Wednesday, March 18, 2009

Relaxation Techniques

This section describes some of the most common relaxation techniques used to manage pain. Many of these techniques, including deep breathing and progressive muscle relaxation, are aimed at achieving a state of profound rest and release, known as the relaxation response.The relaxation response is the antidote to the fight-or-flight mechanism. Invoking the relaxation response regularly can lead to lasting declines in high blood pressure, a decrease in anxiety and depression, and general improvement in the ability to cope with stress.
First, chronic pain conditions can rob you of a sense of control over your body and, thus, your life. Relaxation techniques can help restore that sense of control, which in itself can make you feel a great deal better. Second, some pain conditions may be perpetuated or worsened when the body's normal fight-or-flight response is triggered too easily or becomes stuck in the "on" position. A goal of many relaxation techniques and programs is to turn off the fight-or-flight reaction and calm revved-up muscle, metabolic, and hormonal responses. Essentially, since stress can contribute to or exacerbate pain, relaxation techniques can alleviate pain by easing stress.
Finally, relaxation techniques help activate the body's natural painkillers. Working through a complex web of mind/body networks, relaxation techniques prompt the release of natural chemicals such as endorphins and enkephalins, which enhance mood, reduce pain perception, and stimulate some immune system cells.
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Tuesday, March 17, 2009

Understanding the Neutral Spine Position

Management and prevention of back pain begin by understanding the neutral spine position. Three natural curves are present in a healthy spine. The neck, or the cervical spine, curves slightly inward. The mid back, or the thoracic spine, is curved outward. The low back, or the lumbar spine, curves inward again. The neutral alignment is important in helping to cushion the spine from too much stress and strain. Learning how to maintain a neutral spine position also helps you move safely during activities like sitting, walking, and lifting.
The natural curves of the spine are the result of the muscles, ligaments, and tendons that attach to the vertebrae of the spine. Without these supporting structures, the spine would collapse. They support the spine - much like guide wires support the mast of a ship. This guide wire system is made up mainly of the abdominal and back muscles. The abdominal muscles provide support by attaching to the ribs, pelvis, and indirectly to the lumbar spine. The muscles of the back are arranged in layers, with each layer playing an important role in balancing the spine. By using these muscles together, it is possible to change the curves of the spine.
Controlling pelvic tilt is one way to begin helping to balance the spine. As certain muscles of the back and abdomen contract, the pelvis rotates. As the pelvis rotates forward, the lumbar curve increases. As the pelvis rotates backward, the curve of the low back straightens. Rotation of the pelvis is like a wheel centered at the hip joint. The muscles of the upper thighs also attach to the pelvis and contraction of these muscles can be used to change the curve of the spine.
The abdominal muscles work alone, or with the hamstring muscles to produce a backward rotation of the pelvis. This causes the slight inward curve of the low back to straighten. If these muscles cause the curve of the low back to straighten too much, this may produce an unhealthy slouching posture.
In the other direction, as the hip flexors contract and back extensors contract, the pelvis is rotated forward - increasing the curvature of the lower back. If this curve is increased too much, another unhealthy posture may result. This condition is called lordosis in medical terminology, or swayback in common terms.
A balance of strength and flexibility is the key to maintaining the neutral spine position. This balance is the basis for optimal muscle function. Like a car, an imbalance may lead to wear and tear, eventually damaging the various parts of the car.
Muscle imbalances that affect the spine have many causes. One common cause of muscle imbalance is weak abdominal muscles. As the abdominal muscles sag, the hip flexors become tight, causing an increase in the curve of the low back. This leads to the swayback posture mentioned above. Another common problem results from tight hamstrings. As the hamstring muscles become tight, the pelvis is rotated backwards. This produces an abnormal slouching posture.
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Sleep Pattern & Its Disturbances: Nursing Implications

Prepared by: Asha P Mathew. MSN, Manipal College of Nursing, Manipal University
Sleep is the state of natural rest observed throughout the animal kingdom, in all mammals and birds, and in many reptiles, amphibians, and fish. In humans, other mammals, and many other animals that have been studied - such as fish, birds, ants, and fruit-flies - regular sleep is necessary for survival. The capability for arousal from sleep is a protective mechanism and also necessary for health
and survival.

Sleep can e defined as a normal state of altered consciousness during which the body rests; it is characterized by decreased responsiveness to the environment, and a person can be aroused from it by external stimuli.

