2. LEARNING OUT COMES
1. Adult Development & Aging
1.1 The life span perspective
1.1.1 Four key features of life span perspective
1.1.2 The forces of Development
1.1.3 The three sets of influences
1.2 The meaning of Aging
2. Biosychosocial concept Related to Health
2.1 Definition of terms
2.2 Dynamic Balance:
2.3 Stress, Coping & Adaptation
2.4 Stressors: Threats to the Steady State
2.4.1 Types of Stressors
2
3. LEARNING OUT COMES (Continued)
3. physiologic response to stress
3.1 General Adaptation syndrome
3.2 Local Adaptation Syndrome
3.3 Four personal characteristics that promote
adaptation to stressors
3.4 Interpretation of Stressful Stimuli by the Brain
3.5 Interpretation of Stressful Stimuli(Continued)
3.6 Sympathetic - Adrenal-Medullary Response
3.7 Hypothalamic-pituitary response
3.8 Immunologic Response
3
4. LEARNING OUT COMES (Continued)
3.9 Maladaptive responses to stress
3.10 Stress Management: Nursing Interventions
4. Pain & Pain Management
4
6. Definition:
Watts (2007) indicates that developmental
psychology predicts the ongoing physical,
mental, emotional and behavioural
development in individuals throughout their
lifespan.
People going through the changes of middle to
late adulthood might experience stress and
stress-related reactions, we look at sources that
are present in stress and various reactions.
6
7. 1.1 The Life-Span Perspective
We cannot understand adults’ experiences
without appreciating what came before in
childhood and adolescence.
Placing adulthood in this broader context is what
the life-span perspective is all about.
The life-span perspective divides human
development into two phases:
an early phase (childhood and adolescence)
a later phase (young adulthood, middle age, and
old age).
7
8. 1.1 The Life-Span Perspective(Continued)
The early phase is characterized by rapid age-related
increases in people’s size and abilities.
During the later phase, changes in size are slow, but
abilities continue to develop as people continue
adapting to the environment (Baltes, Lindenberger, &
Staudinger, 2006).
Viewed from the life-span perspective, adult
development and aging are complex phenomena that
cannot be understood within the scope of a single
disciplinary approach.
Understanding how adults change requires input
from a wide variety of perspectives.
Moreover, aging is a lifelong process, meaning that
human development never stops.
8
9. 1.1.1 Four key features of life span (continued)
B. Plasticity: One’s capacity is not predetermined
or set in concrete. Many skills can be trained or
improved with practice, even in late life.
However, there are limits to the degree of
potential improvement,
C. Historical context: Each of us develops within a
particular set of circumstances determined by the
historical time in which we are born and the
culture in which we grow up.
10
10. 1.1.1 Four key features of life span (Continued)
D. Multiple causation: How people develop results
from a wide variety of forces, which we consider
later.
You will see that development is shaped by
biological, psychological, sociocultural, and life-
cycle forces.
11
11. 1.1.1 Four key features of life span (Continued)
The life-span perspective emphasizes that human
development takes a lifetime to complete.
It sets the stage for understanding the many
influences we experience and points out that no
one part of life is any more or less important than
another.
12
12. 1.1.2 The forces of Development
There are forces that direct our development
much as an artist’s hands direct the course of a
painting or sculpture.
These forces are:
1. biological,
2. psychological,
3. sociocultural, and
4. life cycle.
Developmentalists typically consider four
interactive forces that shape us.
13
13. 1.1.2 The forces of Development(Continued)
1. Biological forces include all genetic and health
related factors that affect development.
Examples of biological forces include menopause,
facial wrinkling, and changes in the major organ
systems.
2. Psychological forces include all internal
perceptual, cognitive, emotional, and personality
factors that affect development.
Collectively, psychological forces provide the
characteristics we notice about people that make
them individuals.
14
14. 1.1.2 The forces of Development(Continued)
3. Sociocultural forces include interpersonal,
societal, cultural, and ethnic factors that affect
development.
Sociocultural forces provide the overall contexts in
which we develop.
4. Life-cycle forces reflect differences in how the
same event or combination of biological,
psychological, and sociocultural forces affects
people at different points in their lives.
Life-cycle forces provide the context for the
developmental differences of interest in adult
development and aging.
15
15. 1.1.2 The forces of Development(Continued)
One useful way to organize the biological,
psychological, and sociocultural forces on human
development is with the biopsychosocial
framework.
Together with life-cycle forces, the
biopsychosocial framework provides a complete
overview of the shapers of human development.
Each of us is a product of a unique combination of
these forces.
16
16. 1.1.2 The forces of Development(Continued)
Focusing on only one (or even two or three) of
the forces would provide an incomplete view of
how the person feels.
The biopsychosocial framework, along with life-
cycle forces, will provide a way to understand all
the developmental outcomes you will encounter.
17
17. 1.1.3 The three sets of influences
• Based on this approach, Baltes (1987; Baltes et
al., 2006) identifies three sets of influences that
interact to produce developmental change over
the life span: normative age-graded influences,
normative history-graded influences, and
nonnormative influences.
18
18. 1.1.3 The three sets of influences(Continued)
1. Normative age-graded influences are experiences
caused by biological, psychological, and sociocultural
forces that occur to most people of a particular age.
Some of these, such as puberty, menarche, and
menopause, are biological.
These normative biological events usually indicate
a major change in a person’s life; for example,
menopause is an indicator that a woman can no
longer bear children without medical intervention.
19
19. 1.1.3 The three sets of influences(Continued)
Other normative age-graded influences
involve sociocultural forces, such as:
the time when first marriage occurs and the
age at which someone retires.
Normative age-graded influences typically
correspond to major time-marker events,
which are often ritualized.
20
20. 1.1.3 The three sets of influences(Continued)
2. Normative history-graded influences are events
that most people in a specific culture experience at
the same time.
These events may be biological (such as
epidemics), psychological (such as particular
stereotypes), or sociocultural (such as changing
attitudes toward sexuality).
Normative history-graded influences often give a
generation its unique identity, such as the baby-
boom generation
21
21. 1.1.3 The three sets of influences(Continued)
These influences can have a profound effect. For
example, the attacks on the World Trade Center
on September 11, 2001, fundamentally changed
attitudes about safety and security that had been
held for decades.
22
22. 1.1.3 The three sets of influences(Continued)
3. Non normative influences are random or rare
events that may be important for a specific
individual but are not experienced by most people.
These may be favorable events, such as winning
the lottery or an election, or unfavorable ones,
such as an accident or layoff
The unpredictability of these events makes them
unique.
23
23. 1.1.3 The three sets of influences
Life-cycle forces are especially key in
understanding the importance of normative age-
graded, normative history-graded, and non
normative influences.
For example, history-graded influences may
produce generational differences and conflict;
parents’ experiences as young adults in the 1960s
and 1970s (before AIDS, instant messaging, and
global terrorism) may have little to do with the
complex issues faced by today’s young adults.
24
24. Each person is the product of the interaction of
biological, psychological, sociocultural, and life
cycle forces.
25
25. 1.2 The meaning of Aging
Aging is not a single process.
Rather, it consists of at least three distinct
processes:
primary,
secondary, and
tertiary aging (Birren & Cunningham, 1985).
Primary aging is normal, disease free
development during adulthood.
