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Acute Pain Nursing Diagnosis &
Nursing Care Plan
Let’s take a closer look at how we can effectively care for patients experiencing acute pain. Use this guide to formulate your nursing care plans and nursing interventions for patients experiencing acute pain.
Contents
What is Acute Pain?
Causes of Pain
Signs and Symptoms
Nursing Diagnosis
Goals and Outcomes
Related Care Plans
Nursing Assessment and Rationales
Nursing interventions for acute pain
What is Acute Pain?
Pain is a complex and subjective experience influenced by various factors. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” This definition underscores that pain is not merely a physical sensation but also encompasses emotional and psychological dimensions.
Acute pain is pain that has a duration of less than 3 months and relief can be anticipated or predicted. In contrast, chronic pain is has a duration of more than 3 months without an anticipated or predictable end. The physiological signs of acute pain emerge from the body’s response to pain as a stressor. Acute pain provides a protective purpose to make the person informed and knowledgeable about the presence of an injury or illness. The unexpected onset of acute pain reminds the patient to seek support, assistance, and relief.
Other factors such as the patient’s cultural background, emotions, and psychological or spiritual discomfort may contribute to acute pain. In older patients, assessment of pain can be challenging due to
cognitive impairment and sensory-perceptual deficits. Assessment and management of the nursing diagnosis of acute pain are the main focus of this care plan.
Causes of Pain
Here are the common causes and related factors for patients with Acute Pain:
Tissue Damage. Surgical incisions, injuries, fractures, burns.
Inflammation. Conditions like appendicitis or pancreatitis causing swelling and pain. Nerve Damage. Neuropathic pain from conditions like sciatica or shingles.
Psychological Conditions. Stress-induced headaches or muscle tension. Procedural Pain. Pain resulting from medical procedures or interventions.
Signs and Symptoms
The following are the common manifestations that defines the characteristics of acute pain. Use these subjective and objective data to help guide you through the nursing assessment. Alternatively, you can check out the assessment guide for acute pain in the subsequent sections.
Subjective data
The most common characteristic of acute pain is when the patient reports or complaints about it. It is also the most common chief complaint that brings patients to their health care providers.
Reports of pain using scales (e.g., numeric, Wong-Baker FACES)
Descriptions of pain (e.g., aching, burning, stabbing) Patient complaints of pain
Family or caregiver reports of pain or behavior changes
Objective data
Guarding behavior or protecting the painful area Facial mask of pain (e.g., grimacing, wincing)
Expression of pain (e.g., restlessness, crying, groaning) Autonomic responses to pain, such as: Sweating
Patient describes satisfactory pain control at a level (for example, less than 3 to 4 on a rating scale of 0 to 10) Patient displays improved well-being such as baseline levels for pulse, BP, respirations, and relaxed muscle tone or body posture. Patient uses pharmacological and non-pharmacological pain-relief strategies.
Patient displays improvement in mood, coping.
Nursing Assessment and Rationales
Proper nursing assessment of acute pain is imperative for the development of an effective pain management plan. Nurses play a crucial role in the assessment of pain, use these techniques on how to comprehensively assess acute pain:
Perform pain assessment
1. Perform a comprehensive assessment of pain. Determine the location, characteristics, onset, duration, frequency, quality, and severity of pain via assessment. The patient experiencing pain is the most reliable source of information about their pain. Their self- report on pain is the gold standard in pain assessment as they can describe the location, intensity, and duration. Thus, assessment of pain by conducting an interview helps the nurse in planning optimal pain management strategies.
Using the PQRST Pain Assessment Mnemonic
Alternatively, you can use the nursing mnemonic “PQRST” to guide you during pain assessment:
Provoking Factors : “What makes your pain better or worse?”
Quality (characteristic): “Tell me what it’s exactly like. Is it a sharp pain, throbbing pain, dull pain, stabbing, etc?”
Region (location): “Show me where your pain is.” Severity : Ask your pain to rate pain by using different pain rating methods (e.g., Pain scale of 1- 10, Wong-Baker Faces Scale). Temporal (onset, duration, frequency): “Does it occur all the time or does it come and go?”
Using Numeric Rating Scales (NRS)
The Numeric Rating Scales (NRS) is a pain assessment tool suitable for adults and children over seven who can understand and use numbers to rate their pain intensity.
How to Use :
- Explain the Scale :
Say to the patient: “Please rate your pain on a scale from 0 to 10, where 0 means ‘no pain’ and 10 means ‘the worst pain you can imagine.'”
- Assessment : Ask: “What number between 0 and 10 best describes your pain right now?”
