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    Pmn certification   session v Pmn certification session v Presentation Transcript

    • Section 8 – Pain Diagnoses Pain Management Nursing Presented by: Tracy M. Morris, BSN, RN-BC, Clin. IV, R4 Clinical Educator & Stacey L. Williams, BSN, RN-BC, Clin. IV, R4 Shift Coordinator
    • Objectives: Understand the underlying mechanisms of cancer pain Determine differences between the categories of headaches (migraine, tension-type, cluster, etc.) Define Fibromyalgia State the difference between Complex Regional Pain Syndrome I & II Differentiate between rheumatoid arthritis and osteoarthritis Describe the underlying mechanisms of peripheral neuropathy and its treatment
    • Cancer Pain Three primary physiologic causes of cancer pain: 1. Tumor involvement of an area causing pressure or obstruction 2. Cancer-related procedures and treatments (surgery, diagnostic procedures, chemo/radiation therapy and their side effect) 3. Non-cancer pain syndromes such as diabetic neuropathy, post- herpetic neuralgia, arthritis, or chronic back painASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Cancer Pain Cancer pain can acute or chronic pain Acute pain can be caused by: diagnostic, therapeutic interventions, procedures, mucositis, tumor impingement/invasion, etc. Chronic pain can be caused by: bone pain or nerve compression Neuropathic pain can be caused by direct neural invasion by tumor, pressure from the tumor or nerve structures, or referred pain (pain at a site distant from the painful stimuli innervated by a shared nerve root). Neuropathic pain from chronic post surgical pain (post-mastectomy) and from chemotherapy-related nerve damage. Cancer patients may have nociceptive or neuropathic pain or a combination of both----Take home point!!ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Cancer Pain Cancer pain is considered a multidimensional experience (physiologic, sensory, affective, cognitive, behavioral, and sociocultural dimensions). Key point: with chronic cancer pain the patient rarely has signs of sympathetic nervous system arousalASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Chronic Pain Diagnoses Low Back/Neck Pain (47%)  Many causes, both acute and chronic  Direct injury to bone, tendons, ligaments, spinal nerves, joints or fascia  May be due to ischemia or irritation of nerves  Abnormalities of the central nervous system  Abnormalities or injury of peripheral nerves  May be nociceptive, neuropathic, or mixed  Muscle tension, posture, improper lifting, obesity, overuse and underuse of muscles can impact low back/neck pain  Depression, stress, and anger are psychological issues that may factor in  May be referred pain. Examples include: pancreatitis, kidney disease, uterine disease, labor pain, etc.ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Causes of Acute Back Pain Trauma or fractures Inflammation Neoplasm (metastasis) Infections (epidural abscess) Degenerative Congenital Spinal stenosis ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Factoid The number of medical visits resulting from low back pain is second only to the number of visits for upper respiratory illnesses. Bare & Smeltzer, 2004. Brunner & Suddarth’s Textbook of Medical Surgical Nurse. Lippincott Williams & Wilkins, Philadelphia, PA.
