Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue
damage or described in terms of such damage; sudden or slow onset of any intensity from mild
to severe with anticipated or predictable end and a duration of <6 months.

May be related to

 Surgical procedure; tissue trauma, interruption of nerves, dissection of muscles

Possibly evidenced by

 Reports of stiffness, numbness in chest area, shoulder/arm pain; alteration of muscle tone
 Self-focusing; distraction/guarding behaviors

Desired Outcomes

 Express reduction in pain/discomfort.

 Appear relaxed, able to sleep/rest appropriately.

Nursing Interventions Rationale

Aids in identifying degree of discomfort and
effectiveness of analgesia. The amount of
tissue, muscle, and lymphatic system removed
Consider reports of pain and stiffness, noting can affect the amount of pain experienced.
location, duration, and intensity (0–10 scale). Destruction of nerves in axillary region causes
Note reports of numbness and swelling. Be numbness in upper arm and scapular region,
aware of verbal and nonverbal cues. which may be more intolerable than surgical
pain. Note: Pain in chest wall can occur from
muscle tension, be affected by extremes in heat
and cold, and continue for several months.
Provides reassurance that sensations are not
Discuss normality of phantom breast sensations.
imaginary and that relief can be obtained.
Elevation of arm, size of dressings, and
Facilitate patient to find position of comfort. presence of drains affect patient’s ability to
relax, rest and sleep effectively.
Provide basic comfort measures (reposition on
back or unaffected side, back rub) and
Promotes relaxation, helps refocus attention,
diversional activities. Encourage early
and may enhance coping abilities.
ambulation and use of relaxation techniques,
guided imagery, Therapeutic Touch.
Splint or support chest during coughing and Facilitates participation in activity without
 Nursing Interventions Rationale
deep-breathing exercises. undue discomfort.
Carry out appropriate pain medication on a Maintains comfort level and permits patient to
regular schedule before pain is severe and exercise arm and to ambulate without pain
before activities are scheduled. hindering efforts.
Provides relief of discomfort and pain and
Administer narcotics or analgesics as indicated. facilitates rest, participation in postoperative
therapy.