11.2: Comfort Basic Concepts
Definitions of Pain
Pain has been defined as, “Whatever the patient says it is, experienced whenever they say they are experiencing it.” [1] In 2020 the International Association for the Study of Pain (IASP) released a revised definition of pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” along with these additional notes:
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- Individuals learn the concept of pain throughout all stages of their life.
- A person’s report of an experience as pain should be respected.
- Although pain usually serves an adaptive role, it can have adverse effects on function, socialization, and psychological well-being.
- Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the possibility that a person is experiencing pain. [2]
Pain motivates the individual to withdraw from dangerous stimuli, to protect a damaged body part while it heals, and to avoid similar experiences in the future. Most pain resolves after the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. Additionally, pain can occur in the absence of any detectable stimulus, damage, or disease. [3]
Physiology of Pain
Let’s begin by reviewing the physiological processes of pain. A nociceptor is a type of sensory receptor that responds to potentially damaging stimuli by sending nerve signals to the spinal cord and brain in a process called nociception. There are several types and functions of nociceptors:
- Thermal nociceptors are activated by noxious heat or cold, such as a hot pan.
- Mechanical nociceptors are activated by excess pressure or mechanical deformation, such as a finger getting caught in a car door. They also respond to incisions that break the skin surface.
- Chemical nociceptors are activated by a wide variety of spices commonly used in cooking. For example, capsaicin is a compound in chili peppers that causes a burning sensation of the mucus membranes. It is also used in common over-the-counter creams for pain relief because when it is applied to the skin, it blocks the transmission of pain impulses. [4]
Noxious stimuli are detected by nociceptors and transduced into electrical energy. An action potential is created and transmitted along nociceptor fibers. There are two types of nociceptor fibers, A-Delta and C. A-Delta fibers are fast-conducting fibers and associated with the initial sharp, stinging, or pricking pain sensation. C fibers are slower-conducting fibers and are associated with the secondary sensation of diffuse, dull, burning, and aching pain. The pain impulse is transmitted along these nociceptor fibers to the dorsal horn in the spinal cord and then from the spinal cord to the thalamus, where pain messages are relayed to the cerebral cortex. In the cerebral cortex, pain impulses are perceived and the conscious awareness of pain occurs. [5] , [6] See Figure 11.1 [7] for an illustration of how the pain signal is transmitted from the nociceptors to the spinal cord and then to the brain.
View supplementary videos on pain:
- Karen D. Davis: How does your brain respond to pain? | TED Talk
- A one-minute review of how pain receptors work: Feeling Pain
Types of Pain
Pain can be divided into visceral, deep somatic, superficial, and neuropathic pain.
- Visceral structures are highly sensitive to stretch, ischemia, and inflammation. Visceral pain is diffuse, difficult to locate, and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull. [8]
- Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia, and muscles and is a dull, aching, poorly localized pain. Examples include sprains and broken bones. [9]
- Superficial pain is initiated by the activation of nociceptors in the skin or other superficial tissue and is sharp, well-defined, and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first-degree) burns. [10]
- Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as pain caused by a lesion or disease of the somatosensory nervous system. It is typically described by patients as “burning” or “like pins and needles.” Neuropathic pain can be caused by several disease processes, such as diabetes mellitus, strokes, and HIV, and is generally undertreated because it typically does not respond to analgesics. Medications such as tricyclic antidepressants and gabapentin are typically used to manage this type of pain. [11]
Pain can radiate from one area to another. For example, back pain caused by a herniated disk can cause pain to radiate down an individual’s leg. Referred pain is different from radiating pain because it is perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder. See Figure 11.2 [12] for an illustration of common sites of referred pain.
Factors Affecting the Pain Experience
There are many biological, psychological, and social factors that affect the perception of pain, making it a unique, individual experience. See Table 11.2a for a list of these factors. [13] Nurses must consider these factors while assessing and providing holistic nursing care for patients experiencing pain.
Table 11.2a Biological, Psychological, and Social Factors Affecting Pain
| Biological Factors | Psychological Factors | Social Factors |
|---|---|---|
|
|
|
Acute vs. Chronic Pain
Pain is differentiated between acute pain and chronic pain. Acute pain has limited duration and is associated with a specific cause. It usually causes a physiological response resulting in increased pulse, respirations, and blood pressure. Diaphoresis (sweating, especially to an unusual degree) may also occur. Examples of acute pain include postoperative pain; burns; acute musculoskeletal conditions like strains, sprains, and fractures; labor and delivery; and traumatic injury.
Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or diaphoresis. It may be diffuse and not confined to a specific area of the body. Chronic pain often affects an individual’s psychological, social, and behavioral responses that can influence daily functioning. Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes of chronic pain. Chronic pain can continue even after the original injury or illness that caused it has healed or resolved. Some people suffer chronic pain even when there is no past injury or apparent body damage.
People who have chronic pain often have physical effects that are stressful on the body. These effects include tense muscles, limited ability to move around, lack of energy, and appetite changes. Emotional effects of chronic pain include depression, anger, anxiety, and fear of reinjury. These effects can limit a person’s ability to return to their regular work or leisure activities. [14] It is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities. [15] See Figure 11.3 [16] for an illustration of low back pain, an example of both acute and chronic pain that often affects daily functioning.
Read additional information about pain using the following hyperlinks:
Life Span and Cultural Considerations
The pain experience varies across the life span. Newborns and infants can feel pain but are unable to verbalize it. Repetitive and prolonged pain may be associated with altered pain sensitivity and pain processing later in life. Toddlers and preschoolers often have difficulty describing, identifying, and locating pain. Instead, pain may be demonstrated behaviorally with crying, anger, physical resistance, or withdrawal. School-age children and adolescents may try to be “brave” and rationalize the pain; they are more responsive to explanations about pain.
Older adults are at increased risk for undertreatment of pain. It is estimated that up to 70% of older adults in the community and up to 85% living in long-term care centers have significant pain due to chronic conditions such as osteoarthritis and peripheral neuropathy. Pain is often underassessed in older adults because they are less likely to report it and also because it can present atypically with confusion and agitation. [17]
Other special populations who are at increased risk for the undertreatment of pain include the following:
- Patients with a history of addictive disease
- Nonverbal, cognitively impaired, or unconscious patients
- Patients who endure pain without complaining due to cultural or religious beliefs
- Non-English speaking patients where communicating is a barrier
- Uninsured or underinsured patients where cost of medications is a barrier [18]
Nurses must be especially vigilant of nonverbal signs of pain in these at-risk groups and implement appropriate assessment tools and interventions. Read an example of a patient with untreated pain in the following box.
A teenage boy from the Amish community was admitted to the hospital after he sustained several fractures when his buggy was hit by a motor vehicle. His parents stayed at his bedside throughout his hospital stay. The nurses noticed that although he denied pain, he grimaced and guarded the body parts that were injured. He moaned when repositioned and declined to get out of bed to begin physical therapy when it was prescribed for rehabilitation. However, despite these nonverbal indicators of pain, he continued to deny the existence of pain and refused all pain medication. One day, when his parents left the room briefly to get coffee, the nurse said to the patient, “Most people in your situation experience severe pain. I can see that you are hurting by your expressions when you move. Can you help me to understand why you don’t want any pain medication?” A tear began to fall down the boy’s cheek. He explained that his community does not believe in complaining about pain and to be a man, he must learn how to tolerate suffering. The nurse explained, “It is important for you to attend physical therapy so that you can heal and go home. Can we bring you pain pills every day before physical therapy so that you can participate in the exercises, recover quickly, and go home?” The boy agreed to this plan. The nurse documented her findings and made notes in the care plan to administer the prescribed PRN pain medications one hour before physical therapy was scheduled. She also communicated her findings during the nurse handoff report. The boy was able to satisfactorily complete the prescribed physical therapy and was discharged home the following week.
Use the following hyperlinks to read more information about treating pain:
- Treating pain in Special Populations
- The National Institute on Aging provides a wide range of information for older adults: Pain: You Can Get Help .
- Health in Aging offers additional information on pain management at Pain Management | Aging & Health AZ | American Geriatrics Society .