- Document the Response : Record the number provided by the patient.
Interpretation :
0 : No pain.
1 – 3 : Mild pain. 4 – 6 : Moderate pain.
7 – 10 : Severe pain.
Using Wong-Baker FACES Pain Rating Scale
The Wong-Baker FACES Pain Rating Scale is another pain assessment tool designed for children over three years old and adults who have difficulty expressing their pain verbally, this scale helps patients communicate the intensity of their pain using facial expressions.
Wong-Baker FACES Rating Scale
How to Use :
Add the scores from all five categories for a total between 0 and 10.
Criteria 0 POINTS 1 POINT 2 POINTS
Face
No particular expression or smile.
Occasional grimace or frown; withdrawn; disinterested.
Frequent to constant frown, clenched jaw, quivering chin.
Legs Normal positionor relaxed. Uneasy, restless, tense. Kicking or legs drawnup.
Activity
Lying quietly, normal position, moves easily.
Squirming, shifting back and forth, tense.
Arched, rigid, or jerking.
Cry No cry (awake orasleep).^ Moans or whimpers;occasional complaint.
Crying steadily, screams or sobs; frequent complaints.
Consolability Content, relaxed
Reassured by occasional touching, hugging, or being talked to; distractible.
Difficult to console or comfort.
Interpretation :
0 : Relaxed and comfortable. 1 – 3 : Mild discomfort.
4 – 6 : Moderate pain. 7 – 10 : Severe discomfort/pain.
Using PAINAD Scale (Pain Assessment in Advanced Dementia)
PAINAD Scale is designed to assess pain in patients with advanced dementia who cannot verbally communicate their pain.
How to Use :
- Observation : Observe the patient during rest and activity.
- Scoring :
Score each of the five categories from 0 to 2.
Categories and Scoring :
Criteria 0 1 2
Breathing (Independent of Vocalization)
Normal breathing.
Occasional labored breathing; short periods of hyperventilation.
Noisy labored breathing; long periods of hyperventilation; Cheyne-Stokes respirations
Negative Vocalization None.
Occasional moan or groan; low-level speech with a negative or disapproving quality.
Repeated troubled calling out; loud moaning or groaning; crying.
Facial Expression
Smiling or inexpressive.
Sad, frightened, frowning. Facial grimacing.
Body Language Relaxed. Tense, distressedpacing, fidgeting.
Rigid, fists clenched, knees pulled up, pulling or pushing away.
Consolability No need toconsole.^ Distracted or reassuredby voice or touch.^ Unable to console,distract, or reassure.
Interpretation :
Higher scores indicate more severe pain.
2. Assess the location of the pain by asking to point to the site that is discomforting. Using charts or drawings of the body can help the patient, and the nurse determines specific pain locations. For clients with a limited vocabulary, asking to pinpoint the location helps in clarifying your pain assessment – this is especially important when assessing pain in children. 3. Perform history assessment of pain Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.
13. Provide ample time and effort regarding the patient’s report of their pain experience. Patients may be reluctant to report their pain as they may perceive staff to be very busy and have competing demands on their time from other nurses, doctors, and patients (Manias et al., 2002). Interruptions during pain management can prevent nurses from assessing and managing the patient’s pain experience. 14. Evaluate what the pain suggests to the patient. The meaning of pain will directly determine the patient’s response. Some patients, especially the dying, may consider that the “act of suffering” meets a spiritual need. 15. Regularly reassess and document the patient’s pain level following the initiation of the pain management plan, including each new report of pain and before and after the administration of analgesic agents. Consistent reassessment ensures the effectiveness of pain management strategies and allows timely adjustments to the treatment plan. The frequency of reassessment should align with the patient’s pain stability and institutional policies, ranging from every 10 minutes during acute phases to every 4 to 8 hours for stable pain conditions.
Nursing Interventions for Acute Pain
Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time treating patients. The following are the therapeutic nursing interventions for your acute pain nursing diagnosis:
Provide measures to relieve pain before it becomes severe. It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required. An example would be preemptive analgesia, which is administering analgesics before surgery to decrease or relieve pain after surgery. The preemptive approach is also useful before painful procedures like wound dressing changes, physical therapy, postural drainage, etc.
Acknowledge and accept the client’s pain. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.
Initiating nonpharmacologic pain management
Incorporate nonpharmacologic methods, such as guided relaxation, deep breathing exercises, and music therapy, into the patient’s pain management plan. Nonpharmacologic methods in pain management may include physical, cognitive-behavioral strategies, and lifestyle pain management. See methods below:
Provide cognitive-behavioral therapy (CBT) for pain management. These methods are used to provide comfort by altering psychological responses to pain. Cognitive- behavioral interventions include:
Distraction. This technique involves heightening one’s concentration upon non-painful stimuli to decrease one’s awareness and experience of pain. Drawing the person away from the pain lessens the perception of pain. Examples include reading, watching TV, playing video games, and guided imagery.
