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SUBMITTED TO: Mr. Jonas Borja, RN


June 2012

TEACHING PLAN FOR PAIN MANAGEMENT DESCRIPTION OF THE LEARNER: Mr X is a 27 year old male, private miner. He lives in Backong Beckel, La Trinidad Benguet. It is his first time to be admitted with abdominal pain and low back pain. Mr X stated that he wants to know and understand what causes the pain and how to manage it. Mr X prefers Ilocano or Tagalog as a medium of instruction. LEARNING NEED: What are the causes of pain, and how to prevent and manage the occurrence of pain? LEARNING DIAGNOSIS: Knowledge deficit: prevention and management of pain related to lack of information as manifested by the client claiming that he does not know what the cause is. GOAL: The client will be able to identify causes of pain as well as ways to prevent and manage occurrence of pain.

BLOS: Upon completion of the topic on Pain Management, the client will be able to: 1. Describe what is Pain using his own term.





Definition of Pain.

One-on-one discussion with brochure.

3 minutes: Defining and describing Pain.

Instant oral feedback: the client will correctly answer question about Pain. Instant oral feedback: the client will describe types of pain. Instant oral feedback: client discusses the

2. Identify types of pain.

Types of Pain

One-on-one discussion with brochure.

5 minutes: Brochure: Types of Pain.

3. Discuss how to measure pain.

Ways on measuring pain.

One-on-one discussion with

10 minutes: Brochure: How do


you measure pain?

ways on measuring pain. Instant oral feedback: The client will at least identify ways on managing pain applicable to his case.

4. Identify ways on managing or treating pain.

Treatments of pain.

One-on-one discussion with brochure.

10 minutes: Brochure: What are the treatments of pain?

5. Provide a followup visit after doing health teaching.

The English word 'pain' probably comes from Old French (peine), Latin (poena - meaning punishment pain), or Ancient Greek (poine - a word more related to penalty), or a combination of all three. In medicine pain relates to a sensation that hurts. If you feel pain it hurts, you feel discomfort, distress and perhaps agony, depending on the severity of it. Pain can be steady and constant, in which case it may be an ache. It might be a throbbing pain - a pulsating pain. The pain could have a pinching sensation, or a stabbing one. Only the person who is experiencing the pain can describe it properly. Pain is a very individual experience. Types of pain Acute pain - this can be intense and short-lived, in which case we call it acute pain. Acute pain may be an indication of an injury. When the injury heals the pain usually goes away. Chronic pain - this sensation lasts much longer than acute pain. Chronic pain can be mild or intense (severe). How do we classify pain? Pain can be nociceptive, non-nociveptive, somatic, visceral, neuropathic, or sympathetic. Look at the table below.








Nociceptive Pain - specific pain receptors are stimulated. These receptors sense temperature (hot/cold), vibration, stretch, and chemicals released from damaged cells. Somatic Pain - a type of nociceptive pain. Pain felt on the skin, muscle, joints, bones and ligaments is called somatic pain. The term musculo-skeletal pain means

somatic pain. The pain receptors are sensitive to temperature (hot/cold), vibration, and stretch (in the muscles). They are also sensitive to inflammation, as would happen if you cut yourself, sprain something that causes tissue damage. Pain as a result of lack of oxygen, as in ischemic muscle cramps, are a type of nociceptive pain. Somatic pain is generally sharp and well localized - if you touch it or move the affected area the pain will worsen. Visceral Pain - a type of nociceptive pain. It is felt in the internal organs and main body cavities. The cavities are divided into the thorax (lungs and heart), abdomen (bowels, spleen, liver and kidneys), and the pelvis (ovaries, bladder, and the womb). The pain receptors - nociceptors - sense inflammation, stretch and ischemia (oxygen starvation). Visceral pain is more difficult to localize than somatic pain. The sensation is more likely to be a vague deep ache. Colicky and cramping sensations are generally types of visceral pain. Visceral pain commonly refers to some type of back pain - pelvic pain generally refers to the lower back, abdominal pain to the mid-back, and thoracic pain to the upper back (see below for the meaning of referred pain). Nerve Pain or Neuropathic Pain Nerve pain is also known as neuropathic pain. It is a type of non-nociceptive pain. It comes from within the nervous system itself. People often refer to it as pinched nerve, or trapped nerve. The pain can originate from the nerves between the tissues and the spinal cord (peripheral nervous system) and the nerves between the spinal cord and the brain (central nervous system, or CNS). Neuropathic pain can be caused by nerve degeneration, as might be the case in a stroke, multiple-sclerosis, or oxygen starvation. It could be due to a trapped nerve, meaning there is pressure on the nerve. A torn or slipped disc will cause nerve inflammation, which will trigger neuropathic pain. Nerve infection, such as shingles, can also cause neuropathic pain. Pain that comes from the nervous system is called non-nociceptive because there are no specific pain receptors. Nociceptive in this text means responding to pain. When a nerve is injured it becomes unstable and its signaling system becomes muddled and haphazard. The brain interprets these abnormal signals as pain. This randomness can also cause other sensations, such as numbness, pins and needles, tingling, and hypersensitivity to temperature, vibration and touch. The pain can sometimes be unpredictable because of this. Sympathetic Pain The sympathetic nervous system controls our blood flow to our skin and muscles, perspiration (sweating) by the skin, and how quickly the peripheral nervous system works. Sympathetic pain occurs generally after a fracture or a soft tissue injury of the limbs. This pain is non-nociceptive - there are no specific pain receptors. As with neuropathic pain, the nerve is injured, becomes unstable and fires off random, chaotic, abnormal signals to the brain, which interprets them as pain. Generally with this kind of pain the skin and the area around the injury become extremely sensitive. The pain often becomes so intense that the sufferer daren't use the affected arm or leg. Lack of limb use after a time can cause other problems, such as muscle wasting,osteoporosis, and stiffness in the joints.

