A Focus on Section IBy: Tracy M. Morris, BSN, RN-BC
ANCC Website and how to get started: http://www.nursecredentialing.org/ Eligibility criteria Where to get additional CEUs ◦ www.nursing2009.com ◦ www.advanceweb.com.nurses ◦ www.inroadsforpain.com ◦ www.medscape.com ◦ www.pain.com
Pathophysiology 18 questions 12% of test Pain Assessment 43 questions 29% of test Interventions 24 questions 16% of test Side Effects 17 questions 11% of test Patient and family 17 questions 11% of test Education Collaborative 31 questions 21% of test Institutional IssuesResource: ASPMN Practice Exam for Pain Management NursingCertification Prep
6 Sessions in total Sessions start in August Two sessions per month (August, September and October) 2 CEUS per session Read/prep before session
Core Curriculum for Pain Management Nursing (2010). ASMPN. 2nd edition. Barbara St. Marie. ASMPN Practice Examination for Pain Management Nursing Certification Preparation ASMPN Certification Prep Course 2007 (Audiofiles) ASMPN Study Guide for Pain Management Nursing Certification Preparation ASMPN 17th National Conference – Review Course
Session 1 (Tracy & Stacey) – Overview, Test Outline and Section I of Study Guide Session 2 (Mina & Abby) – Section II & III Session 3 (Mina & Abby) – Section IV, VI and VII Session 4 (Mina & Emily) – Section V Session 5 (Tracy & Stacey) – Section VIII Session 6 (Abbey & Lisa) – Section VIIII, test review and test taking tips
Presented by:Tracy M. Morris,BSN, RN-BC, Clin. IV,R4 Clinical Educator&Stacey L. Williams,BSN, RN-BC, Clin. IV,R4 Shift Coordinator
Define pain Determine the differences between pain and suffering Explain the differences between acute verses chronic pain Discuss nociception and the transmission process (four distinct processes) Explain the difference between nociceptive verses neuropathic pain Describe the dimensions of pain
When you have a poor understanding of pain and its management = failure to treat pain effectively. Understanding the anatomy & physiology of pain is essential to increase our understanding of the pain process and how we can intervene.
Defining Pain (Classic Definitions) ◦ Whatever the experiencing person says it is, existing whenever the experiencing person says it does.” (McCaffery, 1968). ◦ Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” (Mersky, 1986). **Key point: Definitions illustrate the subjectivity of pain impacts both the physical & psychosocial function of the person.
Pain verses Suffering ◦ “Suffering is the person’s response to the sensation of pain. Pain is a primary response, and suffering is a secondary response (Beecher, 1957, as cited in Kahn & Steeves, 1986).” – St. Marie, B. 2010 – p. 10 ◦ A state of severe anguish or distress associated with an event or perceived threat (AMPMN 17th National Conference). ◦ Ferrell & Coyle propose 10 tenets concerning suffering – p. 10.
Acute verses Chronic Pain ◦ Acute pain = nociceptive pain ◦ Chronic pain = persistent pain ◦ Acute pain is “a warning signal to the body that something is wrong or needs attention” (St. Marie, B. 2010 p. 11). Key features: Follows an acute injury to the body (Recent onset) Abates as healing occurs (short duration: 6 months or less) Autonomic response (sympathetic) usually present (protective mechanism): hypertension, tachycardia, diaphoresis, shallow respirations, agitation/restlessness, facial grimace, splinting/guarding behavior, pallor, mydriasis Focus of treatment is on the cause of pain *acute pain can evolve into chronic pain Peripheral nociceptors are involved in transmission of sensation
Acute verses Chronic Pain ◦ Persistent (chronic) pain is “pain or discomfort that continues for an extended period of time (>6 months) Duration at least 1 month longer than usual course of pain / continuous or recurring pain from a chronic condition Cause may not be known *Serves no purpose (harmful effects) *Usually, no autonomic response Persists beyond apparent tissue healing May have acute exacerbations Treatment is focused on pain reduction
Cancer Pain can be acute or chronic (longer than 3 months) Multidimensional experience: physiologic, sensory, affective, cognitive, behavioral, and sociocultural dimensions (St. Marie, B. 2010 p. 13). Neuropathic Pain Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system (St. Marie, B. 2010 p. 14).
