Professional Documents
Culture Documents
NCP Nursing Diagnosis: Acute Pain
NCP Nursing Diagnosis: Acute Pain
* Comfort Level
* Medication Response
* Pain Control
* Analgesic Administration
* Conscious Sedation
* Pain Management
* Patient-Controlled Analgesia Assistance
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.
* Expected Outcomes Patient verbalizes adequate relief of pain or ability to cope with incompletely
relieved pain.
Ongoing Assessment
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.
1. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that
may be administered orally or parenterally (to date, ketorolac is the only available parenteral NSAID).
2. 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.
3. Local anesthetic agents.
1. Nonpharmacological methods include the following: Cognitive-behavioral strategies as follows:
o Imagery The use of a mental picture or an imagined event involves use of the five senses to distract
oneself from painful stimuli.
o 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.
o 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.
o Biofeedback, breathing exercises, music therapy
2. Cutaneous stimulation as follows:
o Massage of affected area when appropriate Massage decreases muscle tension and can promote
comfort.
o Transcutaneous electrical nerve stimulation (TENS) units
o 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.