What is referred pain? Also known as reflective pain. When pain is felt either next to, or at a distance from the origin of an injury it is called referred pain. For example, when a person has a heart attack, even though the affected area is the heart, the pain is sometimes felt around the shoulders, back and neck, rather than in the chest. We have known about referred pain for centuries, but we still do not know its origins and what causes it. How do you measure pain? It is virtually impossible to measure a person's pain objectively. Most experts say that the best way to find out how much pain a person is enduring is by a subjective pain report. A comprehensive assessment of pain should include:

The identification of all the pains. This must include the most important ones. The site, quality, and radiation of pain What factors aggravate and relieve the pain When the pain occurs throughout the day What impact the pain has on the person's function What impact the pain has on the person's mood The sufferers' understanding of their pain What are the treatments for pain? An underlying disorder, if treated effectively, will also get rid of the pain, or at least reduce it. If you have an infection and take antibiotics, the antibiotics may get rid of that infection, resulting also in the elimination of pain. Even if an underlying problem can be treated, you may still need analgesics (pain relievers). Analgesics are good at relieving nociceptive pain, but not neuropathic pain. Chronic pain - long-lasting pain - may need other non-drug treatments as well. Opioid Analgesics Opioid analgesics are also known as narcotics. These are the strongest painkillers and are commonly used after surgery, for cancer, broken bones, burns, and various other situations. Even though opioids are not commonly used to treat non-cancer pain, their usage for non-cancer pain is becoming more widespread and acceptable. Some patients do not respond well to opioids and should not take them. The patient will be given opioids in gradually increasing dosages. The ideal dose is reached when the pain is relieved and the side-effects are tolerable (increase any higher and the side effects become too much for the patient). Dosages should be generally much lower for older patients and infants. The patient is administered opioids every few hours - each dose coinciding with the moment just before the pain starts becoming severe. Some patients are given higher dosages if the pain becomes more intense, while others are given other medications alongside the opioid. Pain can become more intense if the patient needs to move about, or if a wound dressing needs to be changed.

The dosage goes down if the pain intensity drops, until if possible, the doctor switches to a non-opioid analgesic. People with kidney failure, liver problems, COPD (chronic obstructive pulmonary disease, dementia, tend to have more side effects when given opioids. The most common opioid side effects are drowsiness, constipation, nausea, vomiting, and itching. Generally, the side effects lessen as after time. Taking too much opioid can be dangerous. Patients who take opioids for long period become physically dependent and will have withdrawal symptoms when treatment is stopped - it is important that their dosage is tapered off gradually. Nonopioid Analgesics Nonopioid analgesics are used generally for mild to moderate pain. They are not addictive and their pain-relieving effects do not dwindle over time. NSAIDs (nonsteroidal anti-inflammatory drugs) These may be obtained either OTC (over-the-counter) or as a prescription medication, it depends on the dosage. Low dosage NSAIDs are effective for headaches, muscle aches, fever, and minor pains. At a higher dose they help reduce joint inflammation. There are three main types of NSAIDs, and they all block prostaglandins - hormone-like substances that cause pain, inflammation, muscle cramps, and fever.

Traditional NSAIDs - the largest subset of NSAIDs. As is the case with most drugs, they do carry a risk of side-effects, such as stomach upset and gastrointestinal bleeding. The risk of side effects is significantly higher if the patient is over 60. At higher doses, they should only be taken when monitored by a doctor.

COX-2 inhibitors - these also reduce pain and inflammation. However, they are designed to have fewer stomach and gastrointestinal side-effects. In 22004/2005 Vioxx and Bextrawere withdrawn from the market after major studies showed Vioxx carried increased cardiovascular risks, while Bextra triggered serious skin reactions. Some other COX-2 inhibitors are also being investigated for side-effects. The FDA told makers of NSAIDs to highlight warnings on their labels in a black box.

Salicylates - these include aspirin which continues to be a popular medication for many doctors and patients. If your plan to take aspirin more than just occasionally you should consult your doctor. Long term high dosage usage of aspirin carries with it a significant risk of serious undesirable side effects, such as kidney problems and gastrointestinal bleeding. For effective control of arthritis pain and inflammation frequent large doses are needed. Nonacetylated salicylate is designed to have fewer side effects than aspirin. Some doctors may prescribe nonacetylated salicylate if they feel aspirin is too risky for their patient. Nonacetylated salicylate does not have the chemical aspirin has which protects against cardiovascular disease. Some doctors prescribe low dose aspirin along with nonacetylated salicylate for patients who they feel need cardiovascular protection. Natural non-drug pain control therapies and methods.

