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Nursing Care Plans Nursing Diagnosis

Acute Pain
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By Gil Wayne, BSN, R.N. - August 3, 2016  0

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Acute Pain nursing diagnosis is defined as 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 six (6) months.

See Also: Nursing Diagnosis Complete List and Guide » 

The unpleasant feeling of pain is highly subjective in nature that may be experienced by the patient.
Acute Pain serves a protective function to make the patient informed and knowledgeable about the
presence of an injury or illness. The unexpected onset of Acute Pain reminds the patient to seek
support, assistance, and relief. The physiological signs that occur with Acute Pain emerge from the
body’s response to pain as stressor.

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Other factors such as the patient’s cultural background,
ACCEPT emotions, and psychological or spiritual 
discomfort may contribute to the suffering with Acute Pain. In older patients, assessment of pain can be
challenging due to cognitive impairment and sensory-perceptual deficits. Assessment and
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management of the nursing diagnosis of Acute Pain are the main focus of this care plan.

1. Related Factors
2. Defining Characteristics
3. Goals and Outcomes
4. Nursing Care Plans for Acute Pain
5. Acute Pain Nursing Assessment
6. Nursing Interventions for Acute Pain
7. References and Sources
Related Factors
Here are some factors that may be related to the nursing diagnosis Acute Pain that you can use under
the etiology part of your nursing care plan:

Pain coming from medical problems

Pain arising from emotional, psychological, spiritual, or cultural discomfort
Pain due to diagnostic procedures or medical interventions and treatments
Pain emerging from trauma

Defining Characteristics
The nursing diagnosis of Acute Pain is characterized by the following signs and symptoms. Use these
subjective and objective data under the “nursing assessment” column of your care plan:
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Patient complains of pain
Appetite changes ACCEPT 
Self-focused
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Guarding behavior, protecting body part 
Intolerant (e.g., altered time perception, withdrawal from social or physical contact)
Facial mask of pain
Autonomic responses (e.g., diaphoresis, an alteration in BP, HR, pupillary dilation; alteration in RR;
pallor; nausea)
Change in muscle tone: lethargy or weakness; rigidity or tightness
Relief or distraction behavior (e.g., pacing, seeking out other people or activities)
Expressive behavior (e.g., restlessness, moaning, crying)
Hopelessness
Observed evidence of pain using standardized pain behavior checklist
 For those unable to communicate; refer to the appropriate assessment tool (e.g., Behavioral Pain
Scale, Neonatal Infant Pain Scale, Pain Assessment Checklist for Seniors with Limited Ability to
Communicate)
Positioning to avoid pain
Protective gestures
Proxy reporting pain and behavior/activity changes (e.g., family members, caregivers)
Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker FACES scale,
visual analogue scale, numeric rating scale)
Self-report of pain characteristics (e.g., aching, burning, electric shock, pins and needles, shooting,
sore/tender, stabbing, throbbing) using standardized pain scales (e.g., McGill Pain Questionnaire,
Brief Pain Inventory)

Goals and Outcomes

The following are the common nursing care planning goals and expected outcomes for Acute Pain:

Patient describes satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10.
Patient displays improved well-being such as baseline levels for pulse, BP, respirations, and relaxed
muscle tone or body posture.
Patient uses pharmacological and nonpharmacological pain-relief strategies.
Patient displays improvement in mood, coping.

Nursing Care Plans for Acute Pain

Diseases, medical conditions, and related nursing care plans for Acute Pain nursing diagnosis:
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Surgery (Perioperative Client)

Brain Tumor
Fracture
 Hypertension
Tonsillitis
For the complete list, visit: Acute Pain

Acute Pain Nursing Assessment

Proper nursing assessment of Acute Pain is imperative for the development of an effective pain
management plan. Nurses play a crucial role in the assessment of pain, use these techniques on how
to assess for Acute Pain:

Assessment Rationales

Assess pain characteristics:

Assessment of pain experience is the first step

Quality (e.g., burning, sharp, shooting)
in planning pain management strategies. The
Severity (scale of 0 or no pain to 10 or most
most reliable source of information about the
severe pain)
pain is the patient.
Location (anatomical description)
Onset (gradual or sudden)
Descriptive scales such as a visual analogue
Duration (how long; intermittent or
can be utilized to distinguish the degree of pain.
continuous)
Precipitating or relieving factors

Some people deny the existence of pain.

Attention to associated signs may help the nurse
in evaluating
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Assess for signs and symptoms relating to pain. .
temperature may be present in a patient with
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acute pain. The patient’s skin may be pale and 
cool to touch. Restlessness and inability to
 concentrate are also some manifestations. 
Such variables play a big role in modifying the
patient’s expression of pain. Some cultures
Assess to what degree cultural, environmental, simply express feelings, whereas others hold
intrapersonal, and intrapsychic factors may such expression. Nevertheless, health care
contribute to pain or pain relief. providers should not prejudge any patient
response but rather evaluate the unique
response of each individual.

Some patients may be satisfied when pain is no

longer massive; others will demand complete
elimination of pain. This influences the
 Assess the patent’s anticipation for pain relief. perceptions of the effectiveness of the treatment
of the treatment modality and their eagerness to
engage in further treatments.

Other patients may be overlooking of the

effectiveness of nonpharmacological methods
and may be willing to try them, either with or
instead of traditional analgesic medications.
Assess the patient’s willingness or ability to
Often a combination of therapies (e.g., mild
explore a range of techniques aimed at
analgesics with distraction or heat) may be more
controlling pain.
effective. Some patients will feel uncomfortable
exploring alternative methods of pain relief.
However, patients need to be acquainted that
there are other approaches to manage pain.