Trends in Pain Management, Substance Abuse, and Addiction
Several well-known agencies have recently published materials focused on the importance of optimal pain management. For example, in 2017 The Joint Commission published new and revised standards of pain assessment and pain management that apply to all Joint Commission-accredited hospitals. [19] The American Nurses Association published a position statement in 2018 on the ethical responsibility of nurses to properly manage pain. [20] In 2019 the U.S. Department of Health and Human Services published Pain Management Best Practices . [21] Why is there continued emphasis on optimal pain management? Let’s review some trends related to pain management over the past few decades.
Pain assessment and pain management began to undergo significant changes in the 1990s when pain experts recognized that inadequate assessment and treatment of pain had become a public health issue. Recommendations for improving the quality of pain care were followed by initiatives that recognized patients’ reported pain as “the 5th vital sign.” Hospital administrators and regulators began to focus on pain scores, encouraging and incentivizing providers to aggressively treat pain to lower pain scores. These trends led to liberal prescribing of opioid pain medications for both acute and chronic pain.
Unfortunately, this increase in prescription of opioid pain medication led to an associated rise in the number of deaths from overdose. Organizations began to urge caution about the use of opioids for pain, including guidelines published in 2016 by the Centers for Disease Control (CDC) on prescribing opioids for pain. [22] The 2016 CDC guideline led to limited prescriptions of opioids and unintended consequences, such as forced tapering of medications for established patients requiring chronic pain control and the transition of some patients desperate for pain control to using illicit drugs, such as heroin.
In this manner, pain management and the opioid crisis have influenced one another as each continues to evolve. It is imperative for nurses to ensure that patients with painful conditions can work with their health care providers to develop pain treatment plans that balance pain control, optimize function, and enhance quality of life while also minimizing risks for opioid misuse and harm. [23]
Associated Definitions
When discussing the use and abuse of drugs used to treat pain, it is important to distinguish between tolerance, physical dependence, misuse, substance abuse disorder, and addiction.
- Tolerance is a reduced response to pain medication when the same dose of a drug has been given repeatedly, requiring a higher dose of the drug to achieve the same level of response. [24] For example, when a patient receives morphine for palliative care, the dosage often needs to be increased over time because the patient develops a tolerance to the effects of the medication.
- Physical dependence refers to withdrawal symptoms that occur when a chronic pain medication is suddenly reduced or stopped because of physiological adaptations that occur to chronic exposure to the medication. [25] For example, if a patient who receives hydromorphone daily suddenly has their prescription stopped, they will likely experience symptoms of withdrawal, such as sweating, goose bumps, vomiting, anxiety, insomnia, and muscle pain.
- Misuse refers to a person taking prescription pain medications in a manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high). [26]
-
Substance abuse disorder
is a significant impairment or distress from a pattern of substance use (i.e., alcohol, drugs, or prescription medication) with at least two of the symptoms listed below in a given year:
- The use of more of a substance than planned or using a substance for a longer interval than desired
- The inability to cut down despite desire to do so
- Spending a substantial amount of the day obtaining, using, or recovering from substance use
- Cravings or intense urge to use a substance
- Repeated usage causing an inability to meet important social or professional obligations
- Persistent usage despite user’s knowledge that it is causing frequent problems at work, school, or home
- Giving up or cutting back on important social, professional, or leisure activities because of use
- Usage in physically hazardous situations, such as driving, or usage despite it causing physical or mental harm
- Persistent use despite the user’s awareness that the substance is causing, or at least worsening, a physical or mental problem [27]
- Addiction is a chronic disease of the brain’s reward, motivation, memory, and related circuitry reflected in an individual pathologically pursuing reward and/or relief by substance use. Addiction is characterized by several symptoms, such as the inability to consistently abstain from a substance, impaired behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. [28]
Substance Abuse Among Nurses and Nursing Students
Substance abuse and addiction can occur in anyone, including nurses and nursing students. The American Nursing Association released the following statements in 2016:
- Health care facilities should provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.
- Health care facilities and schools of nursing should adopt alternative-to-discipline approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and reentry into safe, professional practice.
- Drug diversion, in the context of personal use, is viewed primarily as a symptom of a serious and treatable disease, and not exclusively as a crime.
- Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion and have the responsibility and means to report suspected or actual concerns. [29]
Read the American Nurses Association (ANA) statement on Substance Use Among Nurses and Nursing Students.
Read the NCSBN brochure on Substance Use Disorder in Nursing. Many states offer assistance to nurses with substance use disorders to maintain their nursing license and employment status. See Wisconsin’s Professional Assistance Procedure (PAP) or New York’s Statewide Peer Assistance for Nurses program.
Read more details about substance abuse disorder in the “ Legal/Ethical ” chapter in Open RN Nursing Pharmacology .
Standards of Care
Pain assessment and management standards were recently revised and published in 2018 by The Joint Commission. The revised standards require hospitals to identify pain assessment and pain management, including safe opioid prescribing, as an organizational priority. Nurses are expected to implement these best practices. See Table 11.2b for a summary of associated requirements that must be incorporated into nursing care. [30] If these components are not included when providing nursing care, the hospital may be cited by The Joint Commission and potentially lose Medicare funding.
Table 11.2b. The Joint Commission’s Pain Assessment and Management Requirements [31]
| Requirement | Rationale |
|---|---|
| Patients are screened for pain during emergency department visits and at the time of admission. |
The misidentification and undertreatment of pain continues to occur in hospitals.
When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment. |
| Criteria to screen, assess, and reassess pain are used that are consistent with the patient’s age, condition, and ability to understand. | An accurate screening and assessment are required for satisfactory pain management, and the hospital is responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately. |
|
Patients are involved in the pain management treatment planning process by:
– Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain – Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) – Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed |
Patient involvement in planning pain management involves information sharing and collaboration between the patient and provider to arrive at realistic expectations and clear goals. Numerous patient factors may cause undertreatment or overtreatment of pain, such as pain expectations, knowledge of pain and its treatment, and underreporting of pain. Patient involvement in the pain management planning process allows the provider to clarify the objectives of the process and guides patients in a manner that increases the likelihood of treatment adherence. |
|
Patient’s pain is treated or they are referred for treatment.
Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches. |
Referrals may be required for patients who present with complex pain management needs, such as the opioid-addicted patient, the patient who is at high risk for adverse events but requires treatment with opioids, or a patient whose pain management needs exceed the expertise of the patient’s provider. |
| Nonpharmacologic pain treatment modalities are promoted. | Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided. Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy. |
| Patients identified as being high risk for adverse outcomes related to opioid treatment are monitored. |
The most dangerous adverse effect of opioid analgesics is respiratory depression.
Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen). |
| Patients experiencing opioid substance abuse are referred to opioid treatment programs. | When clinicians encounter patients who are addicted to opioids, the patients should be referred for treatment. The U.S. Substance Abuse and Mental Health Services Administration provides a directory of opioid treatment programs . |
| The hospital facilitates access to the Prescription Drug Monitoring Program databases. | Prescription Drug Monitoring Programs (PDMP) aggregate prescribing and dispensing data submitted by pharmacies and health care providers. They are an effective tool for reducing prescription drug abuse and diversion. Read more about PDMP in the “ Legal/Ethical ” chapter of the Open RN Nursing Pharmacology textbook. |
|
Patient’s pain is reassessed and responded to through the following:
Evaluation and documentation of: – Response to pain intervention(s) – Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control) – Side effects of treatment |
Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients’ pain is inadequate.
The Joint Commission’s technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient’s ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain. |
|
Patients and their family members are educated on discharge plans related to pain management including the following:
– Pain management plan of care – Side effects of pain management treatment – Activities of daily living, including the home environment that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues – Safe use, storage, and disposal of opioids when prescribed |
During the discharge process, patients and families need education on the importance of how to manage the patient’s pain at home. Unmanaged pain may cause a patient to regress in their recovery process or have uncontrolled pain at home leading to a readmission to the hospital. It is necessary to have a discussion with patients and their families regarding their home environment and activities of daily living that may increase the need for pain management. When a patient is being discharged with an opioid medication, education on safe use, including when and how much medication to take, should be included in the discharge plan. Opioid disposal education is also critical to both reduce diversion and decrease the risk of accidental exposure to someone other than the person for whom the opioid was prescribed. |
Read The Joint Commission’s Pain Assessment and Management Standards for Hospitals .