Myofascial Pain 1. Fibromyalgia Syndrome-diffuse musculoskeletal aching and pain with multiple predictable tender points. 2. Myofascial Pain Syndrome-localized muscle pain possible accompanied by referred pain to another region. Psychological pain – Substance Dependence ◦ Tolerance-need for markedly increased amounts of substance to achieve intoxication or desired effect ◦ Withdrawal-persistent desire occurs or efforts to cut down or control substance use are unsuccessful – time is spent in activities necessary to obtain the substance – social, occupational, or recreational activities are given up because of substance use. St. Marie, B (2010). Core curriculum for pain management nursing. 2nd edition. P. 15-16.
Substance Abuse/Dependence ◦ Physical dependence-a physiologic state in which abrupt cessation of the opioid or administration of an opioid antagonist results in a withdrawal syndrome. ◦ Addiction-is characterized by a persistent pattern of dysfunctional opioid use that may involve: adverse consequences, loss of control over the use of opioids, preoccupation with obtaining opioids despite the presence of adequate analgesia. St. Marie, B. (2010). Core Curriculum for Pain Management. Kendall Hunt Publishing Company
1. Mrs. Thomas is observed talking and laughing with friends in her room. When you enter the room, she starts grimacing and tells you her pain is 8/10. An important concept the nurse should consider as the reason for this change in her behavior: a. is a drug seeker and wants more opioids b. feels that if she does not act this way, the healthcare provider may not believe she has pain. c. is putting on a “show” for her friends to gain sympathy. d. has a history of mental illness.ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
a. Incorrect. Patients are suspected of lying to healthcare providers when their self-report of pain and their pain behaviors do not match. In this situation, more assessment needs to occur.b. Correct. Pts. learn to take “cues” from the healthcare provider on how they “should” respond to pain. Studies have shown pts. who demonstrate pain behaviors receive more analgesics than pts. who do not display pain behaviors.c. Incorrect. The pt.’s pain behaviors were not observed when she was interacting with friends, only when the nurse entered the room.d. Incorrect. This can make assessment a little more difficult; however the most important component of pain assessment is the healthcare provider believes what the pt. says. Further assessment could occur after her friends have left. ASPMN Practice Examination for Pain Management Nursing Certification Preparation
Addiction is characterized by all of the following except:a. “Clock watching,” hoarding of opioid analgesics, requesting extra opioids for fear of running out and demanding behaviors that are eliminated when pain is relieved.b. Impaired control over drug use and compulsive use.c. Continued drug use despite harm.d. Use of opioid for effects other than pain relief.
A. Correct. “Clock watching, hoarding of opioid analgesics, requesting extra opioids for fear of running out and demanding behaviors are signs of pseudoaddiction if they are eliminated when pain is relieved.B. Incorrect. Addiction has one or more of these characteristic features: impaired control over drug use, compulsive use, continued use despite harm and craving.C. Incorrect. Addiction has one or more of these characteristic features: impaired control over drug use, compulsive use, continued use despite harm and craving.D. Incorrect. The American Pain Society defines addiction as “a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief.”
Nociceptive Neuropathic ◦ Normal processing of ◦ Abnormal processing of stimuli sensory input by central or peripheral nervous systemASPMN 17th National Conference Certification Preparation Review Course
Central Pain verses Peripheral Pain Central ◦ Central Neuropathic Pain-pain arising as a direct consequence of a lesion or disease affecting the central somatosensory system. ◦ Poststroke syndrome (thalamic pain syndrome)-a central pain syndrome that may occur when a stroke damages the thalamus or parietal lobe. Peripheral Complex Regional Pain Syndrome I & IISt. Marie, B (2010). Core curriculum for pain management nursing.2nd edition. P. 14-15.
Central & Peripheral Pain ◦ Phantom limp pain-the sensation that the deafferented body part is still present (St. Marie, B. 2010, p. 15). Pain may be exacerbated by physical and psychological factors.
