NCLEX: Pain management

Pain management: A look at pain

Focus topic: Pain management

Pain is a complex, subjective phenomenon that involves biological, psychological, cultural, and social factors. To put it succinctly, pain is whatever the patient says it is, and it occurs whenever she says it does. The only true authority on any given pain is the person experiencing it. Therefore, health care professionals must understand and rely on the patient’s description of her pain when developing a pain management plan. The Joint Commission requires that all patients be assessed for pain.
Each patient reacts to pain differently because pain thresholds and tolerances vary. Pain threshold is a physiologic attribute that denotes the smallest intensity of a painful stimulus required to perceive pain. Pain tolerance is a psychological attribute that describes the amount of stimulus (duration and intensity) that the patient can endure before stating that she’s in pain.

Pain management: Theories about pain

Focus topic: Pain management

Three theories attempt to explain the mechanisms of pain:

  • specificity
  • pattern
  • gate control

Pain management: Let’s get specific

Focus topic: Pain management

The specificity theory maintains that individual specialized peripheral nerve fibers are responsible for pain transmission. This biologically oriented theory doesn’t explain pain tolerance, nor does it allow for social, cultural, or empirical factors that influence pain.

Pain management: Pain pattern

Focus topic: Pain management

The pattern theory suggests that excessive stimulation of all nerve endings produces a unique pattern interpreted by the cerebral cortex as pain. Although this theory addresses the brain’s ability to determine the amount, intensity, and type of sensory input, it doesn’t address nonbiological influences on pain perception and transmission.

Pain management: Opening the gate

Focus topic: Pain management

The gate control theory asserts that some sort of gate mechanism in the spinal cord allows nerve fibers to receive pain sensations. This theory has encouraged a more holistic approach to pain management and research by taking into account the nonbiological components of pain. Pain management techniques, such as cutaneous stimulation, distraction, and acupuncture are, in part, based on this theory.

Pain management: Categorizing pain by duration

Focus topic: Pain management

There are two fundamental pain types that are classified according to their duration: acute and chronic.

Acute pain
Acute pain commonly accompanies tissue damage from injury or disease. It varies from mild to severe in intensity and typically lasts for a brief period (less than 6 months). Acute pain is considered a protective mechanism, alerting the individual to tissue damage or organ disease. A patient can get relief from acute pain, and the pain itself dissipates as the underlying disorder heals.

Pain management: Relief and healing

Focus topic: Pain management

Treatment goals for acute pain include relieving pain and healing the underlying injury or disease responsible for the pain. Palliative treatment may include surgery, drug therapy, application of heat or cold, or psychological and behavioral techniques to control pain.

Pain management

Chronic pain
The cause of chronic pain isn’t always clear. Chronic pain can stem from prolonged disease or dysfunction, as in cancer and arthritis, or it can be associated with a mental disorder such as posttraumatic stress syndrome. It can be intermittent, limited, or persistent and usually lasts 6 months or longer. Instead of stemming from an easily identifiable location, chronic pain is typically generalized. It’s also strongly influenced by the patient’s emotions and environment.

Pain management: Not the pain next door

Focus topic: Pain management

Patients with chronic pain often have difficulty describing what they’re feeling. Different patients also react to the pain in different ways. One may cry out or moan; another may simply withdraw. Changes in appetite and sleep may occur, and patients may become anxious or irritable, but vital signs frequently don’t change.

Pain management: If you can’t beat it, work with it

Focus topic: Pain management

With many patients unable to find complete relief, chronic pain can become a life-altering condition, making long-term pain management challenging. The main goal is to help patients participate as fully as possible in desired daily activities and to get adequate rest, which can improve emotional well-being. Treatments include the use of analgesic medications supplemented with such therapies as massage, heat or ice packs, exercise, meditation, and distraction.

Pain management: Categorizing pain by physiologic source

Focus topic: Pain management

Pain can be classified not just by its duration but also by its physiologic source.

Nociceptive pain
In nociceptive pain, injury or inflammation stimulates special injury-sensing receptors in the peripheral nervous system. The receptors then communicate this information to the brain, resulting in the sensation of pain. The two types of nociceptive pain are somatic pain, which comes from skin, musculoskeletal structures, or connective tissue, and visceral pain, which initiates in organs and the lining of body cavities.

