Nursing Diagnosis: Acute Pain

Chris Pasero and Margo McCaffery

NANDA Definition: Pain is whatever the experiencing
person says it is, existing whenever the person says it does
(McCaffery, 1968); an 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 <6 months (NANDA)

Defining Characteristics:
Subjective
Pain is always subjective and cannot be proved or
disproved. A client's report of pain is the most reliable
indicator of pain (Acute Pain Management Guideline
Panel, 1992). A client with cognitive ability who can speak
or point should use a pain rating scale (e.g., 0 to 10) to
identify the current level of pain intensity (self-report)
and determine a comfort/function goal (McCaffery,
Pasero, 1999).
Objective
Expressions of pain are extremely variable and cannot be
used in lieu of self-report. Neither behavior nor vital signs
can substitute for the client's self-report (McCaffery,
Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However,
observable responses to pain are helpful in clients who
cannot or will not use a self-report pain rating scale.
Observable responses may be loss of appetite and
inability to deep breathe, ambulate, sleep, or perform
activities of daily living (ADLs). Clients may show
guarding, self-protective behavior, self-focusing or
narrowed focus, distraction behavior ranging from crying
to laughing, and muscle tension or rigidity. In sudden and
severe pain, autonomic responses such as diaphoresis,
blood pressure and pulse changes, pupillary dilation, or
increases or decreases in respiratory rate and depth may
be present.

Related Factors: Actual or potential tissue damage

(mechanical [e.g., incision or tumor growth], thermal [e.g.,
burn], or chemical [e.g., toxic substance])
NOC Outcomes (Nursing Outcomes Classification
 Suggested NOC Labels

Pain Level, Pain Control, Comfort Level

Pain: Disruptive Effects

Client Outcomes

Uses a pain rating scale to identify current

level of pain intensity and determines a
comfort/function goal (if client has cognitive
abilities)

Describes how unrelieved pain will be

managed

Reports that the pain management regimen

relieves pain to a satisfactory level with acceptable
or manageable side effects

Performs activities of recovery with a reported

acceptable level of pain (if pain is above the
comfort/function goal, takes action that decreases
pain or notifies a member of the health care team)

States an ability to obtain sufficient amounts

of rest and sleep

Describes a nonpharmacological method that

can be used to control pain

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Conscious Sedation

Patient-Controlled Analgesia (PCA) Assistance

Nursing Interventions and Rationales

Determine whether client is experiencing pain

at the time of the initial interview. If so, intervene
at that time to provide pain relief. The intensity,
character, onset, duration, and aggravating and
relieving factors of pain should be assessed and
documented during the initial evaluation of the
patient (American Pain Society Quality of Care
Committee, 1995; JCAHO, 2000).

Ask client to describe past experiences with

pain and effectiveness of methods used to manage
pain, including experiences with side effects,
typical coping responses, and how he or she
expresss pain. A number of concerns (barriers)
may affect patients' willingness to report pain and
use analgesics (Ward et al, 1993).

Describe adverse effects of unrelieved pain.

Numerous pathophysiological and psychological
morbidity factors may be associated with pain
(McCaffery, Pasero, 1999; Page, Ben-Eliyahu,
1997; Puntillo, Weiss, 1994).

Tell client to report location, intensity (using a

pain rating scale), and quality when experiencing
pain. The intensity of pain and discomfort should
be assessed and documented after any known
pain-producing procedure, with each new report of
pain, and at regular intervals (American Pain
Society Quality of Care Committee, 1995; JCAHO,
2000).

Determine client's current medication use. To

aid in planning pain treatment, obtain a
medication history (Acute Pain Management
Guideline Panel, 1992).
 Explore the need for both opioid (narcotic)
and non-opioid analgesics. Pharmacological
interventions are the cornerstone of pain
management (Acute Pain Management Guideline
Panel, 1992; McCaffery, Pasero, 1999).

Obtain a prescription to administer a non-

opioid (acetaminophen, Cox-2 inhibitor, or a
nonsteroidal antiinflammatory drug [NSAID]),
unless contraindicated, around the clock (ATC).
NSAIDs act mainly in the periphery to inhibit the
initiation of pain impulses (Dahl, Kehlet, 1991).
Unless contraindicated, all patients with acute
pain should receive a non-opioid ATC (Acute Pain
Management Guideline Panel, 1992). The
analgesic regimen should include a non-opioid,
even if pain is severe enough to require the
addition of an opioid (Jacox et al, 1994;
McCaffery, Pasero, 1999).

