BACHELOR OF SCIENCE IN NURSING:

CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID &

ELECTROLYTES, INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC,
PERIOPERATIVE CARE AND CELLULAR ABERRATIONS
COURSE MODULE COURSE UNIT WEEK
1 1 1
Inflammation and Pain

• Read course and unit objectives

• Read study guide prior to class attendance
• Read required learning resources; refer to unit
terminologies for jargons
• Proactively participate in classroom discussions
• Participate in weekly discussion board (Canvas)
• Answer and submit course unit tasks

At the end of this unit, the students are expected to:

• Integrate relevant principles of physical, social, natural and health science and
humanities in a given health and nursing situations based on epidemiologic profile.
• Apply appropriate nursing concepts and actions holistically and comprehensively.
• Discuss the pathophysiologic responses to acute and chronic alterations/problems in
Inflammation and Pain
• Assess the health status/competence of an adult client at risk and/or sick.
• Formulate a plan of care to address the needs/problems based on priorities.
• Implement safe and quality interventions with the client to address the identified
need(s)/problem(s).
• Provide health education using selected planning models to sick clients.
• Evaluate with the client the health status/competence and/or expected outcomes of
nurse-client working relationship.
• Institute corrective measures to prevent or minimize harm arising from adverse
effects.
• Document client responses/nursing care and services rendered and
processes/outcomes of the nurse-client relationship.
• Ensure completeness, integrity, safety, accessibility and security of information.
 • Adhere to protocol and principles of confidentiality in safekeeping and releasing of
records and other information.

Hinkle, J, L, & Cheever, K,H, (2018), Brunner & Suddarth’s Textbook of Medical-
Surgical Nursing (14th ed.), Philadelphia; Wolters Kluwer. pp 224

Pain- an unpleasant sensory and emotional experience associated with actual or potential tissue damage
or described in terms of such damage, sensation of physical or mental suffering.

-A sensation of physical or mental hurt or suffering that causes distress or agony to the one
experiencing it.
-Is subjective in nature, only the person experiencing it may describe it.
-Is protective in nature because it provides warning signal for tissue injury. It helps minimize injury
and is often a protective injury-protection mechanism.
Pain- is whatever the experiencing person say it is, existing whenever he say does-Mc-Caffery

Persistent pain- a pain that contributes insomnia, weight gain, constipation, etc.

Severe pain- an emergency situation deserving attention and professional treatment.

Comfort- implies renewal amplification of power.

Types of Comfort:

1. Relief- experience of having a specific need to meet

2. Ease- state of calm
3. Transcendence-state in which client ease above.

Theories of Pain:

1. Pattern Theory- states that pain is perceived whenever stimulus is intense enough.
2. Specificity Theory- It states that there is a specific nerve receptor for particular stimuli. E.g.
Nociceptor-noxious stimuli, Thermoreceptor-heat/cold, Mechano receptor- pressure,
Chemoreceptor-Chemicals
3. Gate Control Theory- There is a gate in the spinal cors called substantia gelatinosa. When the
gate is open, pains stimulus is transmitted, thus pain is perceived. When the gate is closed,
stimulus is blocked thus, no pain is perceived. This is introduced by Melzack and Wall
4. Affect Theory- It avers that pain is emotional. The intensity of pain perceived depends on the
value of the organ affected to the individual.
 5. Parallel Processing Model- Physiologic or neurologic deciphering of pain sensation and
cognitive emotional properties occur along different nerve fibers.

Types of Pain:

A. By Location
• Referred pain- appear to arise in different areas.
• Visceral pain- pain arise from organ or hollow viscera.
B. By Duration
• Acute pain-it has a sudden/slow onset and regardless of its’ intensity.
• Chronic pain-is prolonged, usually recurring/persisting over 6 months or longer. It is mild to
severe, constant or recurring w/o anticipated or predictable end.
• Cancer pain- may result from direct effect of the disease and its treatment may be unrelated
to disease and its treatment with cancer.
o HIV/AIDS pain- malignant pain which tend to be treated more aggressively.
C. By Intensity
• Mild- pain ranging from1-3
• Moderate-pain ranging from 4-6
• Severe-pain ranging fro, 7-10 w/ worst outcome
D. By Etiology
• Physiological pain- pain when an intact, properly functioning nervous system sends signals
that tissues are damaged.
• Somatic- originates in the skin, muscles, bones and connective tissues.
• Cutaneous pain-occurs over body surface or skin.
• Radiating pain-felt at a source and extends to surrounding tissues.
• Visceral pain- results from activation of pain receptor or hollow viscera; tends to be poorly
located and may have a cramping quality and feeling sick.
• Neuropathic pain-experienced by people who have damaged/malfunctioning nerves,
abnormal due to illness and abnormal nerves in PNS or CNS. It is typically chronic, burning,
tingling and electric shock like pain.
• Peripheral neuropathic pain- follows damage and or sensitization of peripheral nerves.
• Central neuropathic pain- results from malfunctioning nerves in the CNS.
• Sympathetically maintained pain-occurs occasionally when abnormal connections between
pain fibers and SNS. Perpetuate problems with both the pain and sympathetically controlled
functions.

