♥ III.

Respiratory Rate

Respiration = is the exchange of O2 & CO2 in the body.

The Process of Respiration consists of 2 separate functions:

1. Mechanical = involve the active movement of air into and out of the respiratory system [pulmonary ventilation/breathing]

2. Chemical = include the exchange of O2 & CO2 between the alveoli & the pulmonary blood supply [external respiration], the transport

of these gases between the capillaries & body tissue cells [internal respiration].

Respiratory Rates for Different Age Groups:

AGE Newborn 1 year 2 years 8 years 16 years Adult

RANGE 30 – 80 20 – 40 20 – 30 15 – 25 15 – 20 12 – 20
AVERAGE 35 30 25 20 18 16

Depth of respiration can be established by watching the movement of the chest. [SHOW SLIDE]

HOW DOES THE BODY REGULATE RESPIRATION?

Special respiratory centers in the medulla oblongata & Pons of the brain, along w/nerve fibers of the autonomic nervous system, regulate breathing in response to minute changes
in the concentrations of O2 & CO2 in the arterial blood. The primary stimulus for breathing is the level of CO2 tension in the blood. Central chemoreceptors, located in the respiratory
centers, are sensitive to CO2 & hydrogen ion [pH] concentrations. Minor increases in either stimulate respirations. When the partial pressure of oxygen in arterial blood [PaO2] falls below
a00 mmHg (normal), peripheral chemoreceptors in the carotid and aortic bodies stimulate respirations.
Normally, breathing is an involuntary action that requires little effort. However, it is possible to exert conscious control over respiration through breath holding.

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Mechanics of breathing
3
 Pulmonary ventilation depends on changes in the capacity of the chest cavity. In response to impulses sent from the respiratory center along the phrenic nerve, the thoracic
muscles and the diaphragm contract. The ribs move upward from midline ½ 1 inch [1.2 – 2.5 cm], the diaphragm moves downward and out about 0.4 inch [1 cm], and the abdominal
organs move downward and forward, expanding the thorax in all directions. As expansion causes airway pressure to decrease below atmospheric pressure, air moves into the lungs. This
stage of respiration [drawing air into the lungs - inspiration].
When the diaphragm and thoracic muscles relax, the chest cavity decreases in size, and the lungs recoil, forcing air from the lungs until the pressure w/in the lungs again reaches
atmospheric pressure – this stage w/c involves the expelling of air from the lungs is called expiration. Expiration is passive and normally takes 2-3 seconds, compared to 1-1.5 seconds for
inspiration. During normal breathing, you can observe the chest wall and the abdomen gently rising and falling.

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Factors that influence Respiration:
1. Exercise = causes temporary ↑ in rate & depth → demands O2 to ↑ to be available to the tissue and to rid the body
of excess CO2.
2. Pain = acute pain causes an ↑ in respiratory rate but ↓ in depth
3. Stress = ↑rate
4. Smoking = increases resting respiratory rate as a result of changes in airway compliance [elasticity].
5. Fever = when heart rate ↑because of fever, respiratory rate ↑. For every 1°F [0.6 °C] the BT rises, the respiratory
rate may ↑ up to 4 bpm.
6. Pulse rate = when PR increases, RR increases too. The ratio of RR:PR is approximately 1:4. Thus, a client with a
RR if 16 would be expected to have a PR of at least 64.
7. Hemoglobin = RR & depth increase as a result of anemia [reduced Hb], sickle cell anemia [abnormally shaped
red blood cells], & high altitudes [inhibit the binding of oxygen to Hb and trigger similar
compensation efforts.
8. Disease = may be ↑ or ↓by various diseases.
9. Medications = CNS depressants [morphine or general anesthetics – slower, deeper respirations], caffeine and
atropine – shallow, fast breathing]
10. Position = R depth is maximized by standing up; hampered by lying flat; slumping [sitting with shoulders
forward, and the back curved in a „C‟ – prevents chest expansion, w/c impedes breathing.

