Nursing Care Plan for Acute Pain
Content
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 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. Assess for probable cause of pain. Assess patient’s knowledge of or preference for the array of pain-relief strategies available. RATIONALE
Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain. Different etiological factors respond better to different therapies. 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.
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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, 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.
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.
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 patientcontrolled analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). III. Local anesthetic agents.
Narcotics are indicated for severe pain, especially in the hospice or home setting.
http://www.philippinenursingdirectory.com
Nonpharmacological methods include the following: I. Cognitive-behavioral strategies as follows: The use of a mental picture or an imagined event i. Imagery involves use of the five senses to distract oneself from painful stimuli. Heighten one’s concentration upon nonpainful ii. Distraction techniques 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 iii. Relaxation exercises physical and mental awareness and tranquility. The goal of these techniques is to reduce tension, subsequently reducing pain. iv. Biofeedback, breathing exercises, music therapy II. Cutaneous stimulation as follows: Massage decreases muscle tension and can i. Massage of affected area when promote comfort. appropriate ii. Transcutaneous electrical nerve stimulation (TENS) units Hot, moist compresses have a penetrating effect. iii. Hot or cold compress 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 Pain medications are absorbed and metabolized effectiveness and observing for any signs and differently by patients, so their effectiveness symptoms of untoward effects. 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 Patients who request pain medications at more or if current complaint is a significant change frequent intervals than prescribed may actually from patient’s past experience of pain. require higher doses or more potent analgesics. Whenever possible, reassure patient that pain is When pain is perceived as everlasting and time-limited and that there is more than one unresolvable, patient may give up trying to cope approach to easing pain. 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.
If patient is receiving epidural analgesia:
IV incompatibilities are possible.
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.
In the event of respiratory depression, these drugs reverse the narcotic effect. This prevents inadvertent analgesic overdosing.
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PATIENT TEACHING Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures. Explain cause of pain or discomfort, if known. Instruct patient to report pain. 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. Teach patient preoperatively. 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.
RATIONALE
Relief measures may be instituted.
For patients on PCA or those receiving epidural analgesia:
Anesthesia effects should not obscure teaching.
Reference: Nursing Care Plans – Gulanick, Myers, Klopp, Galanes, Gradishar, Puzas
http://www.philippinenursingdirectory.com
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 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. Assess for probable cause of pain. Assess patient’s knowledge of or preference for the array of pain-relief strategies available. RATIONALE
Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain. Different etiological factors respond better to different therapies. 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.
http://www.philippinenursingdirectory.com
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, 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
http://www.philippinenursingdirectory.com
• 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.
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.
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 patientcontrolled analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). III. Local anesthetic agents.
Narcotics are indicated for severe pain, especially in the hospice or home setting.
http://www.philippinenursingdirectory.com
Nonpharmacological methods include the following: I. Cognitive-behavioral strategies as follows: The use of a mental picture or an imagined event i. Imagery involves use of the five senses to distract oneself from painful stimuli. Heighten one’s concentration upon nonpainful ii. Distraction techniques 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 iii. Relaxation exercises physical and mental awareness and tranquility. The goal of these techniques is to reduce tension, subsequently reducing pain. iv. Biofeedback, breathing exercises, music therapy II. Cutaneous stimulation as follows: Massage decreases muscle tension and can i. Massage of affected area when promote comfort. appropriate ii. Transcutaneous electrical nerve stimulation (TENS) units Hot, moist compresses have a penetrating effect. iii. Hot or cold compress 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 Pain medications are absorbed and metabolized effectiveness and observing for any signs and differently by patients, so their effectiveness symptoms of untoward effects. 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 Patients who request pain medications at more or if current complaint is a significant change frequent intervals than prescribed may actually from patient’s past experience of pain. require higher doses or more potent analgesics. Whenever possible, reassure patient that pain is When pain is perceived as everlasting and time-limited and that there is more than one unresolvable, patient may give up trying to cope approach to easing pain. 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.
If patient is receiving epidural analgesia:
IV incompatibilities are possible.
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.
In the event of respiratory depression, these drugs reverse the narcotic effect. This prevents inadvertent analgesic overdosing.
http://www.philippinenursingdirectory.com
PATIENT TEACHING Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures. Explain cause of pain or discomfort, if known. Instruct patient to report pain. 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. Teach patient preoperatively. 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.
RATIONALE
Relief measures may be instituted.
For patients on PCA or those receiving epidural analgesia:
Anesthesia effects should not obscure teaching.
Reference: Nursing Care Plans – Gulanick, Myers, Klopp, Galanes, Gradishar, Puzas
http://www.philippinenursingdirectory.com