Pain Concepts:

• Pain threshold-least amount of stimuli needed for a person to label a sensation as pain.
• Pain tolerance-maximum amount of pain stimuli that a person is willing to withstand without
seeking avoidance of pain relief.
• Hyperalgesia/hyperpathia-a heightened response to a painful stimuli or increased
sensation of pain.
• Allodynia- sensation of pain from a stimuli normally not producing pain. It is also skin
sensitivity to pain.
• Dysesthesia- unpleasant abnormal sensation, imitates the pathology of central neuropathic
pain disorder.
 • Nociceptive pain-pain directly related to tissue damage and may be somatic.
• Sensitization-an increased sensitivity of a receptor after repeated activation by noxious
stimuli or nociceptor.
• Wind-up-progressive increase in excitability and sensitivity of spinal cord neurons leading to
persistent increased pain.
• Pain perception- actual feeling of pain.
• Bradykinin-universal stimulus for pain.

Clinical Manifestations of Pain:

• Postherpetic neuralgia- a case of herpes zoster typically erupts decades after a primary
infection. Has vesicular rash with burning and electric shock pain.
• Phantom pain –feeling that a lost body part is present.
• Phantom limb pain-feeling that a lost body part is present after limb amputation.
• Postmastectomy pain-feeling that a lost breast is present.
• Trigeminal neuralgia-intense stab like pain that is distributed by 1 or more branches of
trigeminal nerve.
• Headache- caused by intracranial or extracranial problem.
• Fibromyalgia-a chronic disorder characterized by widespread musculoskeletal pain, fatigue
and multi-tender points.
• Psychogenic pain-due to emotional factors
• Intermittent-pain stops and starts again.

Pain Pathway:

Stimuli→ Nociceptor→ A Delta Fiber or C Fiber→Ganglion→Dorsal horn→Spinothalamaic

tract→Thalamus (center of awareness of pain)→Cerebral cortex (center for interpretation of
pain)→Responses

Pain Physiology:

• Primary sensory neurons- specialized to detect mechanical, thermal and chemical condition
associated with potential tissue damage.
• Nociception-physiologic processes related to pain perception.
• Nociceptors-specialized pain receptor that can be excited by mechanical, thermal, and
chemical stimuli.
1. Transduction phase- noxious stimuli trigger to release of biochemical mediators and cause
movement of ions across cell membrane exciting nociceptors.
2. Transmission phase-includes 3 segments:
1st segment-pain impulsive travels from the PN fibers to spinal cord.
ü Substance P-serves as a neurotransmitter, enhancing the movement of impulses across
nerve synapse.
ü Dorsal horn- pain signal is mediated and modified by modulating factors before amplified
or damped signal via spinothalamic tract
2nd segment-transmission from spinal via spinothalamic tract to brainstem and thalamus.
3rd segment-transmission of signals between thalamus to somatic sensory cortex.
3. Modulation phase-descending system, occurs when neurons in the thalamus and brainstem send
signals back down to dorsal horn of spinal cord.
 ü Excitatory glial cell amino acids- tends to persist or amplify pain.
4. Perception phase-final phase. It is when client becomes conscious to pain
Pain perception- sum of complex activities in CNS that may character pain and its intensity.

GATE CONTROL Theory Concepts

• Substantia gelatinosa- milieu of CNS. May imbalanced in an excitatory or inhibitory direction-

opens/closes the gate.
• Ion channels-located on the pre or post synaptic gate and also serve as a gate.
• A delta nerve fibers-typically send messages of touch/warm or cold temperature. It has inhibitory
effect to sustantia gelatinosa.

Factors Affecting pain: Ethnic/Cultural Norms, Sex, Developmental stage, age Environment
or support people, Past pain experience, Meaning of pain, etc.

Responses to Pain:
• Involuntary- Physiologic mediated by ANS or SNS. In SNS-mild while in PNS-severe
• Voluntary-Behavioral or emotional response.

