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Stress - Stress is a state produced by a change in the environment that is perceived as challenging, threatening or damaging to the persons dynamic

balance or equilibrium - Stress is your mind and bodys response or reaction to a real or imagined threat, event or change. - It is a disruptive condition that occurs in response to adverse influences from the internal and external environment. Stressors - The threat, event, event or change is commonly called stressors. - Stressors can be internal (thoughts, beliefs, attitudes or external (loss, tragedy, change) event or situation that creates the potential for physiologic, emotional, cognitive, or behavioral changes in an individual. Adaptation - A change or alteration designed to assist in adapting to a new situation or environment Coping - It is the cognitive and behavioral strategies used to manage the stressors that tax a persons resources Illness - It is a personal state in which the person feels unhealthy - It is a state in which a persons physical, emotional, intellectual, social developmental or spiritual functioning os diminished or impaired compared with previous experience. Types of stressor 1. Distress 2. Eustress 3. Internal 4. External 5. Developmental 6. Situational 7. Physiologic 8. Psychosocial Factors affecting impact of stressor - The response to any stressor depends on physiological functioning, personality and behavioral characteristics as well as the nature of the stressor. - The nature of the stressor involves the following factors and each factor influences the response to a stressor a. Intensity i. It may be perceived as minimal, moderate or severe ii. The greater the magnitude of the stressor, the greater the stress response b. Scope i. ( range in which stress encompasses a person's total well-being) - the greater the scope of a stressor, the greater the stress response ii. May involve the entire nation or fewer individuals only c. Duration i. greater the duration, greater the stress response d. Number and nature of the other stressors i. increase in presence of multiple stressors, the greater the stress response Models of Stress 1. Stimulus-Based Model - Stress is defined as a stimulus, a life event or a set of circumstances that arouses physiologic and/or psychological reactions that may increase the individuals vulnerability to illness

Holmes-Rahe Scale: a scale of stressful life events used to document a persons relatively recent experiences; in this view, both positive and negative events are considered stressful

2. Response-Based Model - Stress may also be considered as a response; this definition was developed and described by Hans Selye - Stress is bodys non-specific response to any demand made upon it

3. Transaction Based Model - Based on the work of Lazarus, who stated that the 1st two theories do not consider individual differences - This theory encompasses a set of cognitive, affective and adaptive response that arises out of person environment transactions - Environment and person are inseparable; each affects and is affected by the other - Stress refers to any even in which environmental demands, internal demands or both tax exceed the adaptive resources of an individual, social system or tissue system (Monat & Lazarus, 1991) 4. The Psychosomatic Model - Psychosomatic model is a real problem, and not just a delusion. - The Mind Body Connection (Figure 1) o The psychosomatic model describes the connection between the mind and the body, and the resultant effects on health and disease generated from this connection. The results indicate that mental stress is a contributor to ailments such as paralysis, certain cancers, ulcers, and hypertension (Simmons, 2006).

Coping strategies - Thinking processes and behaviors a person uses to manage stressors. i. Problem solving ii. Day dreaming iii. Making changes in lifestyle iv. Sleeping v. Consulting others for advice and support - It can be adaptive or maladaptive Approaches to Coping 1. Altering the stressor 2. Adapting the stressor 3. Avoiding the stressor Outcome of stress

Outcome depends on the balance between the strength of the stressor and the persons coping methods 1. Adaptation 2. Disease

Responses to Stress and Illness 1. Physiological Response a. General Adaptation Syndrome - Man, whenever he responds to stress the entire body is involved - It involves primarily the Autonomic Nervous System and the Endocrine System (aka. Neuroendocrine response) Stages of GAS Stages of Alarm (SA) - Stimulation of SNS - Increase release off hormones from o Hypothalamus o Posterior pituitary gland o Anterior pituitary gland o Adrenal Cortex o Adrenal medulla Fight or flight response Stages of Resistance (SR) - Characterized by Adaptation - Levels of resistance are increased - The person moves back to homeostasis o PNS activity balances SNS o Hormone levels return to normal Stages of Exhaustion (SE) - Alarm reaction recurs or continues until energy is depleted - The person cannot adapt and subsequently dies

