FAR EASTERN UNIVERSITY

Institute of Nursing
First Semester SY 2020-2021

HAND OUT – MODULE 1

NUR 1213 – PAIN AND SURGERY

COURSE TITLE: Care of Clients with Problems in Oxygenation, Fluid & Electrolytes,
Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and
Chronic.

COURSE CODE: NCM 112

COURSE DESCRIPTION:
This course deals with concepts, principles, theories and techniques of
nursing care management of at risk and sick adult clients in any setting with alterations /
problems in oxygenation, fluid and electrolytes, infectious, inflammatory and immunologic
response, cellular aberrations, acute and chronic. The learners are expected to provide nursing
care to at risk and sick adult clients utilizing the nursing process.

COURSE CREDIT: 8 Units Theory (144 hours)

6 Units RLE (306 hours)
1 unit Skills Lab (51 hours)
5 units RLE (255 hours)

TOTAL LEARNING TIME: 20 Hours

CONCEPTS of NUR 1213:

a. Pain and Surgery - 20 hours (11 %)
b. Fluid & Electrolytes - 24 hours (21 %)
c. Oxy / Respi - 20 hours (28%)
d. Cardio / Hema - 20 hours
e. Communicable Diseases – 28 hours (20 %)
f. Cellular Aberrations - 28 hours 20 %)
Comprehensive Exam - 4 hours
--------------------------------------------------
144 hours (100%)

COURSE PLACEMENT: Third Year, First Semester

PRE REQUISITE: NCM 109

COURSE OUTCOMES:
1. Apply knowledge of physical, social, natural and health
sciences, and humanities in the nursing care of at risk and
sick adult clients with problems in oxygenation, fluid and
electrolytes, infectious, inflammatory, and immunologic
response, cellular aberrations, acute and chronic.
2. Provide safe, appropriate, and holistic nursing care to at
risk and sick adult clients with problems in oxygenation,
fluid and electrolytes, infectious, inflammatory and
immunologic response, cellular aberrations, acute and
chronic, utilizing the nursing process.
3. Apply guidelines and principles of evidence-based
practice in the delivery of care.
4. Practice nursing in accordance with existing laws, legal
ethical and moral principles, and standards.
5. Communicate effectively in speaking, writing and
presenting using culturally appropriate language.
6. Document to include reporting up-to-date client care
accurately and comprehensively.
7. Work effectively in collaboration with inter-, intra, and
multi-disciplinary and multi-cultural teams.
8. Practice beginning management and leadership skills in
delivery of client care using systems approach.
9. Conduct research with an experienced researcher.
10. Engage in lifelong learning with a passion to keep current
with local, national, and global developments in general,
and nursing and health developments in particular.
11. Demonstrate responsible citizenship and prided in being a
Filipino.
12. Apply techno-intelligent care systems and processes in
health care delivery.
13. Adopt the nursing core values in the practice of the
profession.

LEVEL OUTCOMES:
At the end of the third year, given individuals, families,
population groups, and communities with physiologic and
psychosocial health problems and maladaptive patterns of
behavior in varied healthcare settings, the learners demonstrate
safe, appropriate and holistic care utilizing the nursing process,
evidence based practice and research process.

INTENDED CONCEPT LEARNING OUTCOMES:

 At the end of the concept, the students will be able to:
1. Understand the concept of surgery and apply correctly in
the clinical setting.
2. Develop an understanding of the principles of sterile and
aseptic technique and the necessity of their application in
all operative procedures or phases.
3. Acquire basic knowledge and skills about OR nursing in
order to provide better and efficient care to surgical
patients.
4. Develop confidence, alertness and competence among
students in meeting the patient’s needs – physical or
psychological.
5. Apply the nursing process in the care and management of
patient undergoing preoperative, intra operative and post-
operative phase.

HOUSE RULES :
1. 2. There are five modules in Pain and Surgery. Study each
module provided thru canvas religiously.
3. Consultation hours regarding the topics is every lecture
hour.
4. For formative assessment (Quizzes), it will be open on the
day it is intended to answer by the students and are given
48 hours to answer and send it back thru canvas.
5. For Summative assessment (Unit Exam) which will be
open on the third and last week of lecture, it is expected to
be submitted prior to the start of the second concept.
6. Students are expected to read and study the module ahead
of time and have the initiative to gain an additional
knowledge about the concept by reading other references.

