NURSING CARE PLAN Acute Pain ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES’ Nursing Assessment Acute Pain related to tissue in- Pain Control [1605] as evi- Mr. C. is a 57-year-old businessman who was admitted to the sur- jury secondary to surgical inter- denied by often demonstrating logical unit for treatment of a possible strangulated inguinal hernia. invention (as evidenced by the ability to Two days ago he a partial bowel resection. Postoperative or- restlessness; pallor; elevated Use analgesics appropriately dees including NPO, intravenous infusion of D51/2 NS at 125 cc/hr pulse, respirations, and systolic Use nonanalgesic relief left arm, nasogastric tube to low intermittent suction. Mr. C. is in blood pressure; dilated pupils; measures the dorsal recumbent (supine) position and is attempting to draw up and reports of 7/10 abdominal Report uncontrolled his legs. He appears restless and is complaining of abdominal pain) symptoms to health care pain (7 on a scale of 0-10). professional Pain Level [2102]
As evi- Physical Examination Diagnostic Data denied by mild to no Height: 188 cm (6′ 3") Chest x-ray and urinalysis neg- Reported pain Weight: 90.0 kg (200 lb) active, WBC 12,000 Protective body positioning Temperature: 37’C (98.6’F) Restlessness Pulse: 90 BPM Pupil dilation Respirations: 24/minute Perspiration Blood pressure: 158/82 mm Hg Change in BP, HR, R from Skin pale and moist, pupils di- normal baseline data related. Midline abdominal incision, sutures dry and intact. continued on page 1224 NURSING CARE PLAN Acute Pain continued NURSING INTERVENTIONS* /SELECTED ACTIVITIES RATIONALE Pain Management [1400] Perform a comprehensive assessment of pain to include location, Pain is a subjective experience and must be described by the characteristics, onset, duration, frequency, quality, intensity or client in order to plan effective treatment. severity, and precipitating factors of pain. Consider cultural influences on pain response (e.g, cultural beliefs Each person experiences and expresses pain in an individual pain may result in a stoic attitude). manner using a variety of sociocultural adaptation techniques. Reduce or eliminate factors that precipitate or increase Mr. C’s Personal factors can influence pain and pain tolerance.
Factors pain experience (e.g. fear, fatigue, monotony, and lack of that may be precipitating or augmenting pain should be reduced knowledge). or eliminated to enhance the overall pain management program. Teach the use of nonpharmacologic techniques (e.g, relaxation, The use of noninvasive pain relief measures can increase the re- guided imagery, music therapy, distraction, and massage) before, lease of endorphins and enhance the therapeutic effects of pain after, and if possible during painful activities; before pain occurs or relief medications. increases; and along with other pain relief measures. Provide Mr. C. optimal pain relief with prescribed analgesics. Each dient has a right to expect maximum pain relief. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage, and frequency for each individual Medica- tions ordered on a prn basis should be offered to the client at the interval when the next dose is available. Medicate before an activity to increase participation, but evaluate Turning and ambulation activities will be enhanced if pain is con- the hazard of sedation. trolled or tolerable. Assessing level of sedation should precede the activity to ensure nece precautions are put in place. Evaluate the effectiveness of the pain control measures used Research shows that the most common reason for unrelieved through ongoing assessment of Mr. C’s pain experience. pain is failure to routinely assess pain and pain relief. Many clients silently tolerate pain if not specifically asked about it. Analgesic Administration [2210]
Check the medical order for drug, dose, and frequency of anal- Ensures that the nurse has the right drug, right route, right gesic prescribed. dosage, right client, right frequency. Determine analgesic selections (narcotic, nonnarcotic, or NSAID) Various types of pain (e.g, acute, chronic, neuropathic, notice based on type and severity of pain. tive) require different analgesic approaches. Some types of pain respond to nonopioid drugs alone, while others can be relieved by combining a low-dose opioid with a nonopioid. Institute safety precautions as appropriate if Mr. C. receives nar- Side effects of opioid narcotics include drowsiness and sedation. cotic analgesics. Instruct Mr. C. to request pr pain medication before the pain is Severe pain is more difficult to control and increases the client’s severe. anxiety and fatigue.
The preventive approach to pain manage- ment can reduce the total 24-hour analgesic dose. Evaluate the effectiveness of analgesic at regular, frequent inter- The analgesic dose may not be adequate to raise the client’s vals after each administration and especially after the initial doses, pain threshold or may be causing intolerable or dangerous side also observing for any signs and symptoms of untoward effects effects or both. Ongoing evaluation will assist in making neces- (e.g. respiratory depression, nausea and vomiting, dry mouth, and sary adjustments for effective pain management. constipation). Document Mr. C’s response to analgesics and any untoward effects. Documentation facilitates pain management by communicating effective and noneffective pain management strategies to the entire health care team. Implement actions to decrease untoward effects of analgesics Constipation is a common side effect of opioid narcotics, and a (e.g, constipation and gastric irritation). treatment plan to prevent occurrence should be instituted at the beginning of analgesic therapy. For Mr. C, constipation could re- sult from his primary condition or his analgesia. Assess for overall GI functioning, possible complications of surgery (e.g., ileus), as well as opioid-induced constipation or NSAID-induced gastritis. NURSING CARE PLAN Acute Pain continued NURSING INTERVENTIONS/SELECTED ACTIVITIES* RATIONALE Simple Relaxation Therapy [6040) Consider Mr. C’s willingness and ability to participate, preference, The client must feel comfortable trying a different approach to past experiences, and contraindications before selecting a specific pain management. To avoid ineffective strategies, the client relaxation strategy. should be involved in the planning process. Elicit behaviors that are conditioned to produce relaxation, such as Relaxation techniques help reduce skeletal muscle tension, which deep breathing, yawning, abdominal breathing, or peaceful imaging will reduce the intensity of the pain. Create a quiet, nondisruptive environment with dim lights and Comfort and a quiet atmosphere promote a relaxed feeling and comfortable temperature when possible permit the dient to focus on the relaxation technique rather than external distraction. Individualize the content of the relaxation intervention (e.g., by Each person may find different images or approaches to relax- asking for suggestions about what Mr. C. enjoys or finds relaxing). ation more helpful than others. The nurse should have a variety of relaxation scripts or audiovisual aids to help clients find the best one for them. Demonstrate and practice the relaxation technique with Mr. C.
Return demonstrations by the participant provide an opportunity for the nurse to evaluate the effectiveness of teaching sessions. Evaluate and document his response to relaxation therapy. Conveys to the health care team effective strategies in reducing or eliminating pain. EVALUATION Outcomes partially met. The dient verbalizes pain and discomfort, requesting analgesics at onset of pain. States "the pain is a 2" (on a scale of 0-10) 30 minutes after a parenteral analgesic administration. Requests analgesic 30 minutes before ambulation. States willingness to try relaxation techniques; however, has not attempted to do so. "The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individu- alized for each client. APPLYING CRITICAL THINKING 1. Is there any other assessment data you would want to gather to 3. What kind of data would you gather prior to having a discus- help plan Mr. C’s pain management? sion with the primary care provider about options for improv- 2. Mr. C. does not have a PCA. What nursing interventions are im- ing pain control in this dient? portant? See Critical Thinking Possibilities in Appendix A
