Pain management certification session 1

A Focus on Section I
By: Tracy M. Morris, BSN, RN-BC

 ANCC Website and how to get started:
 http://www.nursecredentialing.org/
 Eligibility criteria
 Where to get additional CEUs
◦ www.nursing2009.com
◦ www.advanceweb.com.nurses
◦ www.inroadsforpain.com
◦ www.medscape.com
◦ www.pain.com

Pathophysiology 18 questions 12% of test
Pain Assessment 43 questions 29% of test
Interventions 24 questions 16% of test
Side Effects 17 questions 11% of test
Patient and family 17 questions 11% of test
Education
Collaborative 31 questions 21% of test
Institutional Issues

Resource: ASPMN Practice Exam for Pain Management Nursing
Certification Prep

 6 Sessions in total
 Sessions start in August
 Two sessions per month (August, September
and October)
 2 CEUS per session
 Read/prep before session

 Core Curriculum for Pain Management
Nursing (2010). ASMPN. 2nd edition. Barbara
St. Marie.
 ASMPN Practice Examination for Pain
Management Nursing Certification Preparation
 ASMPN Certification Prep Course 2007
(Audiofiles)
 ASMPN Study Guide for Pain Management
Nursing Certification Preparation
 ASMPN 17th National Conference – Review
Course

 Session 1 (Tracy & Stacey) – Overview, Test
Outline and Section I of Study Guide
 Session 2 (Mina & Abby) – Section II & III
 Session 3 (Mina & Abby) – Section IV, VI and
VII
 Session 4 (Mina & Emily) – Section V
 Session 5 (Tracy & Stacey) – Section VIII
 Session 6 (Abbey & Lisa) – Section VIIII, test
review and test taking tips

Presented by:
Tracy M. Morris,
BSN, RN-BC, Clin. IV,
R4 Clinical Educator
&
Stacey L. Williams,
BSN, RN-BC, Clin. IV,
R4 Shift Coordinator

 Define pain
 Determine the differences between pain and
suffering
 Explain the differences between acute verses
chronic pain
 Discuss nociception and the transmission
process (four distinct processes)
 Explain the difference between nociceptive
verses neuropathic pain
 Describe the dimensions of pain

 When you have a poor understanding of pain
and its management = failure to treat pain
effectively.
 Understanding the anatomy & physiology of
pain is essential to increase our
understanding of the pain process and how
we can intervene.

 Defining Pain (Classic Definitions)
◦ Whatever the experiencing person says it is,
existing whenever the experiencing person says it
does.” (McCaffery, 1968).
◦ Pain is “an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage.” (Mersky, 1986).

**Key point: Definitions illustrate the subjectivity of
pain  impacts both the physical & psychosocial
function of the person.

 Pain verses Suffering
◦ “Suffering is the person’s response to the
sensation of pain. Pain is a primary response, and
suffering is a secondary response (Beecher, 1957,
as cited in Kahn & Steeves, 1986).” – St. Marie, B.
2010 – p. 10
◦ A state of severe anguish or distress associated
with an event or perceived threat (AMPMN 17th
National Conference).

◦ Ferrell & Coyle propose 10 tenets concerning
suffering – p. 10.

Acute Pain verses Chronic Pain

 Acute verses Chronic Pain
◦ Acute pain = nociceptive pain
◦ Chronic pain = persistent pain

◦ Acute pain is “a warning signal to the body that something
is wrong or needs attention” (St. Marie, B. 2010 p. 11).
 Key features:
 Follows an acute injury to the body (Recent onset)
 Abates as healing occurs (short duration: 6 months or less)
 Autonomic response (sympathetic) usually present (protective
mechanism): hypertension, tachycardia, diaphoresis, shallow
respirations, agitation/restlessness, facial grimace,
splinting/guarding behavior, pallor, mydriasis
 Focus of treatment is on the cause of pain
 *acute pain can evolve into chronic pain
 Peripheral nociceptors are involved in transmission of sensation

 Acute verses Chronic Pain
◦ Persistent (chronic) pain is “pain or discomfort that
continues for an extended period of time (>6
months)

 Duration at least 1 month longer than usual course of
pain / continuous or recurring pain from a chronic
condition
 Cause may not be known
 *Serves no purpose (harmful effects)
 *Usually, no autonomic response
 Persists beyond apparent tissue healing
 May have acute exacerbations
 Treatment is focused on pain reduction

 Cancer Pain can be acute or chronic
(longer than 3 months)
Multidimensional experience:
physiologic, sensory, affective,
cognitive, behavioral, and sociocultural
dimensions (St. Marie, B. 2010 p. 13).
 Neuropathic Pain
Pain arising as a direct consequence of
a lesion or disease affecting the
somatosensory system (St. Marie, B.
2010 p. 14).

