sleep and pain 2010

8/2/2019 Sleep and Pain 2010

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SLEEPSLEEP

Kuswantoro Rusca Putra, S.Kp.,M.Kep


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WHAT IS SLEEP

Sleep: This is the state of unconsciousness from which a subject can be aroused by appropriatesensory or other stimuli.

Sleep may also be defined as a normal, periodic,inhibition of the reticular Activating system.

Awake: This is the state of readiness / alertnessand ability to react consciously to various stimuli.

Coma: This is the state of unconsciousness from which a person cannot be aroused by any externalstimuli


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FUNCTIONS OF SLEEPFUNCTIONS OF SLEEP

Restoration theory: Body wears out during

the day and sleep is necessary to put it back

in shape Preservation and protection theory: Sleep

emerged in evolution to preserve energy

and protect during the time of day when

there is little value and considerabledanger


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SLEEP CENTRE

Supra-chiasmatic Nucleus (SCN)

Normal sleep is under control of the reticular

activating system in the upper brain stem and

diencephalon


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VentroLateralVentroLateral PreopticPreoptic Nucleus (Hypothalamus)Nucleus (Hypothalamus)


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Fig. 9-12, p. 280


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SLEEP CENTRE


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SLEEP CENTRE


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SLEEP CENTRE

Sleep is promoted by a complex set of neural

and chemical mechanisms

Daily rhythm of sleep and arousalsuprachiasmatic nucleus of the

hypothalamuspineal glands secretion of

melatonin

Slow-wave sleep: Raphe nuclei of the medulla

and pons and the secretion of serotonin

REM sleep: Neurons of the pons


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NORMAL SLEEP REQUIREMENT

New born = 15 - 20 hours.

Children = 10 -15 hours.

Adults = 6-9 hours.

Old age = 5-6 hours.


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RETICULAR ACTIVATING SYSTEM

Thalamic part causes arousal that is

awakening from deep sleep [sensory input,

pain stimuli, Bright light].

The RAS and cerebral cortex continue to

activate each other through a feedback

system.

The RAS also has a feedback system with

the spinal cord.


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CIRCADIAN RHYTHM

Endogenous circadian rhythms

Rhythm that last about a day humans last around 24. h

Examples:

Activity

Temperature

waking and sleeping

secretion of hormones

eating and drinking


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RETICULAR ACTIVATING SYSTEM

Light:

Retinal ganglion cells send direct projections to the

SCN

this provides information about light to the SCN lightcan also alter blood-borne factors SCN is highly

vascularized

Melatonin:

secreted from the pineal gland increased levels of

melatonin make you sleepy melatonin can act on

receptors in the SCN to phase advance the biological

clock


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TYPES OF SLEEP

There are two types of sleep:

1) Non Rapid Eye Movement Sleep

[Slow Wave Sleep- Dreamless].2) Rapid eye movement sleep

[Dreamful].


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SLOWWAVE SLEEP

1. Slow-wave (non rapid eye movement sleep)

This stage of sleep consists of four stages.

Stage 1: This is an initial stage between

awakening and sleep.

It normally lasts from 1-7 minutes.

the person feels relaxed with eye closed.

If awakened, the person will frequently say that hehas not been sleeping.

E.E.G. findings: Alpha waves diminish and Theta

waves appear on EEG.


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SLOWWAVE SLEEP

Stage 2:

This is the first stage of true sleep.

T

he person experiences only light sleep.It is a little harder to awake the person.

Fragment of dream may be experienced.

Eyes may slowly roll from side to side.

E.EG-findings: Shows sleep spindles (sudden,

sharply, pointed waves 12-14-Hz (cycles/sec).


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SLOWWAVE SLEEP

Stage3:

This is the period of moderately deep sleep.

The person is very relaxed.

Body temperature begin to fall.

B.P decreases.

Difficult to awaken the person.

This stage occurs about 20-25 minutes after

falling asleep.

E.E.G.findings: Shows mixture of sleep spindles and

delta waves.


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SLOWWAVE SLEEP

Stage4: Deep sleep starts

Person become fully relaxed.

