Care of clients with problems in infections,
inflammatory and immunology
Prelims coverage- Oxygenation Disorders
- Cardiovascular Disorder
- Respiratory disorder
Pain Management
Pain is “the 5th vital sign”
- An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage (interaction association to the
study of pain)
- Complex and multifunctional. It involves
sensory, emotional, and cognitive processing
but may lack a specific physical etiology
- Very personal experience that varies from
person to person. What feels very painful to
one person may only feel like mild pain to
another. Factors such as emotional state and
overall physical health can play a big role in how
a person feel pain.
 Pain threshold- physiological attribute
(intensity of the stimuli)
 Pain tolerance – psychological attribute
(endurance of an individual)
Theories about pain
 Specificity- specialized peripheral nerve fibers
are responsible for pain transmission
 Pain pattern- excessive stimulation of all the
nerve endings
-addresses brain ability to determine
the amount of intensity and type of
accessory input
 open gate- asserts that some of the gate
mechanism in the spinal cord allows nerve
fibers to receive pain sensation.
Types of Pain
Duration of pain Inferred pathology
- acute - Nociceptors
- chronic - Neuropathic
Acute Pain
- generally intense and short-lived
 COMPLEX REGIONAL PAIN SYNDROME (CPRS)
- how the body alerts a person to an injury/
localized tissue damage
- triggers body’s fight-or-flight response often
resulting in faster heartbeat and breathing
rates.
Types of acute
 somatic pain- superficial pain on the skin or soft
tissues just how the below
 visceral pain – originate in the internal organs/
lining of cavities
 referred pain – visceral pain at a location often
that tissue damage
CHRONIC PAIN
- pain that lasts more than 1 month
- has pain recurring at interval of months and
years
- fight/flight reactions eventually stop in people
with sympathetic nervous system that triggers
this reaction adapts to pain stimulus
- not associated with cancer or medical
conditions of 3 to 6 months
NOCICEPTIVE PAIN
- Normal functioning of physiologic system that
reads to perception of noxious stimuli (tissue
injury)
- Normal pain transmission
NEUROPATHIC PAIN
- Nerve pain/ neuralgia or neuropathic pain
occurs when a health condition affects the
nerves
OTHER TYPES OF PAIN
 Parietal pain – inflammation in the parietal
peritoneum, more severe than visceral pain
 Breakthrough pain- can produce both acute
and chronic pain
 Psychogenic and idiopathic pain – factors that
influences the patient’s report of pain
- Idiopathic pain is pain without identifiable
etiology
 Cancer related pain -ubiquitous symptom,
either acute/chronic
 Classified by location- helpful in communicating
and treating pain
 Classified by etiology – burn pain
PAIN SYNDROMES
- Painful conditions that follow an injury
- impairment of motor function
 TYPE I CRPS- occurs after a minor trauma unexplained - Increases the patient’s risk for physiologic
difference, burning pain, weakness, skin color and disorder
temp changes - Unable to take a deep breath
- Increased fatigue and decreased mobility
TYPE II- causalgia develop after trauma with
 EFFECTS OF CHRONIC PAIN
deflectable nerve lesions
- Promote tumor growth by suppression of the
 POST MASCTECTOMY immune function
- Sensation of construction accompanied by - Depression
burning picking or numbness in the posterior - Anger
arms - Fatigue
- Aggravated by more vent of the shoulder - Disability
resulting in frozen shoulder from immobilization

