NURSING CARE PLAN GUIDE FOR THE NURSING DIAGNOSIS: Acute Pain

NURSING CARE PLAN GUIDE

NURSING DIAGNOSIS: ACUTE PAIN
NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential
tissue damage or described in terms of such damage (International Association for the Study of
Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable
end and a duration of less than 6 months
SUBJECTIVE, OBJECTIVE CHARACTERISTICS: RELATED FACTORS:
• Patient reports pain • Postoperative pain
• Guarding behavior, protecting body part • Cardiovascular pain
• Self-focused • Musculoskeletal pain
• Narrowed focus (e.g., altered time perception, • Obstetrical pain
withdrawal from social or physical contact) • Pain resulting from medical problems
• Relief or distraction behavior (e.g., moaning, • Pain resulting from diagnostic
crying, pacing, seeking out other people or procedures or medical treatments
activities, restlessness) • Pain resulting from trauma
• Facial mask of pain • Pain resulting from emotional,
• Alteration in muscle tone: listlessness or psychological, spiritual, or cultural distress
flaccidness; rigidity or tension
• Autonomic responses (e.g., diaphoresis;
change in blood pressure [BP], pulse rate; pupillary
dilation; change in respiratory rate; pallor; nausea)
EXPECTED OUTCOMES:
• Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

ASSESSMENT GUIDELINES RATIONALE

Assess pain characteristics:
• Quality (e.g., sharp, burning, shooting)
• Severity (scale of 1 to 10, with 10 being
the most severe) [Other methods such as a
visual analog scale or descriptive scales
can be used to identify extent of pain.]
• Location (anatomical description)
• Onset (gradual or sudden)
• Duration (how long; intermittent or
continuous)
• Precipitating or relieving factors
Observe or monitor signs and symptoms Some people deny the experience of pain when it
associated with pain, such as BP, heart rate, is present. Attention to associated signs may help
temperature, color and moisture of skin, the nurse in evaluating pain.
restlessness, and ability to focus.
Assess for probable cause of pain. Different etiological factors respond better to
different therapies.
Assess patient’s knowledge of or preference for Some patients may be unaware of the
the array of pain-relief strategies available. effectiveness of nonpharmacological methods and
may be willing to try them, either with or instead of
traditional analgesic medications. Often a
combination of therapies (e.g., mild analgesics
with distraction or heat) may prove most effective.

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Evaluate patient’s response to pain and It is important to help patients express as factually
medications or therapeutics aimed at abolishing as possible (i.e., without the effect of mood,
or relieving pain. emotion, or anxiety) the effect of pain relief
measures. Discrepancies between behavior or
appearance and what patient says about pain
relief (or lack of it) may be more a reflection of
other methods patient is using to cope with than
pain relief itself.
Assess to what degree cultural, environmental, These variables may modify the patient’s
intrapersonal, and intrapsychic factors may expression of his or her experience. For example,
contribute to pain or pain relief. some cultures openly express feelings, while
others restrain such expression. However, health
care providers should not stereotype any patient
response but rather evaluate the unique response
of each patient.
Evaluate what the pain means to the individual. The meaning of the pain will directly influence the
patient’s response. Some patients, especially the
dying, may feel that the "act of suffering" meets a
spiritual need.
Assess patient’s expectations for pain relief. Some patients may be content to have pain
decreased; others will expect complete elimination
of pain. This affects their perceptions of the
effectiveness of the treatment modality and their
willingness to participate in additional treatments.
Assess patient’s willingness or ability to explore Some patients will feel uncomfortable exploring
a range of techniques aimed at controlling pain. alternative methods of pain relief. However,
patients need to be informed that there are
multiple ways to manage pain.
Assess appropriateness of patient as a patient- PCA is the intravenous (IV) infusion of a narcotic
controlled analgesia (PCA) candidate: no (usually morphine or Demerol) through an infusion
history of substance abuse; no allergy to pump that is controlled by the patient. This allows
narcotic analgesics; clear sensorium; the patient to manage pain relief within prescribed
cooperative and motivated about use; no history limits. In the hospice or home setting, a nurse or
of renal, hepatic, or respiratory disease; manual caregiver may be needed to assist the patient in
dexterity; and no history of major psychiatric managing the infusion.
disorder.
Monitor for changes in general condition that For example, a PCA patient becomes confused
may herald need for change in pain relief and cannot manage PCA, or a successful
method. modality ceases to provide adequate pain relief,
as in relaxation breathing.
If patient is on PCA, assess the following:
• Pain relief The basal or lock-out dose may need to be
increased to cover the patient’s pain.
• Intactness of IV line If the IV is not patent, patient will not receive pain
medication.
• Amount of pain medication patient is If demands for medication are quite frequent,
requesting patient’s dosage may need to be increased. If
demands are very low, patient may require further
instruction to properly use PCA.
• Possible PCA complications such as Patients may also experience mild allergic
excessive sedation, respiratory distress, response to the analgesic agent, marked by