Obtain a prescription to administer opioid

analgesia if indicated, especially for severe pain.
Opioid analgesics are indicated for the treatment
of moderate to severe pain (Jacox et al, 1994;
McCaffery, Pasero, 1999).

Administer opioids orally or intravenously, not

intramuscularly. Use a preventive approach to
keep pain at or below an acceptable level. Provide
PCA and intraspinal routes of administration when
appropriate and available. The least invasive route
of administration capable of providing adequate
pain control is recommended. The intramuscular
(IM) route is avoided because of unreliable
absorption, pain, and inconvenience. The
intravenous (IV) route is preferred for rapid
control of severe pain. For ongoing pain, give
analgesia ATC. PRN dosing is appropriate for
intermittent pain (Jacox et al, 1994; McCaffery,
Pasero, 1999).
 Discuss client's fears of undertreated pain,
overdose, and addiction. A number of concerns
may affect clients' willingness to report pain and
use opioid analgesics (Ward et al, 1993). Because
of the many misconceptions regarding pain and its
treatment, education about the ability to control
pain effectively and correction of myths about the
use of opioids should be included as part of the
treatment plan (Jacox et al, 1994; McCaffery,
Pasero, 1999). Addiction is extremely unlikely
after patients use opioids for acute pain (Acute
Pain Management Guideline Panel, 1992).

When opioids are administered, assess pain

intensity, sedation, and respiratory status at
regular intervals. Opioids may cause respiratory
depression because they reduce the
responsiveness of carbon dioxide chemoreceptors
located in the respiratory centers of the brain.
Because even more opioid is required to produce
respiratory depression than is required to produce
sedation, patients with clinically significant
respiratory depression are usually also sedated.
Respiratory depression can be prevented by
assessing sedation and decreasing the opioid dose
when the patient is arousable but has difficulty
staying awake (McCaffery, Pasero, 1999; Pasero,
McCaffery, 1994).

Review client's flow sheet and medication

records to determine overall degree of pain relief,
side effects, and analgesic requirements during
the past 24 hours. Systematic tracking of pain
appears to be an important factor in improving
pain management (Faries et al, 1991; JCAHO,
2000).

Administer supplemental opioid doses as

needed to keep pain ratings at or below an
acceptable level. A PRN order for supplementary
opioid doses between regular doses is an essential
backup (American Pain Society, 1999).
 Obtain prescriptions to increase or decrease
opioid doses as needed; base prescriptions on
client's report of pain severity and response to the
previous dose in terms of relief, side effects, and
ability to perform the activities of recovery.
Increase or decrease the dose of opioid based on
assessment of the patient's response. Patients'
responses, and therefore their requirements, vary
widely, so it is less important to focus on the
amount given than on the response (McCaffery,
Pasero, 1999; Pasero, McCaffery, 1994).

When client is able to tolerate oral analgesics,

obtain a prescription to change to the oral route;
use an equianalgesic chart to determine initial
dose. (See Appendix E for an equianalgesic chart.)
The oral route is preferred because it is the most
convenient and cost-effective (Jacox et al, 1994).
Use of equianalgesic doses when switching from
one opioid or route of administration to another
will help to prevent loss of pain control from
underdosing and side effects from overdosing
(McCaffery, Pasero, 1999).

In addition to use of analgesics, support

client's use of nonpharmacological methods to
control pain, such as distraction, imagery,
relaxation, massage, and heat and cold
application. Cognitive-behavioral strategies can
restore the clients' sense of self-control, personal
efficacy, and active participation in own care
(Jacox et al, 1994).

Teach and implement nonpharmacological

interventions when pain is relatively well
controlled with pharmacological interventions.
Nonpharmacological interventions should be used
to supplement, not replace, pharmacological
interventions (Acute Pain Management Guideline
Panel, 1992).
 Plan care activities around periods of greatest
comfort whenever possible. Pain diminishes
activity (Jacox et al, 1994; McCaffery, Pasero,
1999).