DATA TO ASSESS:
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 1. RATE = 1 inspiration/1 expiration = 1 cycle/count 1
2. Depth =
Tidal volume = is the amount of air taken in on inspiration – about 300 – 500 mL for healthy adult; subjective
a. Deep [taking in a very large volume of air and fully expanding one‟s chest or abdomen]
b. Shallow [when the chest barely rises and is difficult to observe];
c. normal [falling between shallow and deep].
3. Rhythm = assess as normal or abnormal; the period between each respiratory cycle [normally the same]
4. Effort = the degree of work required to breathe; breathing is effortless.
5. Breath sounds = use stethoscope

Breathing Patterns
Rate:
☻eupnea = normal respiration that is quiet, rhythmic, & effortless

☻tachypnea = rapid respiration marked by quick, shallow breaths

☻bradypnea = abnormally slow breathing

☻apne = cessation of breathing

Volume:
☻hyperventilation = prolonged & deep breaths; occurs when rapid & deep breathing result in excess loss of CO2 [hypocapnia]; causes are:
a. Anxiety
b. Infection
c. Shock
d. Hypoxia
e. Drugs [aspirin, amphetamines],
f. DM or acid-base imbalance

= person complains of feeling of lightheaded and tingly

☻hypoventilation = shallow respirations; occurs when the rate and depth of respirations are decreased and CO 2 is retained or alveolar
ventilation is compromised.
= this may be caused by:
a. COPD [chronic obstructive pulmonary disease]
b. General anesthesia
c. Other conditions
Rhythm:

☻cheyne-stokes breathing = rhythmic waxing & waning or respirations, from very deep to very shallow breathing & temporary apnea
Ease or Effort:

☻dyspnea = difficult & labored breathing during w/c the individual has a persistent, unsatisfied need for air & feels distressed

☻orthopnea = ability to breathe only in upright sitting or standing positions

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 ♥ Characteristics of Adventitious Breath Sounds:

Breath Sound Respiratory Phase Description Conditions

Fine crackle Predominantly inspiration Dry, ↑pitched crackling, popping; short duration, roll hair Chronic obstructive pulmonary disease, congestive hearth
by ears bet. your fingers to simulate this sound failure, pneumonia, pulmonary fibrosis, atelectasis
Coarse crackle Predominantly inspiration Moist, low pitch crackling, gurgling; long duration Pneumonia, pulmonary edema, bronchitis, atelectasis
Sonorous wheeze Predominantly expiration Low-pitched; snoring Asthma, bronchitis, airway edema, tumor, bronchiolar
spasm, foreign body obstruction
Sibilant wheeze Predominantly expiration High-pitched; musical Asthma, chronic bronchitis, emphysema, tumor, foreign
body obstruction
Pleural friction rub Predominantly expiration Creaking, grating Pleurisy, TB, pulmonary infarction, pneumonia; lung
abscess
Stridor Predominantly inspiration Crowing Croup; foreign body obstruction, large airway tumor

Characteristics of Adventitious Breath Sounds:

Breath Sound Respiratory Phase Description Conditions

Fine crackle Predominantly inspiration Dry, ↑pitched crackling, popping; short duration, roll hair Chronic obstructive pulmonary disease, congestive heart
by ears bet. your fingers to simulate this sound failure, pneumonia, pulmonary fibrosis, atelectasis
Coarse crackle Predominantly inspiration Moist, low pitch crackling, gurgling; long duration Pneumonia, pulmonary edema, bronchitis, atelectasis
Sonorous wheeze Predominantly expiration Low-pitched; snoring Asthma, bronchitis, airway edema, tumor, bronchiolar
spasm, foreign body obstruction
Sibilant wheeze Predominantly expiration High-pitched; musical Asthma, chronic bronchitis, emphysema, tumor, foreign
body obstruction
Pleural friction rub Predominantly expiration Creaking, grating Pleurisy, TB, pulmonary infarction, pneumonia; lung
abscess
Stridor Predominantly inspiration Crowing Croup; foreign body obstruction, large airway tumor

