurotransmitters – acetylcholine and norepinephrine appear to be required
for the REM sleep cycle
Theories of Sleep
1. Active Theory of Sleep – proposes that there are centers that cause sleep by inhibiting other
brain centers
2. Passive Theory of Sleep – states that the RAS of the brain simply fatigues and therefore
becomes inactive thus, sleep occurs.
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
Stages of Sleep
1. NREM ( Non- rapid eye movement ) Stage
a. Stage 1
• Very light sleep
• Drowsy, relaxed
• Readily awakened
b. Stage 2
• Light sleep
• Eyes are still
• Heart and respiratory rate decrease slightly
• Body temperature falls
c. Stage 3
• Domination of PNS
• Body process slows further
• Difficult to arouse
d. Stage 4
• Difficult to arouse
• Decrease BP, RR, PR Temp,
• Decrease metabolism, brain waves, muscle relaxed
2. REM ( Rapid eye movement )Stage
• Eyes appear to roll
• Paradoxical sleep
• Close to wakefulness but difficult to arouse
• Dream state of sleep
PhilHealth Accredited
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
• Sympathetic nervous system dominates
• Flow of gastric acid increases
• Restores a person mentally-learning, psychologic adaptation and memory
• The sleeper reviews the day’s events and processes and stores information.
Functions of Sleep
1. NREM – for body restoration
2. REM – increase in synthetic processes in the brain
Nursing Intervention to Promote Sleep
1. Helping nurse-patient relationship
2. Promote comfort and relaxation
3. Create restful environment
4. Attend to bedtime rituals
5. Adequate exercise. Exercise at least 2 hours before sleep to enhance NREM not immediately
before sleep
6. High protein food. Protein contains tryptophan, which is a CNS depressant
7. Observe habits of sleep periodicity and wake-up time
8. Avoid caffeine and alcohol in the evening
9. Go to bed when sleepy
10. Use the bed mainly for sleep
11. Use sedative- hypnotics judiciously
PhilHealth Accredited
PAASCU
Accredited
Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE
Common Sleep Disorders
1. Insomnia
• Difficulty in falling asleep
• Intermittent sleep
• Premature awakening
2. Hypersomnia
• Excessive sleep ( daytime or nighttime )
• Related to psychologic problems, CNS damage, metabolic disorders
3. Narcolepsy
• Overwhelming sleepiness
• REM uncontrolled
4. Sleep Apnea
• Periodic cessation of breathing during asleep. It is characterized by snoring
5. Parasomnias
• Somnambulism – sleep walking
• Night Terrors – after having slept for few hours the child bolts upright in bed, shakes
and screams, appears pale and terrified
• Nocturnal Enuresis – bedwetting
• Soliloquy – sleep talking
• Nocturnal Erections – wet dreams usually experienced by adolescent males
• Bruxism – clenching and grinding of teeth during sleep. May erode and diminish the
height of dental crowns and may cause the teeth to become loose.
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Hospital Tel. Nos.: 831-9731/36; 831-5641/49 www.sanjuandedios.org College Tel. Nos.: 551-2756; 551-2763 www.sjdefi.edu.ph