PRESENTATION OF COURSE OUTLINE: Please see uploaded files in Canvas

CONCEPT REQUIREMENT: 2 Formative Assessment

1 Summative Assessment

FEU VISION STATEMENT

Guided by the core values of Fortitude, Excellence and Uprightness, Far Eastern University
aims to be a university of choice in Asia.

FEU MISSION STATEMENT

 Far Eastern University provides quality higher education through industry-responsive and
outcome-based curricular programs.
Far Eastern University produces globally competitive graduates who exhibit the core values of
fortitude, excellence and uprightness.
Far Eastern University promotes sustainable and responsive research, extension, heritage and
environment stewardship towards national and global development.

MODULE 1.5 - PAIN

Pain
a. Definition
 Pain is the sensory experience evoked by stimuli that injure or threaten to destroy
tissue, defined introspectively by every man as that which hurts;
 An unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage;
 Is a privately, experienced, unpleasant sensation usually associated with disease or
injury; It has also an emotional component referred to as “suffering.”

b. Terminologies

Pain Perceptions
• the conscious experience of discomfort.
• Children and elderly perceived pain differently than adults;
• Infants 1-2 days old are less sensitive to pain. A full behavioral response to pain is
apparent at 8 – 12 months of age.

Pain Threshold
• the lowest intensity of a painful stimulus that is perceived by a person as pain.
• the amount or degree of noxious stimuli that leads a person to first interpret a sensation
as painful.
• Older children, between 15-18 years old, tend to have a lower pain threshold than do
adults.
• Tends to increase with aging. This change is probably caused by peripheral
neuropathies and changes in the thickness of the skin.

Pain Tolerance
• the maximum intensity or duration of pain that a person is willing to endure once the
threshold has been reached.
• varies greatly among people and in the same person over time;
• a decrease in pain tolerance is evident in the ELDERLY.
• WOMEN appear to be more tolerant to pain than MEN.

Pain Tolerance is DECREASED:

 With repeated exposure to pain;
 By fatigue, anger, boredom, apprehension;
 Sleep deprivation
 Pain Tolerance is INCREASED:
 By alcohol consumption;
 Medication, hypnosis;
 Warmth, distracting activities;
 Strong beliefs or faith

Pain Expression
• the actual feeling that a particular client shows in pain and the view of the health care
professional, also governed by cultural values.

c. Misconceptions and Myths about Pain

1. The nurse or physician is the best judge of a patient’s pain;
Fact: Only the patient can judge the level and distress of the pain; pain management
should be a team approach.
2. Pain is part of aging;
Fact: Pain does not accompany aging unless a disease process or ailments is present.
3. If a person is asleep, they are not in pain;
Fact: People in pain become exhausted and may truly be asleep or merely trying to
sleep. Some people use sleep as an escape mechanisms.
4. Pain is a result, not a cause;
Fact: Unrelieved pain can create other problems such as anger, anxiety, immobility and
delay in healing.
5. Real pain has an identifiable cause;
Fact: There is always a cause of pain, but it may be very obscure and must be assessed
carefully.
6. Very young or very old people do not have as much pain;
Fact: Age is not a determinant of pain, but it may influence expression of pain.
7. Nurse should rely on their own definition of pain and cultural beliefs about pain;
Fact: It is a mistake to impose one’s own definition, cultural beliefs and values to
another person’s pain. Let the patient tell you what pain means.

d. Barriers to Pain
 Reluctant to report pain due to low expectation of obtaining relief;
 Lack of insurance and high cost of medications;
 Pain is a sign of weakness;
 Afraid of side effects from medications;
 Poor clinician-patient communication.

e. Characteristics of Pain
• Pain is subjective and personal;
• Physiologic pain may sometimes broaden to encompass emotional hurt;
• Pain is a symptom not a disease entity;
• Pain is uniquely experienced by each individual and cannot be adequately define,
identify or measure by an observer;
• Pain is a valuable diagnostic indicator, it usually indicates tissue damage or pathology;
• Pain is usually reported as a severe discomfort or uncomfortable sensation;
f. Components of Pain
1. Stimuli
2. Perception
3. Response
4. Intensity
5. Threshold
6. Tolerance

g. Types of Pain
1. According to Source
a. Nociceptive Pain - is the noxious stimuli that are transmitted in an orderly fashion from
the point of cellular injury over peripheral sensory nerves to pathways between the
spinal cord and thalamus, and eventually from the thalamus to the cerebral cortex of the
brain.
 Somatic pain (Superficial & Deep) - caused by injury to skin, muscles, bone, joint, and
connective tissues. Somatic pain often involved inflammation of injured tissue.
Although inflammation is a normal response of the body to injury, and is essential for
healing, inflammation that does not disappear with time & can result in a chronically
painful disease. The joint pain caused by rheumatoid arthritis may be considered an
example of this type of somatic nociceptive pain. 