Neuropathic pain
Damage to peripheral nerves or to the central nervous system can result in neuropathic pain. Patients describe this poorly localized type of pain as tingling, burning or fiery, or shooting. Types of neuropathic pain include phantom limb pain that occurs after a limb amputation as well as the peripheral extremity pain that diabetics often experience.

Pain management: Assessing pain

Focus topic: Pain management

The only way to get an accurate understanding of the patient’s pain is to ask him. Begin by asking the patient to describe his pain. Where does it hurt? What exactly does it feel like? When does it start, how long does it last, and how often does it recur? What provokes it? What makes it feel better? There are a variety of assessment tools that can help. Use one to obtain a more accurate and consistent description of pain intensity and relief — two important measurements. The key to effective pain management is an accurate baseline assessment and continual reassessment of the pain.

Pain management: Where does it hurt?

Focus topic: Pain management

Find out how the patient responds to pain. Does his pain interfere with eating? Sleeping? Working? His sex life? His relationships? Ask the patient to point to the area where he feels pain, keeping in mind that:

  • localized pain is felt only at its origin
  • projected pain travels along the nerve pathways
  • radiated pain extends in several directions from the point of origin
  • referred pain occurs in places remote from the site of origin.

Pain management: Nature’s source

Focus topic: Pain management

Factors that influence the nature of a patient’s pain include duration, severity, and source. The source may be:

  • cutaneous, originating in the skin or subcutaneous tissue
  • deep somatic, which includes nerve, bone, muscle, and supporting tissue
  • visceral, which includes the body organs.
    Watch for physiologic responses to pain (nausea, vomiting, changes in vital signs) and behavioral responses to pain (facial expression, movement and positioning, what the patient says or doesn’t say). Also note psychological responses, such as anger, depression, and irritability.

Pain management: All about attitude

Focus topic: Pain management

Assess the patient’s attitude about pain. Ask him how he usually handles pain. Does he tell others when he hurts, or does he try to hide it? Does his family understand his pain and try to help him deal with it? Does he accept their help?

Pain management: Managing pain

Focus topic: Pain management

Pain management can involve drug therapy with opioid or nonopioid analgesics, including patient-controlled analgesia (PCA) and adjuvant analgesics; neurosurgery; transcutaneous electrical nerve stimulation (TENS); cognitive-behavioral strategies; and intrathecal drug delivery via a pain-control pump.

Pain management: Opioid analgesics

Focus topic: Pain management

Opioid analgesics are prescribed to relieve moderate to severe pain. Opioids can be natural or synthetic. Natural opium alkaloids and their derivatives are called opiates. Morphine (Duramorph) is the prototype for both natural and synthetic opioid analgesics.

Pain management: The agony and the ecstasy

Focus topic: Pain management

Opioid analgesics are classified as full agonists, partial agonists, or mixed agonist-antagonists. Agonists are drugs that produce analgesia by binding to central nervous system (CNS) opiate receptors. These drugs are the drugs of choice for severe chronic pain. They include:

  • codeine
  • hydromorphone (Dilaudid)
  • hydrocodone
  • fentanyl transdermal system (Duragesic)
  • methadone (Dolophine)
  • morphine.

Pain management: Up the anti

Focus topic: Pain management

Agonist-antagonists also produce analgesia by binding to CNS receptors. However, they’re of limited use for patients with chronic pain because many have a ceiling effect or upper dosing limit. As the dosage increases, they also can cause hallucinations and other psychotomimetic effects and, in opioid-dependent patients, can produce withdrawal symptoms. This class of drugs includes:

  • buprenorphine (Buprenex)
  • butorphanol (Stadol)
  • nalbuphine
  • pentazocine (Talwin).

Pain management: Any route you choose

Focus topic: Pain management

Opioid analgesics can be given by many routes, including oral, sublingual, buccal, intranasal, rectal, transdermal, I.M., I.V., epidural, intrathecal, and PCA device. For most patients, oral administration is preferred. I.M. administration, though effective, can result in erratic absorption, especially in debilitated patients.
For severe pain, such as the pain caused by an angina attack, I.V. administration may be preferred because it allows the drug to take effect quickly and permits precise dosage control. Be aware that sudden profound respiratory depression and hypotension can occur with this route. Continuous I.V. infusion using a PCA system allows lower dosing.

