Acute pain is a common nursing diagnosis that refers to an unpleasant sensory and emotional experience arising from actual or potential tissue damage.
It is usually temporary, lasting less than six months, and can range in severity.
Definition of Acute Pain
According to the North American Nursing Diagnosis Association (NANDA), acute pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, with a sudden or slow onset, of any intensity from mild to severe, with an anticipated or predictable end.”
Causes of Acute Pain
Acute pain can be caused by a variety of factors, including:
- Surgical Procedures: Postoperative pain is common after surgical interventions.
- Trauma or Injury: Pain caused by fractures, lacerations, or burns.
- Medical Conditions: Infections, inflammation, or other acute conditions such as myocardial infarction or appendicitis.
- Diagnostic Procedures: Pain from invasive procedures such as biopsies or lumbar punctures.
Subjective and Objective Assessment
Subjective Data:
The patient’s self-report is the most reliable indicator of pain. Common subjective data include:
- The patient verbalizes discomfort or suffering
- Reports of pain ranging from mild to severe
- Descriptions of pain as sharp, aching, burning, or throbbing
Objective Data:
Although pain is subjective, objective signs may include:
- Increased heart rate, respiratory rate, and blood pressure
- Facial grimacing or guarding behavior
- Restlessness, irritability, or inability to concentrate
- Physical evidence of injury or trauma (e.g., surgical incision or inflammation)
Nursing Diagnosis: Acute Pain
- Related to: Tissue injury, surgical interventions, inflammation, or disease processes.
- As evidenced by: Verbal reports of pain, guarding behavior, altered vital signs, facial grimacing, restlessness.
Goals and Desired Outcomes
The primary goal of managing acute pain is to reduce discomfort to a tolerable level for the patient. The desired outcomes include:
- The patient will report a pain level of 3 or less on a scale of 0-10 within 24 hours.
- The patient will exhibit non-verbal signs of comfort, such as relaxation and normal vital signs.
- The patient will demonstrate an understanding of pain management strategies and participate in interventions.
Nursing Interventions and Rationales
1. Assess Pain Regularly
- Rationale: Regular assessment helps monitor the intensity, quality, and duration of pain and assists in determining the effectiveness of interventions.
- Action: Use standardized pain assessment tools like the Numeric Pain Rating Scale (NPRS).
2. Administer Analgesics as Prescribed
- Rationale: Pharmacological intervention is essential for pain management. Non-opioid analgesics such as acetaminophen or NSAIDs may be used for mild pain, while opioid medications may be needed for severe pain.
- Action: Administer medications as ordered, monitor for side effects, and adjust dosages based on the patient’s pain level and response.
3. Educate the Patient on Pain Management
- Rationale: Education helps patients understand their condition and become more involved in their own care. This can lead to better outcomes and reduced anxiety about pain.
- Action: Teach the patient about non-pharmacological pain relief methods such as deep breathing, relaxation techniques, and the application of cold or heat therapy.
4. Position the Patient for Comfort
- Rationale: Proper positioning can relieve pressure on injured or inflamed areas, reducing discomfort.
- Action: Use pillows or other devices to support the body and ensure proper alignment to decrease pain.
5. Promote a Calm and Restful Environment
- Rationale: A calm environment can help reduce anxiety, which can exacerbate the perception of pain.
- Action: Minimize external stimuli, dim lights, and provide quiet surroundings to promote relaxation.
Evaluation
- Evaluate the patient’s pain level at regular intervals and after each intervention.
- Document changes in pain intensity and monitor for any side effects of medications.
- Reassess the patient’s knowledge of pain management techniques to ensure they feel in control and supported.
If pain persists or worsens, consider collaborating with other healthcare professionals, such as pain management specialists or physical therapists, to explore alternative methods for relief.
Nursing Care Plan 1: Pharmacological Pain Management
Nursing Diagnosis:
Acute pain related to tissue injury, surgical procedure, or medical condition, as evidenced by the patient’s verbalization of pain and altered vital signs (e.g., increased heart rate, blood pressure).
Goal:
The patient will achieve a reduction in pain to a level of 3/10 or below within 24 hours, with minimal side effects from medication.
Interventions:
- Administer prescribed analgesics on time
- Rationale: Timely administration of pain medications, especially opioids or NSAIDs, helps maintain consistent pain control, preventing pain from escalating.
- Action: Ensure the patient receives their pain medication as prescribed, monitor for side effects such as respiratory depression or gastrointestinal upset, and adjust the dosage if needed (in consultation with the prescribing physician).
- Assess patient response to medication.
- Rationale: Monitoring the effectiveness of the medication helps determine whether the pain management plan is effective or if changes are needed.
- Action: Assess pain level 30 minutes to 1 hour after medication administration. If pain persists or worsens, notify the physician for possible medication adjustment.