    •  http://www.youtube.com/watch?v=O03nr3z6SUs
    • Myofascial/Fibromyalgia  Myofascial Pain Syndrome  Described as pain related to trigger points (referred pain zones). These trigger points are thought to develop due to acute or chronic muscle strain, then sustained/exacerbated by factors such as muscle overuse, misuse, or underuse, or interference with muscle metabolism interference (caused by inadequacies in nutrition, anemia, estrogen deficiency, etc.)  Mechanical stressors contribute to muscle strain. Examples: poor posture, leg length differences, trauma, repetitive motion injuries, etc.  Muscle tension may be related to emotions (stress, anger, fear, anxiety), which may result in pain by a buildup of waste products at nerve endings.ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Fibromyalgia A chronic, diffuse musculoskeletal pain syndrome characterized by specific tender points the cause of which is still unknown. Characterized by diffuse, constant, aching, musculoskeletal pain associated with specific tender points, morning stiffness, stiffness toward the end of range of motion, fatigue, and non restorative sleep. To meet the American Rheumatological Association criteria for fibromyalgia:  a person must have pain in all four quadrants of the body for at least three months  have tender spots in at least 11 of 18 specific sites. ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Headaches 6 major types 1. Migraine 2. Tension 3. Cluster 4. Chronic daily 5. Analgesic rebound 6. Occipital neuralgia **Focus on the unique differences between the types**ASPMN 17th National Conference – Certification Preparation Review Course
    • Migraine Causes: 1. Vasodilatation 2. Neurogenic inflammation 3. Abnormal serotonin metabolism Exacerbating factors 1. Stress 2. Certain foods/drinks 3. Altered sleep 4. Bright lights 5. Medications 6. SmokingASPMN 17th National Conference – Certification Preparation Review Course
    • Migraines Usually in adults the pain is unilateral 3 phases: 1. Premonitory (hours or days before) 2. Main attack 1. Aura – visual loss, flashing lights, pins and needles on face or limbs, muscle weakness, language problems, dizziness 2. Headache – unilateral, gradual onset, peak, subside; throbbing or pulsating. Photosensitivity, N/V 3. Resolution phaseASPMN 17th National Conference – Certification Preparation Review Course
    • Tension-type Headache  Cause: sustained muscle contraction  Presentation of headache  Bilateral/symmetrical  Dull tightness around the head, neck or scalp  Also described as: pressure, tightness, pounding, aching and non-pulsating  Associated with:  Depression  Sleeping difficulties  Family hxASPMN 17th National Conference – Certification Preparation Review Course
    • Cluster Headache Cause: unknown-?sympathetic nervous system dysfunction due to autonomic appearing response: watery eyes, nasal stuffiness, facial flushing, etc. May be seasonal related or precipitated by alcohol use. Presentation:  Unilateral. Described by many patients as feels “like a hot poker in my eye.”  Typically intense and excruciating in nature.  Rapid onset, episodic and occurs in groups – usually goes into remission for many months/years.ASPMN 17th National Conference – Certification Preparation Review Course
    • Chronic Daily Headache Cause: Unknown Precipitating factors:  Stress  Anxiety  Trauma  Depression  Medication use or discontinuation Presentation:  Occurs daily or 15x a monthASPMN 17th National Conference – Certification Preparation Review Course
    • Analgesic Rebound Headache Cause: withdrawal from frequently used medications. *as regularly used analgesic Presentation:  Cycle of headache, medication ingestion, headache, more medication ingestion, etc. *Difficulty disguising from chronic daily headachesASPMN 17th National Conference – Certification Preparation Review Course
    • Medications for Headache Algorithm Mild Acetaminophen, NSAIDS Intermittent Moderate NSAIDS Combinations, Intermittent Midrin Severe Intermittent 5-HT1 Agonists (Triptans) Ergotamine Derivatives
    • A Closer Look at the Meds Midrin (acetaminophen, Isometheptene, Dichloralphenazone) - Used for tension headache/migraine  Used only after the headache starts-not to prevent headaches  Consult doctor before using with hx of HBP or renal disease 5-HT1 Agonists (Triptans) – agents that have an affinity for serotonin receptors and are able to mimic the effects of serotonin by stimulating the physiologic activity at the cell receptors.  Examples: Sumatriptan (Imitrex) & Zolmitriptan (Zomig) Ergotamine Derviatives – biological activity as a vasoconstrictor = contriction of the intracranial extracerebral blood vessels through the 5-HT1b receptor.
