Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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1: Perioperative Concepts and
Nursing Managements
Glossary
 Ambulatory Surgery – includes outpatient, same-day, or shortstay surgery that does not require an overnight hospital stay
 Bariatrics – having to do with patients who are obese
 Informed Consent – the patient’s autonomous decision about
whether to undergo a surgical procedure, based on the nature of
the condition, the treatment options, and the risks and benefits
involved
 Intraoperative Phase – period of time that begins with transfer
of the patient to the operating room area and continues until the
patient is admitted to the postanesthesia care unit
 Minimally Invasive Surgery – surgical procedures that use
specialized instruments inserted into the body either through
natural orifices or through small incisions
 Perioperative Phase – period of time that constitutes the surgical
experience; includes the preoperative, intraoperative, and
postoperative phases of nursing care
 Postoperative Phase – period of time that begins with the
admission of the patient to the post-anesthesia care unit and
ends after follow-up evaluation in the clinical setting or home
 Preadmission Testing – diagnostic testing performed before
admission to the hospital
 Preoperative Phase – period of time from when the decision for
surgical intervention is made to when the patient is transferred
to the operating room table
Perioperative Nursing
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Communication, teamwork, and patient assessment are crucial
to ensure good patient outcomes in the perioperative setting.
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Perioperative nursing, which spans the entire surgical
experience, consists of three phases that begin and end at
particular points in the sequence of surgical experience events.
Surgery can also be classified based upon the degree of urgency
involved: emergent, urgent, required, elective, and optional
Surgery which needs
to be done in order
to retain quality of life
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Special Populations:
o Elderly Patients
o Obese Patients
o Patients with Disabilities
Preoperative Nursing
 It begins with informed consent (a patient’s autonomous decision
about whether to undergo a surgical procedure).
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PreOp assessment focuses on the prevention of complications:
o Nutritional and Fluid Status
o Dentition
o Drug and Alcohol Use
o Cardiovascular and Respiratory Status
o Hepatic and Renal Function
o Endocrine and Immune Function
o Medications
o Psychosocial and Cultural Factors
Quality and Safety Nursing Alert

A latex allergy can manifest as a rash, asthma, or anaphylactic
shock.
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The possible adverse interactions of some medications require
the nurse to assess and document the patient’s use of
prescription medications, OTC medications (especially aspirin),
herbal agents, and the frequency with which medications are
used. The nurse must clearly communicate this information to
the anesthesiologist or CRNA
Nursing Management
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Choose an appropriate time and place for preoperative teaching.
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Address deep-breathing and coughing, postoperative mobility,
pain management.
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Teach the patient about preoperative fasting.
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Prepare the patient’s bowels and skin as ordered. Administer
preoperative medications.
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Meticulous documentation is necessary
Intraoperative Nursing
Glossary
 Anesthesia – a state of narcosis or severe central nervous system
depression produced by pharmacologic agents
Stepanie Bryn O. Agustero
BSN 3A
1|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Anesthesiologist – physician trained to deliver anesthesia and to
monitor the patient’s condition during surgery
Anesthetic Agent – the substance, such as a chemical or gas,
used to induce anesthesia circulating nurse (or circulator):
registered nurse who coordinates and documents patient care in
the operating room
Laparoscope – a thin endoscope inserted through a small incision
into a cavity or joint using fiber-optic technology to project live
images of structures onto a video monitor; other small incisions
allow additional instruments to be inserted to facilitate
laparoscopic surgery
Malignant Hyperthermia – a rare life-threatening condition
triggered by exposure to most anesthetic agents inducing a
drastic and uncontrolled increase in skeletal muscle oxidative
metabolism that can overwhelm the body’s capacity to supply
oxygen, remove carbon dioxide, and regulate body temperature,
eventually leading to circulatory collapse and death if untreated;
often inherited as an autosomal dominant disorder
Moderate Sedation – previously referred to as conscious
sedation, involves the use of sedation to depress the level of
consciousness without altering the patient’s ability to maintain a
patent airway and to respond to physical stimuli and verbal
commands
Monitored Anesthesia Care – moderate sedation given by an
anesthesiologist or certified registered nurse anesthetist (CRNA)
Registered Nurse First Assistant – a member of the operating
room team whose responsibilities may include handling tissue,
providing exposure at the operative field, suturing, and
maintaining hemostasis
Restricted Zone – area in the operating room where scrub attire
and surgical masks are required; includes operating room and
sterile core areas
Scrub Role – registered nurse, licensed practical nurse, or surgical
technologist who scrubs and dons sterile surgical attire, prepares
instruments and supplies, and hands instruments to the surgeon
during the procedure
Semi-Restricted Zone – area in the operating room where scrub
Sattire is required; may include areas where surgical instruments
are processed
Surgical Asepsis – absence of microorganisms in the surgical
environment to reduce the risk of infection
Unrestricted Zone – area in the operating room that interfaces
with other departments; includes patient reception area and
holding area
The Surgical Environment
 Surgical environment is known for its stark appearance and cool
temperature.
 Surgical asepsis is paramount in the OR.
o A “zone” system is used with appropriate environmental
controls
o Appropriate attire
 Safety issues include exposure to blood and body fluids, and
exposure to latex and adhesive substances, radiation, and toxic
agents and lasers.
Types of Anesthesia and Sedation
 General Anesthesia
 Regional Anesthesia
 Local Anesthesia
 Moderate Sedation (Monitored Anesthesia Care)
Routes of General Anesthesia
 Inhalation
o Inhaled anesthetic agents include volatile liquid agents and
gases. Volatile liquid anesthetic agents produce anesthesia
when their vapors are inhaled.
o When inhaled, the anesthetic agents enter the blood
through the pulmonary capillaries and act on cerebral
centers to produce loss of consciousness and sensation
o The vapor from inhalation anesthetic agents can be given
to the patient by several methods.
 LMA (Laryngeal Mask Airway) – a flexible tube with
an inflatable silicone ring and cuff that can be
inserted into the larynx
 ETT (Endotracheal Tube) – The endotracheal
technique for administering anesthetic medications
consists of introducing a soft rubber or plastic ETT
Stepanie Bryn O. Agustero
BSN 3A
2|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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into the trachea, usually by means of a laryngoscope.
The ETT may be inserted through either the nose or
mouth.
Intravenous Administration
o General anesthesia can also be produced by the IV
administration of various anesthetic and analgesic agents,
such as barbiturates, benzodiazepines, nonbarbiturate
hypnotics, dissociative agents, and opioid agents.
o An advantage of IV anesthesia is that the onset of
anesthesia is pleasant; there is none of the buzzing,
roaring, or dizziness known to follow administration of an
inhalation anesthetic agent.
o The combination of IV and inhaled anesthetic agents
produces an effective and smooth experience for the
patient, with a controlled emergence following surgery
Regional Anesthesia
o In regional anesthesia, an anesthetic agent is injected
around nerves so that the region supplied by these nerves
is anesthetized.
o The effect depends on the type of nerve involved:
 Motor Fibers are the largest fibers and have the
thickest myelin sheath.
 Sympathetic Fibers are the smallest and have a
minimal covering.
 Sensory Fibers are intermediate.
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Examples of Common Local Conduction Blocks
 Brachial Plexus Block – which produces anesthesia of
the arm
 Paravertebral Anesthesia – which produces
anesthesia of the nerves supplying the chest,
abdominal wall, and extremities
 Transsacral (Caudal) Block – which produces
anesthesia of the perineum and, occasionally, the
lower abdomen
Moderate Sedation
o Previously referred to as conscious sedation, is a form of
anesthesia that involves the IV administration of sedatives
or analgesic medications to reduce patient anxiety and
control pain during diagnostic or therapeutic procedures.
o The goal is to depress a patient’s level of consciousness to
a moderate level to enable surgical, diagnostic, or
therapeutic procedures to be performed while ensuring the
patient’s comfort during and cooperation with the
procedures
Monitored Anesthesia Care
o Also referred to as monitored sedation, is moderate
sedation given by an anesthesiologist or CRNA who must be
prepared and qualified to convert to general anesthesia if
necessary
Local Anesthesia
o Injection of a solution containing the anesthetic agent into
the tissues at the planned incision site.
o
o
Local anesthesia is often given in combination with
epinephrine.
Local anesthesia is the preferred anesthetic method in any
surgical procedure.
Quality and Safety Nursing Alert