Read Pain Management Best Practices from the United States Department of Health & Human Services.
- Pasero, C., & MacCaffery, M. (2010). Pain assessment and pharmacological management (1st ed.). Mosby. ↵
- International Association for the Study of Pain. (2017, December 14). IASP terminology . https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698 ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- NursingTimes. (2008, September 18). Anatomy and physiology of pain . https://www.nursingtimes.net/clinical-archive/pain-management/anatomy-and-physiology-of-pain-18-09-2008/#:~:text=The%20transmission%20process%20occurs%20in,higher%20levels%20of%20the%20brain ↵
- " Sketch colored final.png " by Bettina Guebeli is licensed under CC BY-SA 4.0 ) ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
- Murnion, B. P. (2018). Neuropathic pain: Current definition and review of drug treatment. Australian Prescriber, 41 (3), 60–63. https://doi.org/10.18773/austprescr.2018.022 ↵
- “ 1506_Referred_Pain_Chart.jpg ” by OpenStax is licensed under CC BY 3.0 . Access for free at https://cnx.org/contents/C650g-ah@2/Autonomic-Reflexes-and-Homeostasis ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- Cleveland Clinic. (2020, December 8). Acute v. chronic pain . https://my.clevelandclinic.org/health/articles/12051-acute-vs-chronic-pain ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.p df ↵
- “ Lower_back_pain.jpg ” by Injurymap is licensed under CC BY 4.0 ↵
- American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC) . https://www.aacnnursing.org/ELNEC ↵
- American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC) . https://www.aacnnursing.org/ELNEC ↵
- The Joint Commission. (2017, August 29). R3 report | Requirements, rationale, reference. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936C1 ↵
- ANA Center for Ethics and Human Rights. (2018). Position statement: The ethical responsibility to manage pain and the suffering it causes. American Nurses Association. https://www.nursingworld.org/~495e9b/globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- Cleveland Clinic. (2020, December 8). Acute v. chronic pain. https://my.clevelandclinic.org/health/articles/12051-acute-vs-chronic-pain ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices . U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf/ ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices . U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices . U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 ↵
- Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices . U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
- American Nurses Association. (2016, October). Substance use among nurses and nursing students. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/substance-use-among-nurses-and-nursing-students ↵
- The Joint Commission. (2017, August 29). R3 report | Requirements, rationale, reference . https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936C1 ↵
- The Joint Commission. (2017, August 29). R3 report | Requirements, rationale, reference . https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936C1 ↵


11.4: Criticism of Customers
- Write an external critical message to an existing customer.
We have discussed the importance of happy, satisfied customers to the success of a business. But what if an issue arises that necessitates a critical message to an existing customer?
When the need to send a critical message to a customer arises, we should take a step back and think through several factors. What is the exact outcome we desire? How can we communicate firmly yet tactfully so as to maintain our good business relationship? What facts need to be included in the message?
The indirect strategy would be best for a critical message to a customer. Such a message should start with some complementary language about how the relationship is valued. Next, a full explanation of the facts of the matter and any context should be given. After this buffer, the criticism or critique should be revealed, followed by a warm closing.
To: Mike Cross
From: Bill Langely
Subject: Could I ask for your assistance on an important matter?
Dear Mike,
I hope this message finds you well.
It is hard to believe that we have been doing business for over 10 years. The relationship between our companies has been mutually beneficial, and we hope to continue working with you for another decade.
As you may know, we have contracted out our A/P department to a third-party company. They rely on a different financial system than the one we used in all of our prior dealings with your company. Apparently, this system cannot handle your firm applying credit memos to our invoices directly; they must be handled as separate line items. As a result, several of our invoices to you are now showing as late or delinquent. Our finance folks and yours have had several calls on this matter, but apparently your staff wants to continue the older process because it is easier for them. Yours is the only company that still maintains this Payable practice.
I think perhaps you meeting with your CFO would go a long way to satisfy this issue.
We look forward to working with you and your marketing team on our joint efforts at the June trade show. I feel positive about strengthening our relationship as business partners and the bright future ahead.
Best regards,
Bill Langeley
VP Marketing
Arrow LLC
This example message follows the indirect strategy for a critical written communication. The subject line gets attention but delays the bad news until after the buffer. The opening is pleasant and complimentary. The buffer attempts to explain the necessary facts and context, e.g., Mike’s company is the only one with the problem process. The bad news is passive voice (instead of: “Can I ask you to get involved directly to meet with your CFO to resolve this matter?”). The close avoids referring to the problem and instead has a pleasant, future-looking statement.
Contributors and Attributions
- Criticism of Customers. Authored by : Robert Danielson. Provided by : Lumen Learning. License : CC BY: Attribution


1: Getting Started with Microsoft Word and Google Docs
In this unit, we discuss the basic on-screen elements of Microsoft Word and Google Docs. We explore the toolbars, menus, commands, and taskbars. Toolbars and menus are located at the top of the screen and list options that allow you to insert, view, or change the layout of a document. Each menu option lists different commands that let you format, save, and print documents. We also discuss the Quick Access Toolbar and learn how to add and delete commands. As you go through this unit, open up your version of Microsoft Word or Google Docs and follow along with the tutorials. This will help you learn as you explore the window and menu environment.
Upon successful completion of this unit, you will be able to:
- open documents in Microsoft Word and Google Docs;
- identify the parts of documents created in Microsoft Word and Google Docs;
- identify each of the menu elements in Microsoft Word and Google Docs; and
- identify and describe important commands in Microsoft Word and Google Docs.


16.4: Eukaryotic Transcription Gene Regulation
Skills to Develop
- Discuss the role of transcription factors in gene regulation
- Explain how enhancers and repressors regulate gene expression
Like prokaryotic cells, the transcription of genes in eukaryotes requires the actions of an RNA polymerase to bind to a sequence upstream of a gene to initiate transcription. However, unlike prokaryotic cells, the eukaryotic RNA polymerase requires other proteins, or transcription factors, to facilitate transcription initiation. Transcription factors are proteins that bind to the promoter sequence and other regulatory sequences to control the transcription of the target gene. RNA polymerase by itself cannot initiate transcription in eukaryotic cells. Transcription factors must bind to the promoter region first and recruit RNA polymerase to the site for transcription to be established.
Link to Learning
View the process of transcription—the making of RNA from a DNA template—at this site .
The Promoter and the Transcription Machinery
Genes are organized to make the control of gene expression easier. The promoter region is immediately upstream of the coding sequence. This region can be short (only a few nucleotides in length) or quite long (hundreds of nucleotides long). The longer the promoter, the more available space for proteins to bind. This also adds more control to the transcription process. The length of the promoter is gene-specific and can differ dramatically between genes. Consequently, the level of control of gene expression can also differ quite dramatically between genes. The purpose of the promoter is to bind transcription factors that control the initiation of transcription.
Within the promoter region, just upstream of the transcriptional start site, resides the TATA box. This box is simply a repeat of thymine and adenine dinucleotides (literally, TATA repeats). RNA polymerase binds to the transcription initiation complex, allowing transcription to occur. To initiate transcription, a transcription factor (TFIID) is the first to bind to the TATA box. Binding of TFIID recruits other transcription factors, including TFIIB, TFIIE, TFIIF, and TFIIH to the TATA box. Once this complex is assembled, RNA polymerase can bind to its upstream sequence. When bound along with the transcription factors, RNA polymerase is phosphorylated. This releases part of the protein from the DNA to activate the transcription initiation complex and places RNA polymerase in the correct orientation to begin transcription; DNA-bending protein brings the enhancer, which can be quite a distance from the gene, in contact with transcription factors and mediator proteins (Figure \(\PageIndex{1}\)).
In addition to the general transcription factors, other transcription factors can bind to the promoter to regulate gene transcription. These transcription factors bind to the promoters of a specific set of genes. They are not general transcription factors that bind to every promoter complex, but are recruited to a specific sequence on the promoter of a specific gene. There are hundreds of transcription factors in a cell that each bind specifically to a particular DNA sequence motif. When transcription factors bind to the promoter just upstream of the encoded gene, it is referred to as a cis -acting element , because it is on the same chromosome just next to the gene. The region that a particular transcription factor binds to is called the transcription factor binding site . Transcription factors respond to environmental stimuli that cause the proteins to find their binding sites and initiate transcription of the gene that is needed.