 Myofascial Pain
1. Fibromyalgia Syndrome-diffuse musculoskeletal aching
and pain with multiple predictable tender points.
2. Myofascial Pain Syndrome-localized muscle pain
possible accompanied by referred pain to another
region.
 Psychological pain – Substance Dependence
◦ Tolerance-need for markedly increased amounts of
substance to achieve intoxication or desired effect

◦ Withdrawal-persistent desire occurs or efforts to cut
down or control substance use are unsuccessful – time is
spent in activities necessary to obtain the substance –
social, occupational, or recreational activities are given up
because of substance use.

St. Marie, B (2010). Core curriculum for pain management nursing. 2nd edition.
P. 15-16.

 Substance Abuse/Dependence
◦ Physical dependence-a physiologic state in which
abrupt cessation of the opioid or administration of
an opioid antagonist results in a withdrawal
syndrome.

◦ Addiction-is characterized by a persistent pattern
of dysfunctional opioid use that may involve:
adverse consequences, loss of control over the use
of opioids, preoccupation with obtaining opioids
despite the presence of adequate analgesia.

St. Marie, B. (2010). Core Curriculum for Pain
Management. Kendall Hunt Publishing Company

1. Mrs. Thomas is observed talking and laughing
with friends in her room. When you enter the
room, she starts grimacing and tells you her
pain is 8/10. An important concept the nurse
should consider as the reason for this change in
her behavior:
a. is a drug seeker and wants more opioids
b. feels that if she does not act this way, the
healthcare provider may not believe she has
pain.
c. is putting on a “show” for her friends to gain
sympathy.
d. has a history of mental illness.

ASPMN Practice Examination for Pain Management Nursing Certification Preparation.

a. Incorrect. Patients are suspected of lying to
healthcare providers when their self-report of pain
and their pain behaviors do not match. In this
situation, more assessment needs to occur.
b. Correct. Pts. learn to take “cues” from the healthcare
provider on how they “should” respond to pain.
Studies have shown pts. who demonstrate pain
behaviors receive more analgesics than pts. who do
not display pain behaviors.
c. Incorrect. The pt.’s pain behaviors were not observed
when she was interacting with friends, only when the
nurse entered the room.
d. Incorrect. This can make assessment a little more
difficult; however the most important component of
pain assessment is the healthcare provider believes
what the pt. says. Further assessment could occur
after her friends have left.
ASPMN Practice Examination for Pain Management Nursing Certification Preparation

Addiction is characterized by all of the
following except:
a. “Clock watching,” hoarding of opioid
analgesics, requesting extra opioids for fear
of running out and demanding behaviors
that are eliminated when pain is relieved.
b. Impaired control over drug use and
compulsive use.
c. Continued drug use despite harm.
d. Use of opioid for effects other than pain
relief.

A. Correct. “Clock watching, hoarding of opioid analgesics,
requesting extra opioids for fear of running out and
demanding behaviors are signs of pseudoaddiction if
they are eliminated when pain is relieved.
B. Incorrect. Addiction has one or more of these
characteristic features: impaired control over drug use,
compulsive use, continued use despite harm and craving.
C. Incorrect. Addiction has one or more of these
characteristic features: impaired control over drug use,
compulsive use, continued use despite harm and craving.
D. Incorrect. The American Pain Society defines addiction as
“a pattern of compulsive drug use characterized by a
continued craving for an opioid and the need to use the
opioid for effects other than pain relief.”

 Nociceptive  Neuropathic
◦ Normal processing of ◦ Abnormal processing of
stimuli sensory input by central
or peripheral nervous
system

ASPMN 17th National Conference Certification Preparation Review Course

 Central Pain verses Peripheral Pain
 Central
◦ Central Neuropathic Pain-pain arising
as a direct consequence of a lesion or
disease affecting the central
somatosensory system.
◦ Poststroke syndrome (thalamic pain
syndrome)-a central pain syndrome
that may occur when a stroke damages
the thalamus or parietal lobe.
 Peripheral
Complex Regional Pain Syndrome I & II
St. Marie, B (2010). Core curriculum for pain management nursing.
2nd edition. P. 14-15.