26
26. 1.2 The meaning of Aging(Continued)
Changes in biological, psychological,
sociocultural, or lifecycle processes in
primary aging are an inevitable part of the
developmental process;
examples include menopause, decline in
reaction time, and the loss of family and
friends.
27
27. 1.2 The meaning of Aging(Continued)
Secondary aging is developmental changes that are
related to disease, lifestyle, and other
environmentally induced changes that are not
inevitable (e.g., pollution).
The progressive loss of intellectual abilities in
Alzheimer’s disease and related forms of dementia
are examples of secondary aging.
Finally, tertiary aging is the rapid losses that occur
shortly before death.
An example of tertiary aging is a phenomenon
known as terminal drop, in which intellectual
abilities show a marked decline in the last few years
before death. 28
30. 2. Biopsychosocial concept Related to Health
The traditional biomedical models of clinical
medicine focus on pathophysiology and other
biological approaches to disease,
The biopsychosocial approach emphasize the
importance of understanding human health and
illness in their fullest contexts.
• This approach systematically considers
biological, psychological, and social factors and
their complex interactions in understanding
health, illness, and health care delivery.
31
31. 2. Biopsychosocial (Continued)
Systematic consideration of psychological and
social factors requires application of relevant
social sciences, just as consideration of biological
factors requires application of relevant natural
sciences.
Therefore, both the natural and social sciences
are ‘basic’ to medical practice.
32
32. 2. Biopsychosocial (Continued)
While the biomedical approach takes the
reductionistic view that all phenomena are best
understood at the lowest level of natural systems
(e.g., cellular or molecular),
The biopsychosocial approach recognizes that
different clinical scenarios may be most usefully
understood scientifically at several levels of the
natural systems continuum.
33
34. 2. Biopsychosocial (Continued)
To apply the biopsychosocial approach to clinical
practice, the clinician should:
Recognize that relationships are central to providing
health care
Use self-awareness as a diagnostic and therapeutic
tool
Elicit the patient’s history in the context of life
circumstances
Decide which aspects of biological, psychological,
and social domains are most important to
understanding and promoting the patient’s health
Provide multidimensional treatment
35
35. 2.1 Definition of terms
Physiology: is the study of the functional activities of
the living organism and its parts.
Pathophysiology: is the study of disordered function of
the body.
Each different body system performs specific functions
to sustain optimal life for the organism.
Mechanisms for adjusting internal conditions promote
the normal steady state of the organism and ultimately
its survival.
These mechanisms are compensatory in nature and
work to restore balance in the body.
An example of this restorative effort is the development
of rapid breathing (hyperpnea) after intense exercise in
an attempt to compensate for an oxygen deficit and
excess lactic acid accumulated in the muscle tissue.
36
36. 2.1 Definition(Continued)
Pathophysiologic processes result when cellular
injury occurs at such a rapid rate that the body’s
compensatory mechanisms can no longer make
the adaptive changes necessary to remain
healthy.
These observations, plus a sound knowledge of
physiologic and pathophysiologic processes, can
assist in determining the existence of a problem
and can guide the nurse in planning the
appropriate course of action.
37
37. 2.2 Dynamic Balance: The Steady State
Physiologic mechanisms must be understood in
the context of the body as a whole.
The person, as a living system, has both an
internal and an external environment, between
which information and matter are continuously
exchanged.
The goal of the interaction of the body’s
subsystems is to produce a dynamic balance or
steady state (even in the presence of change), so
that all subsystems are in harmony with each
other.
38
38. 2.2 Dynamic Balance(Continued)
Four concepts:- constancy, homeostasis, stress, and
adaptation; - enhance the nurse’s understanding of
steady state.
Claude Bernard, a 19th-century French physiologist,
developed the biologic principle that for life there must
be a constancy or “fixity of the internal milieu” despite
changes in the external environment.
The internal milieu- the fluid that bathed the cells,
the constancy was the balanced internal state
maintained by physiologic and biochemical processes.
His principle implied a static process.
39
39. 2.2 Dynamic Balance(Continued)
Later, Walter Cannon used the term homeostasis
to describe the stability of the internal
environment,
which, he said, was coordinated by homeostatic
or compensatory processes that responded to
changes in the internal environment.
Any change within the internal environment
initiated a “righting” response to minimize the
change.
These biologic processes sought physiologic and
chemical balance and were under involuntary
control.
40
40. 2.2 Dynamic Balance(Continued)
Rene Jules Dubos (1965) further in sighted into
the dynamic nature of the internal environment,
with his theory, two complementary concepts,
homeostasis and adaptation, were necessary for
balance.
Homeostatic processes occurred quickly in
response to stress, rapidly making the
adjustments necessary to maintain the internal
environment.
Adaptive processes resulted in structural or
functional changes over time.
41
41. 2.2 Dynamic Balance(Continued)
Dubos also emphasized that acceptable
ranges of response to stimuli existed and
that these responses varied for different
individuals: “Absolute constancy is only a
concept of the ideal.” Homeostasis and
adaptation were both necessary for survival
in a changing world.
Homeostasis, then, refers to a steady state
within the body.
42
42. 2.2 Dynamic Balance(Continued)
Steady state: a stable condition that does
not change over time, or when change in
one direction is balanced by change in an
opposite direction.
Adaptation: a change or alteration designed
to assist in adapting to a new situation or
environment
43
43. 2.2 Dynamic Balance(Continued)
When a change or stress occurs that causes a
body function to deviate from its stable range,
processes are initiated to restore and maintain
the dynamic balance.
When these adjustment processes or
compensatory mechanisms are not adequate, the
steady state is threatened, function becomes
disordered, and pathophysiologic mechanisms
occur.
44
44. 2.3 STRESS, COPING AND ADAPTATION
Definition of terms:
Stress is a state produced by a change in the
environment that is perceived as challenging,
threatening, or damaging to the person’s dynamic
balance or equilibrium.
The change or stimulus that evokes this state is
the stressor.
45
45. 2.3.1 Definition (Continued)
The nature of the stressor is variable;
An event or change that will produce stress in one
person may be neutral for another, and
An event that produces stress at one time and
place for one person may not do so for the same
person at another time and place.
A person appraises and copes with changing
situations.
The desired goal is adaptation, or adjustment to
the change so that the person is again in
equilibrium and has the energy and ability to
meet new demands.
46
46. 2.3.2 Coping & Adaptation
This is the process of coping with the stress, a
compensatory process with physiologic and
psychological components.
Adaptation is a constant, ongoing process that
requires a change in structure, function, or behavior
so that the person is better suited to the
environment;
it involves an interaction between the person and
the environment.
The outcome depends on the degree of “fit”
between the skills and capacities of the person,
the type of social support available, and the various
challenges or stressors being confronted.
As such, adaptation is an individual process: each
individual has varying abilities to cope or respond. 47
47. 2.3.2 Coping & Adaptation (Continued)
As new challenges are met, this ability to cope and adapt
can change, thereby providing the individual with a wide
range of adaptive ability.
Adaptation occurs throughout the life span as the
individual encounters many developmental and
situational challenges, especially related to health and
illness.
The goal of these encounters is to promote adaptation.
In situations of health and illness, this goal is realized by
optimal wellness.
Because both stress and adaptation may exist at different
levels of a system, it is possible to study these reactions at
the cellular, tissue, and organ levels.
Biologists are concerned mainly with subcellular
components or with subsystems of the total body.
