Pain and Inflammation Management Agents There are two main types of COX enzymes:

 COX-1: Protects the stomach lining and

 Inflammation is a protective response
regulates platelets.
to tissue injury or infection.
 COX-2: Triggers inflammation and pain.
 It involves the accumulation of fluids,
white blood cells (WBCs), and chemical
Nonsteroidal anti-inflammatory drugs (NSAIDs)
mediators at the injury or infection site.
work by inhibiting the COX enzyme, reducing
 The goal of inflammation is to neutralize
prostaglandin synthesis. This helps to:
harmful agents and initiate tissue repair.
 Reduce inflammation
Infection is caused by microorganisms and leads  Relieve pain
to inflammation. However, not all inflammations  Decrease fever
are caused by infections. Some NSAIDs, such as aspirin, also have
anticoagulant effects.
The five cardinal signs of inflammation are:
1. Redness (Rubor)
2. Swelling (Edema)
3. Heat (Calor)
4. Pain (Dolor)
5. Loss of Function (Functio laesa)

Phases of Inflammation

Vascular Phase:

 Occurs 10-15 minutes after injury.

 Involves vasodilation (widening of blood

vessels) and increased capillary
permeability (leakage of fluid from
blood vessels into surrounding tissues).

Delayed Phase:

 Leukocytes (white blood cells) infiltrate

inflamed tissues.