It is the responsibility of all nurses, and particularly
perianesthesia and perioperative nurses, to be aware of latex
allergies, necessary precautions, and products that are latex free.
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Hospital staff are also at risk for development of a latex allergy
secondary to repeated exposure to latex products.
Postoperative Nursing
Glossary
 Dehiscence – partial or complete separation of wound edges
 Evisceration – protrusion of organs through the surgical incision
 First-Intention Healing – method of healing in which wound
edges are surgically approximated and integumentary continuity
is restored without granulation
 Phase I PACU – area designated for care of surgical patients
immediately after surgery and for patients whose condition
warrants close monitoring
 Phase II PACU – area designated for care of surgical patients who
have been transferred from a phase I PACU because their
condition no longer requires the close monitoring provided in a
phase I PACU
 Phase III PACU – setting in which the patient is cared for in the
immediate postoperative period and then prepared for discharge
from the facility
 Postanesthesia Care Unit (PACU) – area where postoperative
patients are monitored as they recover from anesthesia; formerly
referred to as the recovery room or postanesthesia recovery
room
 Second-Intention Healing – method of healing in which wound
edges are not surgically approximated and integumentary
continuity is restored by the process known as granulation
 Third-Intention Healing – method of healing in which surgical
approximation of wound edges is delayed and integumentary
continuity is restored by opposing areas of granulation.
Postoperative Period
 The postoperative period extends from the time the patient
leaves the operating room (OR) until the last follow-up visit with
the surgeon. This may be as short as a day or two or as long as
Stepanie Bryn O. Agustero
BSN 3A
3|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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several months. During the postoperative period, nursing care
focuses on re-establishing the patient’s physiologic equilibrium,
alleviating pain, preventing complications, and educating the
patient about self-care.
Frequent skilled nursing assessment is necessary.
o Focuses on the risks of impaired respirations,
cardiovascular instability, haemorrhage, unstable BP, shock
When stable, the patient is discharged home or discharged to the
postoperative unit.
Nursing Management in the PACU
 Utilized the nursing process
 Frequent, thorough assessment is necessary
 Interventions focus on:
o Respiratory Function
 The primary objective in the immediate postoperative
period is to maintain ventilation and thus prevent
hypoxemia and hypercapnia. Both can occur if the
airway is obstructed and ventilation is reduced
(hypoventilation).
 Patients who have experienced prolonged anesthesia
usually are unconscious, with all muscles relaxed. This
relaxation extends to the muscles of the pharynx.
When the patient lies on their back, the lower jaw
and the tongue fall backward and the air passages
become obstructed. This is called hypopharyngeal
obstruction
o Promoting Cardiac Output
 The primary cardiovascular complications seen in the
PACU include hypotension and shock, hemorrhage,
hypertension, and dysrhythmias.
 Hypotension can result from blood loss,
hypoventilation, position changes, pooling of blood in
the extremities, or side effects of medications and
anesthetics.
 Shock which is one of the most serious postoperative
complications, can result from hypovolemia and
decreased intravascular volume.
 Types of Schock
 Hypovolemic Shock – Most common type
 Cardiogenic Shock
 Neurogenic Shock
 Anaphylactic Shock
 Septic Shock
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Relieving Pain
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Encouraging Activity
Wound Healing (Dressing Changes)
o Wound healing mechanisms (see glossary)
 First intension healing Second intention healing Third
intention healing
Nutrition and GI Function
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Managing Potential Complications
 Venous Thromboembolism
 Hematoma
 Infection (Wound Sepsis)
 Wound Dehiscence and Evisceration.
Discharge Teaching
 Should begin as early as possible
 Because of earlier discharges than in the past, discharge teaching
must be comprehensive
2: Chronic Illness
Glossary
 Chronic Disease – medical or health problem with associated
symptoms or disabilities that require long-term management;
also referred to as non-communicable disease, chronic condition,
or chronic disorder
 Chronic Illness – the experience of living with a chronic disease
or condition; the person’s perception of the experience and the
person’s and others’ responses to the chronic disease or
condition
 Cognitive Disability – limitations in mental functioning and
difficulties with communication, self-care, and social skills
 Developmental Disability – a set of heterogeneous disorders
characterized by difficulties in one or more domains; can include
cognitive, physical, or both cognitive and physical impairments
with an onset before 22 years of age
 Disability – restriction or lack of ability to perform an activity in a
normal manner; the consequences of impairment in terms of a
person’s functional performance and activity—disability
represents impairment at the level of the person (e.g., bathing,
dressing, communication, walking, grooming)
 Intellectual Disability – a disability that occurs before 18 years of
age characterized by significant limitations in both intellectual
functioning and in adaptive behavior, which includes many
everyday social and practical skills
 Multiple Chronic Conditions (MCC) – presence of more than one
chronic disease or condition
Stepanie Bryn O. Agustero
BSN 3A
4|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Non-communicable Diseases – a group of conditions that are not
caused by an acute infection
Secondary Health Conditions or Disorders – any physical,
mental, or social disorders resulting directly or indirectly from an
initial disabling condition
Sensory Disability – a disorder characterized by impairment of
the sense of sight, hearing, smell, touch, or taste (e.g., hearing
loss, deafness, vision loss, blindness)
Psychiatric Disability – is defined as a mental illness or
impairment that substantially limits one’s ability to complete
major life activities, such as learning, working, and
communicating.
Many people with disabilities are at risk for secondary health
conditions (e.g., pressure injuries, urinary tract infections, low
bone density, depression) because of a narrow margin of health.
Chronic Disease and Chronic Illness
 Chronic Disease refers to non-communicable diseases
(conditions not caused by an acute infection or injury), chronic
conditions, or chronic disorders.
 Chronic Illness refers to the human experience of living with a
chronic disease or condition. Includes the person’s perception of
the experience of having a chronic disease or condition and the
person’s and others’ responses to it, including health care
professionals… Only the person and the family really know what
it is like to live with chronic illness. (Larsen, 2019).
 Having multiple chronic conditions (MCC) increases the
complexity of care.
 Thus, patients with MCC are at risk for conflicting medical advice,
adverse effects of medications, unnecessary and duplicative
tests, and preventable hospitalizations, all of which can
negatively affect their health (CDC, 2019b).
 Chronic diseases or conditions are often defined as medical
conditions or health problems with associated symptoms or
disabilities that require long-term management.
 Definitions of chronic disease or chronic illness share the
characteristics of being irreversible, having a prolonged course,
and remaining unlikely to resolve spontaneously
 The main Social Determinants of Health (SDOH) that have been
identified include income and social status, employment and
working conditions, education and literacy, childhood
experiences, physical environment, social supports and coping
skills, healthy behaviors, access to health services, biology and
genetic makeup, gender, culture, race and ethnicity.
Prevention of Chronic Disease
 Risk Factors
o Hypertension (high blood pressure)
o Tobacco and ENDS use or exposure to secondhand smoke
o Overweight or obesity (high BMI)
o Lack of physical activity
o Excessive alcohol use
o Consumption of diets low in fruits and vegetables
o Consumption of food high in sodium and saturated fats
Characteristics of Chronic Conditions
 Psychological and Social Issues: Associated psychological and
social issues must also be addressed, because living for long
periods with illness symptoms and disability can threaten
identity, bring about role changes, alter body image, and disrupt
lifestyles, work, and family life.
 Course of Chronic Disease: Chronic health conditions usually
involve many different phases over the course of a person’s
lifetime. There can be acute periods, stable and unstable periods,
flare-ups, and remissions.
 Progression of Chronic Disease: The rate of progression of
chronic diseases can vary from a rapid downhill course leading
quickly to disability and death within a few months of onset to
those with a slow downhill progression over years.
 Therapeutic Regimens: Keeping chronic conditions under control
requires persistent adherence to therapeutic regimens that may
be complex and may interfere with usual activities or even life
goals. Failing to adhere to a treatment plan or to do so
consistently increases the risks of developing complications and
accelerating the disease process.
 Development of other Chronic Conditions: One chronic disease
can lead to the development of other chronic conditions.
 Family Life: Chronic illness affects the entire family. Family life
can be dramatically altered as a result of role reversals, unfilled
roles, loss of income, time required to manage the illness,
decreases in family socialization activities, and the costs of
treatment.
 Home Life: The day-to-day management of illness is largely the
responsibility of people with chronic disorders and their families.
 Self-Management: The management of chronic conditions is a
continual process. People can be taught how to manage their
conditions.
 Collaborative Process: Managing chronic conditions must be a
collaborative process that involves many different health care
professionals working together with patients and their families to
Stepanie Bryn O. Agustero
BSN 3A
5|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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provide the services and supports that are often needed for
management at home.
Health Care Costs: The management of chronic conditions is
expensive. Many expenses incurred by an individual patient (e.g.,
costs for hospital stays, diagnostic tests, equipment, medications,
and supportive services) may be covered by health insurance and
by federal and state agencies. The Patient Protection and
Affordable Care Act (ACA), passed in 2010, the most significant
change to health care policy in the United States since the
establishment of Medicare and Medicaid, has made available
health insurance for many previously uninsured individuals who
were unable to obtain health insurance.
Lost Income: If a family’s primary income earner becomes ill,
chronic diseases can result in drastic loss in income with
inadequate funds for food, education, and health care.
Living with Uncertainty: Having a chronic illness means living
with uncertainty. Although health care providers may be aware
of the usual progression of a chronic disease such as Parkinson’s
disease or multiple sclerosis, no one can predict with certainty
the course of a person’s illness. Even when a patient is in
remission or symptom free, the person often fears that
symptoms will reappear.
Implications of Managing Chronic Conditions
 Once a chronic condition has occurred, the focus shifts to
managing symptoms, avoiding complications (e.g., eye
complications in a person with diabetes), and preventing other
acute illnesses (e.g., pneumonia in a person with chronic
obstructive lung disease).
 Quality of life—often overlooked by health care professionals in
their approach to people with chronic conditions— is also
important.
 Health-promoting behaviors, such as exercise, are essential to
quality of life even in people who have chronic illnesses or
disabilities, because it helps maintain functional status (Larsen,
2019).
 The need to deal with more than one chronic condition at a time.
The symptoms or treatment of a second chronic condition may
aggravate the first chronic condition.
 The need to hire and oversee caregivers who come into their
homes to assist with ADLs and IADLs
Nursing Care of Patients with Chronic Conditions
 Nursing care of patients with chronic conditions is varied and
occurs in a variety of settings. Care may be direct or supportive
Types of Care
Direct
 may be provided in the
clinic or primary care
provider’s office, a nursemanaged center or clinic, a
hospital, long-term care
facility, or the patient’s
home.
 includes assessing the
patient’s physical status,
providing wound care,
managing and overseeing
medication regimens,
providing education to the
patient and family, and
performing technical tasks
Supportive
 may include ongoing
monitoring, education,
counseling, serving as an
advocate for the patient,
making referrals, and case
management.
Home, Community-Based, and Transitional Care
 Educating Patients About Self-Care
o Well-informed, educated patients are more likely than
uninformed patients to be concerned about their health
and do what is necessary to maintain it. They are also more
likely to manage symptoms, recognize the onset of
complications, and seek health care early
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The nurse cannot assume that patients with a long-standing
chronic condition have the knowledge necessary to manage
the condition.
o The nurse must also recognize that patients may know how
their body responds under certain conditions and how best
to manage their symptoms.
Continuing and Transitional Care
o Most chronic conditions are managed in the home.
Therefore, care and education during hospitalization should
focus on essential information about the condition so that
management can continue once the patient is discharged
home.
o The home health nurse reassesses how the patient and the
family are adapting to the chronic condition and its
treatment and continues or revises the plan of care
accordingly
o Telehealth or telehomecare (use of electronic data and
telecommunications technologies to support long-distance
clinical health care, patient and professional health-related
education, public health, and health administration) has
been used effectively to provide care for patients with
chronic illness.
o Transitional care, if available, should be considered and
implemented when the patient has MCC, has impaired
cognitive status as well as physical limitations, has complex
therapies, or is frail or unstable prior to discharge from the
hospital to home.
o Transitional care nurses serve as the primary coordinator of
care. These nurses conduct assessments of the patient as
well as the family caregivers’ ability to assist in
management of the patient in the home.
Nursing Care for Special Populations with Chronic Illness
o When providing care and education, the nurse must
consider multiple factors (e.g., age; gender; culture and
ethnicity; cognitive status; the presence of physical,
sensory, and cognitive limitations; health literacy) that
influence susceptibility to chronic illness and the ways
patients respond to chronic disorders.
o Populations at high risk for specific conditions can be
targeted for special education and monitoring programs;
this includes those at risk because of their genetic profile
o It is important to consider the effect of a preexisting
disability, or a disability associated with recurrence of a
chronic condition, on the patient’s ability to manage ADLs,
self-care, and the therapeutic regimen.
3: Pain Management
Glossary
 Acute Pain – pain that results from tissue damage that generally
abates as healing occurs; serves as a warning signal that
something is wrong or needs attention
 Adjuvant Analgesic Agent – a substance or medication added to
an analgesic medication regimen to improve analgesia (synonym:
co-analgesic agent)
 Agonist – a medication that binds to an opioid receptor
mimicking the way endogenous substances provide analgesia
 Agonist-Antagonist – a type of opioid (e.g., nalbuphine and
butorphanol) that binds to the kappa opioid receptor site acting
as an agonist (capable of producing analgesia) and
simultaneously to the mu opioid receptor site acting as an
antagonist (reversing mu agonist effects)
 Allodynia – pain due to a stimulus that does not normally
provoke pain, such as touch; typically experienced in the skin
around areas affected by nerve injury and commonly seen with
many neuropathic pain syndromes
 Antagonist – a medication that competes with agonists for opioid
receptor binding sites; can displace agonists, thereby inhibiting
their action
 Breakthrough Pain – a transitory increase in pain that occurs in
the context of otherwise controlled persistent pain
 Ceiling Effect – an analgesic dose above which further dose
increments produce no change in effect
 Central Sensitization – a key central mechanism of neuropathic
pain; the abnormal hyperexcitability of central neurons in the
spinal cord, which results from complex changes induced by the
Stepanie Bryn O. Agustero
BSN 3A
6|P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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incoming afferent barrages of nociceptors and results in an
increased nociceptive neuron response
Chronic or Persistent Pain – pain that may or may not be time
limited but that persists beyond the usual course/time of tissue
healing
Co-analgesic Agent – one of many medications that can either
improve the effectiveness of another analgesic agent or
independently have analgesic action (synonym: adjuvant
analgesic agent)
Comfort–Function Goal – the pain rating identified by the
individual patient above which the patient experiences
interference with function and quality of life (e.g., activities the
patient needs or wishes to perform)
Efficacy – the extent to which a medication or another treatment
“works” and can produce the intended effect—analgesia in this
context
Half-life – the time it takes for the plasma concentration (amount
of medication in the body) to be reduced by 50% (after starting a
medication, or increasing its dose; four to five half-lives are
required to approach a steady-state level in the blood,
irrespective of the dose, dosing interval, or route of
administration; after four to five half-lives, a medication that has
been discontinued generally is considered to be mostly
eliminated from the body)
Hydrophilic – a substance or medication that is readily absorbed
in aqueous solution
Hyperalgesia – an increasingly intense experience of pain
resulting from a noxious stimulus
Intraspinal “within the spine” – refers to the spaces or potential
spaces surrounding the spinal cord into which medications can
be given
Lipophilic – a substance or medication that is readily absorbed in
fatty tissues
Metabolite – the product of biochemical reactions during
medication metabolism
Mu Agonist – any opioid that binds to the mu opioid receptor
subtype and produces analgesic effects (e.g., morphine); used
interchangeably with the terms full agonist, pure agonist, and
morphinelike medication
Multimodal Analgesia or Multimodal Pain Management – the
intentional, concurrent use of more than one pharmacologic or
nonpharmacologic intervention with different methods of action
with the goal to achieve better analgesia while using lower doses
of medications with fewer adverse effects
Neuraxial – of the central nervous system
Neuropathic (Pathophysiologic) Pain – pain caused by injury or
dysfunction (lesion or disease) of one or more nerves of the
peripheral or central nervous systems with resultant impaired
processing of sensory input
Neuroplasticity – the ability of the peripheral and central
nervous systems to change both structure and function as a
result of noxious stimuli
Nociceptive (Physiologic) Pain – pain that is sustained by
ongoing activation of the sensory system that conducts the
perception of noxious stimuli; implies the existence of damage to
somatic or visceral tissues sufficient to activate the nociceptive
system
Nociceptor – a type of primary afferent neuron that has the
ability to respond to a noxious stimulus or to a stimulus that
would be noxious if prolonged
Nonopioid – refers to analgesic medications that include
acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs)
NSAID – an acronym for nonsteroidal anti-inflammatory drug
(pronounced “en said”)
Opioid – refers to morphine and other natural, semisynthetic,
and synthetic medications that relieve pain by binding to multiple
types of opioid receptors; term is preferred to “narcotic”
Opioid Dose–Sparing Effect – occurs when a nonopioid or coanalgesic medication is prescribed in addition to an opioid,
enabling the opioid dose to be lower without diminishing
analgesic effects
Opioid-induced Hyperalgesia – a phenomenon in which
exposure to an opioid induces increased sensitivity to pain, or a
lowered threshold, to the neural activity conducting pain
perception; it is the “flip side” of tolerance
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Opioid Naïve – denotes a person who has not recently taken
enough opioid on a regular enough basis to become tolerant to
the opioid’s effects
Opioid Tolerant – denotes a person who has taken opioids long
enough at doses high enough to develop tolerance to many of
the opioid’s effects, including analgesia and sedation
Pain – an unpleasant experience that is either emotional or
sensory resulting from actual or possible damage to tissues and is
uniquely experienced and described by each person
Peripheral Sensitization – a key peripheral mechanism of
neuropathic pain that occurs when there are changes in the
number and location of ion channels; in particular, sodium
channels abnormally accumulate in injured nociceptors,
producing a lower nerve depolarization threshold, ectopic
discharges, and an increase in the response to stimuli
Physical Dependence – the body’s normal response to
administration of an opioid for 2 or more weeks; withdrawal
symptoms may occur if an opioid is abruptly stopped or an
antagonist is given
Placebo – any medication or procedure, including surgery, that
produces an effect in a patient because of its implicit or explicit
intent and not because of its specific physical or chemical
properties
Preemptive Analgesic Agents – pre-injury pain treatments (e.g.,
preoperative epidural analgesia and preincision local anesthetic
infiltration) to prevent the development of peripheral and central
sensitization of pain
Refractory – nonresponsive or resistant to therapeutic
interventions such as analgesic agents
Substance Use Disorder (SUD) – problematic use of substances
such as opioids, benzodiazepines, or alcohol based on
identification of at least two of the diagnostic criteria listed by
the American Psychiatric Association. It is characterized by
craving the substance; continuing use despite harm; inability to
stop using; and experiencing withdrawal symptoms when
abruptly not using the substance; formerly known as addiction
Titration – upward or downward adjustment of the amount
(dose) of an analgesic agent
Tolerance – a normal physiologic process characterized by
decreasing effects of a medication at its previous dose, or the
need for a higher dose of medication to maintain an effect
Withdrawal – result of abrupt cessation or rapid decrease in
dose of a substance upon which one is physically dependent. It is
not necessarily indicative of substance use disorder
Definition of Pain
 The American Pain Society (APS, 2016) defines pain as “an
unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such
damage” This definition describes pain as a complex
phenomenon that can impact a person’s psychosocial, emotional,
and physical functioning.
 The clinical definition of pain reinforces that pain is a highly
personal and subjective experience: “Pain is whatever the
experiencing person says it is, existing whenever he says it does”
Effects of Pain
 Pain is the primary reason people seek health care and one of the
most common conditions that nurses treat
 Unrelieved pain has the potential to affect every system in the
body and cause numerous harmful effects, some of which may
last a lifetime
Types and Categories of Pain
Type of Pain According to Duration
Acute Pain – involves tissue
Chronic or Persistent Pain is
damage as a result of surgery,
subcategorized as being of
trauma, burn, or venipuncture, cancer or noncancer origin and
and is expected to have a
can persist throughout the
relatively short duration and
course of a person’s life.
resolve with normal healing.
Type of Pain According to Inferred Patology
Nociceptive (Physiologic) Pain
Neuropathic (Pathophysiologic)
refers to the normal functioning Pain is pathologic and results
of physiologic systems that
from abnormal processing of
leads to the perception of
sensory input by the nervous
system as a result of damage to
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West Capitol Road, Balangasan District, Pagadian City
noxious stimuli (tissue injury) as the peripheral or central
being painful. This is the reason nervous system (CNS) or both.
why nociception is described as
“normal” pain transmission.
 Subcategory of Chronic Pain
o Noncancer Chronic Pain include peripheral neuropathy
from diabetes, back or neck pain after injury, and
osteoarthritis pain from joint degeneration.
o Chronic pain may be intermittent, occurring with flares, or
it may be continuous.
 Some conditions can produce both acute and chronic pain. For
example, some patients with cancer have continuous chronic
pain and also experience more intense acute exacerbations of
pain periodically, which is called breakthrough pain (BTP).
Patients may also endure acute pain from repetitive painful
procedures during cancer treatment.
 Patients may have a combination of nociceptive and neuropathic
pain. For example, a patient may have nociceptive pain as a
result of tumor growth, and also report radiating sharp and
shooting neuropathic pain if the tumor is pressing against a nerve
plexus.
Nociceptive Pain
 Nociception includes four specific processes: transduction,
transmission, perception, and modulation