 POST TRAUMATIC HEADACHE DISORDER PATHOPHYSIOLOGY OF PAIN

- Mild head injury than moderate to severe injury
1. PAIN TRANSMISSION –
 Fibromyalgia/fibrositis
- Nociceptors or pain receptors- free nerve
- Generalized musculoskeletal pain, trigger points
endings in the skin that respond only to intense
stiffen, fatigability deep disturbances,
potentially damaging stimuli (mechanical,
aggravated by overextension.
thermal, chemical)
 Hemiplegia- associated shoulder pain
- large internal organs do not contain nerve
- Result from stretching of shoulder joints due to
endings pain produced by; inflammatory,
uncompensated pull of gravity on the unpaired
stretch, ischemia, dilation, spasm
arm
2. PERIPHERAL NERVOUS SYSTEM
- Effects 80 % of stroke patients
 Chemicals that increase the transmission of
 PAIN ASSOCIATED WITH SICKLE CELL DISEASE
pain, histamine, bradykinin, acetylcholine,
- Results from venous occlusion(narrowed veins)
serotonin
caused by the sickle shape of the blood cells,
- Vasodilation and increased vascular permeability,
impaired circulation to a muscle/ organ,
redness, warmth, swelling of the injured area
ischemia and infarction.
 Fibers
 AIDS related pain
a. Delta fiber- myelinated smaller faster
- Neuropathy, esophagitis, headaches, post
b. C-fiber unmyelinated, larger, slower,
herpetic pain and abdominal back and joint
- Second pain- dull aching/
pain.
3. CHEMICAL NERVOUS SYSTEM –
 Guillan- barre syndrome- progressive inflammatory
a. Endorphins- (natural pain killer)-
disorder of the peripheral nervous system
endogenous and morphine – blocks pain on
- Flaccid paralysis- accompanied by paresthesia
brainstem
and pain
b. Enkephalins – blocks pain in spinal cord
 Opioid tolerance- suspect of drug addiction/high
- Found in heavy concentration
doses of drug will require more than therapeutic
- Spinal and modulatory dorsal flow
- Complains of significantly more pain than it
4. CENTRAL NERVOUS SYSTEM
usually
 Fibers enters dorsal horn
a. Reticular formation- pain signals
o REDNESS- RUBOR
from the lower body to cerebral
o WARMTH- CALOR
cortex
o FAINT- PALOR b. Thalamus- receives projections
from multiple ascending pain
pathways
 EFFECTS OF ACUTE PAIN STRESS RESPONSE - Not a relay Centre but
- Increased metabolic and cardiac output is involved in processing
- Impaired insulin response nociceptors
- Increased production of cortisol
- Increased retention of fluid
 c. Limbic system- responsible for
modulating emotional and mood
aspects of pain
d. Cerebral cortex- may reduce pain
by interrupting the transmission of
information from the spinal cord
level by activating descending pain
modulatory system in the
brainstem.
5. DESCENDING CONTROL SYSTEM- system of fibers
that originates in the lower and midportion of
the brain
FACTORS THAT INFLUENCE PAIN RESPONSE
1. Past experience- the more experience a person
has had in pain the more frightened he/she is
about subsequent painful events.
2. Anxiety and depression- no consistent
relationship between anxiety and pain
3. Culture- nurse must react to the person’s pain
perception and not with the pain behavior
because the behavior is different from his/her
own
4. Age- no difference in responses of younger and
older adults
5. Placebo effect- “dummy treatment” occurs when
a person responds to the medication or other
treatment because of an expectation that the
treatment will work rather than because it
actually does so
NURSING ASSESSMENT OF PAIN
1. INTENSITY – pain threshold- smallest stimulus in
pain
- Pain tolerance- maximum amount of pain
 PAIN ASSESSMENT TOOLS
1. RATING SCALE- a quick method of
determining the patient’s perception of
pain intensity
a. Simple descriptive- no pain to worse
possible pain
b. Numeric- 1 to 10
c. Visual analog
2. FACE RATING SCALE – illustrations of five
or more
3. BODY DIAGRAM – allows patient to
draw the location and radiation
4. QUESTIONNAIRE- provides the patient
with key question
2. TIMING
- Onset acute chronic, sudden/gradual
- Duration- shorter/ longer
- Relationship between time and intensity
- Changes in rhythmic patterns
3. LOCATION- best administrative by having the
patient point to the area of the body involved
a. Localized pain- felt only at its origin
b. Projected pain- travels along the nerve
pathways
c. Radiated pain- extends in several directions
from the point of origin
d. Referred pain- occurs in places connected at
the site of the origin
4. QUALITY- asks the patient to describe the pain in
his or her own words without giving any clues
- If the patient cannot describe pain, offer the
words like burning, aching or throbbing
5. Personal
- Asks how the pain has affected the
person’s ADL
- Meaning attached to the pain
experience helps the nurse understand the
pain
6. Aggravating and alleviation factors
- Asks if anything makes the pain worse and what
makes it better or rs between activity in the
past
7. Pain behavior- non verbal and verbal expressions
of pain
PHYSIOLOGIC RESPONSE TO PAIN
1. TACHYCARDIA- INCREASED HR
2. HYPERTENSION- INCREASED BP
3. TACHYPNEA- FAST BREATHING
4. PALOR
5. DIAPHORHESIS – EXCESSIVE SWEATING
6. MYDRIASIS
7. HYPERVIGILANCE
8. INCREASED MUCLE FORMS
NURSES ROLE IN PAIN MGT.
A.ADVOCATE
B. EDUCATOR
APPROACHES IN USING ANALGESIC AGENTS
 BALANCED ANESTHESIA
- OPIOIDS
- NSAID’S
- LOCAL ANESTHESIA
 PRN (PRO RE NATA)
 PREVENTIVE APPROACH
 INDIVIDUALIED DOSAGE
- PATIENT CONTROLLED ANALGESIA
LOCAL ANESTHETIC AGENTS - LIVER DAMGE
- SENSITIVITY
- Typical application
- EMLA (eutectic mixture/ emulsion of local CONTRAINDICATIONS
anesthetic lidocaine and prilocaine)
- Epidural – intraspinal administration - Renal dysfunction
- Hypertension

OPIOD ANALGESIC AGENT

CARDIOVASCULAR SYSTEM
 AGONIST – drugs that can produce analgesia by
binding to CN’s opiate receptors, DOC for  HEART-
severe pain - Muscular pumping organ of the body
- CODEINE - Occupies most of the left mediastinum
- HYDROMORPHONE - Weighs approx. 300-400 g
- LEVORPHANOL - Resembles a closed fist
- MEPERIDINE - Covered by a membrane called
- METHADONE PERICARDIUM
- MORPHINE -
- PROPOXYPHENE

 AGONIST – ANTAGONIST – have a ceiling effect

or upper dosing limit, can cause hallucinations
and psychotomimetic effects and withdrawal
symptoms

CONTRAINDICATIONS OF OPIOD ADMINISTRATION

- SEVERE RESPIRATORY DISEASE
- CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- HEPATIC OR RENAL IMPAIRMENT because
they’re metabolized by the severe and excreted
by kidney
- HEAD INJURIES/ ICP
ADVERSE EFFECTS
- DROWNISES
- DIZINESS
- NAUSEA – (ICE CHIPS)
- VOMMITING
- ITCHING
- CONSTIPATION – increase fluid intake
- URINE RETENTION- DIURETICS
- TOLERANCE
- PYSIOLOGIC AND PSYCHOLOGICAL DEPENDANCE
ADVERSE EFFECTS OF NSAID’S
- GI IRRITATION
- HEPATOXICITY
- NEPHROTOXICITY
- HEADACHE