Chemical Mediators in Inflammation

 Prostaglandins are key mediators in the

inflammatory response. Types of NSAIDs and Their Therapeutic Uses
NSAIDs can be classified into several categories
 Effects of prostaglandins include: based on their chemical structure:
 Salicylates: Aspirin
o Vasodilation
 Para-chlorobenzoic acid derivatives:
o Increased capillary permeability
Indomethacin
o Sensitization of nerve cells to
 Phenylacetic acids: Diclofenac
pain
 Propionic acid derivatives: Ibuprofen,
Naproxen
 Fenamates: Meclofenamate
 Oxicams: Piroxicam
 Selective COX-2 inhibitors: Celecoxib
Therapeutic uses of NSAIDs include:
 Pain relief: Primarily for joint and
musculoskeletal pain
 Anti-inflammatory: Rheumatoid
arthritis, osteoarthritis, and other
Cyclooxygenase (COX) Enzymes and NSAIDs inflammatory conditions
 Antipyretic: Lower fever (although less
Cyclooxygenase (COX) is an enzyme that
effective than their anti-inflammatory
converts arachidonic acid into prostaglandins,
role)
which contribute to inflammation and pain at
 Antiplatelet (Aspirin): Prevents clot
tissue injury sites.
formation in cardiovascular disorders
 Nursing Interventions:
Aspirin and COX Inhibitors  Administer one hour before or two
 Aspirin inhibits both COX-1 and COX-2, hours after meals.
reducing pain and inflammation but  Monitor vital signs.
also increasing the risk of  Monitor response to medication.
gastrointestinal issues.
 High doses of aspirin can lead to gastric General Side Effects and Adverse Reactions of
distress. First-Generation NSAIDs:
 Fewer side effects than aspirin but
COX-2 Inhibitors are more selective in targeting gastric irritation is common.
COX-2, which is primarily involved in  Taken without food, can cause sodium
inflammation and pain. This can reduce the risk and water retention.
of gastrointestinal side effects compared to non-  Alcohol can increase gastric irritation
selective NSAIDs. However, some COX-2 and should be avoided.
inhibitors have been associated with increased
risk of cardiovascular events. Selective COX-2 Inhibitors (Second-Generation
NSAIDs)
COX-2 Inhibitors  COX-2 inhibitors reduce inflammation
 Selective COX-2 inhibitors (e.g., and pain.
Celecoxib, Valdecoxib) block only COX-2,  Nonselective NSAIDs inhibit COX-1 and
offering pain and inflammation relief COX-2, decreasing stomach protection.
without gastrointestinal side effects.  Preferred for patients with severe
 These inhibitors may also have potential arthritis needing high doses of anti-
roles in cancer prevention. inflammatory drugs.
 COX-2 inhibitors reduce the risk of
Pharmacokinetics and Pharmacodynamics of peptic ulcers and gastric bleeding.
NSAIDs Examples:
 Pharmacokinetics: NSAIDs are absorbed  Celecoxib (Celebrex)
in the gastrointestinal tract and have  Nabumetone (Relafen) - Not a "true"
varying half-lives. COX-2 inhibitor but inhibits COX-2 more
 Pharmacodynamics: They inhibit than COX-1.
prostaglandin synthesis, reducing
inflammation and pain. Use of NSAIDs in Older Adults
Adverse Effects of NSAIDs  Used for conditions like osteoarthritis
 Common side effects include and rheumatoid arthritis.
gastrointestinal upset, bleeding, and  Complications:
ulcers. o GI distress, including ulceration,
 Long-term use of NSAIDs can lead to is more common in older
kidney damage and cardiovascular risks. adults.
o COX-2 inhibitors have reduced
Adverse Effects of NSAIDs GI problems but may cause
COX-1 Inhibitors: edema.
 Gastric disturbances  Recommendations:
 Skin rash o Evaluate renal function and
 Blood dyscrasias/bleeding increase fluid intake.
 CNS disturbances o Lower NSAID dose to minimize
 Nephrotoxicity risks.
COX-2 Inhibitors: Corticosteroids
 CNS disturbances  Examples: Prednisone, prednisolone,
 Nephrotoxicity dexamethasone.
 Myocardial infarction  Mechanism of action: Control
 Stroke inflammation by suppressing
components of the inflammatory
Contraindications: process.
 Hypersensitivity  Use: Often used for arthritic flare-ups
 Asthma but not the primary choice due to side
 Renal disease effects.
 Liver disease
  Dosage:  Gout: An inflammatory condition
o Long half-life; administered affecting joints, often caused by uric
once daily. acid buildup.
o Taper off dosage over 5-10 days
 Complications: Gouty arthritis, urinary
when discontinuing.
calculi, gouty nephropathy.
Disease-Modifying Antirheumatic Drugs
(DMARDs)  Dietary Considerations: Avoid foods
 Used when NSAIDs are insufficient to high in purine (e.g., organ meats,
control rheumatoid arthritis. sardines) and alcohol, especially beer.
 Include: Immunosuppressive agents,
Antigout Drug: Colchicine
immunomodulators, and antimalarials.
 Effectiveness: Effective but more toxic  Mechanism:
than NSAIDs.
 Benefit: Help modify the disease o Inhibits migration of leukocytes
process for patients with immune- to inflamed sites.
mediated arthritis. o Effective for alleviating acute
Immunosuppressive Agents gout symptoms but not for
 Treat refractory rheumatoid arthritis. other inflammatory disorders.
 Examples: Azathioprine (Imuran), Uric Acid Inhibitor: Allopurinol
Cyclophosphamide (Cytoxan),  Mechanism:
Methotrexate (Mexate).
 Origin: Originally used for cancer Inhibits uric acid biosynthesis,
o
treatment but effective in low doses for lowering serum uric acid levels.
arthritis. o Used prophylactically for
chronic gout and renal
Immunomodulators impairment.
 Pharmacokinetics:
 Immunomodulators disrupt the
inflammatory process and delay its o Absorbed in the GI tract, half-
progression. life 2-3 hours.
o Promotes uric acid solubility
