Comfort, rest, and sleep are needed for well-being. The total person—the physical, emotional, social, and spiritual—is affected by comfort, rest, and sleep problems. Discomfort and pain can be physical or emotional. Whatever the cause, they affect rest, sleep, function, and quality of life.

Rest and sleep restore energy and well-being. Illness and injury increase the need for rest and sleep. The body needs more energy for healing, repair, and daily functions.

See Focus on Long-Term Care and Home Care: Comfort, Rest, and Sleep.

Focus on Long-Term Care and Home Care

Comfort, Rest, and Sleep

Long-Term Care

The Omnibus Budget Reconciliation Act of 1987 (OBRA) and the Centers for Medicare & Medicaid Services (CMS) require care that promotes well-being. Therefore nursing center rooms are designed and equipped for comfort.

Comfort

Comfort is a state of well-being. The person has no physical or emotional pain. He or she is calm and at peace. Age, illness, and activity affect comfort. So do temperature, ventilation, noise, odors, and lighting. Such factors are controlled to the meet the person’s needs (Chapter 20).

See Focus on Communication: Comfort.

Focus on Communication

Comfort

Do not assume the person is comfortable. Ask the following.

• “Are you comfortable?”

• “How can I help you be more comfortable?”

• “Are you warm enough?”

• “Do you need another blanket?”

• “Do you need another pillow?”

• “Should I adjust your pillow?”

Pain

Pain or discomfort means to ache, hurt, or be sore. It is unpleasant. Comfort and discomfort are subjective (Chapter 8). That is, you cannot see, hear, touch, or smell pain or discomfort. You must rely on what the person says. Report complaints to the nurse for the nursing process.

Pain differs for each person. What hurts to one person may ache to another. What one person calls sore, another may call aching. If a person complains of pain or discomfort, the person has pain or discomfort. Believe the person.

Pain is a warning sign from the body. Often called the fifth vital sign (Chapter 29), it signals tissue damage. Pain often causes the person to seek health care.

See Focus on Communication: Pain.

See Focus on Surveys: Pain.

Focus on Communication

Pain

Communicating with persons about pain promotes comfort. You can say:

• “I want you to be comfortable. Please tell me if you are having any pain.”

• “I will tell the nurse about your pain.”

If a person complains of pain, the person has pain. You must rely on what the person tells you. Promptly report any complaints of pain to the nurse.

Focus on Surveys

Pain

Pain interferes with well-being. Pain affects function, mobility, mood, sleep, and quality of life. The agency must:

• Recognize when a person has pain.

• Identify when pain might occur.

• Evaluate pain and its causes.

• Manage or prevent pain.

You may be the first to notice signs and symptoms of pain. You must recognize a change in the person’s behavior and function. And you must report such changes to the nurse.

You provide pain-relief measures according to the care plan. Therefore a surveyor may ask you questions about pain. Examples are:

• What are the signs and symptoms of pain?

• How do you ask a person to rate the intensity of pain?

• What factors can cause pain or make it worse?

• When and how do you report observations about pain?

• How do you assist the nurse with pain-relief measures?

Types of Pain

Doctors use the type of pain for diagnosing. Nurses use the type for the nursing process.

• Acute pain is felt suddenly from injury, disease, trauma, or surgery. It may signal a new injury or a life-threatening event. There is tissue damage. Acute pain lasts a short time and lessens with healing.

• Chronic pain (persistent pain) continues for a long time (months or years) or occurs off and on. There is no longer tissue damage. Chronic pain remains long after healing. Arthritis is a common cause.

• Radiating pain is felt at the site of tissue damage and in nearby areas. Pain from a heart attack is often felt in the left chest, left jaw, left shoulder, and left arm. Gallbladder disease can cause pain in the right upper abdomen, the back, and the right shoulder (Fig. 31-1).

Figure 31-1 Gallbladder pain may radiate to the right upper abdomen, the back, and the right shoulder.

• Phantom pain is felt in a body part that is no longer there. For example, a person with an amputated leg may still sense leg pain.

Factors Affecting Pain

A person may handle pain well one time and poorly the next time. Many factors affect reactions to pain.

Past Experience.

Past experiences help us learn what to do or expect. Whether it is going to school, driving, taking a test, shopping, having a baby, or caring for children, the past prepares us for like events at another time. We also learn from the experiences of others.

The severity of pain, its cause, how long it lasted, and if relief occurred all affect the current response to pain. Knowing what to expect can help or hinder the person’s response.

Some people have not had pain. When it occurs, pain can cause fear and anxiety. They can make pain worse.

Anxiety.

Anxiety relates to feelings of fear, dread, worry, and concern. The person is uneasy, tense, and feels troubled or threatened. Sensing danger, the person does not know what is wrong or why.

Pain and anxiety are related. Pain can cause anxiety. Anxiety worsens pain. Reducing anxiety helps lessen pain. For example, the nurse explains about pain after surgery and about pain-relief drugs. The person knows the cause of pain and what to expect. This helps lessen anxiety and therefore the amount of pain.