Sleep is generally characterized by a reduction in voluntary body movement, temporary blindness, decreased reaction to external stimuli, loss of consciousness, a reduction in audio receptivity, an increased rate of anabolism (the synthesis of cell structures), and a decreased rate of catabolism (the breakdown of cell structures.
Almost a third of the general population has some problems with sleep during any given year. More than half of the 9000 participants in a study of sleep in elderly persons (65 years or older) reported the following as sleep pattern disturbance that they experience most of the time:
* Trouble falling asleep
* Frequent awakening
* Waking too early
* Needing to nap
* Not feeling rested
These disturbances may be secondary to situational, environmental or developmental stressors, or they may be associated with illness or with pre-existing disorders. The relationship is often reciprocal, in that the disorder decreases sleep & the decreased sleep affects the disorder.

Chronobiology refers to the study of biologic changes as they occur in relation to time. The sleep wake cycle is one of the circadian rhythms of the body. Circadian rhythms follow an approximate 24 hour cycle through a complex process linked to light & dark. The effect of illness & hospitalization may disrupt these rhythms, particularly in older persons. Ultradian cycles are circadian rhythms of less than 24 hours. The recurrent pattern of sleep stages, repeating approximately 90 minutes in adults, is an example. Chronopharmacology refers to the study of how biorhythms affect the absorption, metabolism, & excretion of drugs. E.g.the blood level achieved by a continuous infusion of heparin varies throughout the day.

The purpose of sleep is still unclear. Theories suggest that:
* It is a time of restoration and preparation for the next period of wakefulness
* During NREM stage 4 body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells
* Protein synthesis and cell division for the renewal of tissues occur during rest and sleep
* REM sleep appears to be important for cognitive restoration
The benefits of sleep often go unnoticed until a person develops a problem resulting from sleep deprivation. A loss of REM sleep leads to feelings of confusion. Various body functions ( eg. Motor performance, memory and immune function) alter when prolonged sleep loss occurs

Sleep duration and quality vary among persons of all age groups
* Infants 16 Hours /Day
* Toddlers 12 Hours /Day
* Preschoolers 11 Hours /Day
* Schoolers 9 - 10 hours /day
* Adolescents 8 – 9 hours /day
* Adults 6 – 8 hours /day
As people age, their circadian clock advances, causing advanced sleep phase syndrome. The syndrome is common in older adults and often is the reason behind the complaint of waking early in the morning and unable to get back to sleep. They get sleepy early in the evening.

A number of factors affect the quality and quantity of of sleep. Often more than one factor combined to cause a sleep problem.
* Physical illness (eg. Nausea, mood disorders, breathing difficulty, pain)
* Drugs and substances (eg. Tryptophan)
* Lifestyle (eg. Daily routines, exercises)
* Usual sleep patterns and excessive daytime sleepiness
* Emotional stress
* Environment ( ventilation)
* Sound
* Exercise and fatigue
* Food and caloric intake

Sleep pattern disturbance is a nursing diagnosis that is defined as a disruption of sleep time that causes discomfort or interferes with a desired life cycle. A sleep pattern disturbance may be related to one of more than 80 sleep disorders identified in the international classification of sleep disorders, a partial list of which is given below:
International classification of sleep disorders
Intrinsic sleep disorders
* Psycho physiologic insomnia
* Narcolepsy
* Obstructive sleep apnea syndrome
* Central sleep apnea syndrome
* Periodic limb movement disorder
* Restless leg syndrome
Extrinsic sleep disorders
* Inadequate sleep hygiene
* Environmental sleep disorder
Circadian rhythm sleep disorders
Arousal disorders
* Sleep walking
* Sleep terrors
Sleep – wake transition disorders
Parasomnias usually associated with REM sleep
* Nightmares
* Sleep paralysis
Other Parasomnias
* Sleep bruxism
* Sleep enuresis
* Primary snoring
Sleep disorders associated with medical or psychiatric disorders
Associated with mental disorders
Associated with neurologic disorders
Associated with medical disorders
Proposed sleep disorders

Diagnostic assessment:
* Polysomnography
* Electroencephalogram
* Multiple sleep latency test (MSLT)
MSLT is performed to assess the impairment of daytime alertness. It is performed a day after a standard polysomnogram. The time required for clients to fall asleep when in a relaxed state is evaluated at 2 hour intervals, with each nap limited to 20 minutes. The type of sleep also is assessed.