Transduction
o Refers to the processes by which noxious stimuli, such as a
surgical incision or burn, activate primary afferent neurons
called nociceptors, located throughout the body.
o These neurons have the ability to respond selectively to
noxious stimuli generated as a result of tissue damage from
mechanical (e.g., incision, tumor growth), thermal (e.g.,
burn, frostbite), chemical (e.g., toxins, chemotherapy), and
infectious sources.
o Prostaglandins are lipid compounds that initiate
inflammatory responses that increase tissue swelling and
pain at the site of injury.
o NSAIDs produce pain relief by mediating inflammation at
the site of trauma, primarily by blocking the formation of
prostaglandins.
o Acetaminophen is known to be a COX inhibitor that has
minimal peripheral effect, is not anti-inflammatory, and can
both relieve pain and reduce fever by preventing the
formation of prostaglandins in the CNS
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J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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o
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Transmission
o Effective transduction generates an action potential that is
transmitted along the lightly myelinated rapid conducting
A-delta fibers and the unmyelinated slower impulse
conducting C fibers.
o The endings of A-delta fibers detect thermal and
mechanical injury, allow relatively quick localization of pain,
and are responsible for a rapid reflex withdrawal from the
painful stimulus.
o Unmyelinated C fibers respond to mechanical, thermal,
and chemical stimuli. They produce poorly localized and
often aching or burning pain.
o A-beta (β) fibers are the largest of the fibers and respond
to touch, movement, and vibration but do not normally
transmit pain
o The primary A-delta fibers release glutamate. Glutamate is
a key neurotransmitter because it binds to the N-methyl-Daspartate (NMDA) receptor and promotes pain
transmission.
Perception
o Perception is the result of the neural activity associated
with transmission of noxious stimuli
o It requires activation of higher brain structures for the
occurrence of awareness, emotions, and impulses
associated with pain/
Modulation
o Modulation of the information generated in response to
noxious stimuli occurs at every level from the periphery to
the cortex and involves many different neurochemicals
o For example, serotonin and norepinephrine are inhibitory
neurotransmitters that are released in the spinal cord and
the brain stem by the descending (efferent) fibers of the
modulatory system.
o Some antidepressants provide pain relief by blocking the
body’s reuptake (resorption) of serotonin and
norepinephrine, extending their availability to fight pain
Additional Info
 Nociception
o Is the physiological process by which the body detects and
responds to noxious or harmful stimuli, commonly known
as pain. The nociceptive process involves four main stages:
o Transduction:
 Transduction is the conversion of noxious stimuli into
electrical signals.
 Specialized receptors called nociceptors detect
potentially damaging stimuli such as heat, pressure,
or chemicals. When activated, nociceptors convert
these stimuli into electrical signals, creating action
potentials.
o Transmission:
 Transmission involves the relay of the pain signals
from the site of injury or stimulation to the spinal
cord and then to the brain.
 After transduction, the electrical signals (action
potentials) travel along nerve fibers, known as A-
o
delta and C fibers, towards the spinal cord. At the
spinal cord, these signals are transmitted to neurons
that carry them to the brain, specifically to areas
associated with pain perception.
Perception:
 Perception is the conscious awareness and
interpretation of the pain signals.
 In this stage, the brain processes and interprets the
incoming signals, giving rise to the conscious
experience of pain. The perception of pain is
influenced by various factors, including emotions,
past experiences, and individual pain thresholds.
Modulation:
 Modulation involves the modification or control of
pain signals, either enhancing or inhibiting them.
 Inhibitory and facilitatory pathways in the nervous
system can modulate the intensity of pain signals.
This modulation can occur at various levels, including
the spinal cord and higher brain centers. Endogenous
substances like endorphins, which are natural
painkillers, play a role in modulating the perception
of pain.
These four processes work together to enable the body to
detect, transmit, interpret, and regulate the experience of
pain in response to harmful stimuli, contributing to the
overall protective function of pain in maintaining body
integrity.
Neuropathic Pain
 Neuropathic pain is caused by either a lesion or a disease
involving the somatosensory nervous system
 Although specific causes may vary based on the underlying
pathology, it is theorized that there are changes in the ion
channels; imbalance of the stimuli processing between excitatory
and inhibitory somatosensory signals; activity of glial cells; or
potential differences in modulation of pain that occur with
neuropathic pain
 Peripheral Mechanisms
o Nerve endings in the periphery can become damaged,
leading to abnormal reorganization in the nervous system
called maladaptive neuroplasticity
o Changes in ion channels can occur, such as increased
sodium channel activity in sensory nerves resulting in
heightened excitability, increased transduction, and release
of neurotransmitters. These and many other processes lead
to a phenomenon called peripheral sensitization
o Allodynia, or pain from a normally non-noxious stimulus
(e.g., touch), is one such type of abnormal sensation and a
common feature of neuropathic pain
o Hyperalgesia is an increased response of pain sensation
from a stimulus which at a usual pain threshold produces a
less intense pain response.
 Central Mechanisms
o Central sensitization is defined as abnormal
hyperexcitability of central 686 neurons in the spinal cord,
which results from complex changes induced by incoming
afferent barrages of nociceptors, which also can result in
allodynia and hyperalgesia
Additional Info
 Neuropathic pain is a type of pain that arises from a dysfunction
or damage to the nervous system, particularly the peripheral or
central nervous system. Unlike nociceptive pain, which results
from actual or potential tissue damage, neuropathic pain is often
characterized by abnormal signaling within the nervous system. It
can be chronic and may persist long after the initial injury or
damage has healed. Neuropathic pain can manifest in various
ways, such as burning, tingling, electric shock-like sensations, and
hypersensitivity to touch. The processes involved in neuropathic
pain include:
o Peripheral Nerve Damage: Neuropathic pain often begins
with damage to the peripheral nerves, which are
responsible for transmitting signals between the body and
the spinal cord. This damage can result from conditions like
diabetes, infections, traumatic injuries, or autoimmune
disorders.
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J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Aberrant Signal Processing: In neuropathic pain, there is a
disruption in the normal processing of pain signals. Nerve
fibers may become hyperexcitable, and the transmission of
signals can become distorted, leading to spontaneous and
exaggerated pain sensations even in the absence of an
actual noxious stimulus.
o Central Sensitization: Neuropathic pain can also involve
central sensitization, where the central nervous system,
including the spinal cord and brain, becomes hypersensitive
to pain signals. This heightened sensitivity can amplify the
perception of pain and contribute to the chronic nature of
neuropathic pain.
o Altered Modulation: The modulation of pain signals is
disrupted in neuropathic pain. Inhibitory pathways that
normally dampen pain signals may be impaired, while
excitatory pathways may be enhanced. This imbalance
contributes to the persistent and often intense nature of
neuropathic pain.
o Neuroplastic Changes: Chronic neuropathic pain can lead
to structural and functional changes in the nervous system,
a phenomenon known as neuroplasticity. These changes
can perpetuate the pain experience, making it more
resistant to treatment and contributing to the long-term
nature of neuropathic pain.
Common examples of conditions associated with neuropathic
pain include diabetic neuropathy, post-herpetic neuralgia
(resulting from shingles), nerve compression syndromes, and
certain types of traumatic nerve injuries. Treatment of
neuropathic pain often involves a multidisciplinary approach,
combining medications, physical therapy, and sometimes surgical
interventions to address the underlying causes and manage
symptoms.
Pain Assessment
 The highly subjective nature of pain causes challenges in
assessment and management; however, the patient’s self-report
is the undisputed standard for assessing the existence and
intensity of pain
 The following are components of a comprehensive pain
assessment:
o Location(s) of pain: Ask the patient to state or point to the
area(s) of pain on the body.
o Intensity: Ask the patient to rate the severity of the pain
using a reliable and valid pain assessment tool.
o Numeric Rating Scale (NRS): The NRS is most often
presented as a horizontal 0- to 10-point scale, with word
anchors of “no pain” at one end of the scale, “moderate
pain” in the middle of the scale, and “worst possible pain”
at the end of the scale.
o Wong–Baker FACES Pain Rating Scale: The FACES scale
consists of six cartoon faces with word descriptors, ranging
from a smiling face on the left for “no pain (or hurt)” to a
frowning, tearful face on the right for “worst pain (or
hurt).”
o Faces Pain Scale—Revised (FPS-R): The FPS-R has six faces
to make it consistent with other scales using the 0 to 10
metric. The faces range from a neutral facial expression to
one of intense pain and are numbered 0, 2, 4, 6, 8, and 10.
o Verbal descriptor scale (VDS): A VDS uses different words
or phrases to describe the intensity of pain, such as “no
pain, mild pain, moderate pain, severe pain, very severe
pain, and worst possible pain.”
o Visual Analogue Scale (VAS): The VAS is a horizontal
(sometimes vertical) 10-cm line with word anchors at the
extremes, such as “no pain” on one end and “pain as bad as
it could be” or “worst possible pain” on the other end.
(Impractical and rarely used)
o Quality: Ask the patient to describe how the pain feels.
Descriptors such as “sharp,” “shooting,” or “burning”
o Onset and duration: Ask the patient when the pain started
and whether it is constant or intermittent.
o Aggravating and relieving factors: Ask the patient what
makes the pain worse and what makes it better.
o Effect of pain on function and quality of life: The effect of
pain on the ability to perform recovery activities should be
regularly evaluated in the patient with acute pain.
o Comfort–function goal (pain intensity): For patients with
acute pain, identify short-term functional goals and
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reinforce to the patient that good pain control will more
likely lead to successful achievement of the goals.
o Other information: The patient’s culture, past pain
experiences, and pertinent medical history such as
comorbidities, laboratory tests, and diagnostic studies are
considered when establishing a treatment plan
Patients who are unable to report their pain are at higher risk for
undertreated pain than those who can report
The Hierarchy of Pain Measures is recommended as a
framework for assessing pain in patients who are nonverbal. The
key components of the hierarchy require the nurse to (1) attempt
to obtain self-report, (2) consider underlying pathology or
conditions and procedures that might be painful (e.g., surgery),
(3) observe behaviors, (4) evaluate physiologic indicators, and (5)
conduct an analgesic trial.
o FLACC: indicated for use in young children. Scores are
assigned after assessing Facial expression, Leg movement,
Activity, Crying, and Consolability, with each of these five
categories assigned scores from 0 to 2, yielding a total
composite score of 0 to 10.
o PAINAD (Pain Assessment IN Advanced Dementia):
indicated for use in adults with advanced dementia who
are not able to verbalize their needs.
o CPOT (Critical Care Pain Observation Tool): indicated for
use in patients in critical-care units who cannot self-report
pain, whether or not they may be intubated
Following initiation of the pain management plan, pain is
reassessed and documented on a regular basis to evaluate the
effectiveness of treatment. At a minimum, pain should be
reassessed with each new report of pain and before and after the
administration of analgesic agents
The frequency of reassessment depends on the stability of the
patient and the timing of peak effect of the medication
administered, which is generally between 15 and 30 minutes
following parenteral administration and following oral
administration
Pain Management
 Optimal pain relief is the responsibility of every member of the
health care team and begins with titration of the analgesic agent,
followed by continued prompt assessment, analgesic agent
administration, and nonpharmacologic interventions during the
course of care to safely achieve pain intensities that allow
patients to meet their functional goals with relative ease.
Pharmacologic Management of Pain: Multimodal
Analgesia
 A multimodal regimen intentionally and simultaneously
combines medications with different underlying mechanisms,
along with nonpharmacologic interventions, which allows for
lower doses of each of the medications in the treatment plan,
reducing the potential for adverse effects
 Routes of Administration
o Oral is the preferred route of analgesic administration and
should be used whenever feasible. Generally best
tolerated, easiest to administer, and most cost-effective.
o When the oral route is not possible, such as when patients
cannot swallow, are NPO (nothing by mouth), or
nauseated, other routes of administration are used.
o Patients with cancer pain who are unable to swallow may
take analgesic agents by the transdermal, rectal, or
subcutaneous route of administration
o In the immediate postoperative period, the IV route is most
often the first-line route of administration for analgesic
delivery, and patients are transitioned to the oral route as
tolerated
o The rectal route of analgesic administration is an
alternative route when oral or IV analgesic agents are not
an option (e.g., for palliative purposes during end-of-life