48
48. 2.3. 2 Coping & Adaptation (Continued)
Behavioral scientists, including many nurse
researchers, study stress and adaptation in
individuals, families, groups, and societies;
They focus on how a group’s organizational
features are modified to meet the requirements
of the social and physical environment in which
they exist.
Thus, adaptation is a continuous process of
seeking harmony in an environment.
The desired goals of adaptation for any system are
survival, growth, and reproduction.
49
49. 2.4 Stressors: Threats to the Steady State
A stressor may be defined as an internal or
external event or situation that creates the
potential for physiologic, emotional, cognitive, or
behavioral changes in an individual.
2.4.1 TYPES OF STRESSORS
Stressors exist in many forms and categories.
They may be described as:
physical,
physiologic, or
psychosocial.
50
50. 2.4.1 TYPES OF STRESSORS(Continued)
Physical stressors include cold, heat, and chemical
agents;
physiologic stressors include pain and fatigue.
Examples of psychosocial stressors are fear of
failing an examination and losing a job.
Stressors can also occur as normal life transitions
that require some adjustment, such as going from
childhood into puberty, getting married, or giving
birth.
51
51. 2.4.1 TYPES OF STRESSORS(Continued)
Stressors have also been classified as:
1. Day-to-day frustrations or hassles;
2. Major complex occurrences involving large
groups, even entire nations; and
3. Stressors that occur less frequently and involve
fewer people.
1. The day-to-day stressors, includes such common
occurrences as :
getting caught in a traffic jam, experiencing
computer downtime, and having an argument
with a spouse or roommate.
52
52. 2.4.1 TYPES OF STRESSORS(Continued)
These experiences vary in effect;
for example, encountering a rainstorm while one
is vacationing at the beach will most likely evoke a
more negative response than it might at another
time.
These less dramatic, frustrating, and irritating
events—daily hassles—have been shown to have
a greater health impact than major life events
because of the cumulative effect they have over
time.
They can lead to high blood pressure, palpitations,
or other physiologic problems ( Jalowiec, 1993).
53
53. 2.4.1 TYPES OF STRESSORS(Continued)
2. Major complex occurrences…
The second group of stressors influences larger
groups of people, possibly even entire nations.
These include:
events of history, such as terrorism and war, which
are threatening situations when experienced either
directly, in the war zone, or indirectly, as through live
news coverage.
The demographic, economic, and technological
changes occurring in society also serve as stressors.
The tension produced by any stressor is sometimes a
result not only of the change itself, but also of the
speed with which the change occurs.
54
54. 2.4.1 TYPES OF STRESSORS(Continued)
3. The third group of stressors has been studied most
extensively and concerns relatively infrequent
situations that directly affect the individual.
This category includes the influence of life events
such as:
death
birth
marriage
divorce, and
retirement.
It also includes the psychosocial crises described by
Erikson as occurring in the life cycle stages of the
human experience.
55
55. 3. PHYSIOLOGIC RESPONSE TO STRESS
The physiologic response to a stressor, whether it is
a physical stressor or a psychological stressor, is a
protective and adaptive mechanism to maintain the
homeostatic balance of the body.
The stress response is a “cascade of neural and
hormonal events that have short- and long-lasting
consequences for both brain and body . . .;
A stressor is an event that challenges homeostasis,
with a disease outcome being looked upon as a
failure of the normal process of adaptation to the
stress” (McEwen & Mendelson, 1993, p. 101).
56
56. 3. PHYSIOLOGIC RESPONSE TO STRESS (Continued)
In next slides we discuss the roles of the nervous,
endocrine, and immune systems.
These systems are interrelated, and
interrelationship is reflected in a person’s
physiologic response to stress
57
57. 3. PHYSIOLOGIC RESPONSE TO STRESS (Continued)
Further, stress activation of these systems affects
other body systems, such as:
the cardiovascular,
respiratory,
gastrointestinal,
renal, and reproductive systems.
The complex process by which an event is perceived
as a stressor and the body responds is not fully
understood.
58
58. 3.1 General Adaptation syndrome
A person’s response to a stressor (real or imagined,
and physiologic or emotional/psychologic)
determines the impact that stress will have on the
body.
Hans Selye, a pioneer in stress research, in 1936
showed:
stressors from different sources produced a similar
physical response.
He termed this physical response to stress the
general adaptation syndrome (GAS), a theory of
adaptation to biologic stress.
It has three stages: alarm reaction, stage of
resistance, and stage of exhaustion. 59
59. 3.1 General Adaptation syndrome(continued)
During the alarm phase, the sympathetic “fight-
or-flight” response is activated with release of
catecholamines, and
the onset of the adrenocorticotropic hormone
(ACTH)–adrenal cortical response.
The alarm reaction is defensive and anti
inflammatory but self-limited.
Because living in a continuous state of alarm
would result in death, the person moves into the
second stage, resistance.
60
60. 3.1 General Adaptation syndrome(continued)
The person moves into the second stage, resistance.
During this stage, adaptation to the noxious stressor
occurs, and cortisol activity is still increased.
If exposure to the stressor is prolonged, exhaustion
sets in and endocrine activity increases.
This produces deleterious/toxic effects on the body
systems,
especially the circulatory, digestive, and immune
systems that can lead to death.
Stages one and two of this syndrome are repeated,
in different degrees, throughout life as the person
encounters stressors.
61
61. 3.1 General Adaptation syndrome(Continued)
Selye compared the general adaptation syndrome
with the life process.
During childhood, there are too few encounters
with stress to promote the development of
adaptive functioning, and the child is vulnerable.
During adulthood, the person encounters a
number of life’s stressful events and develops a
resistance or adaptation.
During the later years, the accumulation of life’s
stressors and the wear and tear on the organism
again deplete the person’s ability to adapt,
resistance falls, and eventually death occurs.
62
62. 3.2 Local Adaptation Sydrome
According to Selye’s theory, a local adaptation
syndrome also occurs.
This syndrome includes the inflammatory
response and repair processes that occur at the
local site of tissue injury.
The local adaptation syndrome occurs in small,
topical injuries, such as contact dermatitis.
If the local injury is severe enough, the general
adaptation syndrome is activated as well.
63
63. 3.2 Local Adaptation syndrome (Continued)
Selye emphasized that stress is the nonspecific
response common to all stressors, regardless of
whether they are physiologic, psychological, or
social.
The many conditioning factors in each person’s
environment account for why different demands are
interpreted by different people as stressors.
Conditioning factors also account for differences in
the tolerance of different people for stress
some people may develop diseases of adaptation,
such as:
hypertension
migraine headaches, while others are unaffected.
64
64. 3.3 Four personal characteristics that
promote adaptation to stressors
1. Resilience,
2. hardiness,
3. attitude, and
4. optimism.
Resilience is being resourceful and flexible and
having good problem-solving skills. Individuals who
possess a high degree of resilience are not as likely
to perceive an event as stressful or taxing.
65
65. Hardiness is a combination of three
characteristics: commitment, control, and
openness to change. Together they provide the
courage and motivation needed to turn stressful
circumstances from potential calamities into
opportunities for personal growth.
Other internal characteristics such as:
age
health,
energy,
personal belief systems,
commitments or life goals,
66
67. 3.4 Interpretation of Stressful Stimuli by the
Brain
Physiologic responses to stress are mediated by
the brain through a complex network of chemical
and electrical messages.