A. Assessment: Assess client’s usual sleep habits and recent sleep quality as part of the initial nursing history. If sleep quality is reported to be poor, explore the nature of disturbances by noting the following:
* Usual activities in the hour before retrieving
* Sleep latency
* Number and perceived cause of awakenings
* Regularity of sleep pattern
* Consistency of rising time
* Frequency and duration of naps
* Events associated with initial onset of sleep disturbances
* Ease of falling asleep in places other than the usual bedroom
* Situations in which client fights sleepiness
* Daily caffeine intake
* Use of alcohol, sleeping pills,and other medications
* Incidence of morning headaches
* Frequency of snoring, apparent pauses in breathing, and kicking movements
* Objective data may include visible signs of fatigue and lack of sleep, such as circles under the eyes, lack of coordination, drowsiness and irritability.

B. Nursing diagnosis:
1. Disturbed sleep pattern related to changes in routine due to hospitalization and pain
Disturbed sleep pattern related to lack of cues for day- night schedule; manifested by erratic sleep schedule, frequent naps and nocturnal wandering

C. Client Outcome criteria:
client increases nocturnal sleep time by 20% over next 2 weeks.

D. Nursing intervention
*offer meals at regular times, corresponding to client’s previous pattern
*provide active meaningful activities during daytime hours, including exposure to natural light, and an outdoor environment when possible
*monitor frequency and duration of naps
*create an individualized bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom and settling a routine
* Do not waken even if incontinent. Change and assist the client to the bathroom when he or she spontaneously awakens
*if turning or other care is necessary, try to provide for periods up to 2 hours of undisturbed sleep time whenever possible
*mealtimes are important social cues, that reinforce circadian rhythms, which tend to weaken with advancing age
*light exposure is communicated through the retina to the suprachiasmatic nucleus, helping to set the circadian clock
*napping is not contraindicated but is best at the time of day opposite to the midpoint of the nocturnal sleep period. Short naps are preferable to avoid deep sleep
*reduced stimulation and rituals associated with sleep enhance sleep onset
*older adults who can turn themselves generally do better to have their sleep undisturbed and tend to waken spontaneously if wet when their sleep cycle lightens
* Sleep cycles average 90 mts. A sleep latency of 20- 30 mts mean it would take about 2 hours to experience a full sleep cycle.

The adequacy of sleep is important factor in caring for clients with acute and chronic illness. Some sleep disturbances are temporary and related to the stress of hospitalization. It is possible that temporary stress problems will be corrected only after the client’s return home. Clients with sleep disturbances may need follow –up care with repeated assessments to determine whether the problem was corrected. Clients with long term sleep disorders may need ongoing support to maintain the effectiveness of treatment. The nurse can play a pivotal role in environmental modification and client teaching to minimize the impact of sleep.

1.Black JM, Hawks JH. Medical Surgical Nursing clinical management for positive outcomes. Vol 1.7th edition. Saunders; India 2005 Pp 461-500.
2.Potter PA, Perry AG. Basic nursing- essentials for practice. 6th edition. Missouri: Mosby publishers; 2007
3.Brunner. Medical surgical nursing. 6th edition. London: Mosby publishers; 2005.
4.Lewis SM, Heitkemper MM, Dirksen SR. Medical surgical nursing. 6th edition. Philadelphia: Mosby publishers; 2004.
5.Tylor C, Lillis C, Le Mone P. fundamentals of nursing- the art and science of nursing care. 5th edition. London: Lippincott Williams & Wilkins publishers; 2006
6.Lewis, Heitkemper, Dirksen. Medical Surgical nursing.6th edition. Mosby. Page no 131-157.
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Thursday, March 12, 2009

Managing Your Pain

What is Pain?
Pain is your body's alarm system that tells you something is wrong. When a part of your body is injured, nerves in that area release chemical signals that go to your brain where they are recognized as pain.
People experience pain differently. The amount of pain you experience depends on the type and location of the pain, and how sensitive you are to pain. You may feel pain more quickly,
or intensely than someone else who has a higher tolerance for pain. Anxiety and fear can make the pain feel worse. You are the best authority to judge your pain and its relief.
Your physician and nurse can work with you to choose the type of pain management that is best for you.

Describe Your Pain
There are two categories of pain:
1. Acute pain usually has a definite onset and does not last a long time. This is the type of pain you might have after a cut, burn, or sprained ankle. It usually subsides as the injury heals.
2. Chronic pain lasts for longer periods of time, such as arthritis, back pain, or cancer pain.
The Pain Rating Scale can help you describe how severe your pain is.

It is very important to tell your doctor or nurse everything you can about your pain so they can help you relieve it. When you are asked to describe your pain consider the following questions.
• When the pain began?
• What the pain feels like (sharp, dull, throbbing)?
• Where is the pain?
• What type of pain (constant or intermittent)?
• What makes it worse (walking, coughing, moving, etc.)?
• What pain prevents you from doing (sleeping, eating, socializing, etc.)?
• What relieves your pain?
• How severe your pain is on the Pain Rating Scale?