 Central & Peripheral Pain
◦ Phantom limp pain-the sensation that the
deafferented body part is still present (St. Marie, B.
2010, p. 15).
 Pain may be exacerbated by physical and psychological
factors.

What can some of the causes be behind the
development of neuropathic pain?

 Chemically induced – chemotherapy
 Ischemia – diabetic neuropathy
 Trauma – chronic post-surgical pain
 Infection – post-herpetic neuralgia
 Cancer

What are the characteristics
of neuropathic pain?

 Shooting
 Tingling
 Burning
 Electric shock

Nociceptive Mixed Type Neuropathic
Pain Pain

Post herpetic CRPS
Sickle cell
crisis neuralgia
Postop
pain Distal
polyneuropathy Trigeminal
Arthritis
neuralgia
Sports/Exercise
injures

ASPMN 17th National Conference Certification Preparation Review Course

 Pain Transmission (Nociception)
◦ Nociceptive pain is pain arising from
activation of nociceptors.
◦ Nociceptor is a sensory receptor that is
capable of transducing and encoding
noxious stimuli.
◦ Nociception is the neural processes of
encoding and processing noxious
stimuli.
 Nociception (normal processing of
pain) – Involves 4 processes
1. Transduction
2. Transmission
3. Perception
4. Modulation

Visceral  Somatic
◦ Produced in organs ◦ Occurs in bone, joint,
◦ May be referred to distant muscle, skin or
site connective tissue
◦ Pain in hollow organ ◦ Aching, throbbing
 Intermittent cramping and ◦ Localized
poorly localized

Ms. Jones is a 75 year-old female admitted
with the diagnosis of abdominal pain. On
assessment, she complains of pain 8/10, she
states it hurts all over and describes it as a
squeezing/cramping pain. Her pain type would
be described as:
a. Nociceptive somatic pain
b. Neuropathic pain
c. Nociceptive visceral pain
d. Peripherally generated pain


a. Incorrect. Nociceptive somatic pain arises from bone,
joint, muscle, skin, or connective tissue. It is usually
aching or throbbing in quality and it is well localized.
b. Incorrect. Neuropathic pain is caused by stimuli
which are abnormally processed by the nervous
system, examples of which include phantom limb
pain and neuropathies.
c. Correct. Nociceptive visceral pain arises from visceral
organs. It is diffuse and poorly localized unlike
somatic pain, which is usually localized. Visceral pain
from a hollow viscus like the bowel is usually
described as squeezing or cramping.
d. Incorrect. Peripherally generated pain is neuropathic
pain, examples of which include painful
neuropathies.

Mr. D, is a 57-year-old male who presents to the
clinic complaining of bilateral foot pain. He says it
is constant and rates it at a 5/10. His PMH includes
HBP, CAD, diabetes and ETOH abuse. He describes
his foot pain as burning, and states he feels like he
is “walking on stones.” Mr. D is most likely
suffering from which type of pain?
a. Nociceptive pain
b. Viceral pain
c. Neuropathic pain
d. Somatic pain


a. Incorrect. Nociceptive pain is caused by
noxious stimuli from somatic or visceral
structures.
b. Incorrect. Visceral pain arises from visceral
organs such as the GI tract and pancreas.
c. Correct. Neuropathic pain arises from the
peripheral or central nervous system and pts.
Describe it as burning or stinging. Pts. with a
hx of ETOH abuse and/or diabetes can develop
a painful peripheral neuropathy.
d. Incorrect. Somatic pain is a form of nociceptive
pain which arises from bone, joint, muscle,
skin, or connective tissue. It is usually aching or
throbbing in quality and it is well localized.


 Transduction is the first step of the process
◦ It is the transfer of energy from one form to
another causing the neuron to respond 
converting stimulus energy into electrical impulse.
◦ It begins with the free nerve endings (nociceptors)
respond to a noxious stimuli. Noxious stimuli
occurs when tissue damage and inflammation
occurs as a result of: infection, inflammation,
trauma, surgery, etc (Wood, S. 2008).