b. Local Adaptation Syndrome/inflammatory response - The body produces, many localized responses to stress. These include blood clotting; wound healing, accommodation of the eye to light and response to pressure. All forms of the LAS share the following characteristics The response is localized; it does not involve the entire body systems The response is adaptive. This means that a stressor is necessary to stimulate it The response is short term; it does not persist indefinitely The response is restorative, meaning that the LAS helps restore homeostasis to the body region or part A. Inflammatory Response The inflammatory response is stimulated by trauma or infection. This response localizes the inflammation, thus preventing its spread, and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning The inflammatory response alerts the nurse that the body is adapting to a local injury. During adaptation, the inflammatory response protects the body from infection and promotes healing. B. Reflex pain response The reflex pain response is a localized response of the central nervous system to pain. It is an adaptive, involuntary and predictable response and protects tissue from further damage

Pain receptors and send sensory impulses to the spinal cord where they synapse with the spinal motor neurons. The motor impulses travel back to the site of the stimulation causing the flexor muscles in the limb to contract.

Pain - Is a universal human experience; it is defined as unpleasant sensory and emotional experience arising from actual or potential tissue damage (NANDA, 2007) - It is a stressor that can trigger both physiological and psychological discomfort Nature of pain - It is a response to noxious stimuli and can be protective mechanism to prevent further injury as is seen in clients who guard or protect an injured body part. o Sensation of pain as the warning of potential tissue damage may be absent in people with nerve/spinal cord abnormalities, diabetic neuropathy, multiple sclerosis, nerve/spinal cord injury or other neurological disorders Types of pain - Pain origin o Cutaneous pain- caused by stimulation of the cutaneous nerve endings in the skin and results in a well-localized burning or prickling sensation; Eg. Getting a knot in the hair that is pulled out during combing o Somatic- non localized and originates in support structures such as tendons, ligaments, and nerves Eg. Jamming a knee or finger o Visceral Pain Discomfort in the internal organs and is less localized and more slowly transmitted than cutaneous pain Difficult to assess because the location may not be directly related to the cause Referred Pain: o pain originating from the abdominal organs because the sensation of pain is not felt in the organ itself but instead is perceived at the spot where the organs were located during fetal development o Areas of referred pain Neuropathic pain: o Arises from damage to portions of the peripheral or central nervous system o Is a result of abnormal processing of sensory input by either the peripheral or central nervous system o This is not nociceptive pain o Difference between nociceptive and neuropathic Myofascial pain o Pain that occurs as a result of small, hypersensitive region in muscle, ligament, fascia or joint capsule called trigger point o Often accompanied by a localized deep ache that is surrounded by a referred area of hyperalgesia, or extreme sensitivity to pain - Pain duration o Acute pain Most frequently identified by its sudden onset and relatively short duration, mild to severe intensity and a steady decrease in intensity over a period of days to weeks Eg. Needle sticks, surgical incisions and fractures o Recurrent acute pain Identified by repetitive painful episodes that may recur over a prolonged period or throughout the clients lifetime Theses painful episodes alternate with pain-free intervals

Eg. Migraine headaches, sickle cell pain crises, angina pectoris pain due to myocardial hypoxia Chronic Pain Identified as long-term (lasting 6 months or longer), persistent, nearly constant, or recurrent pain that produces significant negative changes in the clients life A primary motivator for individuals to seek health care intervention, can greatly influence a clients quality of life, including emotional, social, vocational and financial areas Chronic malignant pain Pain that occurs as a result of progressive tissue injury Eg. Person with cancer or with 3rd degree burn Chronic nonmalignant pain Occurs in person who do not have progressive tissue injury Eg. Forms of neuralgia (paroxysmal pain that extends along the course of one or more nerves, Low back pain, Rheumatoid arthritis, Phantom limb pain (a form of neuropathic pain that occurs after amputation with pain sensations referred to an area in the missing portion of the limb), Myofascial pain syndromes (group of muscle disorders characterized by pain, muscle spasm, tenderness, stiffness and limited motion) Intractable pain Used when pain is resistant in all therapies

