Acute pain is a significant nursing diagnosis that requires careful assessment and management. This comprehensive guide covers everything nurses need to know about diagnosing and treating acute pain, including detailed care plans and evidence-based interventions.
What is Acute Pain?
Acute pain is a temporary unpleasant sensory and emotional experience that typically lasts less than three months. Unlike chronic pain, acute pain has an anticipated endpoint and usually serves as a warning signal for tissue damage or potential injury.
Causes of Acute Pain
Acute pain can result from various factors:
Physical Trauma
- Surgery
- Injuries
- Burns
- Fractures
- Muscle strain
Disease Processes
- Infections
- Inflammation
- Organ dysfunction
- Acute medical conditions
Diagnostic/Therapeutic Procedures
- Injections
- Wound care
- Physical therapy
- Medical procedures
Signs and Symptoms
Subjective Indicators
- Verbal pain reports
- Description of pain characteristics
- Reports of sleep disturbance
- Decreased appetite
- Anxiety or distress
Objective Indicators
- Facial grimacing
- Guarding behavior
- Vital sign changes
- Altered mobility
- Changes in muscle tone
- Diaphoresis
Nursing Assessment
1. Pain Assessment (PQRST Method)
- Provocative/Palliative factors
- Quality of pain
- Region/Radiation
- Severity scale
- Timing
2. Physical Examination
- Vital signs monitoring
- Assessment of the affected area
- Observation of behavioral cues
- Evaluation of functional limitations
3. Pain Scale Utilization
- Numeric Rating Scale (0-10)
- Visual Analog Scale
- Wong-Baker FACES Scale
- FLACC Scale for non-verbal patients
Nursing Care Plans
Care Plan 1: Post-Surgical Acute Pain
Nursing Diagnosis Statement:
Acute pain related to surgical incision and tissue trauma
Related Factors/Causes:
- Tissue trauma from surgical procedure
- Inflammatory response
- Movement of the affected area
- Anxiety about recovery
Nursing Interventions and Rationales:
Assess pain characteristics using standardized tools
- Ensures accurate pain evaluation and appropriate intervention selection
Administer prescribed analgesics
- Provides timely pain relief and prevents pain escalation
Position the patient to minimize incisional strain
- Reduces pain and promotes comfort
Teach deep breathing techniques
- It helps manage pain and reduces anxiety
Desired Outcomes:
- Patient reports pain level ≤3/10
- Demonstrates ability to perform ADLs with minimal pain
- Uses prescribed pain management techniques effectively
Care Plan 2: Trauma-Related Acute Pain
Nursing Diagnosis Statement:
Acute pain related to traumatic injury
Related Factors/Causes:
- Direct tissue damage
- Edema and inflammation
- Muscle tension
- Psychological stress
Nursing Interventions and Rationales:
Implement RICE protocol as appropriate
- Reduces swelling and minimizes pain
Monitor vital signs regularly
- Identifies pain-related physiological changes
Provide emotional support
- Reduces anxiety and improves pain tolerance
Apply prescribed immobilization devices
- Prevents further injury and reduces pain
Desired Outcomes:
- Maintains stable vital signs
- Reports decreased pain intensity
- Demonstrates proper use of prescribed pain management methods
Care Plan 3: Procedure-Related Acute Pain
Nursing Diagnosis Statement:
Acute pain related to invasive medical procedures
Related Factors/Causes:
- Tissue manipulation
- Insertion of medical devices
- Positioning requirements
- Anticipatory anxiety
Nursing Interventions and Rationales:
Provide pre-procedure education
- Reduces anxiety and improves cooperation
Use distraction techniques
- It helps manage pain perception
Monitor for complications
- Ensures early intervention if needed
Document pain management effectiveness
- Facilitates continuity of care
Desired Outcomes:
- Expresses understanding of procedure
- Reports acceptable pain levels during/after the procedure
- Demonstrates reduced anxiety
Care Plan 4: Movement-Related Acute Pain
Nursing Diagnosis Statement:
Acute pain related to impaired physical mobility
Related Factors/Causes:
- Musculoskeletal injury
- Joint inflammation
- Muscle weakness
- Fear of movement
Nursing Interventions and Rationales:
Assist with gentle range of motion exercises
- Prevents stiffness and maintains function
Teach proper body mechanics
- Reduces pain during movement
Apply heat/cold therapy as ordered
- Provides local pain relief
Encourage gradual activity progression
- Builds confidence and improves mobility
Desired Outcomes:
- Demonstrates proper body mechanics
- Reports decreased pain with movement
- Achieves optimal mobility level
Care Plan 5: Inflammatory-Related Acute Pain
Nursing Diagnosis Statement:
Acute pain related to an inflammatory process
Related Factors/Causes:
- Tissue inflammation
- Immune response
- Edema
- Chemical mediators
Nursing Interventions and Rationales:
Administer anti-inflammatory medications
- Reduces inflammation and associated pain
Monitor for signs of infection
- Ensures appropriate treatment
Elevate affected area
- Reduces edema and discomfort
Provide comfort measures
- Promotes rest and healing
Desired Outcomes:
- Shows reduced signs of inflammation
- Reports decreased pain intensity
- Maintains adequate rest periods
References
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- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
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