The neural and hormonal actions that maintain
homeostatic balance are integrated by the
hypothalamus, which is located in the center of
the brain, surrounded by the limbic system and
the cerebral hemispheres.
68
69. 3.5 Interpretation of Stressful Stimuli(Continued)
The hypothalamus integrates autonomic nervous
system mechanisms that maintain the chemical
constancy of the internal environment of the
body.
Together with the limbic system, it also regulates
emotions and many visceral behaviors necessary
for survival (eg, eating, drinking, temperature
control, reproduction, defense, aggression).
The hypothalamus is made up of a number of
nuclei; the limbic system contains the amygdala,
hippocampus, and septal nuclei, along with other
structures.
70
70. 3.5 Interpretation of Stressful Stimuli(Continued)
The cerebral hemispheres are concerned with
cognitive functions: thought processes, learning,
and memory.
The limbic system has connections with both the
cerebral hemispheres and the brain stem.
In addition, the reticular activating system, which
is a network of cells that forms a two-way
communication system, extends from the brain
stem into the midbrain and limbic system.
This network controls the alert or waking state of
the body. 71
71. 3.5 Interpretation of Stressful Stimuli(Continued)
In the stress response, afferent impulses are
carried from sensory organs (eye, ear, nose, skin)
and internal sensors (baroreceptors,
chemoreceptors) to nerve centers in the brain.
The response to the perception of stress is
integrated in the hypothalamus, which
coordinates the adjustments necessary to return
to homeostatic balance.
The degree and duration of the response varies;
major stress evokes both sympathetic and
pituitary adrenal responses. 72
72. 3.5 Interpretation of Stressful Stimuli(Continued)
Neural and neuroendocrine pathways under the
control of the hypothalamus are also activated in
the stress response.
First, there is a sympathetic nervous system
discharge, followed by a sympathetic-adrenal-
medullary discharge.
If the stress persists, the hypothalamic-pituitary
system is activated.
73
73. 3.5.1 Sympathetic nervous system response
The sympathetic nervous system response is
rapid and short lived.
Norepinephrine is released at nerve endings that
are in direct contact with their respective end
organs to cause an increase in function of the
vital organs and a state of general body arousal.
The heart rate is increased and peripheral
vasoconstriction occurs, raising the blood
pressure. Blood is also shunted away from
abdominal organs.
74
74. 3.5.2 Purpose of the Activity
The purpose of these activities is to provide better
perfusion of vital organs (brain, heart, skeletal
muscles).
Blood glucose is increased, supplying more readily
available energy.
The pupils are dilated, and mental activity is
increased; a greater sense of awareness exists.
Constriction of the blood vessels of the skin limits
bleeding in the event of trauma.
75
75. 3.5.2 Purpose of the Activity
The person is likely to experience cold feet,
clammy skin and hands, chills, palpitations, and a
knot in the stomach.
Typically, the person appears tense, with the
muscles of the neck, upper back, and shoulders
tightened; respirations may be rapid and shallow,
with the diaphragm tense.
76
76. 3.6 Sympathetic - Adrenal-Medullary Response
In addition to its direct effect on major end
organs, the sympathetic nervous system also
stimulates the medulla of the adrenal gland to
release the hormones epinephrine and
norepinephrine into the bloodstream.
The action of these hormones is similar to that
of the sympathetic nervous system and have the
effect of sustaining and prolonging its actions.
77
77. 3.6 Sympathetic - Adrenal-Medullary
(Continued)
Epinephrine and norepinephrine are
catecholamines that stimulate the nervous
system and produce metabolic effects that
increase the blood glucose level and increase the
metabolic rate.
The effect of the sympathetic and adrenal-
medullary responses is summarized.
This effect is called the “fight-or-flight” reaction.
78
78. 3.7 Hypothalamic-pituitary response
The longest-acting phase of the physiologic
response, which is more likely to occur in
persistent stress, involves the hypothalamic
pituitary pathway.
The hypothalamus secretes corticotropin
releasing factor, which stimulates the anterior
pituitary to produce ACTH.
ACTH in turn stimulates the adrenal cortex to
produce glucocorticoids, primarily cortisol.
79
79. 3.7 HYPOTHALAMIC-PITUITARY… (Continued)
Cortisol stimulates protein catabolism, releasing
amino acids; stimulates liver uptake of amino
acids and their conversion to glucose
(gluconeogenesis); and inhibits glucose uptake
(anti-insulin action) by many body cells but not
those of the brain and heart.
These cortisol-induced metabolic effects provide
the body with a ready source of energy during a
stressful situation.
80
80. 3.7 Hypothalamic-pituitary… (Continued)
These cortisol-induced metabolic effects provide
the body with a ready source of energy during a
stressful situation.
This effect has some important implications.
For example, a person with diabetes who is under
stress, such as that caused by an infection, needs
more insulin than usual.
81
81. 3.7 Hypothalamic-pituitary… (Continued)
Any patient who is under stress (caused, for
example, by illness, surgery, trauma or prolonged
psychological stress) catabolizes body protein
and needs supplements.
Children subjected to severe stress have retarded
growth.
The actions of the catecholamines (epinephrine
and norepinephrine) and cortisol are the most
important in the general response to stress.
Other hormones released are antidiuretic
hormone (ADH) from the posterior pituitary and
aldosterone from the adrenal cortex.
82
82. 3.7 Hypothalamic-pituitary… (Continued)
ADH and aldosterone promote sodium and water
retention, which is an adaptive mechanism in the
event of hemorrhage or loss of fluids through
excessive perspiration.
ADH has also been shown to influence learning
and may thus facilitate coping in new and
threatening situations.
Secretion of growth hormone and glucagon
stimulates the uptake of amino acids by cells,
helping to mobilize energy resources.
83
83. 3.7 Hypothalamic-pituitary… (Continued)
Endorphins, which are endogenous opiates,
increase during stress and enhance then
threshold for tolerance of painful stimuli.
They may also affect mood and have been
implicated in the so-called “high” that long
distance runners experience.
The secretion of other hormones is also affected,
but their adaptive function is less clear.
84
84. 3.8 Immunologic Response
Research findings show that the immune system
is connected to the neuroendocrine and
autonomic systems.
Lymphoid tissue is richly supplied by autonomic
nerves capable of releasing a number of different
neuropeptides that can have a direct effect on
leukocyte regulation and the inflammatory
response.
Neuroendocrine hormones released by the
central nervous system and endocrine tissues can
inhibit or stimulate leukocyte function.
85
87. 3.9 Maladaptive responses to stress
When the responses to stress are
ineffective, they are referred to as
maladaptive.
Maladaptive responses are chronic,
recurrent responses or patterns of response
over time that do not promote the goals of
adaptation.
88
88. 3.9 Maladaptive responses to stress(Continued)
The goals of adaptation are:
somatic or physical health (optimal wellness);
psychological health or having a sense of well-
being (happiness, satisfaction with life, morale);
and
enhanced social functioning, which includes
work, social life, and family (positive
relationships).
Maladaptive responses that threaten these goals
include faulty appraisals and inappropriate coping
(Lazarus, 1991a). 89
89. 3.9 Maladaptive responses to stress(Continued)
The frequency, intensity, and duration of
stressful situations contribute to the
development of negative emotions and
subsequent patterns of neurochemical
discharge.
By appraising situations more adequately
and coping more appropriately, it is possible
to anticipate and defuse some of these
situations.