Pain Management Nursing Certification Preparation Study Guide p. 21

So where are nociceptors found?
 The are distributed in:
Somatic structures (skin, muscle, connective tissue,
bones & joints)
Visceral structures (organs and gastro-intestional
tract)
So how does the nerve endings (nociceptors)
determine different types of pain?
Determine by nerve endings (nociceptors) of C
fibers and A-delta fibers – each are associated with
different qualities of pain.
Wood, Sharon (2008). Nursing times.net. Anatomy and physiology of pain.
Retreived on 6/2/2010 from www.nursingtimes.net

 Categories of noxious stimuli
◦ Mechanical (tumor growth, abscess, incision)
◦ Thermal (burn, scald)
◦ Chemical (infection, toxic substance)

*Regardless of cause of stimuli (internal/external) a
release of mediators from the damaged cells are
released:
 Serotonin
 Substance P
 Prostaglandin
 Bradykinin
 Potassium
 Histamine

Resource: Pain Management Nursing Certification Preparation Study Guide p. 22

 Chemical mediators activate the nociceptors
to the noxious stimuli = Pain impulse is
generated.
How exactly is the pain impulse generated?
Action potential, which is the exchange of
NA+ & K+ ions occurs within cells.

 Transmission = pain impulse is transmitted
◦ Occurs in 3 steps
1. From site of transduction along the nociceptor fibers
to the dorsal horn in the spinal cord
2. From the spinal cord to the brain stem (ascending
tract)
3. Through connections between the thalamus, cortex
and higher level of the brain


 Perception of pain is the end
result of the neuronal activity of
pain transmission and where pain
becomes a conscious
multidimensional experience
(emotional, behavioral,
motivational, etc.)  when pain
impulse transmitted to brain stem
and thalamus = multiple areas
are activated and a response is
activated.

 Hypothalamus
◦ Activator of emotional input
◦ Controls emotional response
 Limbic system
◦ Generates purposeful goal-directed behavior
◦ Affects mood states
 Thalamus
◦ Allows perception
 Reticular formation at the brainstem
◦ Triggers arousal and alertness
◦ Add emotive response
 Cerebral cortex
◦ Receives the message

 Modulation involves changing or inhibiting
transmission of pain impulses in the spinal
cord.
◦ The complex pathways involved in this process are
referred to as the descending modulatory pain
pathways  can lead to either an increase in the
transmission of pain impulses (excitatory) or a
decrease in transmission (inhibition).

Wood, Sharon (2008). Nursing times.net. Anatomy and physiology of
pain. Retreived on 6/2/2010 from www.nursingtimes.net

What does descending inhibition involve?
It involves the release of inhibitory
neurotransmitters that block or partially block
the transmission of pain impulses = analgesia.
Inhibitory neurotransmitters include:
 endogenous opioids (endorphins)
 acetylcholine
 serotonin
 Gamma-aminobutyric acid (GABA)
 Norepinephrine
 Oxytocin

Cortex

Sub
P Thalamus Pain

Action
Potential
Spinal Cord Serotonin &
Release of Norepi-
neurotransmitters nephineprine
reuptake
inhibited
NA+ &
Endogenous
Opioids
Released

Injury

ASMPN 17th National Conference – Review Course

1. Mr. T enters the ER following a cut to his left
hand. Which of the following identifies the
four (4) processes of nociception?
a. Perception, endorphin release, gate is open, pain
reduction.
b. Transmission, perception, T-Cell activation, pain
reduction.
c. Peception, control of activation, distraction,
modulation.
d. Transduction, transmission, perception,
modulation


d. Correct. Transduction is a tranfer of energy
from one form to another causing the
neurons to respond. Transmission is the
process of moving the painful message from
the nerve ending from the periphery, to the
spinal cord and into the ascending tract to
the brain. Perception is the conscious relation
that pain is present. Modulation occurs when
the brain inhibits pain impulses through the
decending pathway.


 Pain is a multi-dimensional experience
◦ Physical dimension
◦ Sensory dimension
◦ Affective dimension
◦ Cognitive dimension
◦ Behavioral dimension
◦ Sociocultural dimension
◦ Spiritual dimension

Resource: Pain Management Nursing Certification Preparation Study
Guide p. 23.