Superficial somatic pain or Cutaneous pain – perceived as sharp or burning discomfort or

pricking quality.
ex. Insect bite , paper cut 
Deep somatic pain – produce localized sensations that are sharp, throbbing and intense.
- usually described as dull or aching, diffuse discomfort and localized in one area.
ex. arthritis

 Visceral pain - refers to pain that originates from ongoing injury to the internal organs
or the tissues that support them. When the injured tissue is a hollow structure, like the
intestine or the gall bladder, the pain often is poorly localized and cramping. When the
injured structure is not a hollow organ, the pain may be pressure-like, deep, and
stabbing. It is usually accompanied by ANS symptoms such as nausea & vomiting,
pallor, hypotension, & sweating.

b. Neuropathic Pain - pain that is processed abnormally by the nervous system and
usually results from damage to either the pain pathways in peripheral nerves or pain
processing centers in the brain.

c. Psychogenic pain – is a simple label for all kinds of pain that can be best explained by
psychological problems. Sometimes occur in the absence of any identifiable disease in
the body. More often, there is a physical problem but the psychological cause for the
pain is believed to be the major cause for the pain.

2. According to Characteristics (Onset, intensity & Duration)

 a. Acute Pain – usually of short duration (less than 6 months) and often described in
sensory term such as sharp, stabbing and shooting and accompanied by observable physical
responses.
 Recent onset
 Symptomatic of primary injury or disease
 Specific and localized
 Severity is associated with acuity of the injury or disease process
 Responds favorable to drug therapy and requires gradual decrease in drug therapy.
 Diminishes with healing
 Suffering decreases as pain decreases.

Psychological & Behavioral Response to Acute Pain:

Fear
General sense of unpleasantness or unease
Anxiety

Physical Response to Acute Pain:

Increased HR, RR & BP
Pallor or flushing , dilated pupils
Diaphoresis
Increased blood sugar
Decreased gastric motility & gastric secretion
Decreased blood flow to the viscera, kidneys and skin
Nausea

b. Chronic Pain – is a major health concern. Divided into three (3) types:
 Chronic Nonmalignant pain – low back pain to rheumatoid arthritis
 Chronic Intermittent pain – migraine, headache
 Chronic Malignant pain – cancer
 Remote onset
 Uncharacteristic of primary injury or disease
 Nonspecific and generalized
 Severity is out of proportion to the stage of the injury or disease
 Responds poorly to drug therapy
 Requires increase in drug therapy
 Persists beyond healing stage
 Suffering intensifies

Characteristics of Patients Experiencing Chronic Pain:

Depression
Increased or decreased appetite and weight
Poor physical tone
Social withdrawal and life role changes
Decrease concentration
Poor sleep
Preoccupation with physical manifestation
Intermittent Pain
 produces a physiologic response similar to acute pain.

Persistent Pain
 allows for adaptation (functions of the body are normal but the pain is not relieved)

Referred Pain
 used to describe discomfort that is perceived in a general area of the body, but not in the
exact site where an organ is anatomically located.

1. Myofascial Pain – trigger points, small hyperirritable areas within a m. in which n.

impulses bombard CNS & are expressed at referred pain.

2. Sclerotomic & Dermatomic Pain – deep pain; may originate from sclerotomic,
myotomic, or dermatomic nerve irritation/injury.

h. Transmission of Pain
1. TRANSDUCTION – begins a response to a noxious stimulus (painful stimulus) that
results in tissue injury, can be mechanical, thermal or chemical. ‘’ IT TRIGGERS THE
RELEASE OF NOXIOUS STIMULI’’.
a. is the conversion of chemical information in the cellular environment to
electrical impulses that move toward the spinal cord. The chemicals that are
released by the damaged cells stimulate specialized pain receptors located in the
free nerve endings of peripheral sensory nerves called NOCICEPTORS.

2. TRANSMISSION – the phase during which the peripheral nerve fibers form synapses
w/ neurons in the spinal cord, the pain impulses move from the spinal cord sequentially
levels in the brain, the impulses ascend to the reticular activating system, the limbic
system and the thalamus and finally the cerebral cortex.