Pain management: Caution is the key

Focus topic: Pain management

Opioids can produce severe adverse effects; therefore, caution is the key. They’re contraindicated in patients with severe respiratory depression and should be used cautiously in patients with:

  • chronic obstructive pulmonary disease
  • hepatic or renal impairment because they’re metabolized by the liver and excreted by the kidneys
  • head injuries or any condition that raises intracranial pressure (ICP) because they increase ICP and can induce miosis (which can mask pupil dilation, an indicator of increased ICP).

Pain management: But wait, there’s more…

Focus topic: Pain management

Other possible adverse effects include drowsiness, dizziness, nausea, vomiting, itching, constipation, and urine retention. Prolonged use of opioids can cause physical dependency, an expected consequence of long-term opioid use that shouldn’t be confused with addiction.

Pain management: I’ll pencil you in

Focus topic: Pain management

Analgesic schedules are commonly used in managing chronic pain. This approach may call for a single medication (usually an opioid) or a combination of medications to be administered on a set schedule. If breakthrough or acute pain occurs, additional medications may be added.

Monitoring
Before giving an opioid analgesic, make sure the patient isn’t already taking a CNS depressant such as a barbiturate. Concurrent use of another CNS depressant enhances drowsiness, sedation, and disorientation.
During administration, check the patient’s vital signs and watch for respiratory depression. If his respiratory rate declines to 10 breaths/minute or less, call his name, touch him, and tell him to breathe deeply. If he can’t be aroused or if he’s confused or restless, notify the practitioner and prepare to administer oxygen. If ordered, administer an opioid antagonist such as naloxone.

Pain management

Pain management: Countering adverse effects

Focus topic: Pain management

Opioids may have several adverse effects. To prevent or manage them, follow these recommendations:

  • If the patient experiences persistent nausea and vomiting during therapy, ask the practitioner about changing medications and give the patient an antiemetic, such as promethazine (Phenergan), as ordered.
  • To help prevent constipation, administer a stool softener together with a mild laxative. Also, provide a high-fiber diet, and encourage fluids, as ordered. Regular exercise may also promote motility.
  • Encourage the patient to practice coughing and deep-breathing. These exercises promote ventilation and prevent pooling of secretions, which can cause respiratory difficulty.
  • Because opioid analgesics can cause postural hypotension, take measures to avoid accidents. For example, keep the bed at the lowest level with its side rails raised. If the patient is able to move around, help him in and out of bed and walk with him to provide support if necessary.

Pain management: Evaluate for effect

Focus topic: Pain management

Evaluate the effectiveness of the drug. Is the patient experiencing relief? Does his dosage need to be increased because of persistent or worsening pain? Is he developing a tolerance to the drug? Remember that the patient should receive the smallest effective dose over the shortest period. At the same time, a dosage that’s too low to be effective is pointless. Opioid analgesics are safe and effective; they simply require close monitoring to ensure the most effective dosage. Physical and psychological dependence are rare. In fact, psychological dependence occurs in less than 1% of hospitalized patients.

Pain management: Getting worse instead of better?

Focus topic: Pain management

Not all patients develop a tolerance to opioids. If a patient has been taking an opioid long-term and suddenly doesn’t have pain relief, check for worsening of the patient’s condition. Don’t assume he has developed tolerance.

Patient teaching
Teach the patient about his drug therapy and ways to avoid or resolve adverse effects. Tell him to:

  • take the prescribed drug before the pain becomes intense to maximize its effectiveness and talk with the practitioner if the drug seems less effective over time
  • not increase the dose or frequency of administration and take a missed dose as soon as he remembers, while maintaining the interval between doses
  • skip the missed dose if it’s just about time for the next dose to avoid serious complications of a double dose
  • refrain from drinking alcohol while taking the drug to avoid pronounced CNS depression
  • talk with his practitioner if he decides to stop taking the drug because the practitioner can suggest an appropriate gradual dosage reduction to avoid withdrawal symptoms
  • avoid postural hypotension by getting up slowly when getting out of bed or a chair
  • eat a high-fiber diet, drink plenty of fluids, and take a stool softener, if prescribed.

Pain management: Watch out for O.D.

Focus topic: Pain management

Teach the patient’s family the signs of overdose: cold, clammy skin; confusion; severe drowsiness or restlessness; slow or irregular breathing; pinpoint pupils; or unconsciousness. Tell them to notify the practitioner immediately if they notice these signs. Teach them how to maintain the patient’s respiration in an emergency until help arrives.