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 • Possible PCA complications such as
excessive sedation, respiratory distress,
urinary retention, nausea/vomiting,
constipation, and IV site pain, redness, or
swelling
If patient is receiving epidural analgesia, assess
the following:
• Pain relief
• Numbness, tingling in extremities, a
metallic taste in the mouth
• Possible epidural analgesia
complications such as excessive sedation,
respiratory distress, urinary retention, or
catheter migration
NURSING INTERVENTIONS
Anticipate need for pain relief.
Respond immediately to complaint of pain.
Eliminate additional stressors or sources of
discomfort whenever possible.
Provide rest periods to facilitate comfort, sleep,
and relaxation.
Determine the appropriate pain relief method.
Pharmacological methods include the following:
I. Nonsteroidal antiinflammatory drugs
(NSAIDs) that may be administered
orally or parenterally (to date, ketorolac
is the only available parenteral NSAID).
II. Use of opiates that may be administered
orally, intramuscularly, subcutaneously,
intravenously, systemically by patient-
controlled analgesia (PCA) systems, or
epidurally (either by bolus or continuous
infusion).
III. Local anesthetic agents.
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Patients may also experience mild allergic
response to the analgesic agent, marked by
generalized itching or nausea and vomiting.
Intermittent epidurals require redosing at intervals.
Variations in anatomy may result in a "patch
effect."
These symptoms may be indicators of an allergic
response to the anesthesia agent, or of improper
catheter placement.
Respiratory depression and intravascular infusion
of anesthesia (resulting from catheter migration)
can be potentially life-threatening.
RATIONALE
One can most effectively deal with pain by
preventing it. Early intervention may decrease the
total amount of analgesic required.
In the midst of painful experiences a patient’s
perception of time may become distorted. Prompt
responses to complaints may result in decreased
anxiety in the patient. Demonstrated concern for
patient’s welfare and comfort fosters the
development of a trusting relationship.
Patients may experience an exaggeration in pain
or a decreased ability to tolerate painful stimuli if
environmental, intrapersonal, or intrapsychic
factors are further stressing them.
The patient’s experiences of pain may become
exaggerated as the result of fatigue. In a cyclic
fashion, pain may result in fatigue, which may
result in exaggerated pain and exhaustion. A quiet
environment, a darkened room, and a
disconnected phone are all measures geared
toward facilitating rest.
Narcotics are indicated for severe pain, especially
in the hospice or home setting.
Nonpharmacological methods include the following:
I. Cognitive-behavioral strategies as follows:
i. Imagery
ii. Distraction techniques
iii. Relaxation exercises
iv. Biofeedback, breathing exercises,
music therapy
II. Cutaneous stimulation as follows:
i. Massage of affected area when
appropriate
ii. Transcutaneous electrical nerve
stimulation (TENS) units
iii. Hot or cold compress
Give analgesics as ordered, evaluating
effectiveness and observing for any signs and
symptoms of untoward effects.
Notify physician if interventions are unsuccessful Patients who request pain medications at more
or if current complaint is a significant change
from patient’s past experience of pain.
Whenever possible, reassure patient that pain is When pain is perceived as everlasting and
time-limited and that there is more than one
approach to easing pain.
If patient is on PCA:
Dedicate use of IV line for PCA only; consult
pharmacist before mixing drug with narcotic
being infused.
If patient is receiving epidural analgesia:
Label all tubing (e.g., epidural catheter, IV tubing
to epidural catheter) clearly to prevent
inadvertent administration of inappropriate fluids
or drugs into epidural space.
For patients with PCA or epidural analgesia:
Keep Narcan or other narcotic-reversing agent
readily available.
Post "No additional analgesia" sign over bed.
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The use of a mental picture or an imagined event
involves use of the five senses to distract oneself
from painful stimuli.
Heighten one’s concentration upon nonpainful
stimuli to decrease one’s awareness and
experience of pain. Some methods are breathing
modifications and nerve stimulation.
Techniques are used to bring about a state of
physical and mental awareness and tranquility.
The goal of these techniques is to reduce
tension, subsequently reducing pain.
Massage decreases muscle tension and can
promote comfort.
Hot, moist compresses have a penetrating effect.
The warmth rushes blood to the affected area to
promote healing. Cold compresses may reduce
total edema and promote some numbing,
thereby promoting comfort.
Pain medications are absorbed and metabolized
differently by patients, so their effectiveness
must be evaluated from patient to patient.
Analgesics may cause side effects that range
from mild to life-threatening.
frequent intervals than prescribed may actually
require higher doses or more potent analgesics.
unresolvable, patient may give up trying to cope
with or experience a sense of hopelessness and
loss of control.
IV incompatibilities are possible.
In the event of respiratory depression, these
drugs reverse the narcotic effect.
This prevents inadvertent analgesic overdosing.
 PATIENT TEACHING RATIONALE
Provide anticipatory instruction on pain causes,
appropriate prevention, and relief measures.
Explain cause of pain or discomfort, if known.
Instruct patient to report pain. Relief measures may be instituted.
Instruct patient to evaluate and report
effectiveness of measures used.
Teach patient effective timing of medication
dose in relation to potentially uncomfortable
activities and prevention of peak pain periods.
For patients on PCA or those receiving epidural analgesia:
Teach patient preoperatively. Anesthesia effects should not obscure teaching.
Teach patient the purpose, benefits, techniques
of use/action, need for IV line (PCA only), other
alternatives for pain control, and of the need to
notify nurse of machine alarm and occurrence
of untoward effects.

Reference: Nursing Care Plans – Gulanick, Myers, Klopp, Galanes, Gradishar, Puzas

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