Eliciting the Relaxation Response. Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, and deep breathing.
Guided imagery. Involves the use of mental pictures or guiding the patient to imagine an event to distract from the pain.
Repatterning Unhelpful Thinking. Involves patients with strong self-doubts or unrealistic expectations that may exacerbate pain and result in failure in pain management.
Other CBT techniques include Reiki, spiritually directed approaches, emotional counseling, hypnosis, biofeedback, meditation, and relaxation techniques. Provide cutaneous stimulation or physical interventions Cutaneous stimulation provides effective pain relief, albeit temporary. The way it works is by distracting the client away from painful sensations through tactile stimuli. Cutaneous stimulation techniques include:
Massage. When appropriate, massaging the affected area interrupts the pain transmission, increases endorphin levels, and decreases tissue edema. Massage aids in relaxation and decreases muscle tension by increasing superficial circulation to the area. Massage should not be done in areas of skin breakdown, suspected clots, or infections.
Heat and cold applications. Cold works by reducing pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. Cold is best when applied within the first 24 hours of injury while heat is used to treat the chronic phase of an injury by improving blood flow to the area and through reduction of pain reflexes.
Acupressure. An ancient Chinese healing system of acupuncture wherein the therapist applies finger pressure points that correspond to many of the points used in acupuncture.
Contralateral stimulation. Involves stimulating the skin in an area opposite to the painful area. This technique is used when the painful area cannot be touched.
Transcutaneous Electrical Nerve Stimulation (TENS). Is the application of low-voltage electrical stimulation directly over the identified pain areas or along with the areas that innervate pain.
Immobilization. Restriction of movement of a painful body part is another nonpharmacologic pain management. To do this, you need splints or supportive devices to hold joints in the position optimal for function. Note that prolonged immobilization can result in muscle atrophy, joint contracture, and cardiovascular problems. Check with the agency protocol.
Aspirin. It can prolong bleeding time and should be stopped a week before a client undergoes any surgical procedure. Should never be given to children below 12 years of age due to the possibility of Reye’s syndrome. May cause excessive anticoagulation if the client is taking warfarin.
Acetaminophen (Tylenol). May have serious hepatotoxic side effects and possible renal toxicity with high dosages or with long-term use. Limit acetaminophen usage to 3 grams per day.
Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side effects than COX-1 NSAIDs.
Administer opioids as ordered. Opioids are indicated for severe pain and can be administered orally, IV, PCA systems, or epidurally.
Opioids for moderate pain. These include codeine, hydrocodone, and tramadol (Ultram) which are combinations of nonopioid and opioid.
Opioids for severe pain. These include morphine, hydromorphone, oxycodone, methadone, and fentanyl. Most of these are controlled substances due to potential misuse. These drugs are indicated for severe pain, or when other medications fail to control pain.
Administer coanalgesics (adjuvants), as ordered. Coanalgesics are medications that are not classified as pain medication but have properties that may reduce pain alone or in combination with other analgesics. They may also relieve other discomforts, increase the effectiveness of pain medications, or reduce the pain medication’s side effects. Commonly used coanalgesics include:
Antidepressants. Is a common coanalgesic that helps in increasing pain relief, improving mood, and reducing excitability.
Local Anesthetics. These drugs block the transmission of pain signals and are used for pain in specific areas of nerve distribution.
Other coanalgesics. Include anxiolytics, sedatives, and antispasmodics to relieve other discomforts. Stimulants, laxatives, and antiemetics are other coanalgesics that reduce the side effects of analgesics.
Manage acute pain using a multimodal approach. A multimodal approach is based on using two or more distinct methods or drugs to enhance pain relief (rather than resorting to opioid use or other pain management strategies alone). Different combinations of analgesic medications, adjuvants, and procedures can act on different sites and pathways in an additive or synergistic fashion. Combining medications and techniques allows the lowest effective dose of each drug to be administered, resulting in reduced side effects. Administer analgesia before painful procedures whenever possible. Doing so will help prevent pain caused by relatively painful procedures (e.g., wound care, venipunctures, chest tube removal, endotracheal suctioning, etc.).
Perform nursing care during the peak effect of analgesics. Oral analgesics typically peak in 60 minutes, and intravenous analgesics in 20 minutes. Performing nursing tasks during the peak effect of analgesics optimizes client comfort and compliance in care.
Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects. The patient’s effectiveness of pain medications must be evaluated individually since they are absorbed and metabolized differently.
Using Patient-Controlled Analgesia (PCA)
Educate the patient on the proper use of PCA, ensuring they understand how to self- administer doses and the importance of pressing the button only when needed. Patient understanding and education is important in effective pain management. It ensures that the patient correctly uses the PCA device to achieve desired pain relief and prevents misuse or overuse.
Monitor the patient’s sedation level and respiratory status closely, especially when a basal rate is included in the PCA regimen. Continuous monitoring helps detect signs of over-sedation or respiratory depression, which are potential risks when using opioids, particularly for opioid-naïve patients.
Instruct staff, family, and visitors not to press the PCA button for the patient and to inform the nurse if there are any concerns about pain control. Unauthorized use of the PCA by others (PCA by proxy) can lead to over-sedation or other safety issues. Ensuring that only the patient controls the PCA maintains safe and effective pain management.
Assess the patient’s cognitive and physical ability to use the PCA equipment regularly. Regular assessment ensures that the patient remains capable of using the device safely and effectively. Any change in the patient’s condition that impacts their ability to use the PCA should prompt a reassessment of their pain management plan.
Educate the patient and authorized family members, if applicable, about Authorized Agent Controlled Analgesia (AACA) when PCA use by the patient is not feasible. In situations where the patient cannot use the PCA independently, an authorized agent can help manage the patient’s pain safely and effectively. Proper education ensures that the designated person understands their role and the safety measures required.
Promptly adjust or discontinue the basal rate if increased sedation or respiratory changes are noted. Quick action to modify the opioid dosage helps prevent complications such as respiratory depression and supports safe pain management practices.
Document and reassess pain levels frequently, especially before and after PCA administration. Consistent documentation and reassessment help evaluate the effectiveness of the PCA therapy and guide any necessary adjustments for optimal pain management.
Older adults have an increased risk of GI adverse effects from NSAIDs. Choosing NSAIDs carefully and adding a proton pump inhibitor when necessary can reduce the risk of GI complications.
Consider opioid therapy over NSAIDs for older adults who are at high risk for GI complications. Opioids may be a safer alternative than NSAIDs for pain management in older adults to minimize the risk of GI toxicity. The American Geriatrics Society recommends opioids for this reason, particularly when NSAID use is contraindicated or poses significant risk.
Educate older patients and caregivers on the potential side effects of both NSAIDs and opioids, including signs of GI distress and sedation. Patient and caregiver education promotes early detection of side effects and ensures timely intervention, contributing to safer pain management.
Review all medications to identify potential interactions due to polypharmacy. Minimizes the risk of adverse drug reactions and enhances medication safety.
Implement gentle physical therapies like massage or warm compresses, ensuring skin integrity is maintained. Provides pain relief while considering the fragility of elderly skin and tissues.
Face the patient, speak clearly, and ensure they have any necessary hearing or vision aids. Overcomes sensory impairments, facilitating effective communication and understanding.
Patients with Cognitive Impairments
Use observational pain assessment tools like the PAINAD scale to evaluate pain levels. Allows for pain assessment when the patient cannot self-report effectively.
Observe for non-verbal signs of pain, such as facial grimacing, agitation, or changes in usual behavior. Identifies pain through behavioral cues when verbal communication is limited.
Provide care from consistent caregivers to establish familiarity and reduce anxiety. Consistency enhances trust and may improve the patient’s cooperation with interventions.
Simplify communication by using short sentences, clear instructions, and visual cues. Aids understanding despite cognitive limitations, ensuring the patient can participate in care.
Involve family members or caregivers in the pain management plan. They can offer valuable insights into the patient’s behaviors and preferences, enhancing individualized care.
Placebos
Avoid the use of placebos for pain management in clinical practice. The use of placebos in a deceitful manner violates ethical principles, breaches trust in the nurse- patient relationship, and deprives patients of appropriate pain assessment and treatment.
Educate the healthcare team about the ethical and legal implications of using placebos deceptively.
Raising awareness helps prevent the misuse of placebos and promotes adherence to evidence- based and ethical pain management practices.
Validate and accept the patient’s report of pain, regardless of the presence of physical stimuli. Research has shown that pain relief following placebo administration does not invalidate a patient’s pain report. Acknowledging and addressing patient-reported pain supports trust and effective treatment.
Incorporate evidence-based pain management strategies tailored to the individual’s needs instead of relying on placebos. Personalized pain management promotes optimal patient outcomes, enhances comfort, and supports trust between the patient and healthcare provider.
