Nursing Interventions for Acute Pain

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 less than 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

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

Suggested NIC Labels

Conscious Sedation
Patient-Controlled Analgesia (PCA) Assistance

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Nursing Interventions and Rationales for Acute Pain