Physiology of Pain NOCICEPTION : process by which individual becomes consciously aware of pain - Four fundamental process: 1. Transduction - The changing of noxious stimuli in sensory nerve endings to energy impulses o Presence of noxious stimuli (pin prick) o Tissue damage: cell damage release the following sensitizing substances: Prostaglandins Bradykinin Serotonin Substance P Histamine o Release of these substances alters the electrical charge on the neuronal membrane o The impulse is then ready to be transmitted along the nociceptor fibers 2. Transmission - Movement of impulses from site of origin to the brain o The specific action of pain varies depending on the type of pain o Cutaneous pain Cutaneous nerve transmission travel through a reflex arc from the nerve ending to the brain 300 feet/second, with a reflex response causing an almost immediate reaction. Eg. Touching a hot stove Sensory nerve ending in the skin initiates nerve transmission that travels through the dorsal root ganglion to the dorsal horn in the gray matter of the spinal cord Impulse travel through an interneuron that synapses with a motor neuron, which exits the spinal cord at the same level Motor neuron and stimulation of the muscle it innervates is responsible for the swift movement of the hand away from the hot stove o Visceral Pain Transmission of pain impulses is slower and less localized than in cutaneous pain

Internal organs have a minimal number of nociceptors which explains why visceral pain is poorly localized and is felt as a dull aching or throbbing sensation

Gate Control Theory of Pain - Proposed by Melzack and Wall which was the first to recognize that the psychological aspects of pain are as important as the physiological aspects - Pain perception is regulated through a gating mechanism at the dorsal horn of the spinal cord, as a result, the level of conscious awareness of painful sensation is altered - Based on the premise that pain impulses travel through either small diameter nerve cells or large-diameter nerve cells, both cells which pass through the same gate. - The large-diameter cells have the ability, when properly stimulated, to close the gate and thus block transmission of the pain impulse to the brain 3. Perception - Developing conscious awareness of pain o When an impulse has been transmitted to the cortex and is interpreted by the brain, the information becomes available on a conscious level o It is then the person becomes aware of the intensity, location and quality of pain o This information is interpreted in light of previous pain experience o A clients perceptions and attitudes about pain are dramatically influenced by many factors including previous experiences and cultural background Pain threshold level of intensity at which pain becomes appreciable or perceptible and varies with each individual and type of pain Pain tolerance level of intensity or duration of pain the client is willing or able to endure 4. Modulation - The changing of pain impulses o Refers to activation of descending neural pathways that inhibit transmission of pain Descending because they involve neurons originating in the brain stem that descend to the dorsal horn of the spinal cord Descending fibers release substances that produce analgesia by blocking the transmission of noxious stimuli o It is a result of the effects of endogenous opioids also called endorphins and enkephalins Endorphins produces at various points in the CNS often in response to pain or stress when produces, they bind to opioid receptor sites, providing pain relief and a sense of euphoria Enkephalins Believed to be less potent than endorphins and are found throughout the brain and parts of the spinal cord Role of Endorphins and Enkephalins - Endogenous (produced within the body) opiates that respond to stress and painful stimuli - These substance may actually enhance the mood of an individual - Eg. Thought to cause the so-called HIGH in long distance runners Factors affecting the pain experience Age and Gender - Can greatly influence a clients perception of the pain experience Infant:

Sensitive to pain and typically exhibit discomfort through crying or physical movement Toddler: o Use crying and physical movement to indicate pain and they also begin to develop the skills needed to verbally describe pain or point to the area that is hurting Adolescents: o Sense great peer pressure and may be reluctant to admit having pain for fear and being called weak or sensitive Adults: o Continue pain behaviors they learned as children and may also be reluctant to admit pain or seek medical care because of fear of the unknown or fear of the impact that treatment may have on their lifestyle Older adults: o Often ignore pain, they view it as an unavoidable consequence of aging; they believe that nothing can be done to relieve the pain (MYTH) o Under detection of pain may be a result of the clients cognitive-perceptual deficits and may result to under treatment and under reporting o Stress and Anxiety - It increases muscle tension and sensitize the nervous system to stimuli - A painful stimulus further excites the nervous system creating a pain-anxiety-stress cycle Previous Experience with pain - Previous exposure to pain will often influence their reactions. - Coping mechanisms that were used in the past may affect clients judgments as to how the pain will affect their lives and what measures they can use to successfully manage pain on their own. Cultural Norms and Attitudes - Some culture, tolerance to pain and therefore suffering in silence is expected while on other cultures full expression of pain may include physical and emotional responses Nursing Process Assessment - Collection of subjective and objective data through the use of various assessment tools and construction of a database to use in developing a pain management plan - In the normal course of doing business, pain should be nursings 5th vital sign, as basic to practice as temperature, pulse, respiration and blood pressure Data Collection - Gathering subjective information on the client o Intensity o Location o Quality o Associated manifestation (nausea, constipation, dizziness) o Aggravating factors (variables that worsen pain; exercise, stress or food) o Alleviating factor (lying down, avoiding certain foods, taking medication) - Assessment of the: o Family/Significant others o Nurse Non-verbal signs of pain Facial grimacing Splinting of the painful area Distorted posture Impaired mobility Insomnia

Assessment tools - Single most effective method of identifying the presence and intensity of pain in clients 1. Initial Pain Assessment tool - Developed by McCaffery and Pasero - Effective when clients have complex pain problems because it assesses location, intensity, quality, precipitating and alleviating factors and how the pain affects function and quality life. - Once this tool is completed, another less detailed tool can be used for ongoing monitoring of the clients pain level. 2. Pain Intensity Scale - Verbal Rating Scale (VRS) o Uses adjectives ranging from no pain to excruciating pain in order to describe the intensity - Numeric Rating Scale (NRS) o Used together with VRS to collect more accurate client input o Clients are asked to assign their pain a number, with 0 meaning no pain and 10 representing the worst possible pain o If there are multiple painful areas, this question can be asked regarding each area 3. Nonverbal Pain Scale - Requires the nurse to observe a clients behavior for indicators of pain 4. Pain Diary - Client input is essential if accurate assessment data are to be collected - Includes self-monitoring of symptoms o Date/Time o Intensity o Situation (What were you doing?) o How did you feel? o What were you thinking? o What did you do to ease the pain? o How effective was the pain control strategy 5. Wong/Baker Faces Rating Scale - Can be used with children as young as 3 years old and it helps children express their level of pain by pointing to a cartoon face that most closely resembles how they are feeling - This tool has also been found to be useful for non-English speaking clients and cognitively impaired, older clients 6. Poker Chip Tool - Consist of four red poker chips that can easily be carried in a pocket to be available when needed - This tool can be used with children 4 to 13 years old. - The chips are aligned horizontally on a hard surface in front of the child and they are described as pieces of hurt - The child is then asked: how many pieces of hurt do you have right now? Nursing Diagnosis 1. Acute Pain - Less than 6 months

Anxiety Attention seeking depression Pain threshold Pain tolerance level

Defining Characteristics o Verbalization of severe discomfort o Restlessness o Variation in vital signs indicative of autonomic responses o Guarding behavior o Grimace o Sleep disturbance o Self-focus o Distracted behavior o Changes in appetite and eating 2. Chronic Pain - More than 6 months Defining Characteristics o Verbalization of pain over an extended period of time o Impaired functional ability o Sleep disturbance o Guarding behavior o Irritability o Self-focus o Restlessness o Depression o Muscle atrophy of affected area o Weight changes o Fatigue o Fear of re-injury Outcome Identification and Planning - Mutual goal setting is of utmost importance - It should be SMART; Example: It is unrealistic for a post-operative client to expect to have a pain-free post-operative period - The goal of pain relief might be to keep the clients pain at a level below 4 on a pain scale from 0 to 10 o Relief of pain or discomfort o Decrease in intensity of pain and discomfort o Absence of complication o Ability to verbalize knowledge of how to effectively cope with pain Implementation Standards for appropriate pain management in hospitals: o Recognize each clients right to pain assessment and treatment o Respect each clients cultural beliefs and values o Find methods to overcome any obstacles to pain management such as language barrier o Educate staff, clients and family caregivers about pain management o Utilize an interdisciplinary committee to develop a plan of care and monitor the pain management process (the plan should be appropriate to clients age and/or abilities) Nurse-Client Relationship - Establish rapport Client Education - Define pain, identify the probable causes and introduce to them the assessment tool and the tool that they want to use - Instruct about importance of round-the-clock dosing and PRN medication - Pain management and follow up patient for discharged client - Non-pharmacological and pharmacological interventions for clients experiencing pain