care). Diarrhea, perianal abscess or fistula, and
abdominoperineal resection are also relative
contraindications.
o The topical route of administration is used for both acute
and chronic pain.
o A more invasive method used to manage pain is
accomplished using neuraxial analgesia, which involves
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West Capitol Road, Balangasan District, Pagadian City
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administering medication in the epidural or subarachnoid
space
Intrathecal catheters for acute pain management are used
most often for providing anesthesia or a single bolus dose
of an analgesic agent.
A pain management technique that involves the use of an
indwelling catheter is the continuous peripheral nerve
block (also called perineural anesthesia), whereby an initial
local anesthetic block is established and followed by the
placement of a catheter or catheters through which an
infusion of local anesthetic, usually ropivacaine or
bupivacaine, is infused continuously to the targeted site of
innervation.
Dosing Regimen
 Around-The-Clock (ATC) dosing regimens are designed to control
pain for patients who report pain being present 12 hours or more
during a 24-hour period; when pain is continuous.
 PRN dosing of analgesic agents is appropriate for intermittent
pain, such as prior to painful procedures and for BTP
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Patient-Controlled Analgesia
 Patient-controlled analgesia (PCA) is an interactive method of
pain management that allows patients to treat their pain by selfadministering doses of analgesic agents
 A PCA infusion device is programmed so that the patient can
press a button (pendant) to self-administer a dose of an analgesic
agent (PCA dose) at a set time interval (demand or lockout) as
needed.
 The primary benefit of PCA is that it recognizes that only the
patient can feel the pain and only the patient knows how much
analgesic will relieve it.
 Authorized Agent Controlled Analgesia – candidates for PCA but
unable to use the PCA equipment, the nurse or a capable family
member may be authorized to manage the patient’s pain using
PCA equipment
Analgesic Medications
Analgesic Medications
Nonopioid
Opioid
Category
Examples
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Antipasmodic
Agents
acetaminophen
and NSAIDs
Antipasmodic
Agents
morphine,
hydromorphone,
fentanyl, and
oxycodone
Co-analgesic
Agents
local
anesthetics,
some
anticonvulsants,
and some
antidepressants
postoperative pain. IV formulations of ketorolac and
ibuprofen are available for acute pain treatment.
o Adverse Effects: Acetaminophen is widely considered one
of the safest, best tolerated, and most cost effective of the
analgesic agents; A principle of nonopioid analgesic use is
to administer the lowest dose for the shortest time
necessary (NSAID)
 Acetaminophen
 Hepatotoxicity (liver damage) as a result of
overdose.
 Acetaminophen interactions that warrant
caution: Alcohol (serious liver damage), and
Warfarin (toxicity w/ bleeding)
 NSAIDS
 gastric toxicity and ulceration (most common)
 carry a risk of CV adverse effects
 can negatively impact renal function
 Most nonselective NSAIDs increase bleeding
time
Opioid Analgesic Agents
o Divided into two major groups: (1) mu agonist opioids
comprise the larger of the two groups and include
morphine, hydromorphone, hydrocodone, fentanyl,
oxycodone, and methadone, among others. (2) agonist–
antagonist opioids include buprenorphine, nalbuphine, and
butorphanol
o There are three major classes of opioid receptor sites
involved in analgesia: the mu, delta, and kappa
o The opioid analgesic agents that are designated as first line
(e.g., morphine, hydromorphone, fentanyl, and oxycodone)
belong to the mu opioid agonist
o They bind as agonists, producing analgesia, at the kappa
opioid receptor sites, and as weak antagonists at the mu
opioid receptor sites.
o Antagonists (e.g., naloxone, naltrexone, naloxegol) are
medications that also bind to opioid receptors but produce
no analgesia; reverse adverse effects, such as respiratory
depression
o Administration: The goal of titration is to use the smallest
dose that provides satisfactory pain relief with the fewest
adverse effects
 Patients with cancer pain most often are titrated
upward over time for progressive pain
 Patients with acute pain, particularly postoperative
pain, are eventually titrated downward and
discontinued as pain resolves
o Equianalgesia
Nonopioid Analgesic Agents
o Indications: mild to some moderate nociceptive pain (e.g.,
from surgery, trauma, or osteoarthritis); added to opioids,
local anesthetics, and/or anticonvulsants as part of a
multimodal analgesic regimen for more severe nociceptive
pain; surgical patients should routinely be given
acetaminophen and an NSAID in scheduled doses
throughout the postoperative course
o Administration: Nonopioids are often combined in a single
tablet with opioids, such as oxycodone or hydrocodone;
 Acetaminophen is versatile in that it can be given by
multiple routes of administration, including oral (has
a long history of safety in recommended doses in all
age groups), rectal, and IV (approved for the
treatment of pain and fever and is given by a 15minute infusion in single or repeated dose);
 A benefit of the NSAID group is the availability of a
wide variety of agents for administration via
noninvasive routes. Ibuprofen, naproxen, and
celecoxib are the most widely used oral NSAIDs; If
rectal formulations are unavailable, an intact oral
tablet or a crushed tablet in a gelatin capsule may be
inserted into the rectum. The rectal route may
require higher doses than the oral route to achieve
similar analgesic effects; Diclofenac can be prescribed
in patch and gel form for topical administration, and
an intranasal patient-controlled formulation of
ketorolac has been approved for the treatment of
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J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Substance Use Disorder, Physical Dependence, and Tolerance
o Physical Dependence – a normal response that occurs with
repeated administration of the opioid; It is manifested by
the occurrence of withdrawal symptoms when c the opioid
is suddenly stopped or rapidly reduced, or an antagonist
such as naloxone is given; Withdrawal symptoms may be
suppressed by the natural, gradual reduction of the opioid
as pain decreases or by gradual, systematic reduction,
referred to as tapering
o Tolerance – also a normal physiologic response that can
occur with regular administration of an opioid and consists
of a decrease in one or more effects of the opioid
o Substance Use Disorder (SUD) – historically known as
addiction or addictive disease, and defined as a chronic,
relapsing, treatable neurologic disease; the impaired use of
a substance even while experiencing major problems,
characterized by impaired control over use, compulsive
use, continued use despite harm, and craving for the
substance
o Withdrawal – occurs when a medication or substance to
which the body has become dependent is abruptly reduced
or discontinued; Withdrawal is exhibited by a cascade of
unpleasant symptoms including anxiety, nausea, vomiting,
rhinitis, sneezing, chills, hot flashes, abdominal cramping,
tremors, diaphoresis, hyperreflexia, diarrhea, piloerection,
and/or insomnia
o Pseudoaddiction – a mistaken diagnosis of substance use
disorder that occurs when a patient’s pain is not well
controlled; the patient may begin to manifest symptoms
suggestive of SUD
Select Opioid Analgesic Agents
o Morphine
 The standard against which all other opioid
medications are compared
 A hydrophilic medication (readily absorbed in
aqueous solution), which accounts for its slow onset
and long duration of action
 It has two principal, clinically significant metabolites:
morphine-3-glucuronide (M3G) and morphine-6glucuronide (M6G).
o Fentanyl
 A lipophilic (readily absorbed in fatty tissues) opioid
and as such has a fast onset and short duration of
action
 Most commonly used IV opioid when rapid analgesia
is desired; no clinically relevant metabolites;
produces minimal hemodynamic adverse effects
o Hydromorphone
 Less hydrophilic than morphine but less lipophilic
than fentanyl, which contributes to an onset and
duration of action that is intermediate between
morphine and fentanyl
 This medication is often used as an alternative to
morphine, especially for acute pain because the two
medications produce similar analgesia and have
comparable adverse effect profiles.
o Oxycodone
 Available in the United States for administration by
the oral route only and is used to treat all types of
pain. Single-entity short-acting and modified-release
oxycodone formulations are used most often for
moderate to severe cancer pain and in some patients
with moderate to severe noncancer pain
o Oxymorphone
 Has been available for many years in parenteral
formulation and more recently in short-acting and
modified-release oral tablets for the treatment of
moderate to severe chronic pain
 It must be taken on an empty stomach (1 hour
before or 2 hours after a meal), and coingestion of
alcohol at the time of dosing must be avoided
because food and alcohol can increase the serum
concentration of the medication up to 300%
o Hydrocodone
 Commercially available only in combination with
nonopioids (e.g., with acetaminophen or ibuprofen),
which limits its use to the treatment of mild to some
moderate pain
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Methadone
 A unique synthetic opioid analgesic medication that
may have advantages over other opioids in carefully
selected patients
 No active metabolites, methadone has a very long
and highly variable half-life
Dual-Mechanism Analgesic Agents
o The dual-mechanism analgesic agents tramadol and
tapentadol bind weakly to the mu opioid receptor site and
block the reuptake (resorption) of the inhibitory
neurotransmitters serotonin and norepinephrine at central
synapses in the spinal cord and brain stem of the
modulatory descending pain pathway
o Tramadol
 Used for both acute and chronic pain and is available
in oral short-acting and modified-release
formulations, including a short-acting tablet in
combination with acetaminophen
o Tapentadol
 Available in short-acting and modified-release oral
formulations. This medication has been shown to
produce dose-dependent analgesia comparable to
oxycodone
o Opioids to Avoid
 Codeine
 Meperidine
o Adverse Effects of Opioid Analgesic Agents
 Constipation, nausea, vomiting, pruritus,
hypotension, and sedation (most common)
 Respiratory depression, while less common, is the
most serious and feared of the opioid adverse effects
 Postoperative ileus; opioid-induced androgen
deficiency and sleep disordered breathing;
 Prophylactic treatment (e.g., dexamethasone and a
serotonin receptor antagonist, such as ondansetron,
at the end of surgery)
 Excessive sedation can progress to clinically
significant respiratory depression
 Opioid-induced respiratory depression is dose related
and preceded by increasing sedation. Prevention of
clinically significant opioid-induced respiratory
depression begins with the administration of the
lowest effective opioid dose, careful titration, close
monitoring of sedation and respiratory function and
status (i.e., rate, depth, regularity, excursion)
throughout therapy, and prompt dose reduction
when advancing sedation is detected
Co-Analgesic Medications
o Local Anesthetics
 Local anesthetics have a long history of safe and
effective use for all types of pain management.
 sodium channel blockers
 The Lidocaine patch 5% is placed directly over or
adjacent to the painful area for absorption into the
tissues directly below (12 hours on, 12 hours off
regimen).
 Bupivacaine, which can be instilled in a surgical
wound, have longer duration of action
 CNS signs of systemic toxicity include ringing in the
ears, metallic taste, irritability, and seizures. Signs of
cardiotoxicity include circumoral tingling and
numbness, bradycardia, cardiac arrhythmias, and CV
collapse
o Membrane Stabilizer Anticonvulsant Medications
 The anticonvulsant calcium channel blockers
Gabapentin and Pregabalin are first-line analgesic
agents for neuropathic pain
 Initial doses of Gabapentin may not provide
analgesia; titration to effective dosing may take up to
2 months.
 Pregabalin has a more rapid onset of action with
expected maximum effect typically reached in 2
weeks.
 initiated with low doses and titrated according to
patient response
 Primary adverse effects of anticonvulsants are
sedation and dizziness
o Antidepressant Medications
Stepanie Bryn O. Agustero
BSN 3A
12 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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2 major groups: the tricyclic antidepressants (TCAs)
and the serotonin and norepinephrine reuptake
inhibitors (SNRIs).
 The TCAs desipramine and nortriptyline and the SNRIs
duloxetine and venlafaxine as first-line options for
neuropathic pain treatment
 Their delayed onset of action makes them
inappropriate for acute pain treatment
 Initiated with low doses and titrated according to
patient response
 Primary adverse effects of TCAs are dry mouth,
sedation, dizziness, mental clouding, weight gain, and
constipation. Orthostatic hypotension is a potentially
serious TCA adverse effect. The most serious adverse
effect is cardiotoxicity, and patients with significant
heart disease are at high risk.
 SNRIs are thought to have a more favorable adverse
effect profile and to be better tolerated than the
TCAs. Due to the side effects, including delirium and
confusion, amitriptyline is not indicated for use in
older adults
 The most common SNRI adverse effects are nausea,
headache, sedation, insomnia, weight gain, impaired
memory, sweating, and tremors
o Ketamine
 an NMDA antagonist, it blocks the binding of
glutamate at the NMDA receptors and thus prevents
the transmission of pain to the brain via the
ascending pathway
 At high doses, this medication can produce
psychomimetic effects (e.g., hallucinations, dreamlike
feelings)
 does not produce respiratory depression
 given most often by the IV route but can also be given
by the oral, rectal, intranasal, and subcutaneous
routes
 used as a third-line analgesic agent for refractory
acute pain
Use of Placebos
o A placebo is “any sham medication or procedure designed
to be void of any known therapeutic value”
o When a person responds to a placebo in accordance with
its intent, it is called a positive placebo response
Nonpharmacologic Methods of Pain Management
Nonpharmacologic therapies are usually effective alone for mild

