Pmn certification session v

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 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

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
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 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

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.

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