Pain management

Pain management: Avoiding addiction

Focus topic: Pain management

A concern many health care workers have when caring for patients taking opioid analgesics is the risk of addiction. Discussing the possibility with at-risk patients can help reduce that risk.

Pain management: Nonopioid analgesics

Focus topic: Pain management

Nonopioid analgesics are prescribed to manage mild to moderate pain. When used with an opioid analgesic, they help relieve moderate to severe pain and also allow lower dosing of the opioid agent. These drugs include acetaminophen (Tylenol) and NSAIDs, such as aspirin, ibuprofen (Advil), indomethacin (Indocin), naproxen (Naprosyn), naproxen sodium (Aleve), and ketorolac.

Pain management: Special effects

Focus topic: Pain management

NSAIDs and acetaminophen produce antipyretic and analgesic effects. In addition, as their name suggests, NSAIDs have an antiinflammatory effect. Because these drugs all differ in chemical structure, they vary in their onset of action, duration of effect, and method of metabolism and excretion.
In most cases, the analgesic regimen includes a nonopioid drug even if the patient’s pain is severe enough to warrant treatment with an opioid. They’re commonly used to treat postoperative and postpartum pain, headache, myalgia, arthralgia, dysmenorrhea, and cancer pain.

Pain management: Not so special effects

Focus topic: Pain management

The chief adverse effects of NSAIDs include:

  • inhibited platelet aggregation (rebounds when drug is stopped)
  • GI irritation
  • hepatotoxicity
  • nephrotoxicity
  • headache.
    NSAIDs shouldn’t be used in patients with aspirin sensitivity, especially those with allergies, asthma, and aspirin-induced nasal polyps, due to the increased risk of bronchoconstriction or anaphylaxis. Also, NSAIDs are contraindicated in patients with thrombocytopenia, and should be used cautiously in neutropenic patients because antipyretic activity may mask the only sign of infection. Some NSAIDs are contraindicated in patients with renal dysfunction, hypertension, GI inflammation, or ulcers.

Pain management: Just call me in the morning

Focus topic: Pain management

Aspirin increases prothrombin and bleeding times; consequently, it’s contraindicated in a patient with a bleeding disorder. Don’t administer aspirin with anticoagulants or ulcer-causing drugs such as corticosteroids. Avoid aspirin use in a patient scheduled for surgery within 1 week.
Acetaminophen may be used in place of aspirin and other NSAIDs in patients with peptic ulcer or a bleeding disorder. High doses of acetaminophen may lead to hepatic damage, however.

Monitoring
Before administering nonopioid analgesics, check the patient’s history for a previous hypersensitivity reaction, which may indicate hypersensitivity to a related drug in this group. If the patient is already taking an NSAID, ask him if he has experienced GI irritation. If he has, the practitioner may choose to reduce the dosage or discontinue the drug.
Always report any abnormalities in renal and liver function studies. Also, monitor hematologic studies and evaluate complaints of nausea or gastric burning. Watch for signs of iron deficiency anemia, such as pallor, unusual fatigue, and weakness.

Patient teaching
For a patient taking an NSAID, teach him the signs and symptoms of overdose, hypersensitivity, and GI bleeding, such as rash, dyspnea, confusion, blurred vision, nausea, bloody vomitus, and black, tarry stools. Tell him to report any of these signs to his practitioner immediately.
If the patient is taking acetaminophen, teach him that nausea, vomiting, abdominal cramps, or diarrhea may indicate an overdose and that he should notify his practitioner immediately.

Pain management: Understanding adverse effects

Focus topic: Pain management

To help the patient respond to adverse effects, teach him to:

  • take his medication with food or a full glass of water to minimize the GI upset
  • remain upright for 15 to 30 minutes after taking his medication if he experiences esophageal irritation
  • notify the practitioner if he experiences gastric burning or pain
  • take special care to avoid injury that could cause bleeding because NSAIDs can increase bleeding time
  • talk to the practitioner about persistent tinnitus (a reversible, dose-related adverse effect)
  • exercise caution when driving or using machinery when taking ibuprofen, naproxen, or sulindac (which may cause dizziness)
  • get periodic blood tests to detect nephritis or hepatotoxicity.

