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Pain Assessment and Management for Michigan Nurses (Mandatory)2 Contact HoursRelease Date: March 7, 2020Expiration Date: March 7, 2023FacultyAnn M. Schreier, PhD, RN, received her baccalaureatedegree in nursing from Boston University, an MSN fromUniversity of California, San Francisco, and her PhD fromStanford University. Currently Dr. Schreier is a professor atEast Carolina University, College of Nursing in the NursingScience Department. She is a past president of the AmericanSociety of Pain Management Nursing.Ann M. Schreier has disclosed that she has no significantfinancial or other conflicts of interest pertaining to thiscourse.Peer reviewer:Susan L. Rubin, MSN, RN, received her baccalaureate degreein nursing from West Chester University and a master’sdegree in clinical trials nursing from Drexel University. She isa published author who has experience as a progressive careunit nurse with a special interest in cardiac nursing.Susan L. Rubin has disclosed that she has no significantfinancial or other conflicts of interest pertaining to thiscourse.Course overviewThe following program will provide nurses with an overviewof the physiology of pain and will differentiate betweenacute and chronic pain. The focus of the program willbe on assessment, as well as on pharmacologic andnonpharmacologic treatment modalities for the patientexperiencing pain.Learning objectivesAfter completing this course, the learner will be able to: Recall the definition, the nature, the impact, and theexpression of pain. Differentiate between nociceptive and neuropathic pain. Discuss the physiology of pain. Choose the appropriate pain assessment tool forindividual clients based upon cognitive abilities. Demonstrate an understanding of various treatments foracute and chronic pain, including pharmacological andnonpharmacological treatment modalities.Discuss the special considerations for pain management inpopulations such as the elderly, pediatric, and those whoare addicts or at risk for addiction.Select appropriate educational information for patientsregarding pain management.Discuss barriers to adequate treatment of pain.How to receive credit Read the entire course online or in print which requires a2-hour commitment of time. Complete the self-assessment quiz questions which are atthe end of the course or integrated throughout the course.These questions are NOT GRADED. The correct answeris shown after you answer the question. If the incorrectanswer is selected, the rationale for the correct answer isprovided. These questions help to affirm what you havelearned from the course. Depending on your state requirements you will be askedto complete either:An affirmation that you have completed theeducational activity. A mandatory test (a passing score of 70 percent isrequired). Test questions link content to learningobjectives as a method to enhance individualizedlearning and material retention. If requested, provide required personal information andpayment information. Complete the MANDATORY Course Evaluation. Print your Certificate of Completion. CE Broker reportingElite, provider # 50-4007, reports course completion resultswithin 1 business day to CE Broker. If you are licensed inArkansas, District of Columbia, Florida, Georgia, Kentucky,Mississippi, New Mexico, North Dakota, South Carolina, orWest Virginia, your successful completion results will beautomatically reported for you.Accreditations and approvalsElite is accredited as a provider of nursing continuingprofessional development by the American NursesCredentialing Center’s Commission on Accreditation.Individual state nursing approvalsIn addition to states that accept ANCC, Elite is an approvedprovider of continuing education in nursing by: Alabama,Provider #ABNP1418 (valid through February 5, 2025);California Board of Registered Nursing, Provider #CEP17480(valid through January 31, 2024); California Board ofVocational Nursing and Psychiatric Technicians (LVN Provider#15058, PT Provider #15020) valid through December 31,2023; District of Columbia Board of Nursing, Provider #504007; Florida Board of Nursing, Provider #50-4007; GeorgiaBoard of Nursing, Provider #50-4007; Kentucky Board ofNursing, Provider #7-0076 (valid through December 31, 2023);Mississippi Board of Nursing, Provider #50-4007; and NorthDakota Board of Nursing, Provider #50-4007. This CE programsatisfies the Massachusetts Board’s regulatory requirementsas defined in 244 CMR 5.00: Continuing Education.EliteLearning.com/NursingBook Code: ANCCMI2522BPage 1