90
90. 3.9 Maladaptive responses to stress(Continued)
Coping processes that include the use of alcohol
or drugs to reduce stress increase the risk of
illness.
For example, people who demonstrate “type A”
personality behaviors such as:
impatience,
competitiveness,
achievement orientation
having an underlying hostile approach to life are
more prone than others to develop stress-related
illnesses. 91
91. 3.9 Maladaptive responses to stress(Continued)
Type A behaviors increase the output of
catecholamines, the adrenalmedullary
hormones, with their attendant effects on the
body.
Other forms of inappropriate coping include
denial, avoidance, and distancing. Denial may be
illustrated by the woman who feels a lump in her
breast but downplays its seriousness and delays
seeking medical attention.
The intent of denial is to control the threat, but it
may also endanger life.
92
92. 3.9 Maladaptive responses to stress(Continued)
Conclusion:
A general model of illness, based on Selye’s
theory, suggests that any stressor elicits a state of
disturbed physiologic equilibrium.
If this state is prolonged or the response is
excessive, it will increase the susceptibility of the
person to illness.
93
93. 3.10 Stress Management: Nursing Interventions
3.10. 1. Promoting a Healthy Lifestyle
Lifestyles or habits that contribute to the risk of
illness can be identified through a health risk
appraisal.
3.10. 2. Enhancing Coping Strategies
“coping enhancement” as a nursing intervention
and defined it as “assisting a patient to adapt to
perceived stressors, changes, or threats that
interfere with meeting life demands and roles”
94
94. 3.10.2 Enhancing Coping Strategies (Continued)
The five predominant ways of coping with illness
were as follows:
Trying to be optimistic about the outcome
Using social support
Using spiritual resources
Trying to maintain control either over the
situation or over feelings
Trying to accept the situation
95
95. 3.10.3 Teaching Relaxation Techniques
The goal of relaxation training is to produce a
response that counters the stress response.
When this goal is achieved, the action of the
hypothalamus adjusts and decreases the activity
of the sympathetic and parasympathetic nervous
systems.
96
96. 3.10.3 Teaching Relaxation Techniques (Continued)
The different relaxation techniques share four
similar elements:
1. a quiet environment
2. a confortable position,
3. a passive attitude, and
4. a mental device (something on which to focus
the attention, such as a word, phrase, or sound).
97
97. 3.10.3 Teaching Relaxation Techniques
(Continued)
Progressive muscle relaxation involves tensing and
releasing the muscles of the body in sequence and
sensing the difference in feeling.
Benson’s Relaxation Response
Benson (1993) describes the following steps of the
Benson Relaxation Response:
1. Pick a brief phrase or word that reflects your basic
belief system.
2. Choose a comfortable position.
3. Close your eyes.
4. Relax your muscles.
98
98. Benson’s Relaxation Response (Continued)
5. Become aware of your breathing, and start
using your selected focus word.
6. Maintain a passive attitude.
7. Continue for a set period of time.
8. Practice the technique twice daily.
99
99. 3.10.4 Educating About Stress Management
Two commonly prescribed nursing educational
interventions—
providing sensory information and
providing procedural information(eg, preoperative
teaching)—have the goal of reducing stress and
improving the patient’s coping ability.
100
100. 3.10.5 Enhancing Social Support
Social support has been found to provide
the individual with several different types of
emotional information; such as:
are cared for and loved.
are esteemed and valued.
are belonging to a network of
communication and mutual obligation.
101
101. 3.10.6. Recommending Support and Therapy
Groups
Professional, civic, and religious support groups
are active in many communities.
There are also encounter groups, assertiveness
training programs, and consciousness-raising
groups to help people modify their usual
behaviors in their transactions with their
environment.
Being a member of a group with similar
problems or goals has a releasing effect on a
person that promotes freedom of expression
and exchange of ideas.
102
103. 4. Pain Management
4.1 Definition:
Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage (Merskey & Bogduk, 1994).
This definition encompasses the multidimensional
nature of pain
104
104. 4.1 Definition(Continued)
Another broad definition of pain is “whatever
the person says it is, existing whenever the
experiencing person says it does” (McCaffery &
Beebe, 1989, p.7).
This definition emphasizes the highly subjective
nature of pain and pain management.
The patient is the best authority on the existence
of pain.
Therefore, validation of the existence of pain is
based on the patient’s report that it exists.
105
105. 4.1 Definition(Continued)
The American Pain Society coined the phrase
“Pain: The 5th Vital Sign” (Campbell, 1995) to
emphasize its significance.
It is the most common reason for seeking health
care.
It occurs with many disorders, diagnostic tests,
and treatments.
It disables and distresses more people than any
single disease.
106
106. 4.1 Definition (Continued)
Since nurses spend more time with the patient in
pain than do other health care providers, nurses
need to understand:
the pathophysiology of pain,
the physiologic and psychological consequences
of acute and chronic pain, and
the methods used to treat pain.
239
107
107. 4.2 Nature of pain
Pain is subjective and highly individualized.
Its stimulus is physical and/or mental in
nature.
It interferes with personal relationships and
influences the meaning of life.
Only the patient knows whether pain is
present and how the experience feels.
May not be directly proportional to amount
of tissue injury
108
108. 4.3 Pathophysiology of Pain
The sensory experience of pain depends on
the interaction between the nervous
system and the environment.
The processing of noxious stimuli and the
resulting perception of pain involve the
peripheral and central nervous systems.
109
109. 4.3.1 Pain Transmission
The transmission of pain perceptions to
and from the area of the brain that
interprets pain are nociceptors, or pain
receptors, and chemical mediators.
Nociceptors are receptors that are
preferentially sensitive to a noxious
stimulus.
110
110. 4.3.1 Pain Transmission (Continued)
Nociceptors are free nerve endings in the skin
that respond only to intense, potentially
damaging stimuli.
Such stimuli may be mechanical, thermal, or
chemical in nature.
The joints, skeletal muscle, fascia, tendons, and
cornea also have nociceptors that have the
potential to transmit stimuli that produce pain.
However, the large internal organs (viscera) do
not contain nerve endings that respond only to
painful stimuli.
111
111. 4.3.1 Pain Transmission (Continued)
Pain originating in these organs results from
intense stimulation of receptors that have other
purposes.
For example, inflammation, stretching, ischemia,
dilation, and spasm of the internal organs all
cause an intense response in these multipurpose
fibers and can cause severe pain.
112
112. 4.3.1 Pain Transmission (Continued)
Nociceptors are part of complex
multidirectional pathways.
These nerve fibers branch very near their
origin in the skin and send fibers to local
blood vessels, mast cells, hair follicles, and
sweat glands.
113
113. 4.3.1 Pain Transmission (Continued)
When these fibers are stimulated, histamine is
released from the mast cells, causing
vasodilation.
Nociceptors respond to high-intensity
mechanical, thermal, and chemical stimuli.
Some receptors respond to only one type of
stimuli; others, called polymodal nociceptors,
respond to all three types of stimuli.
These highly specialized neurons transfer the
mechanical, thermal, or chemical stimulus into
electrical activity or action potentials. 114
114. 4.3.1 Pain Transmission (Continued)
The cutaneous fibers located more centrally
further branch and communicate with the
paravertebral sympathetic chain of the
nervous system and with large internal
organs.
115
115. 4.3.2 Peripheral Nervous System
A number of algogenic (pain-causing) substances
that affect the sensitivity of nociceptors are
released into the extracellular tissue as a result of
tissue damage.