Pain management: Adjuvant analgesics

Focus topic: Pain management

Adjuvant analgesics are drugs that have other primary indications but are used as analgesics in some circumstances. Adjuvants may be given in combination with opioids or used alone to treat chronic pain. Patients receiving adjuvant analgesics should be reevaluated periodically to monitor their pain level and check for adverse reactions.

Pain management: A real potpourri

Focus topic: Pain management

Drugs used as adjuvant analgesics include certain anticonvulsants, local and topical anesthetics, muscle relaxants, tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, psychostimulants, and cholinergic blockers.

Pain management

Pain management

Pain management: Neurosurgery

Focus topic: Pain management

Neurosurgery is an extreme form of pain management and is rarely needed. However, there are a number of procedures, such as rhizotomy and cordotomy, that can control pain by surgically modifying critical points in the nervous system.

Pain management: TENS

Focus topic: Pain management

TENS relieves acute and chronic pain by using a mild electrical current that stimulates nerve fibers to block the transmission of pain impulses to the brain. The current is delivered through electrodes placed on the skin at points determined to be related to the pain. TENS is used to treat:

  • chronic pain
  • postoperative pain
  • dental pain
  • labor or pelvic pain
  • pain from peripheral neuropathy or nerve injury
  • postherpetic neuralgia
  • reflex sympathetic dystrophy
  • musculoskeletal trauma
  • phantom limb pain.

Pain management

Pain management: Can’t touch this

Focus topic: Pain management

Although TENS therapy presents few risks, the electrodes should never be placed over the carotid sinus nerves or over laryngeal or pharyngeal muscles. Similarly, the electrodes should never be placed on the eyes or over the uterus of a pregnant patient because this treatment’s safety during pregnancy has yet to be determined. TENS is contraindicated if the patient has a pacemaker. The current may also interfere with electrocardiography or cardiac monitoring. Furthermore, TENS shouldn’t be used when the etiology of the pain is unknown because it might mask a new pathology.

Patient preparation
Make sure that the skin beneath the electrode sites is intact. Clean it with an alcohol wipe and dry well. Clip the hair in the area if necessary. Next, if electrodes aren’t pregelled, apply a small amount of electrode gel to the bottom of each to improve conductivity. Place the electrodes on the skin. If they aren’t self-adhering, secure them with tape, leaving at least 2 (5 cm) between the electrodes.

Pain management: Turn that off!

Focus topic: Pain management

Make sure the controls on the control box are turned to the OFF position. Attach the leadwires to the electrodes, and plug them into the control box. Set the pulse width and rate as recommended. Turn on the unit, and adjust the intensity to the prescribed setting or to the setting most comfortable for the patient. Now secure the unit to the patient. After the prescribed duration of treatment, turn the unit off and remove the electrodes. Wash and dry the patient’s skin. Then clean the unit and replace the battery pack.

Monitoring
Assess the patient for signs of excessive or inadequate stimulation. Muscle twitching may indicate over stimulation, whereas an inability to feel any tingling sensation may mean that the current is too low. If the patient complains of pain or intolerable paresthesia, check the settings, connections, and electrode placements. Adjust the settings if necessary. If you must relocate the electrodes during treatment, first turn off the TENS unit. Evaluate the patient’s response to each TENS treatment and compare the results. Also, use your baseline assessment to evaluate the effectiveness of the procedure.

Patient teaching
If the patient will use the TENS unit at home, have him demonstrate the procedure, including electrode placement, the setting of the unit’s controls, electrode removal, and proper care of the equipment. Explain that he should strictly follow the prescribed settings and electrode placements.
Warn against using high voltage, which can increase pain, or using the unit to treat pain for which he doesn’t know the cause. Also, tell the patient to notify the practitioner if pain worsens or develops at another site.

Pain management: It’s electric

Focus topic: Pain management

If skin irritation occurs, instruct the patient to keep the area clean and apply a soothing lotion. However, if skin breakdown occurs, he should notify the practitioner. Make sure the patient understands that he should remove the unit before bathing or swimming.