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Mild pain : non-pharmacological techniques as primary intervention with medication available as back-up Moderate and Severe pain: non-pharmacological techniques can be an effective adjunctive or complimentary, treatment

Pharmacological Pain Management (Medications) 1. NSAIDs - Classified as a non-opioid pharmacological agents together with Salicylates (aspirin) and acetaminophen - It has antipyretic or anti-inflammatory properties - Useful in treating mild to moderate pain, especially painful conditions involving inflammation - Eg. Ibuprofen, ketorolac, diclofenac - Adverse effect: o gastrointestinal bleeding because they block prostaglandin synthesis and can interfere with the mucosal barrier of the GIT COX-2 (cyclooxygensa isoenzyme inhibitors may be given as an alternative: it has a sparing effect on platelet aggregation and on the GIT COX-2 should be cautioned with allergic reactions (asthma, urticaria) o use cautiously with impaired renal function; because renal function depends on prostaglandin 2. Opioid Analgesic - Works by binding with opioid receptor sites in the CNS and PNS - Alters the release of neurotransmitters and therefore, pain transmission is interrupted at several sites at the CNS - The result is an altered perception of an response to pain - Eg. Codeine oxycodone, morphine, meperidine (Demerol) and hydrocodone - Side effect: o unwanted effect of constipation due to the systemic effect of opioid analgesics on nerves to the GI tract pharmacological treatment is indicated for client with chronic or high dose use Non-pharmacological: Eat high fiber food Drink 8-10 glass/day Increase physical activity (walking) Consume a hot beverage about 30 mins. Prior to the planned time for bowel movement Use stimulant laxatives or stool softener as prescribed. Non-pharmacological Management for Pain 1. Cognitive-Behavioral Interventions - Designed to educate clients and to modify clients attitude and behaviors a. Distraction - Pain management strategy that focuses the clients attention on something other than the pain and associate negative emotions o interactive games or listening to music b. Reframing - Techniques that teaches clients to monitor their negative thoughts and replace them with ones that are more positive o Teaching a client to view pain by expressing not. Ive had similar pain before, and its gotten better c. Biofeedback - Method that may helpful for the client in pain, especially one who has difficulty relaxing muscle tension - It is a process through which individuals learn to influence their physiological responses; it can alter their pain experience

d. Cutaneous stimulation - Cold application (Cryotherapy) o Alleviates edema by reducing vascular flow o Counteracts inflammation o Reduces fever o Diminishes muscle spasms o Elevates pain threshold as a result of decreasing the velocity of nerve conduction - Heat application o increases blood flow, increases tissue metabolism, decreases vasomotor tone and increase the viscoelasticity of connective tissue making it particularly effective in easing joint stiffness/pain - Cold, heat, pressure, vibration, or massage: use in increasing large diameter nerve fiber input to block small diameter pain fiber messages e. Transcutaneous stimulation - Is achieved through use of transcutaneous electrical nerve stimulation, acupuncture or acupressure - Transcutaneous electrical nerve stimulation: method of applying minute amounts of electrical stimulation to large diameter nerve fibers via electrodes placed on the skin 2. Alternative /Complimentary therapies a. Acupuncture - Insertion of fine, solid needles into specific acupuncture points enhancing the flow of qi through various meridians of the body - It is believed that the qi flow decreases the pain response b. Acupressure - The application of pressure to the same acupuncture points of the body c. Herbs d. Nutrition - Dietary practices may affect pain by inhibiting biochemical events associated with inflammation - Foods may trigger painful episodes: cheese, citrus fruits, red wine can contribute to the onset of migraine headache e. Physical Stimulation - Passive forms o Massage: it promotes muscle relaxation and decreasing tension and stress; it is believed that it might stimulate release of endogenous endorphins, enhancing pain relief - Active forms o Tai Chi and Yoga: both offer slow, deliberate movements that combine mental relaxation with physical movement and stretching. The resultant benefit is physical and mental stress reduction and thereby some pain relief f. Relaxation Technique - A variety of methods used to decrease anxiety and muscle tension o Imagery A strategy that uses mental images to assists with relaxation o Progressive muscle relaxation A strategy in which muscles are alternately tensed and relaxed g. Manipulation of Environment - Environment can exert influence on the perception of pain; therefore, changes in ones environment may reduce pain levels o Pet Therapy Interactive sessions between client and animals; said to be helpful for some clients experiencing chronic pain o Horticultural Therapy Treatment that includes looking at, touching and growing plants has several therapeutic benefits including pain reduction, relaxation and improved energy level. o Music Therapy Help ease pain by producing relaxation and providing distraction