 Begins with pain-producing tissue injury,
neurochemistry and pain pathways.
 Autonomic nervous system activity =
increase BP, heart rate, sweating and skin
temp. changes.
 Influence the pain duration (acute to chronic)

Resource: Pain Management Nursing Certification Preparation Study Guide p.
23.

 What the pain feels like.
 Influences the location, severity and quality of
pain.
 Focus on your pain assessment questions:
◦ Where do you hurt?
◦ Scale 0-10?
◦ Can you describe your pain?
◦ What makes your pain better?
◦ What makes your pain worse?

Guide p. 23.

 Incorporates emotional
responses to pain:
depression, mood changes,
irritability, stress, anxiety,
anger, personality traits and
psychiatric diagnoses.
 Depression and chronic pain
frequently co-exist.

Guide p. 24.

 3 aspects involved:
◦ Meaning of pain to the individual
◦ The individual’s view of him or herself
◦ Pain’s effect on the individual’s thought processes
 Attitudes, beliefs and knowledge about pain
and its treatment are important parts of this
dimension
 Effective coping skills may enhance the
management of pain.
 **The cognitive domain strongly influences
the behavioral dimension.

Guide p. 25.

 1st part of behavioral dimension: behavior
may show the presence or severity of the
pain.
 2nd part of behavioral dimension: specific
behaviors may help identify the etiology of
the pain.
 **The absence of behavioral indicators of
pain does not mean the absence of pain**

Guide p. 26.

 Encompasses the demographic, ethnic,
economics and other sociocultural influences
of the patient/their caregivers.
 Includes the beliefs, values, attitudes and
practices shared by a group.
 Previous pain experiences within the
healthcare system, may also affect the
person’s pain.

Resource: Pain Management Nursing Certification
Preparation Study Guide p. 26.

 Incorporates the meaning of pain as well as
the suffering (emotional/spiritual pain)
involved when pain occurs.
 Suffering is a subjective secondary response,
while pain is a primary response to the
environment.

An example of a physical response to pain
would be the pt:
a. Reports she is depressed
b. Reports she gets some relief with massage
c. Reports her heart races when her pain is
severe
d. Rubs her neck during her appointment and
changes positions frequently


a. Incorrect. The depression response is an
affective response.
b. Incorrect. The sensation felt with massage is
a sensory response.
c. Correct. The physiological response to pain
is a physical response.
d. Incorrect. The change in her behavior is a
behavioral response.


A person’s affective response to pain is most
influenced by:
a. Genetics
b. Emotional state
c. Environment
d. socioeconomics


a. Incorrect. While genetics may influence
affective response, emotional state produces
affective response
b. Correct. An emotional reaction to a painful
situation is an affective response.
c. Incorrect. Environmental influences on affect
are not consistent.
d. Incorrect. Socioeconomic influences do not
produce a consistent affective response.


An example of the sociocultural dimension of
pain is:
a. A pt. doesn’t fill their prescription due to
lack of insurance coverage.
b. A pt. becomes anxious when she thinks
about an upcoming procedure.
c. The pt. believes her headaches are coming
from a tumor.
d. The pt. explains how she turns her pain
over to a higher power.

ASPMN Practice Examination for Pain Management Nursing Certification
Preparation.

a. Correct. A pt. may not fill a prescription due
to lack of insurance coverage or adequate
funds.
b. Incorrect. Emotional response is an example
of the affective dimension.
c. Incorrect. This is an intellectual response
and therefore cognitive dimension.
d. Incorrect. This is a spiritual dimension to
the pt’s pain, giving the pain meaning.


The End!
Thank you for your attention
and energy!
Congratulations, you are
one step closer to becoming
ANCC Certified in Pain
Management!

American Society for Pain Management Nursing. 17th
National Conference. Certification Preparation Review
Course. American Society for Pain Management Nursing.
American Society for Pain Management Nursing. Practice
Examination for Pain Management Nursing Certification
Preparation.
American Society for Pain Management Nursing. Study Guide
for Pain Management Nursing Certification Preparation.
St. Marie, B (2010). Core curriculum for pain management
nursing. 2nd edition. Kendall Hunt Professional.
Wood, S. (2008). Nursing times.net. Anatomy and physiology
of pain management. Retrieved from
www.nursingtimes.net on June 2nd of 2010.

Pain management certification session 1

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