 Examples: and diuresis.
o IL-1 receptor antagonists: Uricosurics
Anakinra (Kineret)  Mechanism: Increase the rate of uric
o TNF blockers: Etanercept acid excretion by inhibiting its
(Enbrel), Infliximab (Remicade), reabsorption.
Adalimumab (Humira),  Examples: Probenecid (Benemid) and
Leflunomide (Arava) Sulfinpyrazone (Anturane).
 Usage: Effective for chronic gout; not
 Adverse Effects: Increased risk of severe recommended during acute attacks.
infections; contraindicated during active Adverse Effects of Antigout Drugs
infections.  Nausea and vomiting (N/V)
Antimalarials  Indigestion
 Blood dyscrasias
 Antimalarials treat rheumatoid arthritis  Liver damage
when other treatments fail.  Gastrointestinal (GI) disturbances
Nursing Interventions
 Mechanism: Unclear; takes 4-12 weeks
 Increase fluid intake: To prevent renal
to become effective.
calculi.
 Combination: Often combined with  Monitor I&O: To assess fluid balance.
NSAIDs for better control of arthritis.  Administer with meals: To reduce GI
upset.
Antigout Drugs
 Monitor blood work: Including serum
 Antigout drugs increase uric acid uric levels and electrolyte levels.
excretion and decrease uric acid
Health Teaching
formation.
 Weight management: Lose weight if
needed.
  Dietary restrictions: Avoid high purine  Increased chest circumference (by
foods (organ meats, sardines, shellfish, about 23/8" [6 cm])
etc.) and fermented beverages such as  1 Altered breathing, with abdominal
beer, ale, wine. breathing replacing thoracic breathing
as pregnancy progresses
 Slight increase (two breaths/minute) in
Physiologic adaptations to pregnancy respiratory rate
 Increased pH, leading to mild
respiratory alkalosis
Cardiovascular system
Metabolic system
 Cardiac hypertrophy  Increased water retention
 Displacement of the heart  Decreased serum protein level
 Increased blood volume and heart rate  Increased intracapillary pressure and
 Supine hypotension permeability
 Increased fibrinogen and hemoglobin  Increased serum lipid, lipoprotein, and
levels cholesterol levels
 Decreased hematocrit  Increased iron requirements and
carbohydrate needs
Gastrointestinal system  Increased protein retention
 Weight gain of 25 to 30 lb (11.3 to 13.6
 Gum swelling kg)
 Lateral and posterior displacement of
the intestines
 Superior and lateral displacement of the Integumentary system
stomach  Hyperactive sweat and sebaceous
 Delayed intestinal motility and gastric glands
and gallbladder emptying time  Hyperpigmentation
 Constipation  Darkening of nipples, areolae, cervix,
 Displacement of the appendix from vagina, and vulva
McBurney's point  Pigmentary changes in nose, cheeks,
 Increased tendency of gallstone and forehead (facial chloasma)
formation  Striae gravidarum and linea nigra
 Breast changes (such as leaking of
colostrum)
Endocrine system  Palmar erythema and increased
 Increased basal metabolic rate (up 25% angiomas
at term)  Faster hair and nail growth with
 Increased iodine metabolism thinning and softening
 Slight parathyroidism
 Increased plasma parathyroid hormone
level Genitourinary system:
 Slightly enlarged pituitary gland  Dilated ureters and renal pelvis
 Increased production of prolactin  Increased glomerular filtration rate
 Increased cortisol level and renal plasma flow early in
 Decreased maternal blood glucose level pregnancy
 Decreased insulin production in early  Increased clearance of urea and
pregnancy creatinine
 Increased production of estrogen,  Decreased blood urea and nonprotein
progesterone, and human chorionic nitrogen levels
somatomammotropin  Glycosuria
 Decreased bladder tone
Respiratory system Reproductive system
 Increased vascularization of the
respiratory tract  Increased sodium retention from
 Shortening of the lungs hormonal influences
 Upward displacement of the diaphragm  Increased uterine dimension
 Increased tidal volume, causing slight  Hypertrophied uterine muscle cells (5 to
hyperventilation 10 times normal size)
  Increased vascularity, edema,  Increase fiber intake in the diet.
hypertrophy, and hyperplasia of the  Set a regular time for bowel
cervical glands movements.
 Increased vaginal secretions with a pH  Drink more fluids, including water and
of 3.5 to 6 fruit juices (unless contraindicated).
 Discontinued ovulation and maturation Avoid caffeinated drinks.
of new follicles
Hemorrhoids
 Thickening of vaginal mucosa, loosening
of vaginal connective tissue, and  Rest on the left side with the hips and
hypertrophy of small-muscle cells lower extremities elevated to provide
 Changes in sexual desire better oxygenation to the placenta and
fetus.
Musculoskeletal system
 Avoid constipation.
 Increase in lumbosacral curve  Apply witch hazel pads
accompanied by a compensatory  Get adequate exercise.
curvature in the cervicodorsal region  Take sitz baths with warm water as
 Stoop-shouldered stance due to often as needed to relieve discomfort.
enlarged breasts pulling the shoulders  Apply ice packs for reduction of
forward swelling, if preferred over heat
 Separation of the rectus abdominis
muscles in the third trimester, allowing Varicosities
protrusion of abdominal contents at the  Walk regularly.
midline  Rest with the feet elevated daily.
 Avoid standing or sitting for long
Dealing with pregnancy discomforts
periods.
Urinary frequency  Avoid crossing the legs.
 Avoid wearing constrictive knee-high
 Void as necessary. stockings; wear support stockings
 Avoid caffeine. instead.
 Perform Kegel exercises.  Stay within recommended weight gain
Fatigue range during pregnancy.