Enhancers and Transcription
In some eukaryotic genes, there are regions that help increase or enhance transcription. These regions, called enhancers , are not necessarily close to the genes they enhance. They can be located upstream of a gene, within the coding region of the gene, downstream of a gene, or may be thousands of nucleotides away.
Enhancer regions are binding sequences, or sites, for transcription factors. When a DNA-bending protein binds, the shape of the DNA changes (Figure \(\PageIndex{1}\)). This shape change allows for the interaction of the activators bound to the enhancers with the transcription factors bound to the promoter region and the RNA polymerase. Whereas DNA is generally depicted as a straight line in two dimensions, it is actually a three-dimensional object. Therefore, a nucleotide sequence thousands of nucleotides away can fold over and interact with a specific promoter.
Turning Genes Off: Transcriptional Repressors
Like prokaryotic cells, eukaryotic cells also have mechanisms to prevent transcription. Transcriptional repressors can bind to promoter or enhancer regions and block transcription. Like the transcriptional activators, repressors respond to external stimuli to prevent the binding of activating transcription factors.
Summary
To start transcription, general transcription factors, such as TFIID, TFIIH, and others, must first bind to the TATA box and recruit RNA polymerase to that location. The binding of additional regulatory transcription factors to cis -acting elements will either increase or prevent transcription. In addition to promoter sequences, enhancer regions help augment transcription. Enhancers can be upstream, downstream, within a gene itself, or on other chromosomes. Transcription factors bind to enhancer regions to increase or prevent transcription.
Glossary
- cis -acting element
- transcription factor binding sites within the promoter that regulate the transcription of a gene adjacent to it
- enhancer
- segment of DNA that is upstream, downstream, perhaps thousands of nucleotides away, or on another chromosome that influence the transcription of a specific gene
- trans -acting element
- transcription factor binding site found outside the promoter or on another chromosome that influences the transcription of a particular gene
- transcription factor binding site
- sequence of DNA to which a transcription factor binds


7.2E: Right Triangle Trigonometry (Exercises)
For the following exercises, use side lengths to evaluate.
17. \(\cos \frac{\pi}{4}\)
18. \(\cot \frac{\pi}{3}\)
19. \(\tan \frac{\pi}{6}\)
20. \(\cos \left(\frac{\pi}{2}\right)=\sin \left(\longrightarrow^{\circ}\right)\)
21. \(\csc \left(18^{\circ}\right)=\sec \left(\longrightarrow^{\circ}\right)\)
For the following exercises, use the given information to find the lengths of the other two sides of the right triangle.
22. \(\cos B=\frac{3}{5}, a=6\)
23. \(\tan A=\frac{5}{9}, b=6\)
For the following exercises, use Figure 1 to evaluate each trigonometric function.
Figure 1
24. \(\sin A\)
25. \(\tan B\)
For the following exercises, solve for the unknown sides of the given triangle.
26.
27.
28. A 15-ft ladder leans against a building so that the angle between the ground and the ladder is \(70^{\circ} .\) How high does the ladder reach up the side of the building? Find the answer to four decimal places.
29. The angle of elevation to the top of a building in Baltimore is found to be 4 degrees from the ground at a distance of 1 mile from the base of the building. Using this information, find the height of the building. Find the answer to four decimal places.


13.5: Somatic Motor Responses
By the end of this section, you will be able to:
- List the cortical components of motor processing
- Describe the pathway of descending motor commands from the cortex to the skeletal muscles
- Compare different descending pathways, both by structure and function
- List the structures and steps involved in a reflex arc
- Describe several reflex arcs and their functional roles
The defining characteristic of the somatic nervous system is that it controls skeletal muscles. Somatic senses inform the nervous system about the external environment, but the response to that is through voluntary muscle movement. The term “voluntary” suggests that there is a conscious decision to make a movement. However, some aspects of the somatic system use voluntary muscles without conscious control. One example is the ability of our breathing to switch to unconscious control while we are focused on another task. However, the muscles that are responsible for the basic process of breathing are also utilized for speech, which is entirely voluntary.
Cortical Responses
The information on sensory stimuli registered through receptor cells is relayed to the CNS along ascending pathways. In the cerebral cortex, the initial processing of sensory perception can lead to the incorporation of sensory perceptions into memory, but more importantly, it leads to a response. The completion of cortical processing through the primary, associative, and integrative sensory areas initiates a similar progression of motor processing, usually in different cortical areas.
Prefrontal Cortex
Whereas the sensory cortical areas are located in the occipital, temporal, and parietal lobes, motor functions are largely controlled by the frontal lobe. The most anterior regions of the frontal lobe—the prefrontal areas—are important for executive functions , which are cognitive functions that lead to goal-directed behaviors. These higher cognitive processes include working memory that can help organize and represent information that is not in the immediate environment. The prefrontal lobe is responsible for aspects of attention, such as inhibiting distracting thoughts and actions so that a person can focus on a goal and direct behavior toward achieving that goal. The functions of the prefrontal cortex are integral to the personality of an individual, because it is largely responsible for what a person intends to do and how they accomplish those plans.
Secondary Motor Cortices
In generating motor responses, the executive functions of the prefrontal cortex will need to initiate actual movements. One way to define the prefrontal area is any region of the frontal lobe that does not elicit movement when electrically stimulated. These are primarily in the anterior part of the frontal lobe. The regions of the frontal lobe that remain are the regions of the cortex that produce movement. The prefrontal areas project into the secondary motor cortices, which include the premotor cortex and the supplemental motor area . The premotor area aids in controlling movements of the core muscles to maintain posture during movement, whereas the supplemental motor area is hypothesized to be responsible for planning and coordinating movement. The supplemental motor area also manages sequential movements that are based on prior experience (that is, learned movements). Neurons in these areas are most active leading up to the initiation of movement. For example, these areas might prepare the body for the movements necessary to drive a car in anticipation of a traffic light changing.
Adjacent to these two regions are two specialized motor planning centers. The frontal eye fields are responsible for moving the eyes in response to visual stimuli. There are direct connections between the frontal eye fields and the superior colliculus. Also, anterior to the premotor cortex and primary motor cortex is Broca’s area . This area is responsible for controlling movements of the structures of speech production.
Primary Motor Cortex
The primary motor cortex is located in the precentral gyrus of the frontal lobe. The primary motor cortex receives input from several areas that aid in planning movement, and its principle output stimulates spinal cord neurons to stimulate skeletal muscle contraction. The primary motor cortex is arranged in a similar fashion to the primary somatosensory cortex, in that it has a topographical map of the body, creating a motor homunculus. The neurons responsible for musculature in the feet and lower legs are in the medial wall of the precentral gyrus, with the thighs, trunk, and shoulder at the crest of the longitudinal fissure.  Also, the relative space allotted for the different regions is exaggerated in muscles that have greater enervation. The greatest amount of cortical space is given to muscles that perform fine, agile movements, such as the muscles of the fingers and the lower face. The “power muscles” that perform coarser movements, such as the buttock and back muscles, occupy much less space on the motor cortex.
Descending Pathways
The motor output from the cortex descends into the brainstem and to the spinal cord to control the musculature through motor neurons. Neurons located in the primary motor cortex, named Betz cells , are large cortical neurons that synapse with lower motor neurons in the spinal cord or the brainstem. The two descending pathways traveled by the axons of Betz cells are the corticospinal tract and the corticobulbar tract . Both tracts are named for their origin in the cortex and their targets—either the spinal cord or the brainstem (the term “bulbar” refers to the brainstem as the bulb, or enlargement, at the top of the spinal cord).
These two descending pathways are responsible for the conscious or voluntary movements of skeletal muscles. Any motor command from the primary motor cortex is sent down the axons of the Betz cells to activate upper motor neurons in either the cranial motor nuclei or in the ventral horn of the spinal cord. The axons of the corticobulbar tract are ipsilateral, meaning they project from the cortex to the cranial motor nucleus on the same side of the nervous system. The corticobulbar tract controls the movement of muscles in the face, head and neck. Conversely, the axons of the corticospinal tract are largely contralateral, meaning that they cross the midline of the brainstem or spinal cord and synapse on the opposite side of the body. The corticospinal tract controls movement of muscles of limbs and trunk. Therefore, the right motor cortex of the cerebrum controls muscles on the left arm, for example, and vice versa.