What can some of the causes be behind the development of neuropathic pain? Chemically induced – chemotherapy Ischemia – diabetic neuropathy Trauma – chronic post-surgical pain Infection – post-herpetic neuralgia Cancer
What are the characteristics of neuropathic pain? Shooting Tingling Burning Electric shock
Nociceptive Mixed Type Neuropathic Pain Pain Post herpetic CRPS Sickle cell crisis neuralgiaPostoppain Distal polyneuropathy Trigeminal Arthritis neuralgia Sports/Exercise injures ASPMN 17th National Conference Certification Preparation Review Course
Pain Transmission (Nociception) ◦ Nociceptive pain is pain arising from activation of nociceptors. ◦ Nociceptor is a sensory receptor that is capable of transducing and encoding noxious stimuli. ◦ Nociception is the neural processes of encoding and processing noxious stimuli. Nociception (normal processing of pain) – Involves 4 processes 1. Transduction 2. Transmission 3. Perception 4. Modulation
Visceral Somatic ◦ Produced in organs ◦ Occurs in bone, joint, ◦ May be referred to distant muscle, skin or site connective tissue ◦ Pain in hollow organ ◦ Aching, throbbing Intermittent cramping and ◦ Localized poorly localized
Ms. Jones is a 75 year-old female admittedwith the diagnosis of abdominal pain. Onassessment, she complains of pain 8/10, shestates it hurts all over and describes it as asqueezing/cramping pain. Her pain type wouldbe described as:a. Nociceptive somatic painb. Neuropathic painc. Nociceptive visceral paind. Peripherally generated pain ASPMN Practice Examination for Pain Management Nursing Certification Preparation
a. Incorrect. Nociceptive somatic pain arises from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and it is well localized.b. Incorrect. Neuropathic pain is caused by stimuli which are abnormally processed by the nervous system, examples of which include phantom limb pain and neuropathies.c. Correct. Nociceptive visceral pain arises from visceral organs. It is diffuse and poorly localized unlike somatic pain, which is usually localized. Visceral pain from a hollow viscus like the bowel is usually described as squeezing or cramping.d. Incorrect. Peripherally generated pain is neuropathic pain, examples of which include painful neuropathies. ASPMN Practice Examination for Pain Management Nursing Certification Preparation
Mr. D, is a 57-year-old male who presents to theclinic complaining of bilateral foot pain. He says itis constant and rates it at a 5/10. His PMH includesHBP, CAD, diabetes and ETOH abuse. He describeshis foot pain as burning, and states he feels like heis “walking on stones.” Mr. D is most likelysuffering from which type of pain?a. Nociceptive painb. Viceral painc. Neuropathic paind. Somatic pain ASPMN Practice Examination for Pain Management Nursing Certification Preparation
a. Incorrect. Nociceptive pain is caused by noxious stimuli from somatic or visceral structures.b. Incorrect. Visceral pain arises from visceral organs such as the GI tract and pancreas.c. Correct. Neuropathic pain arises from the peripheral or central nervous system and pts. Describe it as burning or stinging. Pts. with a hx of ETOH abuse and/or diabetes can develop a painful peripheral neuropathy.d. Incorrect. Somatic pain is a form of nociceptive pain which arises from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and it is well localized. ASPMN Practice Examination for Pain Management Nursing Certification Preparation
Transduction is the first step of the process ◦ It is the transfer of energy from one form to another causing the neuron to respond converting stimulus energy into electrical impulse. ◦ It begins with the free nerve endings (nociceptors) respond to a noxious stimuli. Noxious stimuli occurs when tissue damage and inflammation occurs as a result of: infection, inflammation, trauma, surgery, etc (Wood, S. 2008). Pain Management Nursing Certification Preparation Study Guide p. 21
So where are nociceptors found? The are distributed in: Somatic structures (skin, muscle, connective tissue, bones & joints) Visceral structures (organs and gastro-intestional tract)So how does the nerve endings (nociceptors) determine different types of pain? Determine by nerve endings (nociceptors) of C fibers and A-delta fibers – each are associated with different qualities of pain.Wood, Sharon (2008). Nursing times.net. Anatomy and physiology of pain.Retreived on 6/2/2010 from www.nursingtimes.net
Categories of noxious stimuli ◦ Mechanical (tumor growth, abscess, incision) ◦ Thermal (burn, scald) ◦ Chemical (infection, toxic substance) *Regardless of cause of stimuli (internal/external) a release of mediators from the damaged cells are released: Serotonin Substance P Prostaglandin Bradykinin Potassium HistamineResource: Pain Management Nursing Certification Preparation Study Guide p. 22
Chemical mediators activate the nociceptors to the noxious stimuli = Pain impulse is generated.How exactly is the pain impulse generated? Action potential, which is the exchange of NA+ & K+ ions occurs within cells.
