Chapter 9: Stress and Stress Management

• Stress occurs when individuals perceive that they cannot adequately cope with the demands
being made on them or with the threats to their well-being.

• Key personal characteristics—such as hardiness, sense of coherence, resilience, and attitude

—buffer the impact of stress.

• The physiologic response of the person to stress is reflected in the interrelationship of the
nervous, endocrine, and immune systems. Stress activation of these systems affects other
systems, such as the cardiovascular, respiratory, gastrointestinal, renal, and reproductive
systems.

• Stress can have effects on cognitive function, including poor concentration, memory
problems, distressing dreams, sleep disturbances, and impaired decision-making.

• Long-term stress may increase the risk of cardiovascular diseases such as atherosclerosis
and hypertension. Other conditions either precipitated or aggravated by stress include
migraine headaches, irritable bowel syndrome, and peptic ulcers.

• Coping is defined as a person’s cognitive and behavioral efforts to manage specific external
or internal stressors that seem to exceed available resources.

• Coping can be either positive or negative. Positive coping includes activities such as
exercise and use of social support. Negative coping may include substance abuse and denial.

• Coping strategies can also be divided into two broad categories: emotion-focused coping
and problem-focused coping.

• Emotion-focused coping involves managing the emotions that an individual feels when a
stressful event occurs. Problem-focused coping attempts to find solutions to resolve the
problems causing the stress.

• Relaxation strategies can be used to cope with stressful circumstances and elicit the
relaxation response.

• The relaxation response is the state of physiologic and psychologic deep rest. It is the
opposite of the stress response and is characterized by decreased sympathetic nervous
system activity, which leads to decreased heart rate and respiratory rate, decreased blood
pressure, decreased muscle tension, decreased brain activity, and increased skin temperature.

• Regular elicitation of the relaxation response can be achieved through relaxation breathing,
meditation, imagery, music, muscle relaxation, and massage.

***Chapter 10: Pain

• Pain is defined as whatever the person experiencing the pain says it is, existing whenever
the person says it does.
• Untreated pain can result in unnecessary suffering, physical and psychosocial dysfunction,
impaired recovery from acute illness and surgery, immunosuppression, and sleep
disturbances.

• Inadequate pain management may be due to (1) insufficient knowledge and skills to assess
and treat pain; (2) unwillingness of providers to believe patients’ report of pain; (3) lack of
time, expertise, and perceived importance of conducting regular pain assessments; (4)
inaccurate and inadequate information regarding addiction, tolerance, respiratory
depression, and other side effects of opioids; and (5) fear that aggressive pain management
may hasten or cause death.

• Components of the nursing role include (1) assessing pain and communicating this
information to other health care providers, (2) ensuring the initiation and coordination of
adequate pain relief measures, (3) evaluating the effectiveness of these interventions, and (4)
advocating for people with pain.

• Pain has many dimensions and components, including the following:

o The physiologic dimension of pain includes the genetic, anatomic, and physical
determinants of pain.
o The affective component of pain is the emotional response to the pain experience.
o The behavioral component of pain refers to the observable actions used to express or
control the pain.
o The cognitive component of pain refers to beliefs, attitudes, memories, and meaning
attributed to the pain.
o The sociocultural dimension of pain encompasses factors such as demographics,
support systems, social roles, and culture.

• The emotional distress of pain can cause suffering, which is defined as the state of severe
distress associated with events that threaten the intactness of the person.

• Culture also affects the experience of pain, specifically the pain expression, medication use,
and pain-related beliefs and coping.

• Pain is most commonly categorized as nociceptive or neuropathic based on underlying

pathology or as acute or chronic.

• Nociception is the physiologic process by which information about tissue damage is

communicated to the central nervous system. Nociception involves transduction,
transmission, perception, and modulation.
o Transduction is the conversion of a mechanical, thermal, or chemical stimulus into
a neuronal action potential.
 Noxious (tissue-damaging) stimuli cause the release of numerous chemicals
into the area surrounding the peripheral nociceptors. Inflammation and the
subsequent release of chemical mediators increase the likelihood of
transduction.
 The pain produced from activation of peripheral nociceptors is called
nociceptive pain.
 Pain arising from abnormal processing of stimuli by the nervous system is
called neuropathic pain.
 Decreasing the effects of chemicals released at the periphery is the basis of
 several drugs (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]).
o Transmission is the movement of pain impulses from the site of transduction to the
brain.
 Dermatomes are areas on the skin that are innervated primarily by a single
spinal cord segment.
 Referred pain must be considered when interpreting the location of pain
reported by the person with injury to or disease involving visceral organs.
o Perception occurs when pain is recognized, defined, and responded to by the
individual experiencing the pain. The brain is necessary for pain perception.
o Modulation involves the activation of descending pathways that exert inhibitory or
facilitatory effects on the transmission of pain.