PATTERNS OF BREATHING

1. Normal Respiration. Respiratory rate depends upon age and condition of patient. Infants have very high respiratory rates. In Adults the respiratory rate is between 12 and 20
breaths per minute. In silent breathing the rise and fall is about the same. Small variations occur. In natural breathing, sighs occur naturally. A sigh is a larger than usual
breath. In this type of breathing, there is a complete absence adventitious of sounds. The trained individual will be able to hear normal air entry and exit from the lungs.
Diagrammatic representation of rate and amplitude of breathing are shown in diagram numbered 1 (below).

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Diagram 1. Graphic Representation of Normal Respirations / minute.

2. Bradypnea . This is a slow repiratory rate which is seen in the post anaesthetic or sedated patient. If blood gases are normal, the nurse will need to keep a close eye on
the patient. If oxygen saturation and blood gases are compromised then the patient may need to be given naloxone or some other respiratory stimulant. Bradypnea is
also seen in patients who have taken overdoses of barbiturates and/or hypnotics. Bradypnea with a respiratory rate of more than ten breaths may correct itself as the
patient recovers from the anaesthetic gases. Sometimes, in bradypnea, the patient compensates by increasing the tidal volume thereby the blood gases and oxygen
saturation remain stable. Diagramatic representation of bradypnea is shown in diagram numbered 2 (below).

Diagram 2. Graphic Representation of Bradypnea. Respiratory rate is 8b/min.

3. Tachypnea . Tachypnea means elevated respiratory rate. In some situations, this might be usual, for example when climbing a flight of stairs. In disease it is
indicative of problems with oxygenation. It occurs when the patient is breathing really hard to compensate for the higher than usual PCO2. When the patient is
tachypneic it is important to sit him up in bed. For nursing positions, please see: this article.

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A diagramatic representation is shown in diagram 3 (below). In tachypnea the tidal volume is decreased, the minute volume may be the same because the respiratory rate is
increased. Decreased tidal volume will have bad consequences for the patient because a lot of energy is being spent on moving dead air space which does not help oxygenate the
interior of lungs where gas exchange takes place.

Diagram 3. Graphic Representation of Tachypnea. Respiratory rate is 28 b/min.

4. Kussmauls Respirations. This type of respirations is seen in very ill patients. It is a type respiration characterized by deeper noisy,and higher than normal respiratory
rates. E ach breath is almost like a deep sigh but as already stated the rate is higher than usual. In these patients blood gases will be deranged because of a primary
disorder for example diabetic ketoacidosis. Diagramatic representation is shown in diagram 4 (below).

Their hyperventilation helps get rid of ketones. This respiration was first described by Adolf Kussmaul, a German Physician.

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 Diagram 4. Graphic Representation of Kussmaul Respirations at 18 b / minute.

5. Biot’s Respirations. These respirations are characteristically a brupt and irregular. They alternate with periods of apnea with periods of breathing that are consistent
in rate and depth, often the result of increased intracranial pressure. These are shown, in diagrammatic form below in diagram 5 (below).

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Diagram 5. Graphic Representation of Biot’s Respirations. Rate is variable. Note the varialbe amplitued and apnea.

Maintainence and management of respiratory tract is discussed in my previous publication. Please see the attached hyperlink. Respiratory Tract Infections

6. Cheyne-stokes Respirations (breathing) is a type of breathing which starts of with small shallow respirations, gradually increase in frequency and amplitude and then
decrease into a periond of apnea. The whole cycle may take upto two minutes. If you are the nurse standing by the bedside the period of apnoea may be frightening
long. If your patient is hooked upto a pulase oxymeter, you will notice that his/her oxygen saturation does not drop. If oxygen saturation drops to below 95 % the
physician should be notified.

