Acute Pain NCP

Nursing Diagnoses:

·         Acute pain related to disruption of skin, tissue, and muscle integrity; musculoskeletal or bone trauma

·         Acute pain related to presence of tubes and drains

Cause Analysis:

ASSESSMENT	OBJECTIVES	INTERVENTIONS	RATIONALE
Objective Cues: Reports of pain (PQRST) Subjective Cues: ·         Alteration in muscle tone ·         facial mask of pain ·         Distraction, guarding, or protective behaviors ·         Self-focusing, narrowed focus	Short-term: Within 4 hours of providing nursing interventions, the patient will be report reduced pain to a tolerable level. Long-term: Within 3 days of providing nursing interventions, the patient will be able to participate in activities appropriately.	Independent: ·         Note client’s age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course, including size and location of incision, drain placement, and anesthetic agents used. ·         Review intraoperative and recovery room record for type of anesthesia and medications previously administered. ·         Evaluate pain frequently in immediate postoperative phase and regularly (e.g., hourly per protocol) following transfer, noting characteristics, location, and intensity (0–10 scale). Emphasize client’s responsibility for reporting pain and relief of pain completely. ·         Note presence of anxiety or fear, and relate with nature of and preparation for procedure. ·         Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if client denies pain. ·         Assess causes of possible discomfort other than operative procedure. ·         Provide information about transitory nature of discomfort, as appropriate. ·         Reposition as indicated, such as semi-Fowler’s or lateral Sims’. ·         Provide additional comfort measures such as backrub and heat or cold applications. ·         Encourage use of relaxation techniques such as deep-breathing exercises, guided imagery, visualization, or music. ·         Provide regular oral care, occasional ice chips or sips of fluids as tolerated. ·         Document effectiveness and side or adverse effects of analgesia. Collaborative: ·         Administer medications, as indicated, for example: IV analgesics after reviewing anesthesia record for contraindications and/or presence of agents that may potentiate analgesia ·         Around-the-clock analgesia via patient-controlled analgesia (PCA) or epidural analgesia (PCEA) with intermittent rescue doses, as needed ·         Local anesthetics, such as epidural block or infusion ·         NSAIDs, such as ketorolate (Toradol), diflunisal (Dolobid), or naproxen (Anaprox) ·         Monitor use and effectiveness of transcutaneous electrical nerve stimulation (TENS) unit when used.	·         Approach to postoperative pain management is based on multiple variable factors. Note: Administration of the anticonvulsant lamotrigine (Lamictal) before spinal anesthesia reduces analgesic use and lowers pain scale ratings in the postoperative client. ·         Presence of opioids and droperidol in system potentiates opioid analgesia, whereas inhalation anesthetics have no analgesic effects. In addition, intraoperative local and regional blocks have varying duration based on drug choice and dose. ·         Provides information about need for, and effectiveness of, interventions. Note: It may not always be possible to eliminate pain; however, analgesics should reduce pain to a tolerable level. A frontal and/or occipital headache may develop 24 to 72 hours following spinal anesthesia, necessitating recumbent position, increased fluid intake, and notification of the anesthesiologist for alternative pain relief plan. ·         Concern about the unknown, such as outcome of a biopsy and/or inadequate preparation due to emergent procedure, can heighten client’s perception of pain. ·         Changes in these vital signs often indicate acute pain and discomfort. Note: Some clients may have a slightly lowered BP, which returns to normal range after pain relief is achieved. ·         Discomfort can be caused or aggravated by presence of nonpatent indwelling catheters causing bladder pain, NG tube resulting in gastric fluid and gas accumulation, or parenteral lines that have infiltrated IV fluids or medications. ·         Understanding the cause of the transitory discomfort, such as sore muscles from administration of succinylcholine, which may persist up to 48 hours postoperatively; sinus headache, which may be associated with nitrous oxide; or sore throat, which may be due to intubation, provides emotional reassurance. Note: Paresthesia of body parts suggests nerve injury. Symptoms may last hours or months and require additional evaluation. ·         May relieve pain and enhance circulation. Semi-Fowler’s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims’ will relieve dorsal pressures. ·         Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being. ·         Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities. ·         Reduces discomfort associated with dry mucous membranes due to anesthetic agents and oral restrictions. ·         Respirations may decrease on administration of opioid, or synergistic effects with anesthetic agents may occur. Note: Migration of epidural analgesia toward head may cause respiratory depression or excessive sedation. ·         Analgesics given IV reach the pain centers immediately, providing more effective relief with smaller doses of medication. Note: Initial opioid dosage should be reduced by onefourth to one-third after use of fentanyl (Innovar) or droperidol (Inapsine) to prevent respiratory depressant effects (Deglin & Valler, 2005). ·         Research supports need to administer analgesics around the clock initially to prevent rather than merely treat pain. Use of PCA necessitates detailed client instruction. PCA is considered very effective in managing acute postoperative pain with smaller amounts of opioid and increased client satisfaction. Note: Continuous epidural infusions may be used for 1 to 5 days following procedures that are known to cause severe pain such as certain types of thoracic or abdominal procedures. ·         Analgesics may be injected into the operative site, or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain. Note: Continuous epidural infusions may be used for 1 to 5 days following procedures that are known to cause severe pain such as certain types of thoracic or abdominal surgeries. ·         Useful for mild to moderate pain or as adjuncts to opioid therapy in moderate to severe pain. Allows for a lower dosage of opioids, reducing potential for side effects. Use alternating schedule with NSAIDs administered between opioid doses so peak effect occurs at a different time. ·         TENS may be useful in reducing pain and amount of medication required postoperatively.

 Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 796-798)