    • Occipital Neuralgia Cause: ?nerve root entrapment of C2 or C3 nerve root or cervical myofacial pain Presentation:  Recurrent and episodic  Neuralgic pain starting at base of skull and radiating to front of head. Dull pain follows high intensity pain.  Tender spot over scalp covering occiput
    • Test QuestionA 25 year old man presents to the ER with frequent headaches for the last two weeks. He states that the headaches are severe and “feels likes someone is sticking a hot poker in my left eye.” He eyes are watery and he sounds like he has nasal congestion. What classification of headaches would you suspect your patient might have?A. MigraineB. ClusterC. TensionD. Occipital neuralgia
    •  http://www.youtube.com/watch?v=Zo-xQLigqDo
    • Complex Regional Pain Syndrome(CRPS I & II) The primary difference between CRPS I & CRPS II is the predisposing factor. *Considered to be sympathetically maintained.  Initially = vasodilation, increased temperature, edema  Progression = atrophy of skin & nails, loss of hair, persistent coldness, pallor, cyanosis and stiffness of joints. CRPS I (reflex sympathetic dystrophy)  Injury to bone or soft tissue  Pain persists much longer than expected  NOT limited to single peripheral nerve CRPS II (causalgia)  Injury to nerve is predisposing factor  Limited injury to single nerveASPMN 17th National Conference – Certification Preparation Review Course
    • Complex Regional Pain Syndrome (CRPS I & II)  CRPS is a chronic pain condition  Continuous intense pain (burning) out of proportion to the severity of the injury  gets worse rather than better over time.  CRPS often affects one of the arms, legs, hands or feet.  Causes: Sympathetic nervous system hyperactivity / trigger of immune system  inflammatory response  No cure  focus on relieving symptoms  Analgesics  Antidepressants (tricyclic)  Corticosteriods  Anticonvulsants (gabapentin)  Physical therapy  Sympathetic nerve block  Intrathecal drug pumpSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • HIV-Related Pain  *Similar to cancer pain in that pain syndromes in HIV disease arise from multiple causes. Pain r/t:  Progression of disease  Medical treatment of disease  Infections are the primary cause of pain (viral, fungal, bacterial and parasitic)  Antiretroviral may cause neuropathic pain  **Average 2 or more types of pain at any time  Rheumatologic disorders  HIV-related neoplasms (Kaposi’s Sarcoma, lymphoma)  neuropathic pain or nociceptive painSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • HIV-Related Pain  Types of pain  Oral pain + oral ulcerations (herpes simplex virus, Epstein-Barr virus, etc.)  Candidiasis  Esophageal pain  Abdominal pain  Cryptosporidial diarrhea, salmonella infection, Campylobacter enteritis, etc.  Biliary and pancreatic pain  Anorectal pain  Perirectal abscesses, Kaposi sarcoma, fissures, cancer, genital warts, etc.  Neurological pain  HIV encephalitis, sinus infections, etc.  Peripheral neuropathy pain  Rheumatological pain  Pain r/t HIV therapy  Drugs, chemo, radiation therapy, etc.St. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Sickle Cell Disease  Inherited vaso-occlusive disease characterized by intermittent pain or “crisis”  Cause: A decrease in oxygen tension causing the RBCs to change from their usual flexible disks into sticky, rigid, sickle shapes  clump together  clog small blood vessels  ischemia and tissue death  Precipitating factors:  Infection, overexertion, dehydration, altitude changes  S/S:  *Pain is a hallmark clinical manifestation – pain often present in the bone, chest and abdomenASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Sickle Cell Disease Somatic pain: muscle, bones, tendons Visceral pain: spleen, liver, lungs Pain management can be very challenging  Mild pain = NSAIDS or acetaminophen  Moderate pain = add an opioid  Severe pain = PCA  Pain for several days = sustained-released opioid Physical treatment includes:  Hydration  O2  Massage, acupuncture, PT, etc.ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Phantom Pain Phantom pain is perceived as pain as in a missing body part Cause: Unclear. Seems to originate in the brain  **Thought to be a result of several unspecified/interacting neuronal events involving both the peripheral & central nervous system. S/S:  Burning, crushing, tingling, sharp, “pins & needles”  Pain may be intermittent or continuous  Pain may start after amputation or occur months to years later Treatment  TENS, anticonvulsants, tricyclic antidepressants, spinal cord stimulation, etc.St. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    •  http://www.youtube.com/watch?v=ae4ZdRfZR3I