3. PERCEPTION – refers to the phase of impulse transmission during w/c the brain
experiences pain @ a conscious level (awareness of pain).

4. MODULATION – the last phase of pain impulse transmission during which the brain
interacts with the spinal nerves in a downward fashion to alter the pain experience.

i. Structure and Functions of the Pain System

PERIPHERAL NERVOUS SYSTEM – carries pain impulses to and from the CNS
1. Afferent nerve fibers - carry impulses to the CNS)
2. CNS
3. Efferent nerve fibers – carry impulses from t

The afferent portion is composed of:

1. Nociceptors – naked nerve endings (thermal, chemical and mechanical)
a. A – Delta fibers – rapid rate, transmit ACUTE SHARP PAIN
b. C – Fibers – slower rate and produce chronic type of pain
 2. Afferent nerve fibers
3. Spinal Cord network

AUTONOMIC NERVOUS SYSTEM

 regulates involuntary functions
1. SYMPATHETIC NERVOUS SYSTEM – ‘’ a fight or flight response to stress’’
2. PARASYMPATHETIC – ‘’exhaustion or shock’’ response
3. NEUROTRANSMITTERS

The CNS comprises the spinal cord and the brain

1. The SPINAL CORD – transmits painful stimuli to the brain and motor responses and
pain perception to the periphery.
2. The BRAIN – processes and interprets transmitted pain impulses

j. Factors Affecting Response to Pain

1. Physiologic Factors – age, genetics, quality
2. Affective factors – mood, fear, depression, anxiety
3. Psychosocial factors – family, personal spiritual, cultural beliefs, occupation
4. Cognitive – past experience, knowledge, values, expectations

k. Pain Control Theories

INTENSITY THEORY
 State that pain is the result of excessive stimulation of sensory receptors.

PATTERN THEORY
 Describes that painful and non-painful sensation s are transmitted by nonspecific
receptors through a common pathway to higher centers of the brain.

SPECIFICITY THEORY
 Describe four types of cutaneous sensation: touch, warmth, cold and pain. It focuses on
the direct relationship between the pain stimulus and perception but does not account
for adaptation to pain and the psychosocial factors that modulate the stimulus.

GATE CONTROL THEORY (Melzack & Wall 1965) -

• Nerve fibers carry touch and pain impulses from receptors on the skin to the spinal cord
• Nerve cells in the SG of the spinal cord receive these touch and pain impulses
• Impulses then proceed through transmission cells to the brain
• Fibers from the brain send inhibiting information to the Substantia Gelatinosa (SG) in
dorsal horn of spinal cord w/c serves as a gate for control of pain
 Gate - located in the dorsal horn of the spinal cord
 Smaller, slower n. carry pain impulses
 Larger, faster n. fibers carry other sensations
 Impulses from faster fibers arriving @ gate 1st inhibit pain impulses
(acupuncture/pressure, cold, heat, chem. skin irritation

Three (3) Factors Involved in Opening and Closing the Gate:

 1. The amount of activity in the pain fibers.
2. The amount of activity in other peripheral fibers.
3. Messages that descend from the brain.

Conditions that Open the Gate:

1. Physical Conditions
a. Extent of injury
b. Inappropriate activity level
2. Emotional Conditions
a. Anxiety or worry
b. Tension
c. Depression
3. Mental Conditions
a. Focusing on pain
b. Boredom

Conditions that Closes the Gate:

1. Physical conditions
a. Medications
b. Counter stimulation (e.g., heat, message)
2. Emotional conditions
a. Positive emotions
b. Relaxation, Rest
3. Mental conditions
a. Intense concentration or distraction
b. Involvement and interest in life activities

Pain Assessment
 Effective pain management begins with a comprehensive assessment which allows the
health care provider to characterize the pain, clarify its impact and evaluate other
medical and psychosocial problems. The assessment determines whether additional
evaluation is needed to understand the pain.