Histamine, bradykinin, acetylcholine, serotonin,
and substance P are chemicals that increase the
transmission of pain.
The transmission of pain is also referred to as
nociception.
116
116. 4.3.2 Peripheral Nervous System (Continued)
Prostaglandins are chemical substances
thought to increase the sensitivity of pain
receptors by enhancing the pain provoking
effect of bradykinin.
These chemical mediators also cause
vasodilation and increased vascular
permeability, resulting in redness, warmth,
and swelling of the injured area.
117
117. 4.3.2 Peripheral Nervous System (Continued)
Once nociception is initiated, the nociceptive
action potentials are transmitted by the
peripheral nervous system (Porth, 2002).
The first-order neurons travel from the periphery
(skin, cornea, visceral organs) to the spinal cord
via the dorsal horn.
There are two main types of fibers involved in
the transmission of nociception.
118
118. 4.3.2 Peripheral Nervous System (Continued)
Smaller, myelinated A δ (A delta) fibers
transmit nociception rapidly, which
produces the initial “fast pain.”
Type C fibers are larger, unmyelinated fibers
that transmit what is called second pain.
This type of pain has dull, aching, or burning
qualities that last longer than the initial fast
pain.
119
119. 4.3.2 Peripheral Nervous System (Continued)
Chemicals that reduce or inhibit the transmission
or perception of pain include endorphins and
enkephalins.
These morphine like neurotransmitters are
endogenous (produced by the body).
They are examples of substances that reduce
nociceptive transmission when applied to certain
nerve fibers.
The term “endorphin” is a combination of two
words: endogenous and morphine.
120
120. 4.3.2 Peripheral Nervous System (Continued)
Endorphins and enkephalins are found in heavy
concentrations in the central nervous system.
Morphine and other opioid medications act at
receptor sites to suppress the excitation initiated
by noxious stimuli.
The binding of opioids to receptor sites is
responsible for the effects noted after their
administration.
Each receptor (mu, kappa, delta) responds
differently when activated. 121
121. 4.3.3 Central Nervous System
After tissue injury occurs, nociception (the
neurologic transmission of pain impulses) to the
spinal cord via the Aδ and C fibers continues.
Nociception continues from the spinal cord to the
reticular formation, thalamus, limbic system, and
cerebral cortex.
Here nociception is localized and its
characteristics become apparent to the person,
including the intensity.
122
122. 4.3.3 Central Nervous System(Continued)
The involvement of the reticular formation,
limbic, and reticular activating systems is
responsible for the individual variations in the
perception of noxious stimuli.
Individuals may report the same stimulus
differently based on their anxiety, past
experiences, and expectations.
This is a result of the conscious perception of
pain.
123
124. 4.3.4 Descending Control System
The descending control system is a system of
fibers that originate in the lower and mid portion
of the brain, and
terminate on the inhibitory inter neuronal fibers
in the dorsal horn of the spinal cord.
This system is probably always somewhat active;
it prevents continuous transmission of stimuli as
painful, partly through the action of the
endorphins.
As nociception occurs, the descending control
system is activated to inhibit pain.
125
125. 4.3.4 Descending Control System(Continued)
Cognitive processes may stimulate endorphin
production in the descending control system.
The effectiveness of this system is illustrated by
the effects of distraction.
The distractions of visitors or a favorite TV show
may increase activity in the descending control
system.
Therefore, the person who has visitors may not
report pain because activation of the descending
control system results in less noxious or painful
information being transmitted to consciousness.
126
126. 4.3.4 Descending Control System(Continued)
The enkephalins and endorphins are
thought to inhibit pain impulses by
stimulating the inhibitory interneuronal
fibers, which in turn reduce the
transmission of noxious impulses via the
ascending system (Puig & Montes, 1998).
127
130. 4.5 Types of Pain(continued)
Pain
Acute pain
Chronic (Non
Malignant)pain
Chronic Cancer
related pain
Based on
Duration
131
131. 4.5.1 Based on Duration
Acute pain
When pain lasts only through the expected
recovery period, it is described as acute pain.
Acute pain is protective, has an identifiable
cause, is of short duration, and has limited tissue
damage and emotional response.
It eventually resolves, with or without treatment,
after an injured area heals.
132
132. 4.5.1 Based on Duration (Continued)
Acute Pain (continued)
Complete pain relief is not always achievable,
but reducing pain to a tolerable level is
realistic.
Unrelieved acute pain can progress to chronic
pain.
133
133. 4.5.1 Based on Duration (Continued)
Chronic Pain
Chronic pain is the pain that lasts longer
than 6 months and is constant or recurring
with a mild-to-severe intensity.
It does not always have an identifiable
cause and leads to great personal suffering.
Examples: arthritic pain, head ache, peripheral
neuropathy. 134
134. Chronic pain (Continued)
The possible unknown cause of chronic
pain, combined with the unrelenting nature
and uncertainty of its duration, frustrates a
patient, frequently leading to psychological
depression and even suicide.
Associated symptoms of chronic pain
include fatigue, insomnia, anorexia, weight
loss, hopelessness, and anger.
135
135. Chronic pain (Continued)
CHRONIC PAIN MAY BE :
Chronic non cancer pain
Chronic cancer pain
Chronic episodic pain.
Chronic non cancer(non Malignant) pain:
The chronic pain that resulted due to non
cancer disease conditions is termed as chronic
non cancer pain.
136
136. Chronic pain (Continued)
Chronic cancer pain:
Cancer pain is the pain that is caused by tumor
progression and related pathological processes,
invasive procedures, toxicities of treatment,
infection, and physical limitations.
Approximately 70% to 90% of patients with
advanced cancer experience pain.
137
137. Chronic pain (Continued)
Chronic episodic pain:
Pain that occurs sporadically over an
extended period of time is episodic pain.
Pain episodes last for hours, days, or weeks.
Examples are migraine headaches.
138
138. 4.5.2 Classification based on location
This is based on the site at which the pain is
located. Eg:
Headache
Back pain
Joint pain
Stomach pain
Cardiac pain
Referred pain: pain due to problems in other
areas manifest in different body part.
For example, cardiac pain may be felt in the
shoulder or left arm, with or without chest pain.
139
140. 4.5.3 Based on intensity(Continued)
Mild pain:
Pain scale reading from 1 to 3 is considered
as mild pain
Moderate pain:
Pain scale reading from 4 to 6 is considered
as moderate pain
Severe pain:
Pain scale reading from 7 to 10 is
considered as severe pain 141
142. 4.5.4 Classification based on
etiology(Continued)
Nociceptive pain:
Nociceptive pain is experienced when an intact,
properly functioning nervous system sends signals
that tissues are damaged, requiring attention and
proper care.
For example, the pain experienced following a cut
or broken bone alerts the person to avoid further
damage until it is properly healed.
Once stabilized or healed, the pain goes away
143
143. Nociceptive pain: (Continued)
Somatic pain:
This is the pain that is originating from the skin,
muscles, bone, or connective tissue.
The sharp sensation of a paper cut or aching of a
sprained ankle are common examples of somatic
pain
144
144. Nociceptive pain: (Continued)
Visceral pain:
Visceral pain is pain that results from the
activation of nociceptors of the thoracic, pelvic,
or abdominal viscera (organs).
Characterized by cramping, throbbing, pressing,
or aching qualities.