Acupuncture (AH-q-punk-sher) is based on the belief that life forces or energy move through the body in specific paths. These paths are called meridians (mer-IH-d-uns). With acupuncture, a needle is put into the meridian that runs to the area where you have pain. This needle blocks the meridian which stops or decreases the pain. Aromatherapy (uh-ro-muh-THAIR-uh-p) is a way of using good smells to help you relax and decrease pain. Candles, massage oils, scented bubble baths and even baking cookies are all ways that smells are used. Scientists are learning that good smells may change your mood and help you relax. It may also help your brain makes special chemicals like endorphins (n-DOOR-fins). Endorphins are a natural body chemical like morphine that decrease pain. Biofeedback teaches your body to respond in a different way to the stress of being in pain. Teaching your body to relax helps make the pain less. Caregivers may use a biofeedback machine so that you know right away when your body is relaxed. But, often you may not need any machines. Learn to take your pulse. Then take it while making your mind think about "slowing down" your pulse. This can work with breathing, temperature, and blood pressure too. Breathing exercises are another physical way to help your body relax. Teaching your body to relax helps make the pain less. Breathing in and out very slowly is all you do. Women have used breathing exercise for many years to decrease the pain of childbirth. A fun way to practice breathing slowly is to blow soap bubbles. You know you are doing a good job when you get very large bubbles. Remember to practice when you are not having pain. This helps it work better when you are having pain. Distraction (dih-STRAK-shun) teaches you to focus your attention on something other than pain. Try playing cards or games, watching TV, or taking a walk. You can also visit with friends, paint, pet animals, and write out your feelings. Using planned activities helps to manage the boredom that chronic pain and illness can cause. It may also cause you to relax and keep you from thinking about the pain. Environment (your surroundings) - Being in a quiet place may make it easier for you to deal with the pain. Avoiding bright lights or loud noisy places can also help control your pain. Making sure your home is not too hot or too cold may also decrease pain. Guided imagery (IH-mij-ree) teaches you to put pictures in your mind that will make the pain less intense. With guided imagery, you learn how to change the way your body senses and responds to pain. Imagine floating in the clouds or remembering favorite place. Guided imagery seems to especially help people with chronic lower back pain. Heat and cold can help decrease pain. Some types of pain improve best using heat while other types of pain improve most with cold. Caregivers will tell you if hot and/or cold packs will help your pain. Also, remember that a long warm bath may help calm you and let your muscles relax. A cool shower on a very hot summer day may do the same thing. Laughter - It has been said that "10 minutes of belly laughter gives 2 hours of pain-free sleep!" Laughter helps you breathe deeper and your stomach digest (break down) food. It lowers blood pressure and may cause your brain to make endorphins. Laughter can also help change your moods. It helps you relax and let go of stress, anger, fear, depression, and hopelessness. These are all parts of chronic pain. Massage is often used to help a person become more relaxed. Have someone gently massage your back, shoulders, and neck. Massage can be even more effective if you also use guided imagery, breathing exercises, or music.

Music - It does not matter whether you listen to it, sing, hum or play an instrument. Music increases blood flow to the brain and helps you take in more air. Scientists are learning that it increases energy and helps change your mood. Music also may cause your brain to make special chemicals like endorphins. Endorphins are a natural body chemical like morphine that decrease pain. People who use music often say it decreases their need of medicines for pain and anxiety. Physical therapy can be helpful with pain that was caused by not moving one part of your body. Stretching the muscles and making them stronger around the injured area can help the pain go away. Radiation can be used to decrease the size of a cancer tumor that is pressing on nerves and causing pain. Radiation can also help decrease bone pain. Self-hypnosis is a way to change your level of awareness. This means that by focusing your attention you can move away from your pain. You make yourself open to suggestions like ignoring the pain or seeing the pain in a positive way. It is not known exactly how hypnosis helps pain. But, hypnosis can give long-lasting relief of pain without affecting your normal activities. Self-hypnosis gives you better control of your body. You may feel less hopeless and helpless because you are doing something to decrease the pain. Spinal cord stimulation is a nerve stimulation technique that is similar to TENS. The difference is that in SCS an electrode (a metal wire) is put near the spinal cord during surgery. SCS also uses mild, safe electrical signals to help control pain. TENS is short for transcutaneous (trans-q-TAIN-e-us) electrical nerve stimulation (stih-mew-LA-shun). A TENS unit is a portable, pocket-sized, batterypowered device which attaches to the skin. The TENS unit uses mild, safe electrical signals to help control pain. Touch energy therapies come from very old beliefs that life forces or energy move through the body in specific paths. Touch therapies believe disease may cause these paths to become blocked. The therapies use touch to help unblock these paths, and allow the energy to flow normally. Unblocking the paths may help you relax and decrease pain.