to some moderate-intensity pain.
 They should not be a replacement or alternative but complement
pharmacologic therapies as part of a multimodal approach for
more severe pain.
 The effectiveness of nonpharmacologic methods can be
unpredictable, and although not all will relieve pain, they offer
many benefits to patients with pain.
 Many patients find that the use of nonpharmacologic methods
helps them cope better with their pain and feel greater control
over the pain experience
Lecture Notes
Pain is the 5th vital sign.

 Acute pain is the most severe.
 Radiating pain is the pain that comes from an internal organ that
radiates to another area.
 The primary nursing responsibility for pts experiencing acute pain
is assessing the anxiety level and provide analgesics or opioids
(CNS depressants).
 The primary nursing responsibility for pts experiencing chronic
pain is addressing the psychosocial aspect and evaluating the
functioning of their ADLs.
 For cancer-related pain, nursing responsibilities focus on the risk
for infection, buccal cavity sores and cuts, and leukocytopenia.
Pain scale: 1-3 is mild; 4-7 is moderate; 8- 10 is severe.
 For mild pain, administer non-narcotics and modify
environmental aspects.
 For moderate pain, provide weak and/or non-narcotics (opioids).
 For severe pain, use strong narcotics (opioids).
 Factors affecting pain response:
o Past experiences
o Anxiety and depression
o Culture
o Gerontological considerations (as one grew older, senses
decrease)
o Gender (females have higher pain tolerance)
o Genetics
o Placebo effect
 Characteristics of pain level:
o Intensity
o Location
o Quality
The
“PQRSTU,” “OLDCARTES,” or “COLDSPA” mnemonics are