Transmission = pain impulse is transmitted ◦ Occurs in 3 steps 1. From site of transduction along the nociceptor fibers to the dorsal horn in the spinal cord 2. From the spinal cord to the brain stem (ascending tract) 3. Through connections between the thalamus, cortex and higher level of the brainWood, Sharon (2008). Nursing times.net. Anatomy and physiology of pain.Retreived on 6/2/2010 from www.nursingtimes.net
Perception of pain is the end result of the neuronal activity of pain transmission and where pain becomes a conscious multidimensional experience (emotional, behavioral, motivational, etc.) when pain impulse transmitted to brain stem and thalamus = multiple areas are activated and a response is activated. Wood, Sharon (2008). Nursing times.net. Anatomy and physiology of pain. Retreived on 6/2/2010 from www.nursingtimes.net
Hypothalamus ◦ Activator of emotional input ◦ Controls emotional response Limbic system ◦ Generates purposeful goal-directed behavior ◦ Affects mood states Thalamus ◦ Allows perception Reticular formation at the brainstem ◦ Triggers arousal and alertness ◦ Add emotive response Cerebral cortex ◦ Receives the message
Modulation involves changing or inhibiting transmission of pain impulses in the spinal cord. ◦ The complex pathways involved in this process are referred to as the descending modulatory pain pathways can lead to either an increase in the transmission of pain impulses (excitatory) or a decrease in transmission (inhibition).Wood, Sharon (2008). Nursing times.net. Anatomy and physiology ofpain. Retreived on 6/2/2010 from www.nursingtimes.net
What does descending inhibition involve? It involves the release of inhibitory neurotransmitters that block or partially block the transmission of pain impulses = analgesia.Inhibitory neurotransmitters include: endogenous opioids (endorphins) acetylcholine serotonin Gamma-aminobutyric acid (GABA) Norepinephrine Oxytocin
Cortex Sub P Thalamus Pain Action Potential Spinal Cord Serotonin & Release of Norepi-neurotransmitters nephineprine reuptake inhibited NA+ & Endogenous Opioids Released Injury ASMPN 17th National Conference – Review Course
1. Mr. T enters the ER following a cut to his left hand. Which of the following identifies the four (4) processes of nociception? a. Perception, endorphin release, gate is open, pain reduction. b. Transmission, perception, T-Cell activation, pain reduction. c. Peception, control of activation, distraction, modulation. d. Transduction, transmission, perception, modulation ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
d. Correct. Transduction is a tranfer of energy from one form to another causing the neurons to respond. Transmission is the process of moving the painful message from the nerve ending from the periphery, to the spinal cord and into the ascending tract to the brain. Perception is the conscious relation that pain is present. Modulation occurs when the brain inhibits pain impulses through the decending pathway.ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
Pain is a multi-dimensional experience ◦ Physical dimension ◦ Sensory dimension ◦ Affective dimension ◦ Cognitive dimension ◦ Behavioral dimension ◦ Sociocultural dimension ◦ Spiritual dimension Resource: Pain Management Nursing Certification Preparation Study Guide p. 23.
Begins with pain-producing tissue injury, neurochemistry and pain pathways. Autonomic nervous system activity = increase BP, heart rate, sweating and skin temp. changes. Influence the pain duration (acute to chronic)Resource: Pain Management Nursing Certification Preparation Study Guide p.23.