Activity directorJune D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse PlannerDisclosuresResolution of conflict of interestIn accordance with the ANCC Standards for CommercialSupport for continuing education, Elite implementedmechanisms prior to the planning and implementation of thecontinuing education activity, to identify and resolve conflictsof interest for all individuals in a position to control content ofthe course activity.Sponsorship/commercial support and non-endorsementIt is the policy of Elite not to accept commercial support.Furthermore, commercial interests are prohibited fromdistributing or providing access to this activity to learners.DisclaimerThe information provided in this activity is for continuingrelative to diagnostic and treatment options of a specificeducation purposes only and is not meant to substitute forpatient’s medical condition.the independent medical judgment of a healthcare provider 2022: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of EliteProfessional Education, LLC. The materials presented in this course are meant to provide the consumer with general informationon the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered.It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consulta medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonableefforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not representor warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotesare collected from customer feedback surveys. The models are intended to be representative and not actual customers.Course verificationAll individuals involved have disclosed that they have nosignificant financial or other conflicts of interest pertainingto this course. Likewise, and in compliance with CaliforniaAssembly Bill No. 241, every reasonable effort has been madeto ensure that the content in this course is balanced andunbiased.INTRODUCTIONPain affects millions of people worldwide, and 1 in 5 personsexperience chronic pain (International Association for theStudy of Pain [IASP], 2020). In the United States, high-impactchronic pain (pain that interferes significantly with physicalfunction) is experienced by over 19 million individuals.Pain is defined as an “unpleasant sensory and emotionalexperience associated with actual or potential tissue damageor described in terms of such damage” (IASP, 2020). Paincan be acute (lasting less than three to six months) orchronic (persisting more than three months) (World HealthOrganization [WHO], 2019). In the United States, pain isviewed as a public health crisis and has an impact on thephysical, psychological and social aspects of individualsexperiencing pain (United States Department of Healthand Human Services [USDHHS] National Inter-Agency TaskForce Report, 2019). Each individual’s response to pain isunique and is influenced by biological factors (comorbidities,physiological stress, genetics, and cognition), psychologicaland emotional factors (anxiety, fear, depression), and socialfactors (cultural/familial attitudes toward pain) and previousexperiences of pain (Ireland & Lalkhen, 2019).PrevalenceThe prevalence of pain can be difficult to accurately assessdue to the availability of data. Using data from a subsampleof National Health Interview Survey, 33% of adults withoutcancer reported at least one painful medical diagnosis (Nahinet al., 2019). This data excludes individuals without a medicaldiagnosis who may experience painful conditions and thosewith cancer who are experiencing pain. Because of barriers tohealthcare access and other factors such as reluctance to seekcare, pain prevalence is likely higher (Cooney et al., 2018).In general, women, older individuals, high school educatedindividuals and non-Hispanics were more likely to report apainful medical diagnosis (Nahin et al., 2019).In the United States, it is reported that 50 million (20.4%)adults experience chronic pain and 19 million (8%) have highimpact (severely limits activity) chronic pain. (Dahlhamer et al.,2018). A recent study of Medicare and Medicaid populationsidentified the three most common pain diagnoses as backpain (74%), degenerative spine disease (64%), and neuritis/radiculitis (53%), with many of this population experiencingmore than one pain diagnosis (Murphy et al., 2017). Pain ismore prevalent in the aging population. The prevalence ofpain ranges between 45% to 70% in frail older adults (Reyeset al., 