Respond slowly if awakened.

E.E.G.findings: Dominated by Delta Waves.

Note: Most sleep during each night is of a slow wave

Lasts for 80=90 minutes.

Dreams / night mare even occur.The difference is that the dreams in slow wave

sleep are not remembered but in REM, dreams

can be remembered.


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RAPID EYE MOVEMENT SLEEP

RAPID EYE MOVEMENT SLEEP [PARADOXICALSLEEP/DREAMFUL SLEEPS]

In normal sleep bouts of REM sleep lasting for 5-20

minutes usually appear on the average after every90 minutes.

The first such period occurring 80-100 minutes after theperson falls a sleep.

When the person is in extreme sleep, the duration ofeach bout of REM is very short.

It may even be absent.


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CHARACTERISTICS OF REMS

Active dreaming.

Difficult to arouse by sensory stimuli.

Decreased muscle tone through out the body. Heart rate and respiration usually become

irregularwhich is characteristic of a dream

state. Brain is highly active in REM sleep and

brain metabolism may be increased by 20%.


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CHARACTERISTICS OF REMS

E.E.G.findings: Shows pattern of brain wave

to those of wakefulness that is which it is

called Paradoxical.

In summary, REM sleep is a type of sleep in

which the brain is quite active.


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CHARACTERISTICS OF SWS AND REMS


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DREAMS AND REMS

What are true dreams for?

Although research has yet to answer this

question, a prevalent view today is that dreams

dont serve any purpose at all, but are sideeffects of REM

To exercise groups of neurons during sleep some

are in perceptual and motor areas REM occurs in other mammals and to a much

greater extent in fetuses and infants than adults

REM sleep may help consolidate memories


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DREAMS AND REMS

True dream - vivid, detailed dreams

consisting of sensory and motor sensations

experienced during REM sleep thought - lacks vivid sensory and

motor sensations, is more similar to daytime

thinking, and occurs during slow-wave sleep


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PHYSIOLOGICAL CHANGES IN SLEEP

Physiological changes during sleep:

CVS: Pulse Rate, cardiac output, blood pressure,

and vasomotortone are decreased but the blood

volume is increased.

Respiration: Tidal volume and rate of respiration

is decreased. BMR is decreased 10-15%.

Urine volume: Urine volume is decreased. Secretions: Salivary / lacrimal secretions are

reduced, gastric/sweet secretions are increased.


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PHYSIOLOGICAL CHANGES IN SLEEP

Muscles: Relaxed.

Superficial reflexes are unchanged except plantex

reflex.

Deep reflexes are reduced.

Effects produced by awakening after 60-100 hours:

Equilibrium disturbed.

Neuromuscular junction fatigue. Threshold for pain is lowered.

Some cells dead.


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DISORDERS OF SLEEP

Disorder of sleep:

Insomnia: Inability to sleep

Somnolence: Extreme sleepness

Disorder of slow wave sleep:Sleep talking / sleep walking

[common in children]

Night tremors: Are seen in III, IV stage of slow wave sleep

[common in children]. Disorder of REM sleep:

Night mare = Frightening dream.

Sleep Paralysis= Subject is awake but unable to speak or

move. Sleeping Sickness.


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DISORDERS OF SLEEP

Somnambulism - sleepwalking

Nightmares - frightening dreams that wake a sleeperfrom REM

Night terrors - sudden arousal from sleep andintense fear accompanied by physiological reactions(e.g., rapid heart rate, perspiration) that occur duringslow-wave sleep

Narcolepsy - overpowering urge to fall asleep thatmay occur while talking or standing up

Sleep apnea - failure to breathe when asleep


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DISORDERS OF SLEEP

Night Terrors

experience of intense anxiety from which a person

awakens screaming in terror occur during non REM sleep

more common in children

Sleep Walking

occurs mostly in children

runs in familiesexpressed early in the night during stage 3 and 4

sleep


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PainPain

Kuswantoro Rusca Putra, S.Kp.,M.Kep


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Definitions:

An unpleasant sensory and emotional

experience associated with actual orpotential tissue damage, or described in

terms of damage.