Anxiety - A feeling of dread or uneasiness from unrecognized cause Anxiety Level Mild Moderate Severe Panic Characteristics of anxious persons Increase degree of alertness Increase vigilance Subjective distress Decreased perception and attention Increase subjective distress Selective attention Distorted perception Major perceptual distortion Immobilization; inability to function Impaired communication Nursing Implication Optimal time for a client teaching because of heightened awareness and increased perceptual field Help the client determine a causeand-effect relationship between stressor and anxiety Encourage verbalization Encourage in motor activity Give specific direction Provide limits and structure Maintain client safety (both physical and psychological)

Physiologic SAMR Restlessness Frequent hand movement (moderate) Immobility (severe) Behavioral Decreased attention span Decreased ability to follow directions Increase acting out Increase somatization Interactional Increase in number questions Constant seeking reassurance Frequent shifting of topics of conservation Avoidance of focusing on feelings Focus in equipment or procedure

Grief - Total response to the emotional experience related to loss Kubler-Ross Stages of grief Stage Behavioral Response Denial Anger Bargaining Depression Refuses to believe that loss is happening. Is unready to deal with practical problems, such as prosthesis after the loss of a leg Client or family may direct anger at nurse or staff about matters that normally would not bother them Seeks to bargain to avoid loss May express feelings of guilt or fear of punishment for past sins, real or imagined Grieves over what has happened and what cannot be

May talk freely or may withdraw Acceptance Comes to terms with loss May have decreased interest in surroundings and support persons May wish to begin making plans Manifestations - Chest tightness - Shortness of breath - Sighing - Empty feeling in the abdomen - Loss of muscular power - Intense subjective distress Assisting clients with their grief Provide opportunity for the client to tell their story Recognize and accept the varied emotions that people express in relation to a significant loss Provide support for the expression of difficult feelings such as anger and sadness Include other parts of the family in their grieving Acknowledge the usefulness of mutual help group Encourage self-care by significant others Acknowledge the usefulness of counseling Nursing Intervention - Supporting protective mechanisms Rest Comfort measures Relief of pain Decrease stimuli from environment

Providing structure or explanation Exploration of feelings Encouraging health promotion strategies Exercise Nutrition Sleep Time management

Minimizing stress and anxiety Listen attentively Provide an atmosphere of warmth and trust; convey a sense of caring and empathy Stay with client as needed Control the environment to minimize additional stressors Implement suicide precautions if indicated

Communicate in short, clear statements Health education: Importance of adequate exercise, balance diet, rest and sleep Time management Support groups if any

Using relaxation technique Components: Quiet environment Comfortable position Passive attitude Mental device (focusing on sound, word, phrase, object or breathing pattern)

Approaches Breathing exercises Massage Progressive relaxation Systematically tensing-relaxing of muscle groups from head to toe (1530 mins) Bensons relaxation (20 mins) Imagery Using a conscious suggestion or a mental picture of the desired change Biofeedback Affirmation Therapeutic touch Yoga Meditation Therapeutic touch Music therapy Humor and laughter