2019). The high incidence of pain requires that healthcare workers be informed of the latest and best approachesto pain assessment, treatment, and management to achievethe best outcome.Financial impactThe financial impact of pain is burdensome, with billions ofdollars lost directly (through treatment or caregiving) andindirectly (through lost wages or productivity). It is estimatedthat the total costs associated with those experiencing pain isup to 635 billion annually (Murphy et al., 2017). The misuseof opioid pain prescriptions alone in the United States carriesan economic burden of 78.5 billion a year, which includescosts of health care, lost productivity, addiction treatment,and criminal justice involvement (Florence et al., 2016).Page 2Book Code: ANCCMI2522BEliteLearning.com/Nursing

PHYSIOLOGIC & PATHOLOGIC PAINPain can be considered physiologic or pathologic. Physiologicpain describes the type of pain that occurs when tissue isinjured; its function is to prevent further injury and promotesurvival. The injured person develops a memory in responseto the pain and will avoid being injured in the same fashion(for example: a small child getting burned by the stove willremember not to touch a hot stove in the future). Physiologicpain is often associated with acute, short-lived pain.Neuropathologic pain can also start with an injury to tissuebut eventually changes occur in the peripheral and centralnervous system along somatosensory pathways fromperiphery to cortex (Clauw et al., 2019). These changes donot serve a known purpose and are thought to be the causeof chronic (long-lasting) pain conditions, such as neuropathicpain and fibromyalgia (Clauw et al., 2019).NOCICEPTIVE PAIN AND NEUROPATHIC PAINThere are two main subtypes of pain: nociceptive pain andneuropathic pain.Nociceptive pain is the perception of noxious stimuli usuallycaused by tissue damage. It can further be categorized intosomatic or visceral pain (Rosenquist, 2017). Somatic painresults from tissue injury that occurs in the skin, as well as deeptissue such as fascia, tendons, and bone, and can be describedas sharp, then burning or throbbing, and is easily localized(Montgomery et al., 2018). Visceral pain originates in theviscera, usually in internal organs, and is mediated by stretchreceptors that allow a poorly localized, deep, and dull sensation(Montgomery et al., 2018). Common stimulators of theseafferent nerves are compression, inflammation, ischemia, orinfiltration by tumors (Ramos & Eti, 2019).Neuropathic pain occurs as a result of abnormal neuralactivity resulting from injury, disease, or dysfunction ofthe nervous system. It includes such conditions as diabeticneuropathy, trigeminal neuralgia, and thalamic pain(Montgomery et al., 2018). Neuropathies are the mostprevalent type among individuals with diabetes (Iqbal et al.,2018). Neuropathic pain is prevalent among cancer survivorsand can be a result of cancer or of cancer treatments (Yoon& Oh, 2018). Symptoms of neuropathic pain include burning,shooting, numbing, and tingling (Yoon & Oh, 2018).Scenario 1Mary is a new graduate RN and has begun work in an emergencydepartment. The hospital is a tertiary care hospital that servesa large rural area in the southeastern United States. Mary is stillin her orientation period at the hospital and works with an RNpreceptor named Teresa. Teresa has 10 years of experience in theemergency department and 2 years of experience on a medicalsurgical unit in the same hospital. Today is a Saturday and theemergency department is experiencing a high volume of patients.Teresa assigns Mary to see patients that are less acutely ill. Maryis caring for several patients who are experiencing pain. MichaelJones is a 16-year-old male, who has come to the emergencydepartment after injuring his ankle while playing basketball.His left ankle is swollen and he is unable to stand on his left legwithout grimacing. He has an x-ray that reveals no fracture. Afterthe physician examines him, he diagnoses him with a severesprain and recommends applying ice, wrapping the ankle with anace bandage, and a boot. He instructs Michael not to bear weighton the left foot for one week and to take ibuprofen for pain. Thephysician arranges for a referral to a sports medicine physicianat the hospital. Mary is asked to provide Michael with crutchesand discharge instructions. Michael tells Mary that his ankle isthrobbing and doesn’t think the pain is as sharp as it was at thebeginning.Mary has another patient who