    • Arthritis - RA Rheumatoid arthritis (RA) – (inflammatory) a chronic autoimmune disorder characterized by symmetrical synovitis of the joints  leads to progressive destruction. Cause: unknown, ?combination of environmental & genetic influences Presentation:  A systemic disease: affects synovial joints, muscles, ligaments and tendons S/S:  Aching and burning joint pain  Morning stiffness last >1 hour before improvement  Involves 3 or > jointsASPMN 17th National Conference – Certification Preparation Review Course
    • Arthritis - RA The American Rheumatism Association dx criteria include 6 weeks of the following:  Morning stiffness  Pain on motion or tenderness at one or more joints  Swelling of one or more joints Chronic joint destruction and joint deformity are common – initially an inflammatory response  erosion of cartilage and bone laterASPMN 17th National Conference – Certification Preparation Review Course
    • Arthritis - RA Treatment options  NSAIDS – act by slowing the body’s production of prostaglandins  Ibuprofen  Naproxen  Indomethacin  Corticosteroids – powerful anti-inflammatory agents – used to reduce inflammation and suppress activity of the immune system  Prednisone  Dexamethasone  Disease Modifying Anti-Rheumatic Drugs – influence the disease process itself and do not only treat symptoms  Methotrexate  Sulfasalazine  ImuranASPMN 17th National Conference – Certification Preparation Review Course
    • Osteoarthritis Osteoarthritis (Degenerative joint disease) – is a disease of the cartilage that progressively produces a local tissue response, mechanical change, and failure to function. *Most common non-inflammatory arthritic condition. S/S:  Deep aching pain results from a degenerative process in a single or multiple joints. Pain present at rest, with start of activity and at night in later stages.  Weather may affect pain  Typically affects the joints of the hand, feet, ankles, and spine as well as weight-bearing joints (hips and knees).  Associated with stiffness after inactivity and in the morningASPMN 17th National Conference – Certification Preparation Review Course
    • Osteoarthritis Presentation:  Incidence increases with age  Progressive loss of articular cartilage  Hypertrophy of bone due to wear & tear Treatment:  NSAIDS – used for pain not to reduce inflammation  COX-2 inhibitors  Tylenol  GlucosamineASPMN 17th National Conference – Certification Preparation Review Course
    • Neuropathies  Injury or disease of central or peripheral nervous system  Results in abnormal activation of nociceptive neurons or self- sustaining ectopic discharges across neuronal membrane  Severity of pain may be mild to severe – Pain may also be constant or intermittent  Description: burning, tingling, freezing, electrical, shooting, hot/cold, numb, or “just feels weird.”  Touch may aggravate pain – prostheses, clothes placed on area may increase pain  May be associated with the development of smooth, fragile skin with hair loss. Muscle atrophy can be seen in later stagesASPMN 17th National Conference – Certification Preparation Review Course
    • Peripheral Neuropathy  Consist of damage to the peripheral nervous system (>100 types identified – each with own set of symptoms, development and prognosis). A specific peripheral nerve is damaged.  Cause: inflammation, ischemia, infarction, compression, neuromas. Causes may be inherited or acquired (physical injury, tumors, autoimmune responses, alcoholism, certain medications (chemo agents), vascular and metabolic disorders.  Pathogenesis often unknown or unclear  Polyneuropathies  Diabetes  Drug toxicity  Nutritional deficiencies  HIVSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Peripheral Neuropathy Cont.’ S/S: *Vary depending on what nerve or nerves are involved  Constant or transient burning, aching or lancinating limb pain results from disease of the peripheral nerves (usually of feet and hands). Deep aching pain can be experienced at night.  Associated with sensory loss, such as to pinprick, dull stimuli and temperature. Occasionally associated with weakness and muscle atrophy. Extreme cases can present with muscle wasting, paralysis or organ and gland dysfunction. Treatment:  Treat or stabilize the underlying disease (control blood glucose)  Eliminate the underlying cause (toxins or vitamins deficiencies)  Limit or avoid alcohol consumptionSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Peripheral Neuropathy Cont.’ Treatment Cont.’  Quit smoking  Use anticonvulsant agents, tricyclic antidepressants, local anesthetic (lidocaine or EMLA cream), occupational therapy, physical therapy  Spinal cord stimulation St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain Management Nursing. Kendal Hunt Professional. Second Edition.