• Neuropathic pain is further classified as somatic and visceral.

o Somatic pain is characterized by deep aching or throbbing that is well localized and
arises from bone, joint, muscle, skin, or connective tissue.
o Visceral pain, which may result from stimuli such as tumor involvement or
obstruction, arises from internal organs.

• Neuropathic pain is caused by damage to peripheral nerves or CNS. Common causes of

neuropathic pain include trauma, inflammation, metabolic disease, infections of the nervous
system, tumors, toxins, and neurologic disease.

• Acute pain and chronic pain are different as reflected in their cause, course, manifestations,
and treatment.
o Acute pain typically diminishes over time as healing occurs.
o Chronic pain, or persistent pain, lasts for longer periods, often defined as longer
than 3 months or past the time when an expected acute pain or acute injury should
subside.

• The goals of a nursing pain assessment are (1) to describe the patient’s multidimensional
pain experience for the purpose of identifying and implementing appropriate pain
management techniques and (2) to identify the patient’s goal for therapy and resources for
self-management.

• A comprehensive assessment of pain includes describing the onset, duration, characteristics,

pattern, location, intensity, quality, and associated symptoms such as anxiety and depression.

• Breakthrough pain is a transient, moderate to severe pain that occurs beyond the pain
treated by current analgesics.

• Pain scales are useful tools to help the patient communicate pain intensity. Scales must be
adjusted for age and cognitive development.

• Patients typically describe neuropathic pain as a burning, numbing, shooting, stabbing, or

itchy sensation.

• Nociceptive pain may be described as sharp, aching, throbbing, and cramping. Associated
symptoms such as anxiety, fatigue, and depression may exacerbate or be exacerbated by
pain.

• Strategies for pain management include prescription and nonprescription drugs and nondrug
 therapies such as hot and cold applications, complementary and alternative therapies (e.g.,
herbal products, acupuncture), and relaxation strategies (e.g., imagery).
o All strategies must be documented, both those that work and those that are
ineffective.
o Patient and family beliefs, attitudes, and expectations influence responses to pain and
pain treatment.

• Pain medications generally are divided into three categories: nonopioids, opioids, and co-
analgesic or adjuvant drugs.
o Mild pain often can be relieved using nonopioids alone.
o Moderate to severe pain usually requires an opioid.
o Neuropathic pain often requires a co-analgesic and adjuvant drug.
o Nonopioid pain medications include acetaminophen, aspirin, and nonsteroidal
antiinflammatory agents (NSAIDs).

• NSAIDs are associated with a number of side effects, including bleeding tendencies,
gastrointestinal ulcers and bleeding, and renal and CNS dysfunction.

• Opioids are the strongest analgesics available.

o Opioids produce their effects by binding to receptors in the CNS.
o Common side effects of opioids include constipation, nausea, vomiting, sedation,
respiratory depression, and pruritus.
o A bowel regimen should be instituted at the beginning of opioid therapy and should
continue for as long as the person takes opioids.
o Concerns about sedation and respiratory depression are two of the most common
fears associated with opioids.
o If severe respiratory depression occurs and stimulation of the patient (calling and
shaking patient) does not reverse the somnolence or increase the respiratory rate and
depth, naloxone (Narcan), an opioid antagonist, can be administered intravenously or
subcutaneously.