Goals of Comprehensive Pain Assessment

 Obtain a full description of the pain;
 Determine whether the description fits a well-known pain syndrome;
 Determine whether there is structural disease of the body that may help the pain;
 Try to understand the mechanisms (tissue, nerve injury, psychological processes) that
maintain the pain;
 Describe the negative effects on physical and psychosocial functioning caused by the
pain;
 Understand the medical and psychiatric problems that co-exist with the pain and might
need treatment at the same time

1. Pain Assessment – Health History

 Pattern : onset & duration
 Area : location
  Intensity. : level
 Nature : description

PQRST Format
Provocation – How the injury occurred & what activities ¯ the pain
Quality - characteristics of pain
Aching (impingement), Burning (nerve irritation), Sharp (acute injury), Radiating
within dermatome (pressure on nerve)
Referral/Radiation –
Referred – site distant to damaged tissue that does not follow the course of a peripheral n.
Radiating – follows peripheral n.; diffuse
Severity – How bad is it? Pain scale
Timing – When does it occur? p.m., a.m., before, during, after activity, all the time.

2. Medical History and Physical Examination (H & P)

 helps the nurse to understand the unique pain experience of the client and to formulate a
plan to resolve the pain.
 provides baseline data to allow assessment of the patient’s progression through a pain
experience.

3. Pain Assessment Tools

a. McGill Melzack Pain Questionnaire – a multidimensional assessment tool
composed of 20 words descriptors grouped into 4 namely:

 Sensory (1-10)
 Affective (11-15)
 Evaluative (16)
 Miscellaneous (17-20)
b. Simple Descriptive Pain Intensity Scale –from No pain to Worst possible pain
c. 0 – 10 Numeric Pain Intensity Scale
d. Visual Analog Scale (VAS) / Linear Scale
e. Wong – Baker FACES Pain Rating Scale

Pain Management
 refers to the techniques used to prevent, reduce or relieve pain.
 Effective pain management is a collaborative work, involving good
communication among the patient, family and the health practitioners. A
sense of partnership in trying to find the best therapeutic approach
promotes the most creative, and ultimately the most effective,
approaches. Patient-practitioner partnership can maximize the patient’s
involvement and sense of control in the healing process. Family
communication helps promote positive patterns within the family and
may reduce the stress caused by prolonged pain and impaired function.
Goals in Managing Pain:
1. Reduce pain
2. Control acute pain
3. Protect the patient from further injury while encouraging progressive exercises.

5 General Techniques for Achieving Pain Mgt:

1. Blocking brain perception.
2. Interrupting pain transmitting chemicals at the site of injury.
3. Combining analgesics with adjuvant drugs.
4. Using gate-closing mechanisms.
5. Altering pain transmission at the level of the spinal cord.

Pain Management Methods

 About half of hospitalized patients who have pain are under-medicated.

 Children are at particular risk of poor pain control methods.
 Medications are given as:
PRN – “as needed”
As a prescribed schedule

1. Pharmacological or Drug Interventions

* Adjuvant Drug Therapy
 The so-called adjuvant analgesics are defined as drugs that are on the market for
indications other than pain but may be analgesic in selected circumstances. They
include a very large number of drugs in numerous drug classes (Thiessen, 2003).

Examples of Adjuvant Analgesics

 Antidepressants (Amitriptyline or Elavil, Clomipramine, Desipramine)
 Anticonvulsants (Pregabalin, Gabapentin, Carbamazepine, Phenytoin, Topiramate)
 Local Anesthetic Agents (Mexiletine, Tocainide, Flecainide)
 GABA Agonists (Baclofen)
 N-methyl-D-aspartate (NMDA) Antagonists - (Dextromethorphan, Ketamine,
Amantadine, Memantine)
 Corticosteroids (prednisone, Dexamethasone, Methylprednisolone)

* Non opioid Analgesics

 Includes acetaminophen or paracetamol, dipyrone and nonsteroidal anti-
inflammatory drugs or NSAIDs). The NSAIDs are nonspecific analgesics and
can potentially be used for any type of acute or chronic pain.

 Because they are both analgesic and anti-inflammatory, NSAIDs are particularly
useful for pain related to joint problems and other musculoskeletal disorders.