 Try to get a full night's sleep. Ankle edema

 Schedule a daily rest time.  Avoid standing for long periods.
 Maintain good nutrition.  Rest with the feet elevated.
Breast tenderness  Avoid wearing garments that constrict
the lower extremities.
Wear a supportive bra, especially during sleep if
breast tenderness interferes with sleep. Headache
 Avoid eyestrain.
Vaginal discharge
 Rest with a cold cloth on the forehead.
 Wear cotton underwear.
 Avoid tight-fitting pantyhose. Leg cramps
 Bathe daily.  Straighten the leg and dorsiflex the
ankle.
Backache
 Avoid pointing the toes.
 Avoid standing for long periods.  Rest frequently with feet elevated.
 Apply local heat, such as a heating pad
(set on low) or a hot water bottle. Make
sure to place a towel between the heat
source and the skin to prevent burning.
 Stoop to lift objects—don’t bend.

Round ligament pain

 Slowly rise from a sitting position.

 Bend forward to relieve pain.
 Avoid twisting motions.

Constipation
 uterine fundus is palpable halfway
between the symphysis pubis and the
Assessing pregnancy by weeks umbilicus.
 Maternal recognition of fetal
Weeks 1 to 4 movements, or quickening, occurs
 Amenorrhea occurs. between 16- and 20-weeks’ gestation.
 Breasts begin to change.
 Immunologic pregnancy tests become Weeks 18 to 22
positive: Radioimmu noassay test  The uterine fundus is palpable just
results are positive a few days after below the umbilicus.
implantation; urine hCG test results are  Fetal heartbeats are heard with the
positive 10 to 14 days after amenorrhea fetoscope at 20 weeks' gestation.
occurs.  Fetal rebound or ballottement is
 Nausea and vomiting begin between possible.
the fourth and sixth weeks.
Weeks 23 to 27
Weeks 5 to 8  The umbilicus appears to be level with
 Goodell's sign occurs (softening of the abdominal skin.
cervix and vagina).  Striae gravidarum are usually apparent.
 Ladin's sign occurs (softening of the  Uterine fundus is palpable at the
uterine isthmus). umbilicus.
 Hegar's sign occurs (softening of the  The shape of the uterus changes from
lower uterine segment). globular to ovoid.
 Chadwick's sign appears (purple-blue  Braxton Hicks contractions start.
coloration of the vagina, cervix, and
vulva). Weeks 28 to 31
 McDonald's sign appears (easy flexion  Mother gains 8 to 10 lb (3.5 to 4.5 kg) in
of the fundus toward the cervix). third trimester.
 Braun von Fernwald's sign occurs  The uterine wall feels soft and yielding.
(irregular softening and enlargement of  The uterine fundus is halfway between
the uterine fundus at the site of the umbilicus and xiphoid process.
implantation).  The fetal outline is palpable.
 Piskacek's sign may occur (asymmetrical  The fetus is mobile and may be found in
softening and enlargement of the any position.
uterus).
 The cervical mucus plugs forms. Weeks 32 to 35
 The uterus changes from pear-shaped  The mother may experience heartburn.
to globular.  Striae gravidarum become more
 Urinary frequency and urgency occur. evident.
 The uterine fundus is palpable just
Weeks 9 to 12 below the xiphoid process.
 Fetal heartbeat detected using  Braxton Hicks contractions increase in
ultrasonic stethoscope. frequency and inten-sity.
 Nausea, vomiting, and urinary  The mother may experience shortness
frequency and urgency lessen. of breath.
 By the 12th week, the uterus is palpable
just above the symphy-sis pubis. Weeks 36 to 40
 The umbilicus protrudes.
Weeks 13 to 17  Varicosities, if present, become very
 Mother gains 10 to 12 lb (4.5 to 5.5 kg) pronounced.
during the second tri-mester.  Ankle edema is evident.
 Uterine souffle is heard on auscultation.  Urinary frequency recurs.
Mother's heartbeat increases by about  Engagement, or lightening, occurs.
10 beats/minute between 14- and 30-  The mucus plug is expelled.
weeks’ gestation.  Cervical effacement and dilation begin.
 Rate is maintained until 40 weeks'
gestation.
 By the 16th week, the mother's thyroid
gland enlarges by about 25%, and the
The Psychological Tasks of Pregnancy Education and Support: It's important to
 Pregnancy is a time of significant address any misconceptions or anxieties
psychological transition for both the partners may have regarding pregnancy,
woman and her partner. childbirth, and parenting.
 Emotions range from surprise and
acceptance to worry and impatience. Woman and partner move through emotions
 The nine months of pregnancy allow for such as narcissism and introversion as they
physical and emotional preparation for concentrate on what it will feel like to be a
parenthood. parent. Role-playing and increased dreaming
 These psychological adjustments are are common.
crucial to ensuring a smooth transition
into parenthood.
Third Trimester: Preparing for Parenthood
First Trimester: Accepting the Pregnancy Both Partners:
The Woman: Nesting: Couples often engage in preparing for
Surprise and Ambivalence: Even in planned the baby's arrival through tasks such as
pregnancies, discovering one is pregnant can be arranging the nursery, buying baby items, and
surprising. Around 50% of pregnancies are choosing a name.
unintended or mistimed. Childbirth Education: Attending prenatal classes
helps couples prepare for childbirth and
Rituals and Confirmation: Confirmation of parenting.
pregnancy by healthcare professionals or home
tests marks an emotional shift Life Contingencies:
 External factors like work or financial
Mixed Emotions: Ambivalence is common, with strain can interfere with psychological
feelings of both joy and anxiety coexisting. preparation.
 Healthcare providers should explore any
The Partner: challenges couples are facing during
Emotional Support: Partners may also prenatal visits.
experience mixed emotions and need to
support the woman emotionally. Woman and partner prepare clothing and
sleeping arrangements for the baby but also
Ambivalence and Anxiety: Partners can feel grow impatient with pregnancy as they ready
ambivalent, particularly if they feel unprepared themselves for birth.
for parenthood or worry about financial
changes. Reworking Developmental Tasks:
 Pregnancy often prompts women to
Woman and partner both spend time reflect on their relationships with their
recovering from shock of learning they are own parents, particularly their mothers.
pregnant and concentrate on what it feels like  This process of reflection and emotional
to be pregnant. A common reaction is growth is important in shaping their
ambivalence, or feeling both pleased and not identity as a mother.
pleased about the pregnancy.
Emotional Responses to Pregnancy
Second Trimester: Accepting the Baby  Pregnancy involves a wide range of
The Woman: emotional reactions.
Quickening: Feeling fetal movements helps the  Common responses: grief, narcissism,
woman realize she is carrying a separate entity. introversion/extroversion, body image
concerns, couvade syndrome, stress,
Acceptance: This is the time when the woman mood swings, and changes in sexual
may begin to feel more connected to the baby desire.
and starts preparing emotionally for  Importance of understanding these
motherhood changes to avoid misinterpretation.