Ask client to describe appetite, bowel

elimination, and ability to rest and sleep.
Administer medications and treatments to improve
these functions. Obtain a prescription for a
peristaltic stimulant to prevent opioid-induced
constipation. Because there is great individual
variation in the development of opioid-induced
side effects, these side effects should be
monitored and, if their development is inevitable
(e.g., constipation), prophylactically treated.
Opioids cause constipation by decreasing bowel
peristalsis (Jacox et al, 1994; McCaffery, Pasero,
1999).
Geriatric

Always take the elderly client's reports of pain

seriously and ensure that the pain is relieved. In
spite of what many professionals and clients
believe, pain is not an expected part of normal
aging (McCaffery, Pasero, 1999).

When assessing pain, speak clearly, slowly,

and loudly enough for client to hear; repeat
information as needed. Be sure client can see well
enough to read pain scale (use enlarged scale)
and written materials.

Handle client's body gently. Allow client to

move at own speed.

Use acetaminophen and NSAIDs with low

side-effect profiles such as choline and magnesium
salicylates (Trilisate) and diflunisal (Dolobid), and
watch for side effects, such as GI disturbances and
bleeding problems. Elderly people are at increased
 risk for gastric and renal toxicity from NSAIDs
(Griffin et al, 1991; Acute Pain Management
Guideline Panel, 1992).

Avoid or use with caution drugs with a long

half-life, such as the NSAID piroxicam (Feldene),
the opioids methadone (Dolophine) and
levorphanol (Levo-Dromoran), and the
benzodiazepine diazepam (Valium). The higher
prevalence of renal insufficiency in the elderly
than in younger persons can result in toxicity from
drug accumulation (American Pain Society, 1999;
Acute Pain Management Guideline Panel, 1992;
McCaffery, Pasero, 1999).

Use opioids with caution in the elderly client.

The elderly are more sensitive to the analgesic
effects of opioid drugs because they experience a
higher peak effect and a longer duration of pain
relief. Reduce the initial recommended adult
starting opioid dose by 25% to 50%, especially if
the client is frail and debilitated; then increase the
dose if safe and necessary (Acute Pain
Management Guideline Panel, 1992).

Avoid the use of opioids with toxic

metabolites, such as meperidine (Demerol) and
propoxyphene (Darvon, Darvocet), in elderly
clients. Meperidine's metabolite, normeperidine,
can produce CNS irritability, seizures, and even
death; propoxyphene's metabolite,
norpropoxyphene, can produce both CNS and
cardiac toxicity. Both of these metabolites are
eliminated by the kidneys, making meperidine and
propoxyphene particularly poor choices for elderly
clients, many of whom have at least some degree
of renal insufficiency (Acute Pain Management
Guideline Panel, 1992; McCaffery, Pasero, 1999).
Multicultural

Assess pain in a culturally diverse client using

a self-report 0 to 10 numerical pain rating scale or
 the Wong Baker Faces pain rating scale. Have
scale translated into client's native language if
necessary.. Inadequate pain management is
widespread, especially among minority groups,
and a major reason is the failure to assess pain
properly. The more cultural differences between
patient and nurse, the more difficult it is for the
nurse to assess and treat pain. Self-report of pain
is the single most reliable indicator of pain,
regardless of culture (McCaffery, 1999; McCaffery,
Pasero, 1999).

Administer analgesics on a preventive basis to

keep pain ratings at or below an acceptable level.
Regardless of the patient's cultural background,
pain rated at (4 on a 0 to 10 pain rating scale
interferes significantly with daily function.
Perceived quality of life appears to be comparable
across cultures, with pain ratings of >6 interfering
markedly with a person's ability to enjoy life
(McCaffery, 1999; McCaffery, Pasero, 1999).

Assess for the influence of cultural beliefs,

norms, and values on the client's perception and
experience of pain. The client's experience of pain
may be based on cultural perceptions (Leininger,
1996).

Assess for the role of fatalism on the client's

beliefs regarding their current state of comfort.
Fatalistic perspectives in some African-American
and Latino populations involve the belief that you
cannot control your own fate and influence your
health behaviors (Philips, Cohen, Moses, 1999;
Harmon, Castro, Coe, 1996).

