Pmn certification session v

Presented by:

Tracy M. Morris, BSN, RN-BC, Clin. IV, R4 Clinical Educator

&

Stacey L. Williams, BSN, RN-BC, Clin. IV, R4 Shift Coordinator

Pain Management Nursing

Section 8 – Pain Diagnoses

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 pain

ASPMN 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!!


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 arousal


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.


Causes of Acute Back Pain

Trauma or fractures

Inflammation

Neoplasm (metastasis)

Infections (epidural abscess)

Degenerative

Congenital

Spinal stenosis


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

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.


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.


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. Smoking


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 phase


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 hx


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.


Chronic Daily Headache

Cause: Unknown

Precipitating factors:

Stress

Anxiety

Trauma

Depression

Medication use or discontinuation

Presentation:

Occurs daily or 15x a month


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 headaches


Medications for Headache Algorithm

Mild

Intermittent

Moderate

Intermittent

Severe

Intermittent

Acetaminophen, NSAIDS

NSAIDS Combinations,

Midrin

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 Question

A 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. Migraine

B. Cluster

C. Tension

D. 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 nerve


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 pump

St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain

Management 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 pain



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.



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 abdomen


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.


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.



http://www.youtube.com/watch?v=ae4ZdRfZR3I

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 > joints


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 later


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

Imuran


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 morning


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

Glucosamine


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 stages


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 HIV



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 consumption



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



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 & remissions



Trigeminal Neuralgia Cont.’

Treatment:

Protect area from cold wind

Anticonvulsant agents (Tegretol), tricyclic antidepressants,

topical local anethetic, NSAIDS, antispasticity drugs

(baclofen), ( lidocaine, EMLA, etc.)



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 pains



Brain Pickers

The strongest predictor for developing Post Herpetic Neuralgia

(PHN) is:

a. Advanced age

b. Childhood

c. Immunocompromised state

d. Psychological stress at the time of herpes zoster outbreak

ASMPN Practice Examination for Pain Management Nursing Certification Preparation

Rationale

a. Correct. Advancing age is the strongest predictor for

developing PHN and for its long-term existence

b. Incorrect. Most children do not experience PHN

c. Incorrect. The incidence of PHN is not higher in

immunocomprised patients

d. 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.


Brain Pickers

Trigeminal 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” pain

c. It never lasts more than a minute

d. It never has a pain-free interval


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 Management

Nursing 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 system



Brain Pickers

1. 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 atrophy

b. Rough toughened skin

c. Excessive hair growth

d. Increased sensation to pinprick or temperature


Rationale

a. Correct. Muscle atrophy loss may be seen in later stages

b. Incorrect. Chronic neuropathic pain may be associated with

the development of smooth, fragile skin

c. Incorrect. Chronic neuropathic pain may be associated with

hair loss

d. Incorrect. Chronic neuropathic pain may be associated with

sensory loss especially to pinprick, dull stimuli, or

temperature


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.


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 headedness


Cardiac Pain Cont.’

Treatment:

Administer O2

Morphine

Nitrates


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.).


Spinal Cord Injury/Disease

Treatment:

*Treatment can be difficult

Treat the primary condition

Tricyclic antidepressants

Anticonvulsants

Opioids


Brain Pickers

Most 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 poker

b. The lack of nociceptive pain secondary to injury

c. Cramping in the feet and severe muscle spasticity

d. Well localized pain


Rationale

a. 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 spasticity

d. Incorrect. The pain may be localized, radicular, or diffuse;

it may be constant or intermittent; it may be mild to

disabling.

References

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.

Pmn certification session v

Health & Medicine

Transcript of Pmn certification session v