Examples of NSAIDs
* Salicylates like Aspirin, Diflunisal,Trisalicylate & Salsalate
* Proprionic acids like ibuprofen, naproxen, ketoprofen, fenoprofen, oxaprozin
 * Acetic acids like indomethacin, diclofenac, ketorolac, tolmetin, sulindac,
etodolac
* Oxicams like piroxicam
* Naphthlyalkanones like nabumetone
* Fenamates like mefenamic acid, meclofenamic acid
* Pyrazoles like phenylbutazone

* Opioid Analgesics
 The most effective analgesics (Ellison, 1998). This includes all drugs that interact
with opioid receptors in the nervous system. These receptors are the sites of action
for the endorphins, compounds that already exist in the body and are chemically
related to the opioid drugs that are prescribed for pain.

a. Opioid antagonists – have no analgesic effect and are used to block the effects
of opioid drugs.
Ex. Naloxone, Naltrexone, Nalmafene
b. Opioid Agonist-antagonist - have analgesic effect.
Ex. Buprenorphine, Butorphanol, Nalbuphine, Dezocine

Side Effects associated with Opioid Drugs

 Constipation
 Nausea
 Itch
 Urinary retention
 Dry mouth
 Sexual Dysfunction
 Sleepiness, fatigue, dizziness and mental clouding

2. Non drug Interventions

a. Heat and Cold Therapy
Heat helps soothe stiff joints and relax muscles. Cold helps numb sharp pain and reduce
inflammation. Use temperature therapy to complement meds and self-care. It's simple,
affordable, soothing -- and you have to sit down to use either one.

As a general rule of thumb, use ice for acute injuries or pain, along with inflammation and
swelling. Use heat for muscle pain or stiffness.

* Heat Therapy
 Heat therapy works by improving circulation and blood flow to a particular area due to
increased temperature. Increasing the temperature of the afflicted area even slightly can
soothe discomfort and increase muscle flexibility. Heat therapy can relax and soothe
muscles and heal damage.

Types of Heat Therapy

 Dry heat (or “conducted heat therapy”) includes sources like heating pads, dry heating
packs, and even saunas. This heat is easy to apply.
  Moist heat (or “convection heat”) includes sources like steamed towels, moist heating
packs, or hot baths. Moist heat may be slightly more effective as well as require less
application time for the same resultsTrusted Source.

When NOT TO USE Heat Therapy

 There are certain cases where heat therapy should not be used. If the area in question is
either bruised or swollen (or both), it may be better to use cold therapy.
 Heat therapy also shouldn’t be applied to an area with an open wound.
 People with certain pre-existing conditions should not use heat therapy due to higher
risk of burns or complications due to heat application. These conditions include:
o diabetes
o dermatitis
o vascular diseases
o deep vein thrombosis
o multiple sclerosis (MS)

Risk of Heat Therapy

 Utilize only warm water not “hot” water because of possibility of burn.
 Heat applied directly to a local area, like heating packs, should not be used for more
than 20 minutes at a time.
 If swelling increased, stop the treatment immediately.
 If pain doesn’t lessen after a week or the pain increases within a few days, consult the
doctor.

* Cold Therapy
 is also known as cryotherapy. It works by reducing blood flow to a particular area,
which can significantly reduce inflammation and swelling that causes pain, especially
around a joint or a tendon. It can temporarily reduce nerve activity, which can also
relieve pain.

Ways to Apply Cold Therapy

a. ice packs or frozen gel packs
b. coolant sprays
c. ice massage
d. ice baths
e. cryostretching, which uses cold to reduce muscle spasms during stretching
f. cryokinetics, which combines cold treatment and active exercise and can useful
for ligament sprains
g. whole-body cold therapy chambers

When NOT TO USE Cold Therapy

 People with sensory disorders that prevent them from feeling certain sensations should
not use cold therapy at home because they may not be able to feel if damage is being
done. This includes diabetes, which can result in nerve damage and lessened sensitivity.
 You should not use cold therapy on stiff muscles or joints.
 Cold therapy should not be used if you have poor circulation.
 Risk of Cold Therapy
 If applied too long or too directly, can result in skin, tissue or nerve damage;
 If patient has cardiovascular or heart disease, consult the doctor first prior to use of cold
therapy;
 If cold therapy hasn’t helped an injury or swelling within 48 hours, inform your doctor.

b. Transcutaneous Electrical Stimulation (TENS)

 TENS has been used successfully to help control chronic pain in various conditions,
including chronic neuropathy, arthritis, postoperative pain, post-fracture recovery, low
back pain, postherpetic neuralgia, myofascial pain, and advanced painful malignancies
(Thorsteinsson, 1987).
 The device is an electrical unit that delivers different frequencies and intensities of
stimulation to the skin through electrodes. To increase the chance that TENS can help,
the patient is given a TENS device and then instructed to apply a variety of different
types of stimulation during a trial period. Patients vary a great deal in the type of TENS
that works.