Diagram 6 (above). Cheyne-Stokes Respiration. (Author of Diagram: Sarjeet S. Gill).

7. Apnea. Apnea is the cessation of breathing. There are no respirations during this period. During sleep apnea the patient stops breathing. This may be the result of
upper air way obstruction. Some patients are placed on ventilators, at night, when at home, for this problem. Apnea will result in desaturation and constitutes a
medical emergency. CPR must be started by the first person on the secene.

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 Diagram 7. Diagramatic representation of two breaths of different amplitudes followed by apnea. (copyright of Diagram: Sarjeet S. Gill).

6. Dyspnoea means “difficult breathing”. Patients with advanced diseases like COPD and heart failure will display chronic dyspnoea. Shortness of breath will not be
relieved, even at rest, in the chronically ill. Opioids and benzodiazepines may used with anxious patients. The respiratory rate can vary from 24 b/min to 50b/min. In
these situations the work of breathing is substantially increased and the treating physician has to consider mechanical ventilation, if the condition is reversible.

Non-medical intervention is very important as the patient needs to learn to use his/her breathing optimally and to save each breath for those things that are most important.
These interventions have been discussed before and can be found here.

Students are reminded that our subject matter is external respirations only. It is different from cell respiration which is given below to point out that the two processes are
significantly different.

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 PHYSIOLOGY OF ARTERIAL BLOOD PRESSURE:
Blood Pressure:
Arterial blood pressure = is a measure of the pressure exerted by blood as it pulsates through the arteries.
= because blood moves in waves, there are two blood pressure measures:
a. systolic pressure = the pressure of the blood as a result of contraction of the ventricles (i.e., the pressure of the height of the
blood wave)
b. diastolic pressure = the pressure when the ventricles are @ rest
= the lower pressure, present @ all times w/in the arteries.
Pulse pressure = the difference bet. the systolic pressure & the diastolic pressure

hypertension = persistently high blood pressure (s/s: headache, ringing in the ears, flushing of face, nosebleeds, fatigue)
hypotension = low BP; most commonly used to describe an acute drop in BP, as it occurs during excessive blood loss (s/s: tachycardia,
dizziness, mental confusion, restlessness, cool & clammy skin, pale or cyanotic skin)
Pulse = the wave-like flow of blood from the left ventricle as oxygenated blood
Arterial BP = is the result of several factors:
1) the pumping action of the heart,
2) the peripheral vascular resistance (the resistance supplied by the blood vessels through w/c the blood flows) & the blood
volume & viscosity.
Pumping action of the heart
→ cardiac output = is the volume of blood pumped into the arteries by the heart
Peripheral Vascular Resistance
→ peripheral resistance = can increase BP. The diastolic pressure is especially affected.

♥ Some factors that create resistance in arterial system:

A1. Size of the arterioles & the capillaries determines in great part the peripheral resistance to the blood in the body. A lumen is a channel
w/in a tube: the smaller the lumen of a vessel, the greater the resistance. Normally, the
arterioles are in a state of partial constriction.
Increased vasoconstriction raises the blood pressure, whereas decreased vasoconstriction lowers the blood pressure.
A2. The arteries contain smooth muscles that permit them to contract, thus decreasing their compliance (distensibility). The major factor
reducing arterial compliance is pathologic change affecting the arterial walls.
The elastic and muscular tissues of the arteries are replaced w/fibrous tissue; thus, the arteries lose much of their compliance. The
condition that is most common in middle-aged & elderly adults is known as arteriosclerosis
B1. Blood volume = when the blood volume decreases (for example, as a result of a hemorrhage or dehydration), the BP decreases because
of decreased fluid in the arteries. Conversely, the opposite occurs.
C1. Blood viscosity = viscosity is the physical property that results from friction of molecules in a fluid. In a ciscous (or “thick”) fluid,
there is a great deal of friction among the molecules as they slide by each other. The BP is higher when the blood is highly viscous, that is, when the proportion of red
blood cells to the blood plasma is high. This ration is referred to as the hematocrit. The viscosity increases markedly when the hematocrit is more than 60% to 65%.

