pmn certification session v
DESCRIPTION
TRANSCRIPT
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!!
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 arousal
ASPMN 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. Smoking
ASPMN 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 phase
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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
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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.
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Chronic Daily Headache
Cause: Unknown
Precipitating factors:
Stress
Anxiety
Trauma
Depression
Medication use or discontinuation
Presentation:
Occurs daily or 15x a month
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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
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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
ASPMN 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 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
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management 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 Pain
Management 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 abdomen
ASPMN 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 Pain
Management 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 > joints
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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
ASPMN 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
Imuran
ASPMN 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 morning
ASPMN 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
Glucosamine
ASPMN 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 stages
ASPMN 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 HIV
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management 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 consumption
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management 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 & remissions
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management 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 Pain
Management 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 pains
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management Nursing. Kendal Hunt Professional. Second Edition.
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.
ASMPN Practice Examination for Pain Management Nursing Certification Preparation
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
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.
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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
St. Marie, B (2010). Core curriculum for pain management nursing. American Society for Pain
Management Nursing. Kendal Hunt Professional. Second Edition.
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
ASMPN Practice Examination for Pain Management Nursing Certification Preparation
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
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 headedness
ASPMN Study Guide for Pain Management Nursing Certification Preparation
Cardiac Pain Cont.’
Treatment:
Administer O2
Morphine
Nitrates
ASPMN 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
Opioids
ASPMN Study Guide for Pain Management Nursing Certification Preparation
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
ASMPN Practice Examination for Pain Management Nursing Certification Preparation
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.