helpful in remembering a standardized set of questions used to
gather additional data about a patient’s pain
o PQRSTU
 Provocation/Palliation – What makes your pain
worse? What makes your pain feel better?
 Quality – What does the pain feel like? Note: You can
provide suggestions for pain characteristics such as
“aching,” “stabbing,” or “burning.”
 Region – Where exactly do you feel the pain? Does it
move around or radiate elsewhere? Note: Instruct the
patient to point to the pain location.
 Severity – How would you rate your pain on a scale of
0 to 10, with “0” being no pain and “10” being the
worst pain you’ve ever experienced?
 Timing/Treatment – When did the pain start? What
were you doing when the pain started? Is the pain
constant or does it come and go? If the pain is
intermittent, when does it occur? How long does the
pain last? Have you taken anything to help relieve the
pain?
 Understanding – What do you think is causing the
pain?
o OLDCARTES
 Onset: When did the pain start? How long does it
last?
 Location: Where is the pain?
 Duration: How long has the pain has been going on?
How long does an episode last?
 Characteristics: What does the pain feel like? Can the
pain be described in terms such as stabbing, gnawing,
sharp, dull, aching, piercing, or crushing?
 Aggravating Factors: What brings the pain? What
makes the pain worse? Are there triggers such as
movement, body position, activity, eating, or the
environment?
 Radiating: Does the pain travel to another area or the
body, or does it stay in one place?
 Treatment: What has been done to make the pain
better and has it been helpful? Examples include
medication, position change, rest, and application of
hot or cold.
 Effect: What is the effect of the pain on participating
in your daily life activities?
 Severity: Rate your pain from 0 to 10
o COLDSPA
Stepanie Bryn O. Agustero
BSN 3A
13 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Chronic Obstructive Pulmonary Disease
 A preventable and treatable slowly progressive respiratory
disease of airflow obstruction involving the airways, pulmonary
parenchyma, or both
 The airflow limitation or obstruction in COPD is not fully
reversible.
 COPD may include diseases that cause airflow obstruction (e.g.,
emphysema, chronic bronchitis) or any combination of these
disorders.
 While COPD and lower respiratory diseases are the fourth leading
cause of death for people of all ages in the United States, they
are the third leading cause of death for people ages 65 and over
C: Character
O: Onset
L: Location
D: Duration
S: Severity
P: Pattern
A: Associated Factors
4: Management of Patients with
Chronic Pulmonary Disease
Glossary
 Air Trapping – incomplete emptying of alveoli during expiration
due to loss of lung tissue elasticity (emphysema), bronchospasm
(asthma), or airway obstruction
 Alpha1 -Antitrypsin Deficiency – genetic disorder resulting from
deficiency of alpha1 -antitrypsin, a protective agent for the lung;
increases patient’s risk for developing panacinar emphysema
even in the absence of smoking
 Asthma – a heterogeneous disease, usually characterized by
chronic airway inflammation; defined by history of symptoms
such as wheeze, shortness of breath, chest tightness, and cough
that vary over time and in intensity
 Bronchiectasis – chronic, irreversible dilation of the bronchi and
bronchioles that results from the destruction of muscles and
elastic connective tissue; dilated airways become saccular and
are a medium for chronic infection
 Chest Percussion – manually cupping hands over the chest wall
and using vibration to mobilize secretions by mechanically
dislodging viscous or adherent secretions in the lungs
 Chest Physiotherapy (CPT) – therapy used to remove bronchial
secretions, improve ventilation, and increase the efficiency of the
respiratory muscles; types include postural drainage, chest
percussion, and vibration, and breathing retraining
 Chronic Bronchitis – a disease of the airways defined as the
presence of cough and sputum production for at least a
combined total of 3 months in each of 2 consecutive years
 Chronic Obstructive Pulmonary Disease (COPD) – disease state
characterized by airflow limitation that is not fully reversible;
sometimes referred to as chronic airway obstruction or chronic
obstructive lung disease
 Desaturate – a precipitous drop in the saturation of hemoglobin
with oxygen
 Dry-Powder Inhaler (DPI) – a compact, portable inspiratory flow–
driven inhaler that delivers dry-powder medications into the
patient’s lungs
 Emphysema – a disease of the airways characterized by
destruction of the walls of overdistended alveoli
 Flutter Valve – portable handheld mucous clearance device;
consisting of a tube with an oscillating steel ball inside; upon
expiration, high-frequency oscillations facilitate mucous
expectoration
 Fraction of Inspired Oxygen (FiO2 ) – concentration of oxygen
delivered (e.g., 1.0 equals to 100% oxygen)
 Hypoxemia – decrease in arterial oxygen tension in the blood
 Hypoxia – decrease in oxygen supply to the tissues and cells
 Polycythemia – increase in the red blood cell concentration in
the blood; in COPD, the body attempts to improve oxygencarrying capacity by producing increasing amounts of red blood
cells
 Postural Drainage – positioning the patient to allow drainage
from all lobes of the lungs and airways
 Pressurized Metered-Dose Inhaler (pMDI) – a compact, portable
patient-activated pressurized medication canister that provides
aerosolized medication that the patient inhales into the lungs
 Small-Volume Nebulizer (SVN) – a handheld generator-driven
medication delivery system that provides aerosolized liquid
medication that the patient inhales into the lungs
 Spirometry – pulmonary function tests that measure specific
lung volumes (e.g., FEV1 , FVC) and rates (e.g., FEF25%–75%);
may be measured before and after bronchodilator administration
 Vibration – a type of massage given by quickly tapping the chest
with the fingertips or alternating the fingers in a rhythmic
manner, or by using a mechanical device to assist in mobilizing
lung secretions
Pathophysiology
 In COPD, the airflow limitation is both progressive and
associated with the lungs’ abnormal inflammatory response to
noxious particles or gases.
1. The inflammatory response occurs throughout the proximal
and peripheral airways, lung parenchyma, and pulmonary
vasculature
2. Because of the chronic inflammation and the body’s
attempts to repair it, changes and narrowing occur in the
airways.
a. In the proximal airways (trachea and bronchi
greater than 2 mm in diameter), changes include
increased numbers of goblet cells and enlarged
submucosal glands, both of which lead to
hypersecretion of mucus.
b. In the peripheral airways (bronchioles less than 2
mm diameter), inflammation causes thickening of
the airway wall, peribronchial fibrosis, exudate in
the airway, and overall airway narrowing
(obstructive bronchiolitis).
3. Over time, this ongoing injury-and-repair process causes
scar tissue formation and narrowing of the airway lumen
4. Inflammatory and structural changes also occur in the lung
parenchyma (respiratory bronchioles and alveoli).
5. Alveolar wall destruction leads to loss of alveolar
attachments and a decrease in elastic recoil.
6. Finally, the chronic inflammatory process affects the
pulmonary vasculature and causes thickening of the lining of
the vessel and hypertrophy of smooth muscle, which may
lead to pulmonary hypertension
 Chronic Bronchitis – defined as the presence of cough and
sputum production for at least 3 months in each of 2 consecutive
years.
1. In many cases, smoke or other environmental pollutants
irritate the airways, resulting in inflammation and
hypersecretion of mucus. Constant irritation causes the
mucus-secreting glands and goblet cells to increase in
number, leading to increased mucus production.
2. Mucus plugging of the airway reduces ciliary function.
Bronchial walls also become thickened, further narrowing
the bronchial lumen (Fig. 20-1).
3. Alveoli adjacent to the bronchioles may become damaged
and fibrosed, resulting in altered function of the alveolar
macrophages. This is significant because the macrophages
play an important role in destroying foreign particles,
including bacteria.
4. As a result, the patient becomes more susceptible to
respiratory infection. A wide range of viral, bacterial, and
mycoplasma infections can produce acute episodes of
bronchitis.
5. Exacerbations of chronic bronchitis are most likely to occur
during the winter when viral and bacterial infections are
more prevalent
Stepanie Bryn O. Agustero
BSN 3A
14 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City