Examples: labor pain, angina pectoris, or irritable
bowel.
145
145. Neuropathic pain
Neuropathic pain is associated with damaged or
malfunctioning nerves due to illness , injury, or
undetermined reasons.
Examples:
Diabetic peripheral neuropathy
Phantom limb pain
Spinal cord injury pain
146
146. Neuropathic pain (Continued)
It is usually chronic.
it is described as burning, “electric-shock,”
and/or tingling, dull, and aching.
Neuropathic pain tends to be difficult to treat.
Neuropathic pain is of two types based on which
parts of the nervous system is damaged.
1. Peripheral Neuropathic Pain
2. Central Neuropathic Pain.
147
147. Peripheral neuropathic pain:
Due to damage to peripheral nervous system
Eg: phantom limb pain
Central neuropathic pain:
Results from malfunctioning nerves in the
central nervous system (CNS).
Eg: spinal cord injury pain,
Post-stroke pain.
148
148. 4.6 Factors Influencing Pain
1. Developmental factors
2. Physiological factors- fatigue, genes,
neurological functioning
3. Social factors- attention, previous
experience, family and social support,
spiritual factors.
4. Psychological factors- anxiety, coping style.
5. Cultural factors
149
149. 4.6. 1. Developmental factors
Age:
Age influences pain, particularly in infants
and older adults.
Young children have trouble understanding
pain and the procedures that cause it.
If they have not developed full vocabularies,
they have difficulty verbally describing and
expressing pain to parents or caregivers.
150
150. 4.6.1. Developmental factors
(Continued)
With the developmental factors in mind
assessment should be done for pain in
children.
older adults have a greater likelihood of
developing pathological conditions,
which are accompanied by pain.
151
151. 4.6. 2. Physiological Factors
1. Fatigue.
Fatigue heightens the perception of pain
and decreases coping abilities.
If it occurs along with sleeplessness, the
perception of pain is even greater.
Pain is often experienced less after a restful
sleep than at the end of a long day.
152
152. 2.Genes.
Research on healthy human subjects
suggests that genetic information passed
on by parents possibly increases or
decreases the person’s sensitivity to pain
and determines pain threshold or pain
tolerance.
153
153. 3. Neurological Function.
Any factor that interrupts or influences
normal pain reception or perception
(e.g., spinal cord injury) affects the patient’s
awareness of and response to pain.
154
154. 4.6.3. Social Factors
1.Attention.
The degree to which a patient focuses
attention on pain influences pain
perception.
Increased attention is associated with
increased pain, whereas distraction is
associated with a diminished pain response
155
155. 156
2.Previous Experience.
If a person repeatedly experiences the same
type of pain that was relieved successfully in the
past, the patient finds it easier to interpret the
pain sensation.
If a person is having worst previous experience
he may experience much pain.
3. Family and Social Support
The presence of family or friends can often
make the pain experience less stressful.
The presence of parents is especially important
for children experiencing pain.
156. 4. Spiritual Factors.
Spiritual questions include “Why has this
happened to me?” “Why am I suffering?”
Spiritual pain goes beyond what we can
see.
“Why has God done this to me?” “Is this
suffering teaching me something?”
If the person is experiencing like this
feelings it makes much painful
157
157. 4.6.4. Psychological Factors
1. Anxiety:
Anxiety often increases the perception of pain,
and pain causes feelings of anxiety.
Critically ill or injured patients who perceive a
lack of control over their environment and care
have high anxiety levels.
This anxiety leads to severe pain
2.Coping Style.
Persons with better coping levels perceives less
a pain than the person with lower coping levels.
158
158. 4.6.5 Cultural Factors.
Cultural beliefs and values affect how
individuals cope with pain.
Individuals learn what is expected and
accepted by their culture, including how to
react to pain.
Culture affects pain expression.
Some cultures believe that it is natural to be
demonstrative about pain.
Others tend to be more introverted.
159
160. 4.7.1 Pain Assessment
P recipitating/Alleviating Factors: – What causes the
pain? What aggravates it? Has medication or
treatment worked in the past?
Q uality of Pain: – Ask the patient to describe the
pain using words like “sharp”, dull, stabbing,
burning”
R adiation – Does pain exist in one location or radiate
to other areas?
S everity – Have patient use a descriptive, numeric
or visual scale to rate the severity of pain.
T iming – Is the pain constant or intermittent, when
did it begin.
161
161. 4.7.1 Pain Assessment (Continued)
• Assess for objective signs of pain:
Facial expressions – facial grimacing (a facial
expression that usually suggests disgust or
pain), frowning (facial expression in which
the eyebrows are brought together, and the
forehead is wrinkled), sad face.
Vocalizations - crying, moaning
Body movements – guarding , resistance to
moving
162
164. 4.7.2 Pain Assessment Tools
These are various tools that are designed to
assess the level of pain.
The most commonly used tools are:
1. Verbal Rating Scale
2. Numeric Rating Scale
3. Wong Baker’s Faces Pain Scale
165
165. Verbal Rating Scale
Simple Descriptive pain Intensity scale
166
No
pain
Mild
pain
Moderate
Pain
Severe
pain
Very
severe
pain
Worst
possible
pain
169. 4.8 Pain Management Strategies
Pharmacologic interventions are most effective
when a multimodal or balanced analgesia
approach is used.
Balanced analgesia refers to use of more than
one form of analgesia concurrently to obtain
more pain relief with fewer side effects.
Three general categories of analgesic agents are
opioids, NSAIDs, and local anesthetics.
170
170. 4.8 Pain Management Strategies(Continued)
These agents work by different mechanisms.
Using two or three types of agents
simultaneously can maximize pain relief while
minimizing the potentially toxic effects of any
one agent.
When one agent is used alone, it usually must be
used in a higher dose to be effective.
In other words, although it might require 15 mg
morphine to relieve a certain pain, it may take
only 8 mg morphine plus 30 mg ketorolac (an
NSAID) to relieve the same pain.
171
171. 4.8 Pain Management Strategies(Continued)
PRO RE NATA (PRN)
In the past, the standard method used by most
nurses and physicians in administering analgesia
was to administer the analgesic pro re nata
(PRN), or “as needed.”
The standard practice was for the nurse to wait
for the patient to complain of pain and then
administer analgesia.
As a result, many patients remained in pain
because they did not know they needed to ask
for medication or waited until the pain became
intolerable.
172
172. 4.8 Pain Management Strategies(Continued)
By its very nature, the PRN approach to
analgesia leaves the patient sedated or in
severe pain much of the time.
To receive pain relief from an opioid
analgesic, the serum level of that opioid
must be maintained at a minimum
therapeutic level.
By the time the patient complains of pain,
the serum opioid level is below the
therapeutic level. 173
173. 4.8 Pain Management Strategies(Continued)
In view of the harmful effects of pain and
inadequate pain management, the goal of
tolerable pain has been replaced by the goal of
relieving the pain.
Pain management strategies include both
pharmacologic and nonpharmacologic
approaches.
These approaches are selected on the basis of the
patient’s requirements and goals.
174
174. 4.8 Pain Management Strategies(Continued)
The pharmacologic management of pain requires
close collaboration and effective communication
among health care providers.
Appropriate analgesic medications are used as
prescribed.
They are not considered a last resort to be used
only when other pain relief measures fail.