    • Trigeminal Neuralgia Consist of pain along the second or third division of the trigeminal nerve (fifth cranial nerve). Causes: May be caused by pressure from a blood vessel on the trigeminal nerve as it exits the brain stem or by other disorders that damage the nerve sheath. S/S:  Sudden onset, right side more common, recurrent  Described as sharp, agonizing, electric shock-like stabs of pain felt superficially (across face, nose, lips, eyes, ears, scalp, buccal mucosa) – “lightening strike”  May be triggered by light touch  Short repetitive bursts lasting 1-2 minutes with a refractory period of about 30 seconds to a few minutes – brief duration of repetitive bursts = exacerbations & remissionsSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Trigeminal Neuralgia Cont.’ Treatment:  Protect area from cold wind  Anticonvulsant agents (Tegretol), tricyclic antidepressants, topical local anethetic, NSAIDS, antispasticity drugs (baclofen), ( lidocaine, EMLA, etc.)St. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Postherpetic Neuralgia Cause: Inflammation of peripheral nerve due to active outbreak of herpes zoster (shingles) Presentation:  Pain persisting past the stage of healing lesions after acute herpes zoster. Usually diminishes over time (3 months)  Chronic pain with skin changes along a dermatomal distribution after acute herpes zoster  Most common in adults >50 years of age and those whom are immunocompromised  Pain is described as mild to severe with burning, sharp and brief, intense, shooting painsSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Brain PickersThe strongest predictor for developing Post Herpetic Neuralgia (PHN) is:a. Advanced ageb. Childhoodc. Immunocompromised stated. Psychological stress at the time of herpes zoster outbreak ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Rationalea. Correct. Advancing age is the strongest predictor for developing PHN and for its long-term existenceb. Incorrect. Most children do not experience PHNc. Incorrect. The incidence of PHN is not higher in immunocomprised patientsd. Incorrect. Factors under study but not established as predictors are psychological stress at the time of the HZ outbreak, comorbid depression, somatization, and disease beliefs. ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Brain PickersTrigeminal neuralgia is described as the most excruciating pain to mankind because:a. It is a dull but intense pain on the left and right side of the face.b. This pain is a sudden, excruciating, “lightening-strike” painc. It never lasts more than a minuted. It never has a pain-free interval ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Rationale a. Incorrect. It is recurrent and is felt superficially in the face, nose, lips, eyes, ears, scalp, upper or lower jaw, or buccal mucosa (the distribution of the trigeminal nerve). It more frequently occurs on the right side. b. Correct. This pain is sudden, excruciating, “lightening-strike” pain. c. Incorrect. The pain characteristically occurs in short repetitive bursts lasting several seconds to 1 to 2 minutes, followed by a refractory period of 30 seconds to a few minutes. d. Incorrect. Painful episodes occur several to many times a day, to (rarely) continuously. These episodes may last for up to 2 months then be followed by a pain-free interval before yet another recurrence.ASMPN Practice Examination for Pain ManagementNursing Certification Preparation
    • Postherpetic Neuralgia Cont.’ Treatment:  *Antiviral agents with early detection are most effective if started within 72 hours after onset of rash  Tricyclic antidepressants  Serotonin norepinephrine reuptake inhibitors (Cymbalta)  Anticonvulsants (Neurontin or Lyrica)  Zostrix cream, lidocaine (use after lesions are healed) Prevention: Zoster vaccine is indicated for people >60 years or older without compromised immune systemSt. Marie, B (2010). Core curriculum for pain management nursing. American Society for PainManagement Nursing. Kendal Hunt Professional. Second Edition.