Pain management: Cognitive-behavioral techniques

Focus topic: Pain management

Behavior modification and relaxation techniques can be used to help the patient reduce the suffering associated with pain. These techniques include biofeedback, distraction, guided imagery, hyp- nosis, and meditation. These “mind-over-pain” techniques allow the patient to exercise a degree of control over his pain. In addition, they have the added benefit of being virtually risk-free with few contraindications. Even so, if the patient has a significant psychiatric problem, a psycho therapist should teach him the relaxation techniques.

Patient preparation
Because all of these techniques require concentration, try to choose a time when the patient isn’t feeling pain or when pain is at its lowest ebb. However, if pain is persistent, begin with short, simple exercises and build on the patient’s abilities.

Pain management: First, relaxxxxx…

Focus topic: Pain management

Choose a quiet location and dim the lights. Have the patient remove or loosen restrictive clothing. To help the patient lessen muscle tension, tell him to alternately tighten and relax a specific group of muscles — for example, muscles in his neck — while concentrating on tension and relaxation. Repeat the exercise for all muscles groups. If a particular muscle group is painful, move on to the next group.

Pain management: Good feedback

Focus topic: Pain management

Biofeedback requires the use of a special machine that allows the patient to see how his body reacts to his efforts. When the patient is connected to the machine, he performs the relaxation technique that he finds most beneficial. The equipment provides feedback regarding his progress with tones, lights, or a digital readout. In this way, the patient can determine which techniques work best to promote relaxation and reduce pain.

Pain management: Forgetting to feel the pain

Focus topic: Pain management

Distraction is a technique that involves focusing on music, a book or magazine, or the television or a movie instead of pain and related health issues. If the patient listens to music, suggest that he use a headset to help him focus on the music or imagery produced by the music. Keeping time to the beat or increasing the volume can help if the pain worsens. Other distraction strategies include singing, rhythmic breathing, and meditation.

Pain management: I have a dream

Focus topic: Pain management

In guided imagery, the patient concentrates on visualizing the calm and peaceful images described by the leader, either you or a recording. Many recordings are available, so the patient should experiment to find imagery that helps him most. Quiet and peaceful nature imagery — for example, the smell of spring grass, the sound of rolling ocean surf, or the burbling of a forest brook — seems to be most effective.

Pain management: Look into my eyes

Focus topic: Pain management

Hypnosis is performed by a qualified therapist. During the session, the therapist may use techniques such as symptom suppression, which helps block the patient’s awareness of pain, or symptom substitution, which encourages a positive interpretation of pain.

Pain management: Acting differently

Focus topic: Pain management

In behavior modification therapy, the patient is encouraged to identify behaviors that reinforce or exacerbate pain, suffering, and disability, such as being overly dependent on others or using a cane when it isn’t medically indicated. With the therapist’s help, the patient defines specific goals, such as reducing his dependence on others, and then uses positive and negative reinforcement to shed old behaviors and promote new, beneficial patterns of behavior.

Monitoring
Remember to be consistent when working with the patient, and make sure that all staff members are aware of the patient’s choices for cognitive pain reduction. If the patient becomes frustrated with his progress with any of these techniques, calmly have him stop and try again later. End each session on a positive note by pointing out improvements; even small improvements show progress.

Patient teaching
If the patient has overwhelming psych o social problems, recommend that he seek therapy. Provide him with referrals to appropriate professionals. Any gains in pain management may be quickly lost unless he deals with these factors.
For all others, help develop a plan for using the cognitive behavioral strategies at home. A plan will increase the likelihood that the patient will continue to benefit from these strategies after he’s home again.

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Pain management: Nursing care of the patient in pain

Focus topic: Pain management

These nursing interventions are appropriate for a patient in pain:

  • Assess the pain’s location and ask the patient to rate the pain using a pain scale.
  • Ask the patient to describe the pain’s quality and pattern, including any precipitating or relieving factors.

Pain management: Making faces

Focus topic: Pain management

  • Monitor the patient’s vital signs and note subjective responses to pain, such as facial grimacing and guarding the affected part of the body.
  • Administer pain medication around-the-clock, as ordered. This schedule is preferred to as-needed dosing because it avoids major peaks and valleys of pain and relief. Teach the patient the importance of taking the prescribed analgesics before the pain becomes severe.
  • Provide comfort measures, such as back massage, positioning, linen changes, and oral or skin care.
  • Teach noninvasive techniques to control pain, such as relaxation, guided imagery, distraction, and cutaneous stimulation.
  • Explain the role of sleep and the importance of being well rested.
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