Acute Pain

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

1. Comfort Level

2. Medication Response

3. Pain Control
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

1. Analgesic Administration

2. Conscious Sedation

3. Pain Management

4. 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.
Defining Characteristics:
1. Patient reports pain
2. Guarding behavior, protecting body part
3. Self-focused
4. Narrowed focus (e.g., altered time perception, withdrawal from social or physical
contact)
5. Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other
people or activities, restlessness)
6. Facial mask of pain
7. Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
8. Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate;
pupillary dilation; change in respiratory rate; pallor; nausea)
Related Factors:
1. Postoperative pain
2. Cardiovascular pain
3. Musculoskeletal pain
4. Obstetrical pain
5. Pain resulting from medical problems
6. Pain resulting from diagnostic procedures or medical treatments
7. Pain resulting from trauma
8. Pain resulting from emotional, psychological, spiritual, or cultural distress
Expected Outcomes
1. Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved
pain.

Ongoing Assessment

• 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. Some people deny the
experience of pain when it is present. Attention to associated
signs may help the nurse in evaluating pain.

• Assess for probable cause of pain. Different etiological factors

respond better to different therapies.

• Assess patient’s knowledge of or preference for the array of pain-

relief strategies available. 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.

• 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, intrapersonal, and

intrapsychic factors may contribute to pain or pain relief. These
variables may modify the patient’s expression of his or her
experience. For example, 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 a range of

techniques aimed at controlling pain. Some patients will feel
uncomfortable exploring 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-controlled

analgesia (PCA) candidate: no history of substance abuse; no allergy
to narcotic analgesics; clear sensorium; cooperative and motivated
about use; no history of renal, hepatic, or respiratory disease; manual
dexterity; and no history of major psychiatric disorder. PCA is the
intravenous (IV) infusion of a narcotic (usually morphine or
Demerol) through an infusion pump that is controlled by the
patient. This allows the patient to manage pain relief within
prescribed limits. In the hospice or home setting, a nurse or
 caregiver may be needed to assist the patient in managing the
infusion.

• Monitor for changes in general condition that may herald need for
change in pain relief method. For example, a PCA patient
becomes confused and cannot manage PCA, or a successful
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 requesting If demands
for medication are quite frequent, 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 excessive sedation,
respiratory distress, urinary retention, nausea/vomiting,
constipation, and IV site pain, redness, or swelling Patients
may also experience mild allergic response to the
analgesic agent, marked by generalized itching or
nausea and vomiting.

• If patient is receiving epidural analgesia, assess the following:

 Pain relief Intermittent epidurals require redosing at
intervals. Variations in anatomy may result in a "patch
effect."
 Numbness, tingling in extremities, a metallic taste in the
mouth These symptoms may be indicators of an allergic
response to the anesthesia agent, or of improper
catheter placement.
 Possible epidural analgesia complications such as excessive
sedation, respiratory distress, urinary retention, or catheter
migration Respiratory depression and intravascular
infusion of anesthesia (resulting from catheter
migration) can be potentially life-threatening.
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.

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 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.
III. Local anesthetic agents.
Nonpharmacological methods include the following:
IV. Cognitive-behavioral strategies as follows:
 Imagery The use of a mental picture or an
imagined event involves use of the five senses to
distract oneself from painful stimuli.
 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.
 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.
 Biofeedback, breathing exercises, music therapy
V. Cutaneous stimulation as follows:
 Massage of affected area when appropriate Massage
decreases muscle tension and can promote
comfort.
 Transcutaneous electrical nerve stimulation (TENS)
units
 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:

1. 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.