Rest and Sleep.

Rest and sleep restore energy and reduce body demands. The body repairs itself. Without needed rest and sleep, thinking and coping with daily life are affected. Pain seems worse. Rest and sleep needs increase with illness and injury.

Attention.

Thinking about pain makes it seem worse. Pain may be all that the person thinks about. Even mild pain can seem worse if it is the person’s main focus.

Pain often seems worse at night. Activity is less, music and TV are off, and it is quiet. There are no visitors. Others are asleep. When unable to sleep, the person has time to think about pain.

Personal and Family Duties.

Often pain is ignored when there are children to care for. Some people go to work with pain. Others deny pain, fearing a serious illness. Illness can interfere with a job, going to school, or caring for children, a partner, or ill parents.

The Value or Meaning of Pain.

To some people, pain is a sign of weakness. It may mean a serious illness with painful tests and treatments. Therefore pain is ignored or denied. Pain can bring pleasure. The pain of childbirth is an example.

For some persons, pain means not having to work or assume daily routines. Pain is used to avoid certain people or things. The pain is useful. Some people like to be doted on and pampered. The person values and wants the attention.

Support From Others.

Dealing with pain is often easier when family and friends offer comfort and support. The pain of childbirth is easier with support and encouragement from a loving father. A child bears pain better when comforted by a parent or family member. The use of touch by a valued person is comforting. Just being nearby also helps.

With no family or friends, some people deal with pain alone. Being alone can increase anxiety. The person has more time to think about the pain. Facing pain alone is hard, especially for children and older persons.

Culture.

Culture affects pain responses. In some cultures, the person in pain is stoic. To be stoic means to show no reaction to joy, sorrow, pleasure, or pain. Strong verbal and nonverbal pain reactions are seen in other cultures. See Caring About Culture: Pain Reactions.

Non-English-speaking persons may have problems describing pain in English. The agency must identify these persons. The agency uses interpreters to communicate with the person. All persons have the right to be comfortable and as pain-free as possible.

Caring About Culture

Pain Reactions

People of Mexico and the Philippines may appear stoic in reaction to pain. In the Philippines, pain is viewed as the will of God. It is believed that God will give strength to bear the pain.

In Vietnam, pain may be severe before pain-relief measures are requested. The people of India accept pain quietly. They accept pain-relief measures.

In China, showing emotion is a weakness of character. Therefore pain is often suppressed.

From D’Avanzo CE: Pocket guide to cultural health assessment, ed 4, St Louis, 2008, Mosby.

Illness.

Some diseases affect pain sensations. Central nervous system disorders are examples. The person may not feel pain. Or it may be severe. Pain signals illness or injury. If pain is not felt, the person does not know to seek health care. The person is at risk for undetected disease or injury.

Age.

See Focus on Children and Older Persons: Factors Affecting Pain.

Focus on Children and Older Persons

Factors Affecting Pain

Children

Children know that pain feels bad. They have fewer pain experiences. They do not understand pain or know what to expect.

Children rely on adults to help relieve their pain. They may restrict play, school, and sports to lessen pain. Children cannot manage pain like adults do. Adults can buy some pain-relief drugs. They can go to a doctor. They apply heat or cold applications. They can distract attention away from pain with music, work, reading, and hobbies.

You must be alert to behaviors that signal a child’s pain. Infants cry, fuss, and are restless. Such behaviors also mean hunger and needing a diaper changed. Toddlers and pre-schoolers may not have the words to express pain.

Older Persons

Some older persons have many painful health problems. Chronic pain may mask new pain. Older persons may ignore or deny new pain. They may think it relates to a known problem. Or they deny or ignore pain because of what it may mean.

Thinking and reasoning are affected in some older persons. Some cannot tell you about pain. Behavior changes may signal pain. Increased confusion, grimacing, restlessness, and loss of appetite are examples. A person who normally moans and groans may become quiet and withdraw. A friendly and outgoing person may become agitated and aggressive. One who is nonverbal and quiet may become restless and cry easily.

Always report changes in the person’s behavior. All persons have the right to correct pain management. The nurse does a pain assessment when behavior changes.

Signs and Symptoms

You cannot see, hear, feel, or smell the person’s pain. Rely on what the person tells you. Promptly report any information you collect about pain. Write down what the person says. Use the person’s exact words to report and record. The nurse needs the following information.

• Location. Where is the pain? Ask the person to point to the area of pain. Pain can radiate. Ask the person if the pain is anywhere else and to point to those areas.

• Onset and duration. When did the pain start? How long has it lasted?

• Intensity. Does the person complain of mild, moderate, or severe pain? Ask the person to rate the pain on a scale of 0 to 10, with 10 as the most severe (Fig. 31-2). Or use the Wong-Baker FACES^® Pain Rating Scale (Fig. 31-3). Designed for children, the scale is useful for all age-groups. To use the scale, tell the person that each face shows how a person feels. Read the description for each face. Then ask the person to choose the face best describing how he or she feels.