Any intervention is most successful if initiated
before pain sensitization occurs, and the greatest
success is usually achieved if several interventions
are applied simultaneously. 175
175. 4.8 Pain Management Strategies(Continued)
Pain sensation can be influenced or modified as
follows:
Elimination of the cause of pain
lowering of the sensitivity of nociceptors
(antipyretic analgesics, local anesthetics)
interrupting nociceptive conduction in sensory
nerves (local anesthetics)
suppression of transmission of nociceptive impulses
in the spinal medulla (opioids)
inhibition of pain perception (opioids, general
anesthetics)
Altering emotional responses to pain, i.e., pain
behavior (antidepressants as “coanalgesics,”
176
176. 4.9 Management Of Pain
Pain can be managed through
1. Pharmacological interventions
2. Non pharmacological interventions
177
177. 4.9. 1. Pharmacological interventions
Pharmacological therapy is given by using
Analgesics.
The analgesics may be NON OPIOIDS (NSAIDS) OR
OPIODS OR ADJUVANTS
NSAIDS: Non steroidal anti inflammatory drugs
Opioids: Opioids are medications that relieve
pain. Derived from opium.
178
180. 1. Pharmacological interventions (Continued)
Nonopioids: – Used alone or in conjunction with
opioids for mild to moderate pain
– Eg; NSAIDS- paracetamol, aspirin.
Opioids: – for moderate or severe pain
– Eg: morphine, codeine
Altering emotional responses to pain, i.e., pain
behavior (antidepressants as “co-analgesics,”
181
181. NSAIDs Major Mechanism of Action
The major mechanism by which the NSAIDs
elicit their therapeutic effects is inhibition of
prostaglandin (PG) synthesis.
Specifically NSAIDs competitively inhibit
cyclooxygenases (COXs), the enzymes that
catalyze the synthesis of cyclic endoperoxides
from arachidonic acid to form prostaglandins
182
182. NSAIDs Major Mechanism of Action(Continued)
Two COX isoenzymes have been identified: COX-1
and COX-2.
The COX-2 isoenzyme plays an important role in
pain and inflammatory processes.
Generally, the NSAIDs inhibit both COX-1 and
COX-2.
183
183. NSAIDs Major Mechanism of Action(Continued)
In the case of PG, a cyclopentane ring forms in
the acyl chain.
The letters following PG (D, E, F, G, H, or I)
indicate differences in substitution with hydroxyl
or keto groups;
184
184. NSAIDs Major Mechanism of Action(Continued)
Bronchial muscle. PGE2 and PGI2 induce
bronchodilation; PGF2α causes constriction.
Thromboxane A2 and prostacyclin play a role in
regulating the aggregability of platelets and
vascular diameter.
Leukotrienes increase capillary permeability and
serve as chemotactic factors for neutrophil
granulocytes.
185
186. Patient-Controlled Analgesia
A drug delivery system called patient
controlled analgesia (PCA) is a safe method
for pain management that many patients
prefer.
It is a drug delivery system that allows
patients to self-administer opioids
(morphine and fentanyl) with minimal risk
of overdose.
187
187. Patient-Controlled Analgesia(Continued)
PCA infusion pumps are portable and
computerized and contain a chamber for a
syringe or bag that delivers a small, preset
dose of opioid .
To receive a demand dose, the patient
pushes a button attached to the PCA
device.
188
189. Topical Analgesics
Topical analgesics are applied over the
patients skin either in the form of topical
ointments or transdermal patches.
The patches will be sticking to the skin and
delivers a small amount of dosage
continuously.
190
191. Local Anesthesia
Local anesthesia is the local infiltration of an
anesthetic medication to induce loss of sensation to
a body part.
Local anesthetics work by blocking nerve conduction
when applied directly to the nerve fibers.
They can be applied directly to the site of injury (eg,
a topical anesthetic spray for sunburn) or directly to
nerve fibers by injection or at the time of surgery.
The drugs produce temporary loss of sensation by
inhibiting nerve conduction
They can also be administered through an epidural
catheter.
192
193. Regional Anesthesia
Regional anesthesia is the injection of a
local anesthetic to block a group of sensory
nerve fibers.
Examples of regional anesthesia include
epidural anesthesia and spinal anesthesia.
194
194. Adverse effects
Respiratory depression is the most serious adverse
effect of opioid analgesic agents administered by
intravenous, subcutaneous, or epidural routes.
However, it is relatively rare.
Sedation, is likely to occur when opioid doses are
increased. However, the patient often develops
tolerance quickly,
Nausea and vomiting frequently occur with opioid
use.
Constipation, Tolerance to this side effect does not
occur;
Allergy
Tolerance & Addiction (especially Opioids)
195
198. 4.9.2 Non pharmacologic interventions
Nonpharmacologic nursing activities can assist in
relieving pain with usually low risk to the patient.
Although such measures are not a substitute for
medication, they may be all that is necessary or
appropriate to relieve episodes of pain lasting
only seconds or minutes.
Combining non pharmacologic interventions with
medications may be the most effective way to
relieve pain.
199
199. I) Cutaneous Stimulation and Massage
The gate control theory of pain proposes
that the stimulation of fibers that transmit
nonpainful sensations can block or decrease
the transmission of pain impulses.
Several non pharmacologic pain relief
strategies, including:
rubbing the skin and using heat and cold,
are based on this theory.
200
200. (I) Cutaneous Stimulation (Continued)
A massage does not specifically stimulate
the non-pain receptors in the same
receptor field as the pain receptors, but it
may have an impact through the
descending control system (see earlier
discussion).
Massage also promotes comfort because it
produces muscle relaxation.
201
201. (II) Ice and Heat Therapies
202
Proponents believe that ice and heat stimulate
the non-pain receptors in the same receptor field
as the injury.
For greatest effect, ice should be placed on the
injury site immediately after injury or surgery.
Avoid direct application of ice from skin
Ice should be applied to an area for no longer
than 20 minutes at a time.
This prevents the rebound phenomenon
Long applications of ice may result in frostbite
202. (II) Ice and Heat Therapies(Continued)
Application of heat increases blood flow to an
area and contributes to pain reduction by
speeding healing.
Both dry and moist heat may provide some
analgesia, but their mechanisms of action are not
well understood.
Application of heat to inflamed joints, for
example, may provide temporary comfort, but
increasing the intra-articular temperature may
impair healing (Oosterveld & Rasker, 1994a,
1994b). 203
203. (II) Ice and Heat Therapies(Continued)
Neither therapy should be applied to areas with
impaired circulation or used with patients with
impaired sensation.
204
204. (III)Transcutaneous Electrical Nerve
Stimulation(TENS)
205
TENS uses a battery operated unit with electrodes
applied to the skin to produce a tingling,
vibrating, or buzzing sensation in the area of pain.
It has been used in both acute and chronic pain
relief
thought to decrease pain by stimulating the non-
pain receptors in the same area as the fibers that
transmit the pain.
This mechanism is consistent with the gate
control theory of pain.
205. (III) TENS (Continued)
Another possible explanation for the
effectiveness of TENS is the placebo effect
(the patient expects it to be effective).
206
206. (IV) Distraction
Distraction, involves focusing the patient’s
attention on something other than the pain,
Distraction reduces the perception of pain by
stimulating the descending control system,
resulting in fewer painful stimuli being
transmitted to the brain.
Distraction techniques range from simple
activities, such as watching TV or listening to
music, to highly complex physical and mental
exercises.
207