♥ BP Assessment Sites:
BP is usually assessed in the client’s arm using the brachial artery & a standard stethoscope.
Assessing the BP on a client’s thigh using the popliteal artery is usually indicated in these situations:
1. the BP cannot be measured on either arm (e.g., because of burns, truma, or bilateral mastectomy).
2. the BP on one thigh is to be compared w/the BP on the other thigh
3. the BP cuff is too large for the upper extremities

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♥ BP is not measured on a client’s arm or thigh in the following situations:
1. the client has breast or axilla (or hip) surgery on that side
2. the client has an IV infusion or a blood transfusion in that limb
3. the client has an arteriovenous fistula (e.g., for renal dialysis) in that limb

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BP apparatus with stands

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PARTS OF THE STETHOSCOPE

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Mercury Infant or Child BP apparatus

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 WINNING THE CHILD‟S CONFIDENCE

Recommended bladder sizes of BP cuffs for people w/different arm circumferences

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 Client Arm circumference @ midpoint (cm) Cuff bladder length (cm) Cuff bladder width (cm)
NB 5-7.5 5 3
Infant 7.5-13 8 5
Child 13-20 13 8
Adult 24-32 24 13
Large adult 32-42 32 17
Thigh 42-50+ 42 20

♥ When taking a BP using a stethoscope, the nurse identifies five phases in the series of sounds called Korotkoff’s sounds:

Phase I = the pressure level @ w/c the first faint clear tapping sounds are heard. These sounds gradually become more intense. To assure
that they are not extraneous sounds, the nurse should identify @ least two consecutive tapping sounds.

Phase 2 = the period during deflation when the sounds have a swishing quality.

Phase 3 = the period during w/c the sounds are crisper & more intense.

Phase 4 = the time when the sounds become muffled &have a soft, blowing quality

Phase 5 = the pressure level when the sounds disappear

♥
SELECTED SOURCES OF ERROR IN BP ASSESSMENT
Error Effect
1. bladder cuff too narrow Erroneously high
2. bladder cuff too wide Erroneously low
3. arm unsupported Erroneously high
4. insufficient rest b4 the assessment Erroneously high
5. repeating assessment too quickly Erroneously high systolic or low diastolic readings
6. cuff wrapped too loosely or unevenly Erroneously high
7. deflating cuff too quickly Erroneously low systolic & high diastolic readings
8. deflating cuff too slowly Erroneously high diastolic reading
9. failure to use the same arm consistently Inconsistent measurements
10. arm above level of the heart Erroneously low
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11. assessing immediately after a meal or while client smokes or has pain Erroneously high
12. failure to identify auscultatory gap Erroneously low systolic pressure & Erroneously low diastolic pressure

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 PAIN

As a special experience your instructor has arranged for you to spend a half-day in the ICU. As you enter the ICU, you are a little apprehensive. Your patient today is a 23-year-old Asian
woman who was in an automobile accident yesterday and sustained chest and aabdominal injuries. You walk into the room with your clinical instructor to meet your patient, Miss Eunice Chu Ling.
She was taken to the operating doom during the night to have her spleen removed. She is intubated (has indotracheal tube in her airway that is connected to a ventilator), has an intravenous line
running, and a chest tube on the left side that is draining bloody fluid. Her parents and siblings are in the room sitting rigidly in the chairs smiling at you. Miss Chu Ling is awake and grimacing.
You want to ask her if she is in pain, but she cannot speak.

Pain = an unpleasant sensory or emotional experience associated w/actual or potential tissue damage, or described in terms of such damage [International Association for the Study of Pain – IASP/
American Pain society.