The corticospinal tract descends from the cortex through the deep white matter of the cerebrum. It then passes between the caudate nucleus and putamen of the basal nuclei as a bundle called the internal capsule . The tract then passes through the midbrain as the cerebral peduncles , after which it burrows through the pons. Upon entering the medulla, the tracts make up the large white matter tract referred to as the pyramids (Figure \(\PageIndex{1}\)). The defining landmark of the medullary-spinal border is the pyramidal decussation , which is where most of the fibers in the corticospinal tract cross over to the opposite side of the brain. At this point, the tract separates into two parts, which have control over different domains of the musculature.
Appendicular Control
The lateral corticospinal tract is composed of the fibers that cross the midline at the pyramidal decussation (see Figure \(\PageIndex{1}\)). The axons cross over from the anterior position of the pyramids in the medulla to the lateral column of the spinal cord. These axons are responsible for controlling appendicular muscles.
This influence over the appendicular muscles means that the lateral corticospinal tract is responsible for moving the muscles of the arms and legs. The lower cervical spinal cord and the lumbar spinal cord both have wider ventral horns, representing the greater number of muscles controlled by these motor neurons. The cervical enlargement is particularly large because there is greater control over the fine musculature of the upper limbs, particularly of the fingers. The lumbar enlargement is not as significant in appearance because there is less fine motor control of the lower limbs.
Axial Control
The anterior corticospinal tract is responsible for controlling the muscles of the body trunk (see Figure \(\PageIndex{1}\)). These axons do not decussate in the medulla. Instead, they remain in an anterior position as they descend the brainstem and enter the spinal cord. These axons then travel to the spinal cord level at which they synapse with a lower motor neuron. Upon reaching the appropriate level, the axons decussate, entering the ventral horn on the opposite side of the spinal cord from which they entered. In the ventral horn, these axons synapse with their corresponding lower motor neurons. The lower motor neurons are located in the medial regions of the ventral horn, because they control the axial muscles of the trunk.
Because movements of the body trunk involve both sides of the body, the anterior corticospinal tract is not entirely contralateral. Some collateral branches of the tract will project into the ipsilateral ventral horn to control synergistic muscles on that side of the body, or to inhibit antagonistic muscles through interneurons within the ventral horn. Through the influence of both sides of the body, the anterior corticospinal tract can coordinate postural muscles in broad movements of the body. These coordinating axons in the anterior corticospinal tract are often considered bilateral, as they are both ipsilateral and contralateral.
Extrapyramidal System
Other descending connections between the brain and the spinal cord are called the extrapyramidal system . The name comes from the fact that this system is outside the corticospinal pathway, which includes the pyramids in the medulla. A few pathways originating from the brainstem contribute to this system.
The tectospinal tract projects from the midbrain to the spinal cord and is important for postural movements that are driven by the superior colliculus (Figure \(\PageIndex{2}\)). The name of the tract comes from an alternate name for the superior colliculus, which is the tectum. The reticulospinal tract connects the reticular system, a diffuse region of gray matter in the brainstem, with the spinal cord. This tract influences trunk and proximal limb muscles related to posture and locomotion. The reticulospinal tract also contributes to muscle tone and influences autonomic functions. The vestibulospinal tract connects the brainstem nuclei of the vestibular system with the spinal cord. This allows posture, movement, and balance to be modulated on the basis of equilibrium information provided by the vestibular system. The pathways of the extrapyramidal system are influenced by subcortical structures. For example, connections between the secondary motor cortices and the extrapyramidal system modulate spine and cranium movements. The basal nuclei, which are important for regulating movement initiated by the CNS, influence the extrapyramidal system as well as its thalamic feedback to the motor cortex.
Figure \(\PageIndex{2}\) summarizes both ascending and descending pathways.
Ventral Horn Output
The somatic nervous system provides output strictly to skeletal muscles. The lower motor neurons, which are responsible for the contraction of these muscles, are found in the ventral horn of the spinal cord. These large, multipolar neurons have a corona of dendrites surrounding the cell body and an axon that extends out of the ventral horn. This axon travels through the ventral nerve root to join the emerging spinal nerve. The axon is relatively long because it needs to reach muscles in the periphery of the body. The diameters of cell bodies may be on the order of hundreds of micrometers to support the long axon; some axons are a meter in length, such as the lumbar motor neurons that innervate muscles in the first digits of the feet.
The axons will also branch to innervate multiple muscle fibers. Together, the motor neuron and all the muscle fibers that it controls make up a motor unit. Motor units vary in size. Some may contain up to 1000 muscle fibers, such as in the quadriceps, or they may only have 10 fibers, such as in an extraocular muscle. The number of muscle fibers that are part of a motor unit corresponds to the precision of control of that muscle. Also, muscles that have finer motor control have more motor units connecting to them, and this requires a larger topographical field in the primary motor cortex.
Somatic Reflexes
This chapter began by introducing reflexes as an example of the basic elements of the somatic nervous system. Simple somatic reflexes do not include the higher centers discussed for conscious or voluntary aspects of movement. Reflexes can be spinal or cranial, depending on the nerves and central components that are involved.
The example described at the beginning of the chapter involved heat and pain sensations from a hot stove causing withdrawal of the arm through a connection in the spinal cord that leads to contraction of the biceps brachii (Figure \(\PageIndex{3}\)). The description of this withdrawal reflex was simplified, for the sake of the introduction, to emphasize the parts of the somatic nervous system. But to consider reflexes fully, more attention needs to be given to this example.
As you withdraw your hand from the stove, you do not want to slow that reflex down. Consequently, as the biceps brachii contracts, the antagonistic triceps brachii needs to relax. In the hot-stove withdrawal reflex, this occurs through an interneuron in the spinal cord. The interneuron’s cell body is located in the dorsal horn of the spinal cord. The interneuron receives a synapse from the axon of the sensory neuron that detects that the hand is being burned. In response to this stimulation from the sensory neuron, the interneuron then inhibits the motor neuron that controls the triceps brachii. Without the antagonistic contraction, withdrawal from the hot stove is faster and keeps further tissue damage from occurring.
Another type of reflex is a stretch reflex shown in Figure \(\PageIndex{4}\). In this reflex, when a skeletal muscle is stretched, a muscle spindle receptor is activated. The axon from this receptor structure will cause direct contraction of the muscle. A collateral of the muscle spindle fiber will also inhibit the motor neuron of the antagonist muscles.  The muscle is quickly stretched, resulting in activation of the muscle spindle that sends a signal into the spinal cord through the dorsal root. The fiber synapses directly on the ventral horn motor neuron that activates the muscle, causing contraction. The reflexes are physiologically useful for stability. If a muscle is stretched, it reflexively contracts to return the muscle to compensate for the change in length. In the context of the neurological exam, reflexes indicate that the lower motor neuron is functioning properly.
A specialized reflex to protect the surface of the eye is the corneal reflex , or the eye blink reflex. When the cornea is stimulated by a tactile stimulus, or even by bright light in a related reflex, blinking is initiated. The sensory component travels through the trigeminal nerve, which carries somatosensory information from the face, or through the optic nerve, if the stimulus is bright light. The motor response travels through the facial nerve and innervates the orbicularis oculi on the same side. This reflex is commonly tested during a physical exam using an air puff or a gentle touch of a cotton-tipped applicator.
Concept Review
The motor components of the somatic nervous system begin with the frontal lobe of the brain, where the prefrontal cortex is responsible for higher functions such as working memory. The integrative and associate functions of the prefrontal lobe feed into the secondary motor areas, which help plan movements. The premotor cortex and supplemental motor area then feed into the primary motor cortex that initiates movements. Large Betz cells project through the corticobulbar and corticospinal tracts to synapse on lower motor neurons in the brainstem and ventral horn of the spinal cord, respectively. These connections are responsible for generating movements of skeletal muscles.