is admitted because of back pain.Mr. Ellis is a 62-year-old man complaining of severe back pain.During the admission assessment, Mary asks Mr. Ellis about hispain and uses a numerical rating scale (NRS). Mr. Ellis states thathis pain is currently an 8 out of 10 on the rating scale. He tellsMary that he first started having back pain when he was 59. Hestates that he has managed his pain by taking acetaminophen andresting when it bothers him. He has not seen a physician for hispain because he does not have a physician and doesn’t have a verygood insurance plan. Today, the pain became really severe andwas radiating down his left leg. He also can’t think about anythingelse, so his wife said it was time to go to the emergency room.Self-Assessment Quiz Question #1Teresa asks Mary about Michael’s pain. Mary recallsthat there are two types of pain: nociceptive pain andneuropathic pain. She describes Michael’s pain as:a. Neuropathic pain because of the severity of the pain andhis ability to locate the site and source of the pain.b. Nociceptive pain because he can localize the pain andthere is evidence of tissue damage.c. A combination of nociceptive and neuropathic painbecause although he can localize it, he complains ofgreater severity than expected.d. Nociceptive pain because it is evident that there isinflammation and abnormal nerve functioning.When Mary has a break, she talks with Teresa about her patients.She tells Teresa that she is very puzzled by the fact that Mr. Ellis hasnot sought care for his back pain before. He has been experiencingthis pain for years and now he has come to the emergencydepartment for something that could have been treated in a lesscostly outpatient setting.Self-Assessment Quiz Question #2Which of the following statements are accurate about Mr.Ellis’ pain?a. Many patients are like Mr. Ellis and reluctant to seek careuntil they cannot function.b. Mr. Ellis has likely come to the emergency department toget an opioid.c. Mr. Ellis has acute nociceptive pain.d. All of the above.PHYSIOLOGY OF PAINNociception is a four-stage process that the body utilizes toprocess painful stimuli:1. Transduction: Painful stimuli are converted to neuronalaction potentials at the sensory receptor.2. Transmission: Action potentials move via neurons fromperipheral receptors to the spinal cord and then to thebrain.3.4.Perception: The brain receives the information from theaction potentials and perceives them as painful.Modulation: The process by which the transmission ofpain is altered (Hudspith, 2019; Ireland & Lalkhen, 2019).EliteLearning.com/NursingBook Code: ANCCMI2522BPage 3

TransductionPainful stimuli are first encountered by nociceptors, which arenerve endings. Nociceptors convert painful stimuli (mechanical,chemical, or thermal) into neuronal action potentials that travelthrough the spinal cord and finally to the brain. Nociceptorsare located throughout the body in the skin, muscle, connectivetissue, the circulatory system, and the viscera of the abdomen,pelvis, and thoracic cavity (Hudspith, 2019).Nociceptors can be stimulated by direct injury to the nerveendings themselves or they can be stimulated from therelease of chemicals as a result of the injury as part of theinflammatory response. These chemicals include potassium,hydrogen, lactate, prostaglandins, serotonin, and bradykinin.These chemicals affect the membrane potential of the painreceptor and depolarize, causing an action potential that makesits way to the brain and is processed by the brain as pain(Hudspith, 2019).TransmissionA delta fibers and C fibers are primary afferent neurons thattransmit action potentials (also known as nerve impulses)to the central nervous system. A delta fibers are larger andmyelinated and quickly carry impulses (about 0.1 s) thatresult in sharp first pain response; C fibers are smaller andunmyelinated, taking longer (about 1 s or more) to transmitimpulses and resulting in a dull, aching pain sensation(Hudspith, 2019). A delta fibers are responsible for theinitial sharp pain sensation a person feels, which causes theperson to swiftly remove themselves from the cause of injury(Hudspith, 2019). C fibers rela

The webinar is lead by Dr. Benjamin D. Reese, Jr., PsyD. Dr. Reese is a clinical psychologist and president of BenReese, LLC, a North Carolina-based global diversity, equity, and inclusion consulting firm. He earned a doctorate in clinical psychology from the Rutgers University, Graduate School of Applied and Professional Psychology.