The Partner: Grief During Pregnancy

Involvement: Partners may feel sidelined and Grief may seem incongruent with pregnancy,
seek ways to contribute, often turning to work but it arises from the need to let go of previous
or other activities. roles. Both women and their partners must
adjust to new roles (e.g., daughter to mother, Emotional Lability (Mood Swings)
son to father).  Mood swings are common during
This process involves redefining identity and pregnancy due to hormonal changes
relationships. and narcissism.
 Women and their families should be
Narcissism in Pregnancy aware of these changes to avoid
 Narcissism is self-centeredness during misinterpretation.
pregnancy, focusing on the body and its  One day a situation may seem
changes. distressing, while the next it could be
 A woman may take more time to dress amusing.
or eat and lose interest in extenal
activities. Changes in Sexual Desire
 Protective behaviors toward her body  Sexual desire fluctuates throughout
emerge, such as avoiding risks or pregnancy.
unnecessary nudity.  Decreased libido in the first trimester
 Men may show similar behavior (e.g... due to fatigue or nausea. Increased
reducing risky activities). libido in the second trimester due to
better physical well-being.
Introversion vs. Extroversion  Decrease again in the third trimester
 Introversion: Turning inward, focusing due to physical discomfort.
on oneself and the pregnancy.
 Extroversion: Becoming more outgoing, Supporting the Expectant Family
finding fulfillment in pregnancy, and  Older children may need reassurance
sharing the experience with others. that a new baby won't replace them in
 Individual emotional responses to their parents' affection.
pregnancy vary greatly.  Couples may seek guidance on how to
prepare children for the arrival of a
Body Image and Boundary Concerns sibling.
 Body image and boundary perceptions
change during pregnancy.
 A woman may feel larger in more ways
than just physical.
 These changes contribute to feelings of
vulnerability and protection of the body.

Stress and Pregnancy

 Role changes, physical demands, and
the uncertainty of labor can lead to
stress. Stress impacts decision-making
and the ability to function.
 A strong support system helps mitigate
stress, while lack of support can
increase stress.
 Screening for intimate partner violence
is important during prenatal care.

Couvade Syndrome
 Some men experience Couvade
Syndrome: physical symptoms like
nausea or backache mirroring the
pregnant partner.
 This occurs due to stress, anxiety, and
empathy. Symptoms are typically
harmless unless they cause emotional
distress.