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Categories of Pain

Acute - Pain of short duration with known

cause

Trauma

Surgery

Chronic - prolonged pain with unknown

duration

Chronic benign - osteoarthritis, migraine

Chronic malignant - bone metastasis, pancreatic


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Signs andSymptoms

Acute Pain = Grimacing, sweating,

hypertension, tachycardia

Chronic Pain = Loss of appetite, lack

of sleep, depression, anxiety


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Transmission of Pain

Types of Nerves

Neurotransmitters


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PeripheralandCentralPathways for PainAscending TractsAscending Tracts Descending TractsDescending Tracts

Cortex

Midbrain

Medulla

Spinal Cord

Thalamus

Pons


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MECHANISMS OF PAIN TRANSMISSION

Nociceptors are receptors that are

preferentially sensitive to a noxious stimulus.

Nociceptors are free nerve endings in theskin that respond only to intense, potentially

damaging stimuli.

The joints, skeletal muscle, fascia, tendons,

and cornea also have nociceptors that have

the potential to transmit stimuli that produce

pain


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The large internal organs (viscera) do not

contain nerve endings that respond only to

painful stimuli.


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Prostaglandins are chemical substances

thought to increase the sensitivity of pain

receptors by enhancing the pain provokingeffect of bradykinin

These chemical mediators also cause

vasodilation and increased vascular

permeability, resulting in redness, warmth,and swelling of the injured area


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Chemicals that reduce or inhibit the

transmission or perception of pain include

endorphins and enkephalins.


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There are two main types of bers involved in

the transmission of nociception.

Smaller, myelinated A (A delta) berstransmit nociception rapidly, which produces

the initial fast pain. pain impulses due to

mechanical pressure

Type C bers are larger, unmyelinated bers

that transmit what is called second pain. pain

impulses due to chemicals or mechanical


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Nociceptive pain in the visceral organs may be

referred to other parts of the body


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FACTORS INFLUENCING

THE PAIN RESPONSE

Past Experience

Anxiety and Depression

Culture

Age

Gender Placebo Effect


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Principles of Pain Therapy

Assessment

Treatment

Reassessment and Evaluation


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Questions to Ask about Pain

P-Q-R-S-T format

Provocation How the injury occurred & what activities q othe pain

Quality - characteristics of painReferral/Radiation

Severity How bad is it? Pain scale

Timing When does it occur? p.m., a.m., before, during, afteractivity, all the time

Pattern: onset & duration

Area: location

Intensity: level

Nature: description


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Tools

for pain measurement


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Pain Intensity Rating


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From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, SchwartzP: Wongs Essentials ofPediatricNursing, 6/e, St. Louis, 2001, P. 1301. Copyrighted by Mosby, Inc.

Pain Intensity Rating


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Sample of Childs FACES Pain Rating Scale


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Cries score


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Pain Assessment Techniques

In infants, behavior must beinterpreted by using physiological and

behavioral measures

CRIES is useful for neonates from 32

weeks to infants of up to 1 year

FLACC (full term neonate 7 years)

Preschool children (ages 3 to 7) are in

a transition group in which verbalabilities are developing.


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Frequency of re-assessment

Acute setting of pain

1) within 30 minutes of parenteral drug

administration,

2) within one hour of oral drugadministration,

3) with each report of new or changed

pain


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NON PHARMACOLOGIC INTERVENTIONS

Cutaneous Stimulation and Massage

Ice and Heat Therapies

Transcutaneous Electrical Nerve

Stimulation (TENS)

Distraction

Guided Imagery

Relaxation Techniques

Hypnosis


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59

WHO's three step ladder to

use of analgesic drugs

www.who.int/cancer/palliat

ive/painladder

3

1

2


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OPTIONS FOR TREATMENT OFPAIN

Nonopioids (NSAID, Achetaminofen)

Opioids (Morphine, Codeine, Hydromorphone,

Methadone, Meperidine)

Analgesic Adjuvants(steroids,benzodiazepines,antidepressants, andanticonvulsants)


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Thank you

sleep and pain 2010

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