Non-drug Pain Relief
There are several ways to manage pain with out medication. These techniques can be used alone, or in combination:
physical therapy meditation
occupational therapy imagery
relaxation techniques music
nerve stimulation humor
heat and cold distraction
aroma therapy exercises
therapeutic activities massage

Medications for Pain
Different types of medications control pain:
• Mild to moderate pain relief: acetaminaphen, ibuprofen, and aspirin, etc.
• Moderate to severe pain relief: codeine, morphine, and fentanyl
• Nerve pain relief: some antidepressants and anticonvulsants
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Three Key Components in Back Injury Prevention

The cause of back pain in about 90% of cases is strain or sprain of back muscles, ligaments or soft tissue. These conditions generally heal completely, but often recur if prevention strategies are not used. Back pain in the remaining 10% of cases is due to more serious conditions such as degenerative disk disease or herniated disks in the spine. However, even these cases may be prevented – or treated – with proper posture, conditioning and body mechanics.

Proper posture, conditioning and body mechanics are the key components of any program designed to prevent back injuries.

Proper posture includes standing and sitting in an upright position without slouching, rounding of the shoulders or accentuating the natural curves of the spine. Poor posture typically involves holding the head too far forward or allowing the belly to pull the back forward. If possible, get in the habit of holding in the belly to keep it from protruding and putting excess force on the spine. When standing, bend your knees slightly. Years of poor posture can lead to weakened spine and abdominal muscles that contribute to back pain and injury.

Proper sleeping posture is also important to prevent and relieve back pain. Sleep on a mattress that is firm, not sagging, but not too hard. Do not sleep on your stomach. Instead, sleep on your side with a pillow between your knees or sleep on your back with a pillow under your knees.

Proper conditioning involves overall conditioning of the body and cardiovascular system with aerobic exercise, as well as strengthening and stretching core muscles of the spine and abdomen. Studies have shown that smoking can contribute to back pain and injury, so if you still smoke, you have yet another reason to think about quitting. Walking, swimming, bicycling and, for some people, slow, short-distance running are excellent ways to condition the entire body and improve cardiovascular health. In addition to improving general levels of health and fitness, these activities increase blood flow to the spine.

Aerobic activity, along with a healthy diet, helps prevent weight gain, which is a risk factor for back injury. To begin exercising, try walking for 10 minutes twice per day at a moderate pace and build up to at least one 30-minute walk per day three days a week; walking every day is preferable.

Stretching to increase back and abdomen flexibility should be done 5-7 days per week, and strengthening exercises should be done at least 4-5 days per week. Because back conditions vary, strengthening and stretching the muscles of the spine and abdomen should be done under the direction of a physician or physical therapist. These stabilizing exercises improve support for the spine itself, but proper technique is essential.

Body Mechanics
Body mechanics refers to the way we use our bodies to complete various tasks during activities of daily life. When lifting, bending or stretching, we should think of how we are using our back to avoid provoking an acute injury. There may be a simpler, less strenuous method or posture that can be used to get something done. Don’t be afraid to ask for help.

Instead of bending at the back to pick something up off the floor, stoop down at the knees. Keep the back as straight as possible and maintain proper posture. Instead of reaching overhead, use a sturdy stepstool. Push or pull with your entire body, not just your arms. Wear comfortable, low-heeled shoes.

When lifting, avoid reaching too far out for the object to be moved; instead, stand close and grasp the object close to the body. Maintain proper posture with back straight and head up. Bend at the knees and hips, not at the back or waist, and use your legs to lift. Pivot at the hips, not the back. If possible, lift from a tabletop or from waist height, rather than from the floor or over your head.

When working, whether sitting or standing, pace your activities and take frequent breaks. Vary the position of your body when standing. Stand on a cushioned mat, if possible. When sitting at a desk, think in terms of right angles (90°, or the shape of an L). Knees should be at 90° angles when the soles of the feet are touching the floor. The back and thighs should form 90° angles when the body is sitting properly in a chair. Wrists should be straight and elbows at 90° angles when the hands are on the desk or keyboard. Use a chair with proper low-back support and keep your head back and shoulders relaxed.

Some studies have found that back belts worn to prevent back injuries while lifting are not effective; however, they may help remind you to lift with proper body mechanics. When doing something that you haven’t done in months, whether it’s yard work or golfing, do some simple stretches for your entire body and for the particular muscles involved, before, during and after the activity. Maintaining your level of fitness throughout the year will make injury less likely.
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