Acute pain is an experience that is known to virtually all human beings. It is an unpleasant feeling that can be described as highly subjective as a person experiences it.
As a nursing diagnosis, Acute Pain is defined as an unpleasant emotional and sensory experience resulting from an actual or potential damage of a body tissue.
Types of Pain
Acute and chronic pain are examples of different types of pain. Patients experiencing Acute pain is typically a short-term, severe pain that arises from tissue damage caused by an injury or surgery. It serves as an important alert system, warning the body of potential danger and allowing for prompt attention to a potentially serious condition.
Acute pain and severe pain differs from chronic pain, which is longer lasting more than 6 months and can be caused by an underlying condition such as arthritis, cancer or nerve damage. Painful procedures and postoperative pain are examples of acute pain.
Chronic pain may also be associated with psychological distress, such as depression or anxiety. It can interfere with daily activities and have a detrimental effect on quality of life.
Visceral pain is a type of pain that originates in the body’s organs and is usually associated with an inflammation or infection. It may also be caused by trauma to an abdominal organ, such as the liver or spleen. Visceral pain has often been described as “deep,” “diffuse,” or “dull.”
As pain intensity worsens, vital signs can be affected. An increase in pain may result in an increase in heart rate, respiratory rate, and increased blood pressure.
Pain Assessment Tools
When assessing pain in the patient, pain assessment tools are a great tool to use for nursing students. Pain assessment tools allow nurses to determine the type, intensity, and pain characteristics that patients may be experiencing.
Pain Relief Measures
Nursing students should be prepared to provide safe and effective pain relief measures to treat pain. Pain is an inevitable part of healthcare, and helping to relieve the patient’s pain is an important part of optimal pain management in order to ensure adequate pain control for their patients.
The most important aspect of pain management is the ability to assess pain accurately and often. It is essential that pain is assessed properly and regularly to ensure pain relief measures are appropriate and effective. Nursing students should understand the importance of pain assessment tools, such as pain scales, that can be used to assess pain levels in patients.
It is also important for nursing students to know the types of pain relief medications available for treating pain. Understanding the pharmacology of pain medications can help students choose the most effective medication for their patients.
In addition, nurses should be aware of nonpharmacological pain relief strategies, such as physical therapy, transcutaneous electrical nerve stimulation, music therapy, relaxation techniques, and massage therapy that may reduce pain without the use of pain medications.
5 Nursing Diagnosis Acute Pain
Hip Fracture
Nursing Diagnosis Acute Pain: Acute Pain related to hip fracture secondary to fall, as evidenced by pain score of 10 out of 10, guarding sign on the affected limb, restlessness, and irritability
Desired Outcome: The patient reports a pain score of 0 out of 10.
Nursing Interventions For Acute Pain
Intervention: Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.
Rationale: To create a baseline set of observations and vital signs for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.
Intervention: Administer analgesics pain medication as prescribed.
Rationale: To provide pain relief to the patient.
Intervention: Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.
Rationale: To assess the effectiveness of treatment.
Intervention: Provide more analgesics at recommended/prescribed intervals.
Rationale: To promote pain relief and patient comfort without the risk of overdose.
Intervention: Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.
Rationale: To promote optimal patient comfort and reduce anxiety/ restlessness.
Intervention: Refer the patient to a pain specialist as required.
Rationale: To enable to patient to receive more information and specialized care in pain management if needed.
Deficient Knowledge
Nursing Diagnosis Acute Pain: Deficient Knowledge related to acute pain management as evidenced by patient’s verbalization of “I want to know more how to relieve my pain.”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of his/her acute pain and its management.
Nursing Interventions For Acute Pain
Intervention: Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits).
Rationale: To address the patient’s cognition and mental status towards pain management and to help the patient overcome blocks to learning.
Intervention: Explain what his/her pain management program entails (e.g. pain medication, relaxation techniques, related physiotherapy or exercises). Avoid using medical jargons and explain in layman’s terms.
Rationale: To provide information on his/her pain management program.
Intervention: Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to treat acute pain. Ask the patient to repeat or demonstrate the self-administration details to you.
Rationale: To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Intervention: Educate the patient about non-pharmacological methods for acute pain such as imagery, distraction techniques, recommended exercises, and relaxation techniques.
Rationale: To reduce stress and to promote optimal pain relief without too much dependence on pharmacological means.
Activity Intolerance
Acute Pain Nursing Diagnosis: Activity intolerance related to acute pain as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
Nursing Interventions For Acute Pain
Intervention: Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.
Rationale: To create a baseline of activity levels and mental status related to acute pain, fatigue and activity intolerance.
Intervention: Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.
Rationale: To gradually increase the patient’s tolerance to physical activity.
To prevent triggering of acute pain by allowing the patient to pace activity versus rest.
Intervention: Administer pain medication as prescribed prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.
Rationale: To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Intervention: Refer the patient to physiotherapy / occupational therapy team as required.
Rationale: To provide a more specialized care for the patient in terms of helping him/ her build confidence in increasing daily physical activity.
Infection
Acute Pain Nursing Diagnosis: Acute Pain related to infection secondary to pleurisy as evidenced by pain score of 10 out of 10, pain upon inhalation, shortness of breath
Desired Outcome: The patient reports a pain score of 0 out of 10.
Nursing Interventions For Acute Pain
Intervention: Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10 and describe the pain he/she is experiencing.
Rationale: To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.
Intervention: Administer analgesics and nonsteroidal anti inflammatory drugs pain as prescribed. Administer antibiotics as prescribed.
Rationale: To provide pain relief to the patient. To treat the underlying infection.
Intervention: Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.
Rationale: To assess the effectiveness of treatment.
Intervention: Provide more analgesics at recommended/prescribed intervals.
Rationale: To enhance pain relief and patient comfort without the risk of overdose.
Intervention: Elevate the head of the bed and encourage the patient to sit in semi Fowler’s position. Encourage pursed lip breathing and deep breathing exercises.
Rationale: To relieve shortness of breath and help in lung expansion. To promote optimal patient comfort and reduce anxiety / restlessness.
Intervention: Refer the patient to a pain specialist as required.
Rationale: To enable to patient to receive more information and specialized care in pain management if needed.
Imbalanced Nutrition: Less than Body Requirements
Acute Pain Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to decrease food intake secondary to acute pain as evidenced by weight loss, poor muscle tone and lack of appetite
Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.
Nursing Interventions For Acute Pain
Intervention: Create a daily weight chart and a food and fluid chart. Discuss with the patient the short term and long-term goals of weight gain.
Rationale: To effectively monitory the patient’s daily nutritional intake and progress in weight goals.
Intervention: Administer pain medication as prescribed
Rationale: To provide pain relief, as acute pain may result to disinterest in eating and eventual lack of proper nutrition.
Intervention: Instruct the patient to avoid carbonated beverages and gas-producing food.
Rationale: To reduce abdominal distention which can worsen acute pain.
Intervention: Refer the patient to the dietitian.
Rationale: To provide a more specialized care for the patient in terms of nutrition and diet.
With the use of the nursing care plans above, the patient will be able to experience pain relief, or reduced pain level, and will be able to perform his/her activities of daily living optimally.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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