ACUTE PAIN

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:

• Patient reports pain

• Guarding behavior, protecting body part
• Self-focused
• Narrowed focus (e.g., altered time perception, withdrawal from social or
physical contact)
• Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other
people or activities, restlessness)
• Facial mask of pain
• Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
• Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse
rate; pupillary dilation; change in respiratory rate; pallor; nausea)

Related Factors:

• Postoperative pain
• Cardiovascular pain
• Musculoskeletal pain
• Obstetrical pain
• Pain resulting from medical problems
• Pain resulting from diagnostic procedures or medical treatments
• Pain resulting from trauma
• Pain resulting from emotional, psychological, spiritual, or cultural distress

Expected Outcomes

• Patient verbalizes adequate relief of pain or ability to cope with incompletely

relieved pain.
Ongoing Assessment

• Assess pain characteristics:

o Quality (e.g., sharp, burning, shooting)
o 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.
o Location (anatomical description)
o Onset (gradual or sudden)
o Duration (how long; intermittent or continuous)
o 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:
o Pain relief The basal or lock-out dose may need to be increased to cover
the patient’s pain.
o Intactness of IV line If the IV is not patent, patient will not receive pain
medication.
o 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.
o 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:
o Pain relief Intermittent epidurals require redosing at intervals. Variations
in anatomy may result in a "patch effect."
o 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.
o 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:

1. Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered

orally or parenterally (to date, ketorolac is the only available parenteral
NSAID).
2. 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.
3. Local anesthetic agents.

Nonpharmacological methods include the following:

4. 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
5. 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.