What the pain feels like. Influences the location, severity and quality of pain. Focus on your pain assessment questions: ◦ Where do you hurt? ◦ Scale 0-10? ◦ Can you describe your pain? ◦ What makes your pain better? ◦ What makes your pain worse? Resource: Pain Management Nursing Certification Preparation Study Guide p. 23.
Incorporates emotional responses to pain: depression, mood changes, irritability, stress, anxiety, anger, personality traits and psychiatric diagnoses. Depression and chronic pain frequently co-exist. Resource: Pain Management Nursing Certification Preparation Study Guide p. 24.
3 aspects involved: ◦ Meaning of pain to the individual ◦ The individual’s view of him or herself ◦ Pain’s effect on the individual’s thought processes Attitudes, beliefs and knowledge about pain and its treatment are important parts of this dimension Effective coping skills may enhance the management of pain. **The cognitive domain strongly influences the behavioral dimension.Resource: Pain Management Nursing Certification Preparation StudyGuide p. 25.
1st part of behavioral dimension: behavior may show the presence or severity of the pain. 2nd part of behavioral dimension: specific behaviors may help identify the etiology of the pain. **The absence of behavioral indicators of pain does not mean the absence of pain** Resource: Pain Management Nursing Certification Preparation Study Guide p. 26.
Encompasses the demographic, ethnic, economics and other sociocultural influences of the patient/their caregivers. Includes the beliefs, values, attitudes and practices shared by a group. Previous pain experiences within the healthcare system, may also affect the person’s pain.Resource: Pain Management Nursing CertificationPreparation Study Guide p. 26.
Incorporates the meaning of pain as well as the suffering (emotional/spiritual pain) involved when pain occurs. Suffering is a subjective secondary response, while pain is a primary response to the environment.
An example of a physical response to pain would be the pt: a. Reports she is depressed b. Reports she gets some relief with massage c. Reports her heart races when her pain is severe d. Rubs her neck during her appointment and changes positions frequentlyASPMN Practice Examination for Pain Management Nursing Certification Preparation.
a. Incorrect. The depression response is an affective response. b. Incorrect. The sensation felt with massage is a sensory response. c. Correct. The physiological response to pain is a physical response. d. Incorrect. The change in her behavior is a behavioral response.ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
A person’s affective response to pain is most influenced by:a. Geneticsb. Emotional statec. Environmentd. socioeconomics ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
a. Incorrect. While genetics may influence affective response, emotional state produces affective response b. Correct. An emotional reaction to a painful situation is an affective response. c. Incorrect. Environmental influences on affect are not consistent. d. Incorrect. Socioeconomic influences do not produce a consistent affective response.ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
An example of the sociocultural dimension of pain is:a. A pt. doesn’t fill their prescription due to lack of insurance coverage.b. A pt. becomes anxious when she thinks about an upcoming procedure.c. The pt. believes her headaches are coming from a tumor.d. The pt. explains how she turns her pain over to a higher power.ASPMN Practice Examination for Pain Management Nursing CertificationPreparation.
a. Correct. A pt. may not fill a prescription due to lack of insurance coverage or adequate funds. b. Incorrect. Emotional response is an example of the affective dimension. c. Incorrect. This is an intellectual response and therefore cognitive dimension. d. Incorrect. This is a spiritual dimension to the pt’s pain, giving the pain meaning.ASPMN Practice Examination for Pain Management Nursing Certification Preparation.
The End! Thank you for your attentionand energy! Congratulations, you areone step closer to becomingANCC Certified in PainManagement!
American Society for Pain Management Nursing. 17th National Conference. Certification Preparation Review Course. American Society for Pain Management Nursing.American Society for Pain Management Nursing. Practice Examination for Pain Management Nursing Certification Preparation.American Society for Pain Management Nursing. Study Guide for Pain Management Nursing Certification Preparation.St. Marie, B (2010). Core curriculum for pain management nursing. 2nd edition. Kendall Hunt Professional.Wood, S. (2008). Nursing times.net. Anatomy and physiology of pain management. Retrieved from www.nursingtimes.net on June 2nd of 2010.