    • Brain Pickers1. Chronic neuropathic pain is caused by an accident, injury or certain illness(es). Which of the following conditions may occur with chronic neuropathic pain?a. Muscle atrophyb. Rough toughened skinc. Excessive hair growthd. Increased sensation to pinprick or temperature ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Rationalea. Correct. Muscle atrophy loss may be seen in later stagesb. Incorrect. Chronic neuropathic pain may be associated with the development of smooth, fragile skinc. Incorrect. Chronic neuropathic pain may be associated with hair lossd. Incorrect. Chronic neuropathic pain may be associated with sensory loss especially to pinprick, dull stimuli, or temperature ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Multiple Sclerosis (MS) The neuropathic pain associated with MS is caused by the demyelination of neurons, the spinal cord and the brain  ectopic nerve impulses. Location of pain is dependent upon the spinal cord level of involvement. Acute or persistent Chronic neuropathic pain in MS may be described as burning, aching, prickling or “pins & needles.” Spasticity or muscle spasms/cramps as well as joint tightness or aching related to the spasticity may also occur. ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Cardiac Pain Causes: ischemia from M.I (during or after) or angina Cardiac ischemia pain stimulates vagal reflux and sympathetic impulses that are detrimental to cardiac function and pacing = increase in workload on the heart and increases O2 consumption. Acute nociceptive pain – mild to severe Short lasting or intermittent Described as:  Pressure, squeezing, fullness  In one or both arms, back, neck, jaw or stomach  Dyspnea may be present  Fatigue, sweating, n/v, light headednessASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Cardiac Pain Cont.’ Treatment:  Administer O2  Morphine  NitratesASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Spinal Cord Injury/Disease Injuries are usually due to trauma (MVAs, gunshot wounds, diving accidents, etc.). Can also be due to: vascular pathology inflammatory lesions neoplasms, demyelinating diseases, abscesses, etc. Presentation: - “Central Pain Syndrome” - described as: burning, aching, stabbing, prickling, electrical, pins and needles, intense, constant or occurring in waves.---Neuropathic in nature Most SCI/D pain is felt below the level of the injury in the torso, hips, or groin but may extend into the legs, feet and toes. May also experience nociceptive pain due to:  acute or chronic musculoskeletal injury (bone, joint or muscle trauma or inflammation, muscle spasm, etc.).  Acute or chronic visceral disorders (renal calculi, bowel or sphincter dysfunction, etc.).ASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Spinal Cord Injury/Disease Treatment:  *Treatment can be difficult  Treat the primary condition  Tricyclic antidepressants  Anticonvulsants  OpioidsASPMN Study Guide for Pain Management Nursing Certification Preparation
    • Brain PickersMost Spinal Cord Injury/Disease (SCI/D) pain is felt below the level of the injury in the torso, hips, or groin but may extend into the legs, feet and toes. Another common complaint includes:a. The sensation similar to sitting on a hot pokerb. The lack of nociceptive pain secondary to injuryc. Cramping in the feet and severe muscle spasticityd. Well localized pain ASMPN Practice Examination for Pain Management Nursing Certification Preparation
    • Rationalea. Incorrect. Patients experience cramping in the feet and muscle spasticity; the sensation of a rectal mass or like “sitting on a hot poker” is rare.b. Incorrect. Patients with SCI/D also experience nociceptive pain.c. Correct. Some patients experience cramping in the feet; some develop severe muscle spasticityd. Incorrect. The pain may be localized, radicular, or diffuse; it may be constant or intermittent; it may be mild to disabling.
    • ReferencesAmerican 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.