Pain can cause:

a. Irritability
b. Sleep loss
c. Cognitive impairment
d. Functional impairment
e. Immobility

ORIGIN OF PAIN
1. Cutaneous or superficial pain = arises in the skin or the subcutaneous tissue.
→ touching hot object
2. Visceral pain = stimulation of deep internal pain receptors [abdominal cavity, cranium, or thorax]
Descriptions:
a. Local, achy discomfort to more widespread, intermittent, & crampy pain
= the description of quality and extent of the pain serves as a strong clue to the cause
Ex.
a. Menstrual cramps
b. Labor pain
c. Gastrointestinal infections
d. Bowel disorders
e. Organ cancers
3. Deep somatic pain = originates in the ligaments, tendons, nerves, blood vessels, & bones
= more diffuse than cutaneous pain and tends to last longer
= ex. Fracture or sprain, arthritis, and bone cancer
4. Radiating pain = starts at the source but extends to other locations
= ex. Pain of a severe sore throat may extend to the ears & head
Pain of an episode of gastroesophageal reflux „heartburn‟ → may radiate outward from the sternum to involve the entire upper thorax
5. Referred pain = occurs in an area that is distant from the original site
= ex. Pain from a heart attack may be experienced down the left arm, through the back, or into the jaw
6. Phantom pain = pain is perceived to originate from an area that has been surgically removed.
= ex. Pts w/ amputated limbs may still perceive that the limb exists & experience burning, itching, & deep pain in that area.
7. Psychogenic pain = refers to pain that is believed to arise from the mind; pt perceives the pain despite the fact that no physical cause can be identified;
can be as severe as pain from a physical cause.

CAUSES OF PAIN
1. Nociceptive pain = most common type of pain experienced; occurs when pain receptors [nociceptors], responed to stimuli that are potentially damaging.

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 = nociceptive pain may occur as a result of
a. Trauma
b. Surgery
c. Inflammation

2. Neuropathic pain = complex & often chronic pain that arises when
a. injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli
b. nerve injury may originate from any of conditions such as poorly controlled DM, a stroke, a tumor, or a viral infection
c. some medications [chemotherapy], can trigger nerve injuries that may cause neuropathic pain even after the medication is discontinued
d. 20-40% pts referred to pain clinics suffer from neuropathic pain.

DURATION OF PAIN
1. Acute pain = short duration & generally rapid in onset
= varies in intensity & may last for 6 months
= associated w/injury or surgery
= protective for it indicates potential or actual tissue damage; disappears as the tissues heal
2. Chronic pain = pain that has lasted 6 months or longer, often interferes w/ADLs
= it can related to a progressive disorder or it can occur when there is no current tissue injury as in neuropathic pain
= pts may experience periods of remission [abatement - interruption in the intensity or amount of something] in intensity or degree (as in the manifestations of a
disease)] & exacerbation [Action that makes a problem or a disease (or its symptoms) worse]; Violent and bitter exasperation "his foolishness was followed by an
exacerbation of their quarrel"
= viewed as meaningless & may lead to withdrawal, depression, anger, frustration, & dependence
= next to incurability, chronic pain is the most feared aspect of contracting cancer or another progressive disease.
3. Intractable pain = is both chronic and highly resistant to relief – frustrating to both patient & HCP; it should be approached with multiple methods of
pain relief

QUALITY OF PAIN [words patients use to describe the quality of their pain help care providers to determine the probable cause & most effective treatment].
A. Adjectives:
a. Sharp or dull
b. Aching = A dull persistent (usually moderately intense) pain
c. Throbbing = Pounding or beating strongly or violently; "a throbbing pain"; "the throbbing engine of the boat"
d. Stabbing = Painful as if caused by a sharp instrument; "a stabbing pain"
e. Burning = Pain that feels hot as if it were on fire
f. Ripping = Resembling a sound of violent tearing as of something ripped apart or lightning splitting a tree
g. Searing = Make very hot and dry
h. Tingling = A somatic sensation as from many tiny prickles