Emphysema – a pathologic term that describes an abnormal
distention of the airspaces beyond the terminal bronchioles and
destruction of the walls of the alveoli
1. In emphysema, impaired oxygen and carbon dioxide
exchange results from destruction of the walls of
overdistended alveoli. In addition, a chronic inflammatory
response may induce disruption of the parenchymal
tissues. This end-stage process progresses slowly for many
years.
2. As the walls of the alveoli are destroyed (a process
accelerated by recurrent infections), the alveolar surface
area in direct contact with the pulmonary capillaries
continually decreases.
3. This causes an increase in dead space (lung area where no
gas exchange can occur) and impaired oxygen diffusion,
which leads to hypoxemia.
4. In the later stages of disease, carbon dioxide elimination is
impaired, resulting in hypercapnia (increased carbon
dioxide tension in arterial blood) leading to respiratory
acidosis.
5. As the alveolar walls continue to break down, the
pulmonary capillary bed is reduced in size. Consequently,
resistance to pulmonary blood flow is increased, forcing the
right ventricle to maintain a higher blood pressure in the
pulmonary artery. Hypoxemia may further increase
pulmonary artery pressures (pulmonary hypertension).
6. Cor pulmonale, one of the complications of emphysema, is
right-sided heart failure brought on by long-term high
blood pressure in the pulmonary arteries. This high
pressure in the pulmonary arteries and right ventricle lead
to back up of blood in the venous system, resulting in
dependent edema, distended neck veins, or pain in the
region of the liver.
o
2 Types:
 In the panlobular (panacinar)
 there is destruction of the respiratory
bronchiole, alveolar duct, and alveolus.
 All airspaces within the lobule are essentially
enlarged, but there is little inflammatory
disease.
 A hyperinflated (hyperexpanded) chest,
marked dyspnea on exertion, and weight loss
typically occur.
 To move air into and out of the lungs, negative
pressure is required during inspiration, and an
adequate level of positive pressure must be
attained and maintained during expiration.
 Instead of being an involuntary passive act,
expiration becomes active and requires
muscular effort.
 In the centrilobular (centroacinar)
 Pathologic changes take place mainly in the
center of the secondary lobule, preserving the
peripheral portions of the acinus (i.e., the
terminal airway unit where gas exchange
occurs).
 Frequently, there is a derangement of
ventilation–perfusion ratios, producing chronic
hypoxemia, hypercapnia, polycythemia (i.e., an

increase in red blood cells), and episodes of
right-sided heart failure.
This leads to central cyanosis and respiratory
failure. The patient also develops peripheral
edema.
Risk Factors
 The most important environmental risk factor for COPD
worldwide is cigarette smoking. Smoking depresses the activity
of scavenger cells and affects the respiratory tract’s ciliary
cleansing mechanism, which keeps breathing passages free of
inhaled irritants, bacteria, and other foreign matter.
 Exposure to tobacco smoke accounts for an estimated 80–90% of
cases of chronic obstructive pulmonary disease
 Second-hand smoke Increased age
 Occupational exposure—dust, chemicals
 Indoor and outdoor air pollution
 Genetic abnormalities, including a deficiency of alpha1 antitrypsin, an enzyme inhibitor that normally counteracts the
destruction of lung tissue by certain other enzymes
Clinical Manifestations
 COPD is generally a progressive disease characterized by three
primary symptoms: chronic cough, sputum production, and
dyspnea.
 Weight loss is common, because dyspnea interferes with eating
and the work of breathing is energy depleting
 In patients with COPD who have a primary emphysematous
component, chronic hyperinflation leads to the “barrel chest”
thorax configuration.
 This configuration results from a more fixed position of the ribs in
the inspiratory position (due to hyperinflation) and from loss of
lung elasticity. Retraction of the supraclavicular fossae occurs on
inspiration, causing the shoulders to heave upward.
 In advanced emphysema, the abdominal muscles may also
contract on inspiration.
 There are systemic or extrapulmonary manifestations of COPD.
These include musculoskeletal wasting, metabolic disturbances,
and depression (a frequent comorbidity that accompanies
chronic debilitating illnesses).
 Research has indicated that depression, metabolic syndrome,
and diabetes are frequent comorbidities of COPD
Assessment and Diagnostic Findings
Spirometry is used to evaluate airflow obstruction, which is

determined by the ratio of FEV1 to forced vital capacity (FVC).
 With obstruction, the patient either has difficulty exhaling or
cannot forcibly exhale air from the lungs, reducing the FEV1.
 Spirometry is also used to determine reversibility of obstruction
after the use of bronchodilators
 Arterial blood gas measurements may also be obtained to assess
baseline oxygenation and gas exchange and are especially
important in advanced COPD.
 A chest x-ray may be obtained to exclude alternative diagnoses.
 A computed tomography (CT) chest scan is not routinely
obtained in the diagnosis of COPD, but a high-resolution CT scan
may help in the differential diagnosis.
 Screening for alpha1 -antitrypsin deficiency is suggested for all
adults who are symptomatic, especially for patients younger than
45 years
 Factors that determine the clinical course and survival of patients
with COPD include history of cigarette smoking, exposure to
secondhand smoke, age, rate of decline of FEV1 , hypoxemia,
pulmonary artery pressure, resting heart rate, weight loss,
reversibility of airflow obstruction, and comorbidities.
 In diagnosing COPD, several differential diagnoses must be ruled
out. The primary differential diagnosis is asthma.
 Key factors in determining the diagnosis are the patient’s history,
severity of symptoms, and responsiveness to bronchodilators.
Complications
 Respiratory insufficiency and failure are major life-threatening
complications of COPD. Respiratory insufficiency and failure may
be chronic (with severe COPD) or acute (with severe
bronchospasm or pneumonia in a patient with severe COPD)
Other complications of COPD include pneumonia, chronic
Stepanie Bryn O. Agustero
BSN 3A
15 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City