- Educate the patient on pain medication use and side effects
- Rationale: Understanding the purpose and possible side effects of pain medication empowers the patient to make informed decisions and report any adverse effects promptly.
- Action: Teach the patient about the importance of reporting unrelieved pain or side effects such as nausea, dizziness, or constipation.
Evaluation:
The patient reports pain relief to a tolerable level within the specified timeframe, with no significant side effects noted.
Nursing Care Plan 2: Non-Pharmacological Pain Relief Techniques
Nursing Diagnosis:
Acute pain related to tissue injury, exacerbated by anxiety or fear of movement, as evidenced by verbal reports of pain and reluctance to move.
Goal:
The patient will report reduced pain levels using non-pharmacological techniques, such as relaxation or guided imagery, within 48 hours.
Interventions:
- Instruct the patient in relaxation techniques
- Rationale: Relaxation techniques, such as deep breathing and progressive muscle relaxation, help reduce tension and anxiety, which can exacerbate pain.
- Action: Guide the patient through deep breathing exercises, focusing on slow, controlled breaths to relax the body and distract from pain.
- Apply cold or heat therapy as appropriate
- Rationale: Heat can increase blood flow and reduce muscle tension, while cold therapy can reduce inflammation and numb the area.
- Action: Apply heat or cold packs to the painful area, depending on the nature of the injury and patient preference. Monitor the patient’s skin for any signs of burns or frostbite.
- Encourage the use of guided imagery
- Rationale: Guided imagery involves focusing the mind on positive, calming images, which can help divert attention away from pain and promote relaxation.
- Action: Provide instructions or audio recordings for guided imagery sessions, encouraging the patient to visualize peaceful scenes, such as a beach or forest.
Evaluation:
The patient reports decreased pain levels and demonstrates correct use of relaxation techniques, resulting in improved comfort.
Nursing Care Plan 3: Psychosocial Support for Pain Management
Nursing Diagnosis:
Acute pain related to surgical procedure, compounded by anxiety or fear of further pain, as evidenced by verbalizations of distress and fear of movement.
Goal:
The patient will report decreased anxiety and an improved ability to cope with pain within 24 hours.
Interventions:
- Provide emotional support and reassurance
- Rationale: Anxiety and fear can intensify the perception of pain. Emotional support can help reduce anxiety, thereby reducing the patient’s pain experience.
- Action: Spend time with the patient, actively listen to their concerns, and provide reassurance that their pain is being managed and that interventions are in place to relieve discomfort.
- Involve the patient in care decisions
- Rationale: Involving the patient in the decision-making process increases their sense of control, which can reduce anxiety and improve pain tolerance.
- Action: Discuss the pain management plan with the patient, explain the rationale for each intervention, and encourage them to voice their preferences for pharmacological and non-pharmacological treatments.
- Encourage the presence of family or support persons
- Rationale: Having loved ones present can provide emotional comfort and reduce anxiety, leading to better pain management.
- Action: If desired, allow family members to stay with the patient and involve them in the patient’s care by providing education on how they can assist with pain management techniques.
Evaluation:
The patient reports feeling more in control of their pain and exhibits a decrease in anxiety, leading to improved pain tolerance.
Nursing Care Plan 4: Postoperative Pain Management
Nursing Diagnosis:
Acute pain related to surgical incision and tissue trauma, as evidenced by verbal reports of pain, facial grimacing, and guarding behavior.
Goal:
The patient will report a decrease in pain from 8/10 to 3/10 within 24 hours of implementing the postoperative pain management plan.
Interventions:
- Monitor the patient’s vital signs regularly
- Rationale: Pain often leads to elevated vital signs, such as increased heart rate and blood pressure, which can indicate poorly managed pain.
- Action: Check the patient’s vital signs every 2 to 4 hours, especially after administering pain medications, to ensure pain is adequately managed.
- Use patient-controlled analgesia (PCA) if ordered
- Rationale: PCA allows the patient to control their pain relief by administering small doses of opioid medications, preventing delays in pain relief.
- Action: Ensure that the PCA device is functioning correctly, and educate the patient on how to use it safely, including the maximum allowable doses.
- Promote early mobilization with assistance
- Rationale: Early mobilization can help prevent complications such as blood clots and pneumonia and reduce stiffness, but it may increase pain initially.
- Action: Encourage the patient to begin gentle movement as soon as feasible post-surgery, providing support and assistance as needed to minimize pain.
Evaluation:
The patient reports tolerable pain levels, participates in early mobilization activities, and shows stable vital signs after interventions.
References
- Merskey, H., & Bogduk, N. (1994). Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms (2nd ed.). IASP Press. Link to source
- Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X. J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976–1982. Link to source
- Macintyre, P. E., Scott, D. A., Schug, S. A., Visser, E. J., & Walker, S. M. (2010). Acute Pain Management: Scientific Evidence (3rd ed.). Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Link to source