B. Periodicity:
a. Episodic = Occurring or appearing at usually irregular intervals → "episodic in his affections"
b. Intermittent = Stopping and starting at irregular intervals → "intermittent rain showers"
c. Constant = Uninterrupted in time and indefinitely long continuing → "in constant pain"

C. Intensity:
a. Mild
b. Distracting
c. Moderate
d. Severe
e. Intolerable

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FACTORS INFLUENCING PAIN:
[Pain is universal yet each person experiences and responds to pain differently. This uniqueness gives you a hint about its nature: Pain is a complex phenomenon that influences and is
influenced by emotions, age, socio-cultural factors, and communication & cognitive impairments].

A. Emotion (refer to the story of Ms. Ling)

1. Fear
2. Guilt
3. Anger
4. Helplessness
5. Loneliness

B. Sociocultural factors
= we learn behaviors associated with pain through interaction with family and social support groups
= beliefs about the value of expressing pain or minimizing pain are often tied to culture
= as you care for clients of various backgrounds, you may notice patterns of behavior:
a. Some Latino patients may gain comfort from crying or moaning when they are in pain
b. Some patients of northern European descent may value silence.
= as a HCP, be careful, however, not to assume that patients will react according to responses you have seen in others of the same ethnic or cultural group, because each patient is unique
= 3 words → pain, hurt, ache seemed to be used across many cultures to describe pain, thus, pain assessment tools can be successfully translated into various languages.

PAIN SEVERAL LANGUAGES

LANGUAGE PAIN WHERE?
Spanish Dolor donde?
French Douler Ou?
German Schmerz Wo?
American
Cebuan
Ilongo
Ilocano
Tagalong
Cambodian
Laos
Chinese

C. Communication & Cognitive Impairments

= One of HCP/nurse greatest challenges is caring for patients in pain who have impaired cognition or communication (patients who have suffered stroke or dementia, who are intubated, or
have limited command of the local language).
→ these patients are unable to express their needs verbally and are at risk for underassessment of pain and inadequate pain relief
 May use pain scale measurement to assess the pain/maybe with the help of SO
→ common nonverbal cues of pain include decreased activity, grimacing, frowning, crying, moaning, and irritability.
= less obvious indicators you may see in cognitively impaired patients:
a. Facial expressions (sad or frightened expression, rapid eye blinking)

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b. Vocalizations (noisy breathing, profanity, verbally abusive language)
c. Changes in physical activity (fidgeting, increased pacing or rocking, disruptive behavior)
d. Changes in routines (refusing food, difficulty sleeping)
e. Mental status changes (increased confusion)
f. Physiological cues (elevated blood pressure and pulse); the absence of these cues does not automatically mean that pain is absent

HOW DOES THE BODY REACT TO PAIN?

Our bodily reactions to pain are influenced primarily by the stage of the pain experience, as well as the intensity, the duration, and quality of pain.
Pain triggers a variety of changes in the body.

XXXXXXXXXXXXXXXXXX

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 At the onset of acute pain
↓
The body reacts automatically
↓
By activating the sympathetic nervous system
↓
Fight of flight (stress) → protective response
↓
It minimizes blood loss
Maintains perfusion to vital organs
Prevents and fights infections
Promotes healing
↓
(If pain continues – the body adapts)
↓
Parasympathetic nervous system takes over
↓
However, the actual pain receptors continue to transmit the pain message
↓
The person remains aware of the tissue damage – protective
↓
Example: the pain that you feel for several days after you sprain your ankle
↓
Reminds you to stay off it until it is fully healed
↓
The severity and duration of the pain significantly affect how the person continues to respond to it
↓
Often, the person is able to ignore mild pain, but pain that is severe and unrelieved can consume his thoughts
↓
His daily living patterns change

REFERNCES
1. FON: Theory, Concepts & Applications By: Wilkinson, Judith & Karen Van Leuven Vol. 1, pp. 322-336/ 699-
2. FON: by Kozier & Erbs

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