The extrapyramidal system includes projections from the brainstem and higher centers that influence movement, mostly to maintain balance and posture, as well as to maintain muscle tone. The superior colliculus and red nucleus in the midbrain, the vestibular nuclei in the medulla, and the reticular formation throughout the brainstem each have tracts projecting to the spinal cord in this system. Descending input from the secondary motor cortices, basal nuclei, and cerebellum connect to the origins of these tracts in the brainstem.
All of these motor pathways project to the spinal cord to synapse with motor neurons in the ventral horn of the spinal cord. These lower motor neurons are the cells that connect to skeletal muscle and cause contractions. These neurons project through the spinal nerves to connect to the muscles at neuromuscular junctions. One motor neuron connects to multiple muscle fibers within a target muscle. The number of fibers that are innervated by a single motor neuron varies on the basis of the precision necessary for that muscle and the amount of force necessary for that motor unit. The quadriceps, for example, have many fibers controlled by single motor neurons for powerful contractions that do not need to be precise. The extraocular muscles have only a small number of fibers controlled by each motor neuron because moving the eyes does not require much force, but needs to be very precise.
Reflexes are the simplest circuits within the somatic nervous system. A withdrawal reflex from a painful stimulus only requires the sensory fiber that enters the spinal cord and the motor neuron that projects to a muscle. Antagonist and postural muscles can be coordinated with the withdrawal, making the connections more complex. The simple, single neuronal connection is the basis of somatic reflexes. The corneal reflex is contraction of the orbicularis oculi muscle to blink the eyelid when something touches the surface of the eye. Stretch reflexes maintain a constant length of muscles by causing a contraction of a muscle to compensate for a stretch that can be sensed by a specialized receptor called a muscle spindle.
Review Questions
Q. Which region of the frontal lobe is responsible for initiating movement by directly connecting to cranial and spinal motor neurons?
A. prefrontal cortex
B. supplemental motor area
C. premotor cortex
D. primary motor cortex
- Answer
-
D
Q. Which extrapyramidal tract incorporates equilibrium sensations with motor commands to aid in posture and movement?
A. tectospinal tract
B. vestibulospinal tract
C. reticulospinal tract
D. corticospinal tract
- Answer
-
B
Q. Which region of gray matter in the spinal cord contains motor neurons that innervate skeletal muscles?
A. ventral horn
B. dorsal horn
C. lateral horn
D. lateral column
- Answer
-
A
Glossary
- anterior corticospinal tract
- division of the corticospinal pathway that travels through the ventral (anterior) column of the spinal cord and controls axial musculature through the medial motor neurons in the ventral (anterior) horn
- Betz cells
- output cells of the primary motor cortex that cause musculature to move through synapses on cranial and spinal motor neurons
- Broca’s area
- region of the frontal lobe associated with the motor commands necessary for speech production
- cerebral peduncles
- segments of the descending motor pathway that make up the white matter of the ventral midbrain
- cervical enlargement
- region of the ventral (anterior) horn of the spinal cord that has a larger population of motor neurons for the greater number of and finer control of muscles of the upper limb
- corneal reflex
- protective response to stimulation of the cornea causing contraction of the orbicularis oculi muscle resulting in blinking of the eye
- corticobulbar tract
- connection between the cortex and the brainstem responsible for generating movement
- corticospinal tract
- connection between the cortex and the spinal cord responsible for generating movement
- executive functions
- cognitive processes of the prefrontal cortex that lead to directing goal-directed behavior, which is a precursor to executing motor commands
- extrapyramidal system
- pathways between the brain and spinal cord that are separate from the corticospinal tract and are responsible for modulating the movements generated through that primary pathway
- frontal eye fields
- area of the prefrontal cortex responsible for moving the eyes to attend to visual stimuli
- internal capsule
- segment of the descending motor pathway that passes between the caudate nucleus and the putamen
- lateral corticospinal tract
- division of the corticospinal pathway that travels through the lateral column of the spinal cord and controls appendicular musculature through the lateral motor neurons in the ventral (anterior) horn
- lumbar enlargement
- region of the ventral (anterior) horn of the spinal cord that has a larger population of motor neurons for the greater number of muscles of the lower limb
- premotor cortex
- cortical area anterior to the primary motor cortex that is responsible for planning movements
- pyramidal decussation
- location at which corticospinal tract fibers cross the midline and segregate into the anterior and lateral divisions of the pathway
- pyramids
- segment of the descending motor pathway that travels in the anterior position of the medulla
- reticulospinal tract
- extrapyramidal connections between the brainstem and spinal cord that modulate movement, contribute to posture, and regulate muscle tone
- stretch reflex
- response to activation of the muscle spindle stretch receptor that causes contraction of the muscle to maintain a constant length
- supplemental motor area
- cortical area anterior to the primary motor cortex that is responsible for planning movements
- tectospinal tract
- extrapyramidal connections between the superior colliculus and spinal cord
- vestibulospinal tract
- extrapyramidal connections between the vestibular nuclei in the brainstem and spinal cord that modulate movement and contribute to balance on the basis of the sense of equilibrium
- withdrawal reflex
- automatic withdrawal of an extremity (e.g. a hand) from a painful stimulus
- working memory
- function of the prefrontal cortex to maintain a representation of information that is not in the immediate environment
Contributors and Attributions
-
OpenStax Anatomy & Physiology (CC BY 4.0). Access for free at https://openstax.org/books/anatomy-and-physiology


1.0: Literary Criticism
By reading and discussing literature, we expand our imagination, our sense of what is possible, and our ability to empathize with others. Improve your ability to read critically and interpret texts while gaining appreciation for different literary genres and theories of interpretation. Read samples of literary interpretation. Write a critique of a literary work.
Texts that interpret literary works are usually persuasive texts. Literary critics may conduct a close reading of a literary work, critique a literary work from the stance of a particular literary theory, or debate the soundness of other critics’ interpretations. The work of literary critics is similar to the work of authors writing evaluative texts. For example, the skills required to critique films, interpret laws, or evaluate artistic trends are similar to those skills required by literary critics.
Why Write Literary Criticism?
People have been telling stories and sharing responses to stories since the beginning of time. By reading and discussing literature, we expand our imagination, our sense of what is possible, and our ability to empathize with others. Reading and discussing literature can enhance our ability to write. It can sharpen our critical faculties, enabling us to assess works and better understand why literature can have such a powerful effect on our lives.“Literary texts” include works of fiction and poetry. In school, English instructors ask students to critique literary texts, or works. Literary criticism refers to a genre of writing whereby an author critiques a literary text, either a work of fiction, a play, or poetry. Alternatively, some works of literary criticism address how a particular theory of interpretation informs a reading of a work or refutes some other critics’ reading of a work.
Diverse Rhetorical Situations
The genre of literary interpretation is more specialized than most of the other genres addressed in this section, as suggested by the table below. People may discuss their reactions to literary works informally (at coffee houses, book clubs, or the gym) but the lion’s share of literary criticism takes place more formally: in college classrooms, professional journals, academic magazines, and Web sites.
Students interpret literary works for English instructors or for students enrolled in English classes. In their interpretations, students may argue for a particular interpretation or they may dispute other critics’ interpretations. Alternatively, students may read a text with a particular literary theory in mind, using the theory to explicate a particular point of view. For example, writers could critique The Story of an Hour by Kate Chopin from a feminist theoretical perspective. Thanks to the Internet, some English classes are now publishing students’ interpretations on Web sites. In turn, some students and English faculty publish their work in academic literary criticism journals.
Over the years, literary critics have argued about the best ways to interpret literature. Accordingly, many “schools” or “theories of criticism” have emerged. As you can imagine–given that they were developed by sophisticated specialists–some of these theoretical approaches are quite sophisticated and abstract.
Below is a summary of some of the more popular literary theories. Because it is a summary, the following tends to oversimplify the theories. In any case, unless you are enrolled in a literary criticism course, you won’t need to learn the particulars of all of these approaches. Instead, your teacher may ask you to take an eclectic approach, pulling interpretative questions from multiple literary theories.