atelectasis, pneumothorax, and pulmonary arterial hypertension
(cor pulmonale).
Medical Management
 Therapeutic strategies for the patient with COPD include
promoting smoking cessation as appropriate, providing
supplemental oxygen therapy as indicated, prescribing
medications, and managing exacerbations
 Some patients may benefit from surgical interventions; whereas
others with advanced COPD may benefit from palliative care
 Risk Reduction
o The major risk factor associated with COPD is
environmental exposure and it is modifiable. The most
important environmental exposure is smoking
o Smoking cessation is the single most cost-effective
intervention to reduce the risk of developing COPD and to
stop its progression
o Nicotine replacement—a first-line pharmacotherapy that
reliably increases long-term smoking abstinence rates—
comes in a variety of forms (gum, inhaler, nasal spray,
transdermal patch, sublingual tablet, or lozenge).
Bupropion SR and nortriptyline, both antidepressants, may
also increase long-term quit rates. Other pharmacologic
agents include the antihypertensive agent clonidine;
however, its side effects limit its use. Varenicline, a
nicotinic acetylcholine receptor partial agonist, may assist
in smoking cessation
 Oxygen Therapy – is the administration of oxygen at a
concentration greater than that found in the environmental
atmosphere.
o Oxygen transport to tissues depends on factors such as
cardiac output, arterial oxygen content, concentration of
hemoglobin, and metabolic requirements
o Indications
 A change in the patient’s respiratory rate or pattern
may be one of the earliest indicators of the need for
oxygen therapy. These changes may result from
hypoxemia or hypoxia.
o Complications
 Oxygen is a medication, and except in emergency
situations it is given only when prescribed by a health
care provider.
 In general, a patient with any type of respiratory
disorder is given oxygen therapy only to increase the
partial pressure of arterial oxygen (PaO2 ) back to the
patient’s normal baseline, which may vary from 60 to
95 mm Hg
 Increased amounts of oxygen may produce toxic
effects on the lungs and central nervous system or
may depress ventilation, which is a particularly lethal
adverse effect in patients with COPD
 Oxygen toxicity may occur when too high
concentration of oxygen is given for an extended
period (generally longer than 24 hours)
 Absorption Atelectasis – Oxygen replaces Nitrogen,
the alveoli collapse, causing atelectasis
 Because oxygen supports combustion, there is always
a danger of fire when it is used. It is important to
post “No Smoking” signs when oxygen is in use.
 Oxygen therapy equipment is also a potential source
of bacterial contamination
o Oxygen Administration
 A nasal cannula is used when the patient requires a
low to medium concentration of oxygen for which
precise accuracy is not essential
 A reservoir cannula stores oxygen in a thin
membrane during exhalation. When the patient’s
inspiration exceeds the flow rate into the cannula,
the patient receives additional gas from the reservoir
membrane
 The nasal (oropharyngeal) catheter delivers low to
moderate concentrations of oxygen and is rarely
used. This method of delivering low-flow oxygen is
usually reserved for use in special procedures, such as
those that examine the patient’s airways and lungs
(bronchoscopy).
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Simple masks, low-flow design, are used to
administer low to moderate concentrations of
oxygen.
 Partial rebreathing masks have a reservoir bag that
must remain inflated during both inspiration and
expiration.
 Nonrebreathing masks are similar in design to partial
rebreathing masks except that they have additional
valves.
 Venturi mask is the most reliable and accurate
method for delivering precise concentrations of
oxygen through noninvasive means.
 Transtracheal oxygen catheter requires minor
surgery to insert a catheter through a small incision
directly into the trachea. It is indicated for patients
with chronic oxygen therapy needs.
 Other oxygen devices include aerosol masks,
tracheostomy collars, T-pieces, and face tents, all of
which are used with aerosol devices (nebulizers) that
can be adjusted for oxygen concentrations from 28%
to 100% (0.28 to 1.00).
Quality and Safety Nursing Alert
o Oxygen therapy is variable in patients with COPD; its aim in
COPD is to achieve an acceptable oxygen level without a fall
in the pH (increasing hypercapnia)
Pharmacologic Therapy
o Medication regimens used to manage COPD are based on
disease severity.
 For grade I (mild) COPD, a short-acting bronchodilator
may be prescribed.
 For grade II or III (moderate or severe) COPD, a shortacting bronchodilator and regular treatment with one
or more long-acting bronchodilators may be used.
 For grade III or IV (severe or very severe) COPD,
medication therapy includes regular treatment with
long-acting bronchodilators and/or inhaled
corticosteroids (ICSs) for repeated exacerbations.
o Other pharmacologic treatments that may be used in COPD
include alpha1 - antitrypsin augmentation therapy,
antibiotic agents, mucolytic agents, antitussive agents,
vasodilators, and opioids.
o Vaccines are also effective in that they prevent
exacerbations by thwarting respiratory infections. For
instance, influenza vaccines can reduce serious illness and
death in patients with COPD; Pneumococcal vaccination
also reduces the incidence of community-acquired
pneumonia in the general older adult population
Management of Exacerbations
o An exacerbation of COPD is defined as an event in the
natural course of the disease characterized by acute
changes (worsening) in the patient’s respiratory symptoms
beyond the normal day-to-day variations.
o Roflumilast may be used as a treatment to reduce the risk
of exacerbations in patients with severe COPD associated
with chronic bronchitis and a history of exacerbations
o When the patient with an exacerbation of COPD arrives in
an ED, the first line of treatment is supplemental oxygen
therapy and rapid assessment to determine if the
exacerbation is life-threatening
o A short-acting inhaled bronchodilator may be used to
assess response to treatment. Oral or intravenous (IV)
corticosteroids, in addition to bronchodilators, are
recommended in the hospital management of a COPD
exacerbation.
o The administration of antibiotics remains controversial, but
in general, they should be administered when the patient
has three cardinal symptoms of an exacerbation: increase
in dyspnea, increase in sputum volume, and sputum
purulence
Surgical Management
o A bullectomy is a surgical option for select patients with
bullous emphysema
o Lung Volume Reduction Surgery is a treatment option for
patients with advanced or end-stage COPD (grade IV) with
a primary emphysematous component are limited; it is a
palliative surgical option.
o Lung transplantation is a viable option for definitive
surgical treatment of severe COPD in select patients. It has
Stepanie Bryn O. Agustero
BSN 3A
16 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City

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been shown to improve quality of life and functional
capacity in some patients with COPD
Pulmonary Rehabilitation
o Pulmonary rehabilitation, one of the most cost-effective
treatment strategies, is a holistic intervention aimed at
improving physical and psychological health of patients
with COPD
o The primary goals of rehabilitation are to reduce
symptoms, improve quality of life, and increase physical
and emotional participation in everyday activities
Nutritional Therapy
o Nutritional assessment and counseling are important for
patients with COPD. Nutritional status is reflected in
severity of symptoms, degree of disability, and prognosis.
Significant weight loss is often a major problem; however,
excessive weight can also be problematic, although it
occurs less often. Most patients with COPD have difficulty
gaining and maintaining weight.
Palliative Care
o Palliative care is integral for the patient with advanced
COPD. Unfortunately, palliative care is often not considered
until the disease is far advanced. The overall goals of
palliative care are to manage symptoms and improve the
quality of life for patients and families with advanced
disease
Nursing Management
 Assessing the Patient
o Assessment involves obtaining information about current
symptoms as well as previous disease manifestations
Achieving
Airway Clearance

o Bronchospasm reduces the caliber of the small bronchi and
may cause dyspnea, static secretions, and infection.
Increased mucus production, along with decreased
mucociliary action, contributes to further reduction in the
caliber of the bronchi and results in decreased airflow and
decreased gas exchange. This is further aggravated by the
loss of lung elasticity that occurs with COPD. These changes
in the airway require that the nurse monitor the patient
for dyspnea and hypoxemia
o Diminishing the quantity and viscosity of sputum can clear
the airway and improve pulmonary ventilation and gas
exchange. All pulmonary irritants should be eliminated or
reduced, particularly cigarette smoke, which is the most
persistent source of pulmonary irritation.
o Postural Drainage (Segmented Bronchial Drainage)
 Postural drainage allows the force of gravity to assist
in the removal of bronchial secretions. The secretions
drain from the affected bronchioles into the bronchi
and trachea and are removed by coughing or
suctioning.
o Chest Percussion and Vibration
 Thick secretions that are difficult to cough up may be
loosened by percussing (tapping) and vibrating the
chest or through the use of an HFCWO vest. Chest
percussion and vibration help dislodge mucus
adhering to the bronchioles and bronchi.
 Chest percussion is carried out by cupping the hands
and lightly striking the chest wall in a rhythmic
fashion over the lung segment to be drained
 Vibration is the technique of applying manual
compression and tremor to the chest wall during the
exhalation phase of respiration
Improving
Breathing
Patterns

o The breathing pattern of most people with COPD is shallow,
rapid, and inefficient; the more severe the disease, the
more inefficient the breathing pattern.
o Impaired breathing patterns and shortness of breath are
due to the modified respiratory mechanics of the chest wall
and lung resulting from air trapping (i.e., incomplete
emptying of alveoli during expiration), ineffective
diaphragmatic movement, airway obstruction, the
metabolic cost of breathing, and stress.
o Breathing retraining may help improve breathing patterns.
Training in diaphragmatic breathing reduces the
respiratory rate, increases alveolar ventilation, and
sometimes helps expel as much air as possible during
expiration.
o




Pursed-lip breathing helps slow expiration, prevent
collapse of small airways, and control the rate and depth of
respiration. It also promotes relaxation, which allows
patients to gain control of dyspnea and reduce feelings of
panic.
Promoting Self-Care
o As gas exchange, airway clearance, and the breathing
pattern improve, the patient is encouraged to assume
increasing participation in self-care activities; coordinate
diaphragmatic breathing with activities; self-regulation of
fluid intake
Improving Activity Tolerance
o People with COPD have decreased exercise tolerance
during specific periods of the day, especially in the morning
on arising, because bronchial secretions have collected in
the lungs during the night while the patient was lying down
o Physical conditioning techniques include breathing
exercises and general exercises intended to conserve
energy and increase pulmonary ventilation
Encouraging Effective Coping
Monitoring and Managing Potential Complications
o The nurse must assess for various complications of COPD,
such as life threatening respiratory insufficiency and
failure, as well as respiratory infection and chronic
atelectasis
o The nurse monitors for cognitive changes (personality and
behavioral changes, memory impairment), increasing
dyspnea, tachypnea, and tachycardia, which may indicate
increasing hypoxemia and impending respiratory failure.
o The nurse monitors pulse oximetry values to assess the
patient’s need for oxygen and administers supplemental
oxygen as prescribed.
o The nurse also instructs the patient about signs and
symptoms of respiratory infection that may worsen
hypoxemia and reports changes in the patient’s physical
and cognitive status to the primary provider.
o To prevent pneumonia, the nurse encourages the patient
with COPD to be immunized against influenza and
pneumococcal pneumonia
o The nurse must assess the patient’s actual and potential
triggers that cause bronchospasm so that avoidance or a
treatment plan can be established.
Lecture Notes
COPD

o Emphysema (pink puffers, because of increased retention
of CO2) o
o Chronic bronchitis (blue bloaters, inflammation of the
bronchi due to irritants when the immune system traps
them, releasing mucus)
 Our respiratory drive is inhaling oxygen and exhaling carbon
dioxide.
 In a hemoglobin, the heme carries the O2 while the globin carries
the CO2.
 For dry cough, provide antitussives (Robitussin). For productive
cough (with mucus), provide mucolytics (Solmux).
 Both decreased oxygen (hypoxia) and increased carbon dioxide
(respiratory acidosis) will eventually lead to death.
 Nursing management:
o Avoid the patient from irritants
o Give O2 at 1-3 LPM
o Positioning: orthopneic
 The compensation mechanism is to produce more RBCs resulting
to increased RBCs leading to polycythemia vera.
 Blood pressure will increase to pump the viscous blood
components.
 Factors of COPD:
o Smoking – alveoli recoil is diminished thus, retaining more
CO2
o Air pollutants
o Aging – reduced elasticity, alveoli are overdistended
resulting to poor gas exchange that will lead to hypoxia
 Asthma is reversible.
 Status Asthmaticus – prolonged asthma that will not react to
conventional therapy. Corticosteroids are given.
 Steroids given overly will damage the kidneys and liver resulting
to edema. Its clinical manifestation is respiratory failure
Stepanie Bryn O. Agustero
BSN 3A
17 | P a g e
N o v.
2 0 ,
2 0 2 3
Republic of the Philippines
Province of Zamboanga del Sur
J.H. CERILLES STATE COLLEGE
West Capitol Road, Balangasan District, Pagadian City
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Acknowledgements
To give credit where it’s due, I would like to acknowledge the individuals who contributed to this study material. Special thanks to
Rouylyn for making the 1st part, to Mark Lee for the lecture notes, and to Alliyah and Judelyn for the study guide references. I extend
my appreciation to each individual involved, as their collaborative effort have been instrumental in enriched the quality of the content.
HAHAHHAHAHA chariz thank you mwa!
Stepanie Bryn O. Agustero
BSN 3A
18 | P a g e
N o v.
2 0 ,
2 0 2 3