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
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors
may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional,
psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual;
pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly
patients, where cognitive impairment and sensory-perceptual deficits are more common.
Defining Characteristics:
 Patient reports pain
 Guarding behavior, protecting body part
 Self-focused
 Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
 Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities,
restlessness)
 Facial mask of pain
 Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
 Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in
respiratory rate; pallor; nausea)
Related Factors:
 Postoperative pain
 Cardiovascular pain
 Musculoskeletal pain
 Obstetrical pain
 Pain resulting from medical problems
 Pain resulting from diagnostic procedures or medical treatments
 Pain resulting from trauma
 Pain resulting from emotional, psychological, spiritual, or cultural distress
Expected Outcomes
 Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.
Ongoing Assessment

• 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 associated with pain, such as BP, heart rate, temperature, color
and moisture of skin, restlessness, and ability to focus. Some people deny the experience of pain when it
is present. Attention to associated signs may help the nurse in evaluating pain.

• Assess for probable cause of pain. Different etiological factors respond better to different
therapies.
• Assess patient’s knowledge of or preference for the array of pain-relief strategies available. Some
patients may be unaware of the 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.

• Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving
pain. It is important to help patients express as factually as possible (i.e., without the effect of
mood, 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, intrapersonal, and intrapsychic factors may contribute to
pain or pain relief. These variables may modify the patient’s expression of his or her experience. For
example, 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 a range of techniques aimed at controlling pain. Some
patients will feel uncomfortable exploring 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-controlled analgesia (PCA) candidate: no history of

substance abuse; no allergy to narcotic analgesics; clear sensorium; cooperative and motivated about use; no
history of renal, hepatic, or respiratory disease; manual dexterity; and no history of major psychiatric
disorder. PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through
an infusion pump that is controlled by the patient. This allows the patient to manage pain relief
within prescribed limits. In the hospice or home setting, a nurse or caregiver may be needed to
assist the patient in managing the infusion.

• Monitor for changes in general condition that may herald need for change in pain relief method. For
example, a PCA patient becomes confused and cannot manage PCA, or a successful 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 requesting If demands for medication are quite frequent,
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 excessive sedation, respiratory distress, urinary retention,
nausea/vomiting, constipation, and IV site pain, redness, or swelling Patients may also experience
mild allergic response to the analgesic agent, marked by generalized itching or nausea and
vomiting.
 • If patient is receiving epidural analgesia, assess the following:
 Pain relief Intermittent epidurals require redosing at intervals. Variations in anatomy may
result in a "patch effect."
 Numbness, tingling in extremities, a metallic taste in the mouth These symptoms may be
indicators of an allergic response to the anesthesia agent, or of improper catheter
placement.
 Possible epidural analgesia complications such as excessive sedation, respiratory distress, urinary
retention, or catheter migration Respiratory depression and intravascular infusion of
anesthesia (resulting from catheter migration) can be potentially life-threatening.
Therapeutic Interventions

• Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early
intervention may decrease the total amount of analgesic required.

• Respond immediately to complaint of pain. 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.

• Eliminate additional stressors or sources of discomfort whenever possible. 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.

• Provide rest periods to facilitate comfort, sleep, and relaxation. 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.

• 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). Narcotics are indicated for severe pain, especially in the hospice or home setting.
III. Local anesthetic agents.
Nonpharmacological methods include the following:
IV. Cognitive-behavioral strategies as follows:
 Imagery The use of a mental picture or an imagined event involves use of the five
senses to distract oneself from painful stimuli.
 Distraction techniques Heighten one’s concentration upon nonpainful stimuli to
decrease one’s awareness and experience of pain. Some methods are breathing
modifications and nerve stimulation.
 Relaxation exercises 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.
 Biofeedback, breathing exercises, music therapy
V. Cutaneous stimulation as follows:
 Massage of affected area when appropriate Massage decreases muscle tension and can
promote comfort.
 Transcutaneous electrical nerve stimulation (TENS) units
  Hot or cold compress 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.

• Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of
untoward effects. 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.

• Notify physician if interventions are unsuccessful or if current complaint is a significant change from
patient’s past experience of pain. Patients who request pain medications at more frequent intervals
than prescribed may actually require higher doses or more potent analgesics.

• Whenever possible, reassure patient that pain is time-limited and that there is more than one approach to
easing pain. When pain is perceived as everlasting and unresolvable, patient may give up trying to
cope with or experience a sense of hopelessness and loss of control.
If patient is on PCA:

 Dedicate use of IV line for PCA only; consult pharmacist before mixing drug with narcotic being infused. IV
incompatibilities are possible.
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. In the event of respiratory
depression, these drugs reverse the narcotic effect.

• Post "No additional analgesia" sign over bed. This prevents inadvertent analgesic overdosing.
Education/Continuity of Care

• 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.