Note : If you are interested in learning more about these theories, review either Skylar Hamilton Burris’ Literary Criticism: An Overview of Approaches or Dino F. Felluga’s Undergraduate Guide to Critical Theory
- Schools of Literary Criticism
- New Criticism : Focuses on “objectively” evaluating the text, identifying its underlying form. May study, for example, a text’s use of imagery, metaphor, or symbolism. Isn’t concerned with matters outside the text, such as biographical or contextual information. Online Examples: A Formalist Reading of Sandra Cisneros’s “Woman Hollering Creek” , Sound in William Shakespeare’s The Tempest by Skylar Hamilton Burris
- Reader-Respons : Criticism Focuses on each reader’s personal reactions to a text, assuming meaning is created by a reader’s or interpretive community’s personal interaction with a text. Assumes no single, correct, universal meaning exists because meaning resides in the minds of readers. Online Examples: Theodore Roethke’s “My Papa’s Waltz”: A Reader’s Response (PDF)
- Feminism: Criticism Focuses on understanding ways gender roles are reflected or contradicted by texts, how dominance and submission play out in texts, and how gender roles evolve in texts. Online Example: “The Yellow Wall-Paper”: A Twist on Conventional Symbols , Subverting the French Androcentric Influence by Jane Le Marquand
- New Historicism Focuses on understanding texts by viewing texts in the context of other texts. Seeks to understand economic, social, and political influences on texts. Tend to broadly define the term “text,” so, for example, the Catholic Church could be defined as a “text.” May adopt the perspectives of other interpretive communities–particularly reader-response criticism, feminist criticism, and Marxist approaches–to interpret texts. Online Example Monstrous Acts by Jonathan Lethem
- Media Criticism Focuses on writers’ use of multimedia and hypertexts. Online Examples The Electronic Labyrinth by Christopher Keep, Tim McLaughlin, and Robin Parmar
- Psychoanalytical Criticism Focuses on psychological dimensions of the work. Online Examples: A Freudian Approach to Erin McGraw’s “A Thief” by Skylar Hamilton Burris
- Marxist Criticism Focuses on ways texts reflect, reinforce, or challenge the effects of class, power relations, and social roles. Online Example: A Reading of Shirley Jackson’s “The Lottery” by Peter Kosenko
- Archetypal Criticism Focuses on identifying the underlying myths in stories and archetypes, which reflect what the psychologist Carl Jung called the “collective unconsciousness.” Online Example: A Catalogue of Symbols in The Awakening by Kate Chopin by Skylar Hamilton Burris
- Postcolonial Criticism Focuses on how Western culture’s (mis)representation of third-world countries and peoples in stories, myths, and stereotypical images encourages repression and domination. Online Example: Other Voices
- Structuralism/Semiotics Focuses on literature as a system of signs where meaning is constructed in a context, where words are inscribed with meaning by being compared to other words and structures. Online Example: Applied Semiotics [Online journal with many samples]
- Post-Structuralism/Deconstruction Focuses, along with Structuralism, on viewing literature as a system of signs, yet rejects the Structuralist view that a critic can identify the inherent meaning of a text, suggesting, instead that literature has no center, no single interpretation, that literary language is inherently ambiguous
Powerful works of literature invoke multiple readings. In other words, we can all read the same story or poem (or watch the same movie or listen to the same song) and come up with different, even conflicting, interpretations about what the work means. Who we are reflects how we read texts. Our experiences inspire us to relate to and sympathize with characters and difficult situations. Have we read similar stories? Have we actually faced some of the same challenges the characters in the story face?
In addition, literary theories have unique ways to develop and substantiate arguments. Some theories draw extensively on the work of other critics, while others concentrate on the reader’s thoughts and feelings. Some theories analyze a work from an historical perspective, while others focus solely on a close reading of a text.
Accordingly, as with other genres, the following key features need to be read as points of departure as opposed to a comprehensive blueprint:
Focus
Examine a subject from a rhetorical perspective. Identify the intended audience, purpose, context, media, voice, tone, and persona.Distinguish between summarizing the literary work and presenting your argument. Many students fall into the trap of spending too much time summarizing the literature being analyzed as opposed to critiquing it. As a result, it would be wise to check with your teacher regarding how much plot summary is expected. As you approach this project, remember to keep your eye on the ball: What, exactly (in one sentence) is the gist of your interpretation?
Development
You can develop your ideas by researching the work of other literary critics. How do other critics evaluate an author’s work? What literary theories do literary critics use to interpret texts or particular moments in history? Reading sample proposals can help you find and adopt an appropriate voice and persona. By reading samples, you can learn how others have prioritized particular criteria.
Below are some of the questions invoked by popular literary theories. Consider these questions as you read a work, perhaps taking notes on your thoughts as you reread. You may focus on using one theory to “read and interpret” text or, more commonly, you may compare the critical concerns of different theories.
New Criticism/Formalism
- Character: How does the character evolve during the story? What is unique or interesting about a character? Is the character a stereotypical action hero, a patriarchal father figure, or Madonna? How does a character interact with other characters?
- Setting: How does the setting enhance tension within the work? Do any elements in the setting foreshadow the conclusion of the piece?
- Plot:What is the conflict? How do scenes lead to a suspenseful resolution? What scenes make the plot unusual, unexpected, suspenseful?
- Point of View: Who is telling the story? Is the narrator omniscient (all knowing) or does the narrator have limited understanding?
Reader-Response Criticism
How does the text make you feel? What memories or experiences come to mind when you read? If you were the central protagonist, would you have behaved differently? Why? What values or ethics do you believe are suggested by the story? As your reading of a text progresses, what surprises you, inspires you?
Feminist Criticism
How does the story re-inscribe or contradict traditional gender roles? For example, are the male characters in “power positions” while the women are “dominated”? Are the men prone to action, decisiveness, and leadership while the female characters are passive, subordinate? Do gender roles create tension within the story? Do characters’ gender roles evolve over the course of the narrative?
New Historicism Cristicism
How does the story reflect the aspirations and conditions of the lower classes or upper classes? Is tension created by juxtaposing privileged, powerful positions to subordinated, dominated positions? What information about the historical context of the story helps explain the character’s motivations? Who benefits from the outcome of the story or from a given character’s motivation?
Media Criticism
How does the medium alter readers’ interactions with the text? Has the reader employed multimedia or hypertext? What traditions from print and page design have shaped the structure of the text? In what ways has the author deviated from traditional, deductively organized linear texts?
Cite from the Work
Literary criticism involves close reading of a literary work, regardless of whether you are arguing about a particular interpretation, comparing stories or poems, or using a theory to interpret literature.Do not summarize the story. The purpose of the document is not to inform the readers, but to argue a particular interpretation. You only need to cite parts of the work that support or relate to your argument and follow the citation format required by your instructor (see Using and Citing Sources).
Below is an example from Sample Essays for English 103: Introduction to Fiction, Professor Matthew Hurt. Note how the writer uses block quotes to highlight key elements and paraphrase and summarizes the original works, using quotation marks where necessary.
…Twain offers a long descriptive passage of Huck and Jim’s life on the raft that seems, at first glance, to celebrate the idyllic freedom symbolized by the river and nature. . . A close reading of this passage, however, shows that the river is not a privileged natural space outside of and uncontaminated by society, but is inextricably linked to the social world on the shore, which itself has positive value for Huck. Instead of seeking to escape society, Huck wants to escape the dull routines of life.
The passage abounds with lyrical descriptions of the river’s natural beauty. For example, Huck’s long description of the sunrise over the river captures the peaceful stillness and the visual beauty of the scene:
The first thing to see, looking away over the water, was a kind of dull line — that was the woods on t’other side — you couldn’t make nothing else out; then a pale place in the sky; then more paleness, spreading around; then the river softened up, away off, and warn’t black any more, but gray; . . . sometimes you could hear a sweep screaking; or jumbled up voices, it was so still, and sounds come so far; and by-and-by you could see a streak on the water which you know by the look of the streak that there’s a snag there in the swift current which breaks on it and makes the streak look that way; and you see the mist curl up off of the water, and the east reddens up, and the river, and you make out a log cabin in the edge of the woods, away on the bank on t’other side of the river, . . . then the nice breeze springs up, and comes fanning you from over there, so cool and fresh, and sweet to smell, on account of the woods and the flowers; . . . and next you’ve got the full day, and everything smiling in the sun, and the song-birds just going at it! (129-130)
Here Huck celebrates the beauty of the natural world coming to life at the beginning of a new day. The “paleness” gradually spreading across the sky makes new objects visible which he describes in loving detail for the reader. The “nice breeze” is “cool and fresh” and “sweet to smell,” and the world seems to be “smiling in the sun” as the song-birds welcome the new day.
