KAISER PERMANENTE Medical Care Program Southern California Region, Los Angeles Medical Center

PATIENT EDUCATION PLAN

TOPIC: Pain Management

INFORMATION FOR NURSES (Nurse Will Give Information and Demonstration to Patient)

EXPECTED LEARNING OUTCOMES: Patient will be able to state why pain control is important; Rate their pain; Discuss pain management treatment; State side-effects of pain medication and management; Discuss non-drug treatment for pain management; Know when to notify doctor or nurse if pain medication not effective.

LEARNING AIDS (literature, audiovisual, models, supplies): [ ]Pain Information Guide to Managing Pain [ ]Pain Scale [ ]Video [ ] CCTV [ ]PCA Patient Guide [ ]

DATES/INITIALS

LEVELS OF UNDERSTANDING/SKILL

ASSESSMENT OF EXISTING KNOWLEDGE/SKILL LEVEL: (Past knowledge of

condition, readiness & ability to learn, sensory or other limitations to learning)

Can patient read? [ ] Yes [ ] No [ ] Other limitations:

Translator necessary:[ ]Yes [ ] No [ ]Primary language:

Referrals: *If patient is unable to care for self & no primary caregiver is available to receive instruction, contact Discharge Planner.

PATIENT/FAMILY DEMONSTRATES

1=Need for complete reinforcement

2=Partial understanding/skill

3=Independent understanding/skill

1

2

3

INFORMATION FOR PATIENT - PATIENT INSTRUCTIONS

IMPORTANT KNOWLEDGE/SKILLS FOR SELF-CARE:

An important part of your care is having your pain effectively managed.

Definition of Pain:

1) Pain is what you say it is whenever you say it is.

2) Pain rating scale 0 - 10.

Treatment Plan:

1) Goal for your pain management is to maintain your pain level at or less.

2) Take your pain medication according to the pain management plan.

3) Do not wait for the pain to get severe before taking your medicine.

4) Notify your doctor or nurse if pain medication is not working or you have any unusual symptoms.

Possible Side-Effects:

1) Notify your doctor or nurse if you have any of these symptoms:

a) Excessive sleepiness (although expect some the first 24-36 hours)

b) Nausea and vomiting

c) Rash

d) Constipation

e) Slow breathing

 

If You Notice Any of These Symptoms, Call Your Doctor or Nurse Right Away:

a) Trouble breathing

b) Change in mental state

c) Dizziness

 

Non-Drug Treatment: Some of these treatments, along with your pain medication may be helpful in controlling your pain; hot and cold packs, massage and distraction.

     

NURSE: (indicate if additional discharge instructions were given)

 

 

INITIALS

SIGNATURE (nurse)

   
   
   

COMMENTS:

 

 

REFERRALS:

[ ]Not Applicable

[ ]Home Health

[ ]Advice Nurse - (213) 667-4683

[ ]Member Health Ed. Program

[ ]Health Phone Pamphlet Given

[ ] Medic Alert Info Given

[ ]Other (specify):

PATIENT/FAMILY MEMBER SIGNATURE

_____________________________________________________

DATE ________________________________________________

IF OTHER THAN PATIENT SIGNATURE, RELATIONSHIP TO PATIENT

 

WHITE: HOSPITAL CHART CANARY: PATIENT/FAMILY PINK: OUTPATIENT RECORDS GOLDENROD: HOME HEALTH/HEALTH EDUCATION

 

PEPPAIN.DOC-5/17/95

 

(Note: The format of this form may be altered from the original for use on the Website. All data is the same.)