3 Stages of Pain Response:

• Activations-Begins with perception of pain. A fight/flight response initiated by SNS.
• Rebound-Intense but brief initiated by PNS.
• Adaptation-it is due to endorphins counteracting pain when pain last for many hours
/days.

Pain Assessment and tools:

• CHARACTER-sensation
• ONSET-when the pain started
• LOCATION-where
• DURATION-constant vs intermittent
• EXACERBATION-factors making it worst
• RELIEF-factors making it better
• RADIATION-pattern of shooting
• Wong-Baker Faces Rating Scale-for preverbal children.
• FLACC Scale-has been validated in children from2 mos-7yrs.
• Legmut Facial Expression-cry, activity and consolability.

Pharmacologic Pain Management:

• Rational Polypharmacy-demands that H professionals should be aware of all ingredients of

medications that alleviate pain and use combinations to reduce the need for high doses.

• Multimodal therapy-uses nondrug approaches like heat relaxation.

WHO 3 STEPS APPOACH FOR OPIODS

1. STEP 1- Non-opiod analgesics is the appropriate starting pt.

2. STEP 2- A weak opioid or combination of opioid or combination of opioid/nonopioid with or
w/o analgesic meds
3. STEP 3-strong opiates are administered and titrated.
• Ceiling effect- Once the maximum analgesics benefit is achieved more drug will not
produce more analgesia.
• Equianalgesia-refers to the relative potency of various opioid analgesics compared to
a standard dose of parenteral morphine
• Placebo- any medication including surgery that produces an effect in the client
because of its implicit/ explicit effect and not because of its specific physical or
chemical property.
TYPES OF OPIOIDS
• Full agonist- bind tightly to Mu receptor sites producing maximum pain inhibition, an
agonist effect, has no ceiling effect
• Mixed Agonist-Are antagonists-agonists-antagonists analgesics-act like opioids and
relieve pain, block and inactivate other opioid analgesics, block Mu receptor but
activates Kappa receptor site.
• Partial agonist- have ceiling effect in contrast to full agonist; block Mu receptor or are
neutral receptor but bind with kappa receptor site, good analgesic potency, most
popular
TYPES OF COANALGESICS
• Coanalgesic/adjuvant- a medication that is not classified as a pain medication but
may reduce pain specifically Neuropathic pain.
• Tricyclic antidepressant- useful for central neuropathic pain, burning, stinging quality.
• Anticonvulsant-particularly useful into peripheral neuropathic conditions that often
present w/ stabbing, shooting and electric shock pain.
• Lidoderm-alleviate neuropathic as well as other types of pain particularly allodynia.
OTHER PHARMACOLOGIC MGT.
• Epidural Space- most commonly use in Intraspinal route of administration of pain
med. It is because it has the durameter that acts as protective carrier.
• Continuous Local Anesthetics- continuous subcutaneous administration of long
acting local anesthetics into a near surgical site. Useful for post.op px.
• Patient-controlled analgesia-interactive method of pain management that permits
clients to treat their pain by self administration of analgesia.
• SURGICAL MGT.
• Neurectomy-Interrupts cranial or peripheral nerves by an incision.
• Rhizotomy- Interruption of the anterior or posterior nerve root area close to the spinal
cord.
• Cordotomy or Spinothalamic Tractotomy-The surgical interruption of pain-
conducting pathways within the spinal cord. The incision is made in the anterolateral
pathway opposite the side on which the pain is located.
• Tractotomy-Surgical resection of the anterolateral pathway in the brainstem.
• Gyrectomy-removal of the postcentral gyrus (part of the sensory cortex of brain)
• Hypophysectomy-Destroying of the pituitary gland by injection with absolute alcohol.
• Nerve block- chemical interruption of a nerve pathway effecting by injecting a local
anesthethic into a nerve.
• Sympathectomy-pathways of the sympathetic division of ANS are severed.
 • Spinal cord stimulation- used with persistent pain that has not been controlled with
less invasive therapies, insertion of electrodes

NON-PHARMACOLOGIC MGT.

• Cutaneous Stimulation-provide effective temporary pain relief. It distracts client focus.

• Massage-comfort measure that can aid relaxation, decrease muscle tension, anxiety, etc.
• Heath and Cold Application-heals injury
• Acupressure-from ancient Chinese healing system of acupuncture where finger pressure is
applied to many points of the body.
• Contralateral stimulation- can be accomplished by stimulating the skin in an area opposite to
painful area.
• Bracing-restriction of mvt.
• Transcutaneous Electrical Nerve Stimultaion (TENS)- is a method of applying low voltage
electrical stimulation directly over pain.
• Distraction- draws the person’s attention away from pain and perception of pain.
• Hypnosis-deep state relaxation.