However, Huck includes a number of details within this passage that would seem to work against the language of natural beauty. After describing the gradually brightening sky, Huck notes that “you could see little dark spots drifting along, ever so far away — trading scows, and such things; and long black streaks — rafts.” The sun rise reveals not only natural objects (the brightening sky, the “snag,” the “mist”), but also brings into view man-made objects (“trading scows” and “rafts”) that signify human society’s presence in this natural environment. Similarly, Huck speculates that the picturesque “log cabin” on the distant shore is a “woodyard, likely, and piled by them cheats so you can throw a dog through it anywheres.” Here the marker of human society takes on a sinister tone of corruption as Huck describes how unscrupulous wood sellers stack wood loosely to cheat their customers. Finally, although the breeze is “sweet to smell,” Huck assures the reader that this isn’t always the case: “but sometimes not that way, because they’ve left dead fish laying around, gars, and such, and they do get pretty rank.”
These signs of society’s presence on the river are largely negative. The woodyard is “piled by cheats” and the stacked fish pollute the “sweet” smell of the breeze. At this point, the opposition between “good nature” and “bad society” remains intact. The signs of human presence suggest a corruption of nature’s beauty. In the paragraphs that follow, however, this opposition is subtly reversed. After Huck’s account of the sunrise over the river, he describes how he and Jim watch the steamboats “coughing along up stream.” But when there are no steamboats or rafts to watch, he describes the scene as “solid lonesomeness” (130). No songbirds, no sweet breezes. Without human activities to watch, the scene suddenly becomes empty and “lonesome,” and nothing captures Huck’s attention until more rafts and boats pass by and he can watch them chopping wood or listen to them beating pans in the fog.
Cite Other Critics’ Interpretations of the Work
Criticism written by advanced English majors, graduate students, and literary critics may be more about what other critics have said than about the actual text. Indeed, many critics spend more time reading criticism and arguing about critical approaches than actually reading original works. However, unless you are enrolled in a literary theory course, your instructor probably wants you to focus more on interpreting the work than discussing other critical interpretations. This does not mean, however, that you should write about a literary work “blindly.” Instead, you are wise to find out what other students and critics have said about the work.
Below is a sample passage that illustrates how other critics’ works can inspire an author and guide him or her in constructing a counter argument, support an author’s interpretation, and provide helpful biographical information.
In her critical biography of Shirley Jackson, Lenemaja Friedman notes that when Shirley Jackson’s story “The Lottery” was published in the June 28, 1948 issue of the New Yorker it received a response that “no New Yorker story had ever received”: hundreds of letters poured in that were characterized by “bewilderment, speculation, and old-fashioned abuse.”1 It is not hard to account for this response: Jackson’s story portrays an “average” New England village with “average” citizens engaged in a deadly rite, the annual selection of a sacrificial victim by means of a public lottery, and does so quite deviously: not until well along in the story do we suspect that the “winner” will be stoned to death by the rest of the villagers.
Organization
The format for literary critiques is fairly standard:
- State your claim(s).
- Forecast your organization.
- Marshal evidence for your claim.
- Reiterate argument and elaborate on its significance.
In English classes, you may be able to assume that your readers are familiar with the work you are critiquing. Perhaps, for example, the entire class is responding to one particular work after some class discussions about it. However, if your instructor asks you to address a broader audience, you may need to provide bibliographical information for the work. In other words, you may need to cite the title, publisher, date, and pages of the work (see Citing Sources ).
Literary critiques are arguments. As such, your instructors expect you to state a claim in your introduction and then provide quotes and paraphrased statements from the text to serve as evidence for your claim. Ideally, your critique will be insightful and interesting. You’ll want to come up with an interpretation that isn’t immediately obvious. Below are some examples of “thesis statements” or “claims” from literary critiques:
- In “The Yellow Wallpaper,” by Charlotte Perkins Gilman, the protagonist is oppressed and represents the effect of the oppression of women in society. This effect is created by the use of complex symbols such as the house, the window, and the wall-paper which facilitate her oppression as well as her self expression. [“‘The Yellow Wall-Paper’: A Twist on Conventional Symbols” by Liselle Sant]
- “The Yellow Wallpaper” by Charlotte Gilman is a sad story of the repression that women face in the days of the late 1800’s as well as being representative of the turmoil that women face today. [Critique of “The Yellow Wallpaper” by Brandi Mahon]
- “The Yellow Wallpaper,” written by Charlotte Perkins Gilman, is a story of a woman, her psychological difficulties and her husband’s so called therapeutic treatment of her aliments during the late 1800s. . . Gilman does well throughout the story to show with descriptive phrases just how easily and effectively the man “seemingly” wields his “maleness” to control the woman. But, with further interpretation and insight I believe Gilman succeeds in nothing more than showing the weakness of women, of the day, as active persons in their own as well as society’s decision making processes instead of the strength of men as women dominating machines. “The View from the Inside” by Timothy J. Decker
- In Adventures of Huckleberry Finn, Mark Twain creates a strong opposition between the freedom of Huck and Jim’s life on the raft drifting down the Mississippi River, which represents “nature,” and the confining and restrictive life on the shore, which represents “society.” [ “‘All I wanted was a change’: Positive Images of Nature and Society in Chapter 19 of Adventures of Huckleberry Finn” from Professor Matthew Hurt’s “Sample Essays for English 103: Introduction to Fiction”]
- In Gabriel Garcia Marquez’s short story, “A Very Old Man with Enormous Wings,” an unexpected visitor comes down from the sky, and seems to test the faith of a community. The villagers have a difficult time figuring out just how the very old man with enormous wings fits into their lives. Because this character does not agree with their conception of what an angel should look like, they try to determine if the aged man could actually be an angel. In trying to prove the origin of their visitor, the villagers lose faith in the possibility of him being an angel because he does not adhere to their ordered world. Marquez keeps the identity of the very old man with enormous wings ambiguous to critique the villagers and, more generally, organized religion for having a lack of faith to believe in miracles that do not comply with their master narrative. [“Prove It: A Critique of the Villagers’ Faith in ‘A Very Old Man with Enormous Wings'” from Sample Essays for English 103: Introduction to Fiction, Professor Matthew Hurt]
Style
Literary criticism is a fairly specialized kind of writing. Instead of writing to a general lay audience, you are writing to members of a literary community who have read a work and who developed opinions about the work–as well as a vocabulary of interpretation.
Following are some common words used by literary critics. More specialized terms can be learned by reading criticism or by referring to a good encyclopedia for criticism or writing, including the Writer’s Encyclopedia:
- Protagonist: The protagonist is the major character of the story; typically the character must overcome significant challenges.
- Antagonist: The protagonist’s chief nemesis; in other words, the character whom the protagonist must overcome.
- Symbols: Metaphoric language; see A Catalogue of Symbols in The Awakening by Kate Chopin
- Viewpoint: Stories are told either in the first person or third person point of view. The first person is limited to a single character, although dialog can let you guess at other characters’ intentions. The third person allows readers inside the character’s mind so you know what the character feels and thinks.Viewpoint can be “limited,” where the character knows less than the reader, or “omniscient,” where the reader can hear the thoughts and feelings of all characters. Occasionally writers will use multiple character viewpoint, which takes you from one character’s perspective to another.
- Plot: Plots are a series of scenes, typically moving from a conflict situation to a resolution. To surprise readers, authors will foreshadow “false plants,” which lead readers to anticipate other resolutions. The term “denouement” refers to the unraveling of the plot in the conclusion.
- Literary Criticism. Authored by : Joseph Moxley. Provided by : Writing Commons. Located at : http://writingcommons.org/open-text/genres/academic-writing/literary-criticism/28-literary-criticism . License : CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives
- Academic Writing Tips : How to Write a Literary Analysis Paper. Authored by : eHow. Located at : https://youtu.be/8adKfLwIrVk . License : All Rights Reserved . License Terms : Standard YouTube license