Incorporate folk health care practices and

beliefs into care whenever possible. Incorporating
folk health care beliefs and practices into pain
management care increased compliance with the
treatment plan (Juarez, Ferrell, Borneman, 1998).
 Use a family-centered approach when working
with Latino, Asian American, African-American,
and Native American clients. Involving family in
pain management care increased compliance with
the treatment regimen (Juarez, Ferrel, Borneman,
1998).

Use culturally relevant pain scales (e.g., the

Oucher scale) to assess pain in the client.
Culturally diverse clients may express pain
differently than clients from the majority culture.
The Oucher scale has African-American and
Hispanic versions and is used to assess pain in
children (Beyer, Denyes, Villarruel, 1992).

Ensure that directions for medications are

available in the client's language of choice and are
understood by client and caregiver. Bilingual
instructions for medications increased compliance
with the pain management plan (Juarez, Ferrell,
Borneman, 1998).

Validate the client's feelings and emotions

regarding current health status. Validation lets the
client know the nurse has heard and understands
what was said, and it promotes the nurse-client
relationship. (Stuart, Laraia, 2001;Giger,
Davidhizer, 1995).

Home Care Interventions

Review with client and caregivers the cause(s)

of pain and the medical regimen specific to the
cause. Assess client knowledge and teach disease
process as necessary. Compliance with the
medical regimen for diagnoses involving pain
improves the likelihood of successful management
(Humphrey, 1994).
 Develop a full medication profile, including
medications prescribed by all physicians and all
over-the-counter medications. Assess for drug
interactions. Instruct client to refrain from mixing
medications without physician approval. Pain
medications may significantly impact or be
impacted by other medications and may cause
severe side effects. Some combinations of drugs
are specifically contraindicated (Jacox et al,
1994).

Assess client and family knowledge of side

effects and safety precautions associated with pain
medications (e.g., use caution when operating
machinery when opioids are initiated or dose has
been increased). The cognitive effects of opioids
usually subside within a week of initial dosing or
dose increases (McCaffery, Pasero, 1999). The use
of long-term opioid treatment does not appear to
affect neuropsychological performance. Pain itself
may deteriorate performance of
neuropsychological tests more than oral opioid
treatment (Sjogren et al, 2000).

If administering medication using highly

technological methods, assess home for necessary
resources (e.g., electricity), and ensure that there
will be responsible caregivers available to assist
client with administration. Some routes of
medication administration require special
conditions and procedures to be safe and accurate
(McCaffery, Pasero, 1999).

Assess knowledge base of client and family for

highly technological medication administration.
Teach as necessary. Be sure clients know when,
how, and who to contact if analgesia is
unsatisfactory. Appropriate instruction in the
home increases the accuracy and safety of
medication administration (McCaffery, Pasero,
1999).
Client/Family Teaching

NOTE: To avoid the negative connotations

associated with the words drugs and narcotics,
use the words pain medicine when teaching
clients.

Provide written materials on pain control such

as the Agency for Health Care Policy and Research
(AHCPR) pamphlet, Pain Control: Patient Guide.

Discuss the various discomforts encompassed

by the word pain, and ask client to give examples
of previously experienced pain. Explain pain
assessment process and purpose of the pain rating
scale.

Teach client to use the pain rating scale to

rate intensity of past or current pain. Ask client to
set a comfort/function goal by selecting a pain
level on the rating scale that makes it easy to
perform recovery activities (e.g., turn, cough,
deep breathe). If pain is above this level, client
should take action that decreases pain or notify a
member of the health care team. (See Appendix E
for information on teaching clients to use the pain
rating scale.)

Demonstrate medication administration and

use of supplies and equipment. If PCA is ordered,
determine client's ability to press appropriate
button. Remind client and staff that the PCA
button is for patient-only use.

Reinforce importance of taking pain

medications to keep pain under control.

Reinforce that taking opioids for pain relief is

not addiction and that addiction is very unlikely to
occur.
 Demonstrate use of appropriate
nonpharmacological approaches for controlling
pain, such as heat, cold, distraction techniques,
relaxation breathing, visualization, rocking,
stroking, music, and television.