Pain- an unpleasant sensory and emotional experience associated with actual or potential tissue damage
or described in terms of such damage, sensation of physical or mental suffering.

Referred pain- appear to arise in different areas

Visceral pain- pain arise from organ or hollow viscera.

Acute pain-it has a sudden/slow onset and regardless of its’ intensity.

Chronic pain-is prolonged, usually recurring/persisting over 6 months or longer. It is mild to severe,
constant or recurring w/o anticipated or predictable end.

Cancer pain- may result from direct effect of the disease and its treatment may be unrelated to disease
and its treatment with cancer.

Physiological pain- pain when an intact, properly functioning nervous system sends signals that tissues
are damaged.

Somatic- originates in the skin, muscles, bones and connective tissues.

Cutaneous pain-occurs over body surface or skin.

Radiating pain-felt at a source and extends to surrounding tissues.

Visceral pain- results from activation of pain receptor or hollow viscera; tends to be poorly located and
may have a cramping quality and feeling sick.

Neuropathic pain-experienced by people who have damaged/malfunctioning nerves, abnormal due to

illness and abnormal nerves in PNS or CNS. It is typically chronic, burning, tingling and electric shock like
pain.

Peripheral neuropathic pain- follows damage and or sensitization of peripheral nerves.

Central neuropathic pain- results from malfunctioning nerves in the CNS.

Pain threshold-least amount of stimuli needed for a person to label a sensation as pain.

Pain tolerance-maximum amount of pain stimuli that a person is willing to withstand without seeking
avoidance of pain relief.

Hyperalgesia/hyperpathia-a heightened response to a painful stimuli or increased sensation of pain.

Allodynia- sensation of pain from a stimuli normally not producing pain. It is also skin sensitivity to pain.

Dysesthesia- unpleasant abnormal sensation, imitates the pathology of central neuropathic pain
disorder.

Nociceptive pain-pain directly related to tissue damage and may be somatic.

Sensitization-an increased sensitivity of a receptor after repeated activation by noxious stimuli or

nociceptor.

Wind-up-progressive increase in excitability and sensitivity of spinal cord neurons leading to persistent
increased pain.

Pain perception- actual feeling of pain.

Postherpetic neuralgia- a case of herpes zoster typically erupts decades after a primary infection. Has
vesicular rash with burning and electric shock pain.

Phantom pain –feeling that a lost body part is present.

Phantom limb pain-feeling that a lost body part is present after limb amputation.

Trigeminal neuralgia-intense stab like pain that is distributed by 1 or more branches of trigeminal
nerve.

Fibromyalgia-a chronic disorder characterized by widespread musculoskeletal pain, fatigue and multi-
tender points.

Psychogenic pain-due to emotional factors

Intermittent-pain stops and starts again.

Udan,Josie Quiambao. (2017). Workbook and study guide medical-surgical nursing concepts and clinical
applications, 3rd ed. Manila: APD Educational Publishing House.
Udan,Josie Quiambao. (2017). Medical-surgical nursing: concepts and clinical applications, 3rd ed.
Manila: APD
Educational Pub.

Jarrell, Bruce E. (2016). NMS Surgery, 6th ed. Philadelphia: Wolters Kluwer.

Case Study: Pain Experience

Belle is a young, healthy adult who slipped off the stairs going down to the basement
and struck her forehead on the cement flooring. Belle did not lose consciousness but
did sustain a mild concussion and a hematoma that was 5cm in width and protruded
about 6cm. she experienced immediate acute pain at the site of injury plus a pounding
headache.

1. after an immediate assessment of the localized pain, based on the patient’s

description, what does the nurse anticipate regarding the pain assessment?
2. During the assessment process, the nurse attempts Belle’s physiologic and
behavioral responses to her pain experience. The nurse is aware that the patient
can be in pain yet appear to be “pain free” what is the behavioral response
indicative of acute pain?
3. The nurse uses distraction to help Belle cope with her pain experience. What
suggested activities can help her cope?
4. After treatment, Belles is discharge to home while still in pain. What should the
nurse do?

Udan,Josie Quiambao. (2017). Workbook and study guide medical-surgical nursing concepts and clinical
applications, 3rd ed. Manila: APD Educational Publishing House.

Udan,Josie Quiambao. (2017). Medical-surgical nursing: concepts and clinical applications, 3rd ed.
Manila: APD
Educational Pub.
Jarrell, Bruce E. (2016). NMS Surgery, 6th ed. Philadelphia: Wolters Kluwer.