• Adjuvant analgesic therapies include antidepressants, antiseizure drugs, α 2-adrenergic

agonists, and corticosteroids.
o Tricyclic antidepressants enhance the descending inhibitory system and are effective
for a variety of pain syndromes, particularly neuropathic pain syndromes.
o Antiseizure or antiepileptic drugs (AEDs) affect both peripheral nerves and the CNS
and are effective for neuropathic pain and prophylactic treatment of migraine
headaches.
o Clonidine (Catapres) and tizanidine (Zanaflex) are the most widely used α 2-
adrenergic agonists and may be used for chronic headache and neuropathic pain.
o Corticosteroids—including dexamethasone [Decadron], prednisone, and
methylprednisolone [Medrol]—are used for management of acute and chronic cancer
pain, pain secondary to spinal cord compression, and inflammatory joint pain
syndromes.

• Appropriate analgesic scheduling focuses on prevention or control of pain rather than the
provision of analgesics only after the patient’s pain has become severe.

• Equianalgesic dose refers to a dose of one analgesic that is equivalent in pain-relieving

effects compared with another analgesic.
• Opioids and other analgesic agents can be delivered via many routes.
o Most pain medications are available in oral preparations, such as liquid and tablet
formulations. Opioids can be administered under the tongue or held in the mouth and
absorbed into systemic circulation, which would exempt them from the first-pass
effect.
o Fentanyl citrate (Actiq) is administered transmucosally.
o Intranasal administration allows delivery of a medication (e.g., butorphanol [Stadol])
to highly vascular mucosa and avoids the first-pass effect.
o Analgesics available as rectal suppositories include hydromorphone, oxymorphone,
morphine, and acetaminophen.
o Intravenous administration is the best route when immediate analgesia and rapid
titration are necessary.
o Intraspinal (epidural or intrathecal) opioid therapy involves inserting a catheter into
the subarachnoid space (intrathecal delivery) or the epidural space (epidural
delivery).
o Intraspinally administered analgesics are highly potent because they are delivered
close to the receptors in the spinal cord dorsal horn.
 Long-term epidural catheters may be placed for patients with terminal cancer
or those with certain pain syndromes that are unresponsive to other
treatments.
 Intraspinal catheters can be surgically implanted for long-term pain relief.
 A specific type of IV delivery system is patient-controlled analgesia (PCA)
or demand analgesia. It can also be connected to an epidural catheter (patient-
controlled epidural analgesia [PCEA]). With PCA, a dose of opioid is
delivered when the patient decides that a dose is needed.

• Neuroablative interventions are performed for severe pain that is unresponsive to all other
therapies.

• Neuroaugmentation involves electrical stimulation of the brain and the spinal cord.

• Massage (superficial or deep) is a common therapy for pain. A trigger point is a

circumscribed hypersensitive area within a tight band of muscle and is caused by acute or
chronic muscle strain.

• Exercise is a critical part of the treatment plan for patients with chronic pain, particularly
those experiencing musculoskeletal pain.

• Transcutaneous electrical nerve stimulation (TENS) involves the delivery of an electric

current through electrodes applied to the skin surface over the painful region, at trigger
points, or over a peripheral nerve.

• Percutaneous electrical nerve stimulation (PENS) stimulates deeper peripheral tissues

through a needle with an attached stimulator. The needle is inserted near a large peripheral
or spinal nerve.

• Acupuncture is a technique of Traditional Chinese Medicine in which very thin needles are
inserted into the body at designated points to reduce musculoskeletal pain, repetitive strain
disorders, myofascial pain syndrome, postsurgical pain, postherpetic neuralgia, peripheral
neuropathic pain, and headaches.
• Heat therapy can be either superficial or deep.

• Cold therapy involves the application of either moist or dry cold to the skin.

• Techniques to alter the affective, cognitive, and behavioral components of pain include
distraction, hypnosis, and relaxation strategies.

• The nurse acts as planner, educator, patient advocate, interpreter, and supporter of the patient
in pain and the patient’s family. It is important to realize that a nurse’s beliefs and attitudes
may hinder appropriate pain management.

• Gerontologic considerations:
o Treatment of pain in the elderly patient is complicated.
o Older adults metabolize drugs more slowly than younger persons and thus are at
greater risk for higher blood levels and adverse effects.
o The use of NSAIDs in elderly patients is associated with a high frequency of serious
GI bleeding.
o Older people often take many drugs for one or more chronic conditions.
o Cognitive impairment and ataxia can be exacerbated when analgesics such as
opioids, antidepressants, and antiseizure drugs are used.
o Health care providers for older patients should titrate drugs slowly and monitor
carefully for side effects.