c. Acupuncture
- not sure how it works. Could include:
 Counter-irritation – may close the spinal gating mechanism in pain perception.
 Expectancy
 Reduced anxiety from belief that it will work.
 Distraction
 Trigger release of endorphins

d. Acupressure
 is a method of sending a signal to the body via needles or other means, to turn on its
own self-healing or regulatory mechanisms.
 used for thousands of years in China and the principles is the same with the
acupuncture, i.e. promote relaxation and wellness and to treat disease.

e. Percutaneous Electrical Nerve Stimulation (PENS)

 combines electro-acupuncture and TENS which uses acupuncture like needle probes as
electrodes placed at dermatomal levels corresponding to local pathology.
 The main advantage of PENS over TENS is that it bypasses local skin resistance and
delivers electrical stimuli at the precisely desired level in close proximity to the nerve
endings located in soft tissue, muscle, or periosteum.

f. Non invasive Techniques / Psychological Pain Control Therapy

* Mind / Body Therapy

 Pain and stress are intimately related. There may be a vicious cycle in which pain
causes stress, and stress, in turn, causes more pain.
 Mind/body therapy address these issues and provide a variety of benefits, including a
greater sense of control, improved coping skills, decreased pain intensity and distress,
 changes in the way pain is perceived and understood, and increased sense of well being
and relaxation. These approaches may be very valuable for adults and children with
pain (Rusy, 2000).

* Cognitive – Behavioral Therapy

 addresses psychological component of pain including attitudes, feelings, coping skills
and a sense of control over one’s condition;
 effective in reducing pain and disability when used as part of a therapeutic treatment
for chronic pain.
 provides educational information and diffuse feelings of fear and helplessness;
 helps patient to find a more realistic and balanced view of the pain problem;
 includes teaching of life skills and coping skills that can assist the patient in productive
problem solving and the prevention or minimization of future pain episodes.

* Imagery
 is the use of imagined pictures, sounds, or sensations for generalized relaxation or for
specific therapeutic goals, such as the reduction of pain. These images can be initiated
by the patient or guided by a practitioner. The sessions in which imagery is used can be
individual or group. 

* Relaxation
 systematic relaxation of the large muscle groups.
 Relaxation therapies include a range of techniques such as autogenic training, various
forms of meditation, progressive muscle relaxation, deep breathing, and paced
respiration. The goal of these therapeutic approaches is overall relaxation and stress
reduction. Practice can produce a set of physiologic changes that result in slowed
respiration, lowered pulse and blood pressure, and reduction in the body's inflammatory
response mechanism (Lutgendorf, 2000). This can have a positive impact on health and
improve symptoms in many acute and chronic illnesses and conditions, including pain.


* Biofeedback
 provides biophysiological feedback to patient about some bodily process the patient is
unaware of (e.g., forehead muscle tension).
 use of electronic monitoring instruments to provide patients with immediate feedback
on heart rate, blood pressure, muscle tension, or brain wave activity. This allows the
patient to learn how to influence these bodily responses through conscious control and
regulation.

* Hypnosis
 relaxation + suggestion + distraction + altering the meaning of pain.
 during hypnosis, changes like those found in meditation can occur, such as a slowing of
the pulse and respiration, and an increase in alpha brain waves.
 Medical hypnosis has been shown to be helpful in reducing both acute & chronic pain.

* Prayer
  not usually considered a mind-body or a psychological approach, but it is worthwhile
considering it in this context of mind/body treatments. Changes in the concept of health
and illness, a broadening view of healing and curing, and interest in other cultural
systems of medicine have created a growing openness to the spiritual dimensions of
health

*Physical Therapy
 are useful in teaching patients to control pain, to move in safe and structurally correct
ways, to improve range of motion, and to increase flexibility, strength and endurance. "
Active" and "passive" modalities can both be used, but active modalities, such as
therapeutic exercise, are particularly important when the goal is to improve both
comfort and function.

* Exercises
 have a variety of benefits that produce better stamina and function. Exercise may
reduce the risk of secondary pain problems like muscle strains, and may also lead to
improved confidence and sense of well-being. 

Lecturers:
Ms. Julie C. Danofrata
Ms. Glenda T. Moraňo
Ms. Dhonna Cambe
Dr. Francis Obmerga
Ms. Joyce Acena
Ms. Mary Ann Bayani
Ms. Stephanie Steban
Ms. Sheree Ann Ortua
Dr. Vicente Baylon III
Ms. Vilma Vasquez
Dr. Wilfredo Quijencio