PCA is the IV infusion of an opioid (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. The criteria for implementing PCA include:

No allergy to opioid analgesics

No history of substance abuse
No history of renal, hepatic, or respiratory
Assess the suitability of the patient as a PCA
disease
candidate
No history of major psychiatric disorder
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Cooperative and motivated about use
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Manual dexterity 

 In the hospice or home setting, a nurse or 

caregiver may be needed to assist the patient in
managing the infusion.

If the patient is on PCA, assess the following:

If requests for medication are quite frequent, the

patient’s dosage may need to be increased to
Weigh the amount of pain medication the
promote pain relief. if requests are very low, the
patient is using to his or her reports of pain.
patient may require further guidance to correctly
use PCA.
 Potential PCA complications such as Early assessment of complication is required to
excessive sedation; respiratory distress; prevent serious adverse reactions to opioid
urinary retention; nausea and vomiting; analgesics.
constipation; and IV site pain, or swelling

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

These symptoms may be indicators of an

Tingling in the extremities, numbness, a
allergic response to the anesthesia agent or of
metallic taste in the mouth
incorrect catheter placement.

Potential epidural analgesia complications

Respiratory depression and intravascular
such as extreme sedation, respiratory
infusion of anesthesia (resulting from catheter
distress, urinary retention, or catheter
migration) can be potentially life threatening.
migration

It is essential to assist patients express as

Evaluate the patient’s response to pain and
management strategies.
factually as possible (i.e., without the effect of
mood, emotion, or anxiety) the effect of pain
relief measures. Inconsistencies between
behavior or appearance and what the patient
says about pain relief (or lack of it) may be more
a reflection of other methods the patient is using
to cope with the pain rather than pain relief itself.

The meaning of pain will directly determine the

patient’s response. Some patients, especially the
Evaluate what the pain suggests to the patient.
dying, may consider that the “act of suffering”
meets a spiritual need.
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Nursing Interventions for Acute
ACCEPT Pain 

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time
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treating patients. The following are the therapeutic nursing interventions for your Acute Pain care plan:
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Interventions Rationales

Preventing the pain is one thing that a patient

experiencing it can consider. Early intervention
Foresee the need for pain relief.
may decrease the total amount of analgesic
required.

One’s perception of time may become distorted

during painful experiences. Pain can be
aggravated with anxiety and fear especially
 when pain is delayed. An immediate response to
Acknowledge reports of pain immediately.
reports of pain may decrease anxiety in the
patient. Demonstrated concern for the patient’s
welfare and comfort fosters the development of
trusting relationship.

Patients may experience an exaggeration in pain

Get rid of additional stressors or sources of or a decreased ability to tolerate painful stimuli if
discomfort whenever possible. environmental, intrapersonal, or intrapsychic
factors are further stressing them.

One’s experiences of pain may become

exaggerated as a result of exhaustion. Pain may
Provide rest periods to promote relief, sleep, and
result in fatigue, which may result in exaggerated
relaxation.
pain. A peaceful and quiet environment may
facilitate rest.

Patients with acute pain should be given a

Determine the appropriate pain relief method. nonopioid analgesic around-the-clock unless
contraindicated.

Pharmacological methods include the following: 

Nonopioids (acetaminophen), a nonselective NSAIDs work in peripheral tissues. Some block

NSAID, or a selective NSAID (e.g., the synthesis of prostaglandins, which stimulate
cyclooxygenase [COX]-2 inhibitor) nociceptors. They are effective in managing mild
to moderate pain.

Opioids may be administered orally,

intravenously, systemically by PCA systems, or
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Opioid analgesics use of cookies .
infusion). Intramuscular injections are not
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reliably absorbed. Opioids are indicated for
severe pain, especially in the hospice or home
 setting.
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Local anesthetics block pain transmission and
Local anesthetic agents
are used for pain in specific areas of nerve
distribution.

Nonpharmacological methods include the following:

The aid of an imagined event or a mental picture

involves use of the five senses to divert oneself
from painful stimuli.

Cognitive-behavioral strategies as follows:

 Imagery Increasing one’s concentration, these techniques
Distraction techniques help an individual decrease the pain experience.
Relaxation exercises, biofeedback, breathing Breathing modifications and nerve stimulations
exercises, music therapy are some of the methods.

The aim of these techniques is to lessen the

stress, tension, subsequently decreasing the
pain.

Cutaneous stimulation as follows:

 A massage traps pain transmission, increases

endorphin levels, and minimizes tissue edema.
Massage of the affected area when suitable
This method requires another person to perform
the massage.

 TENS demands the application of two or four

skin electrodes. Pain modulation happens
Transcutaneous electrical nerve stimulation
through a mild electrical current. The patient is
(TENS) units
able to control the intensity and frequency of the
electrical stimulation.

Heat decreases pain through improved blood

blow to the area and through reduction of pain
Hot or cold compress reflexes. Cold lessens pain, inflammation, and
muscle spasticity by decreasing the release of
pain-inducing chemicals and regulating the
conduction
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Effectiveness of pain medications must be
Provide analgesics as ordered, evaluating the
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evaluated individually because it is absorbed
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effectiveness and inspecting for any signs and and metabolized differently by patients.
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symptoms of adverse effects. Analgesics may cause mild to severe side 
effects.

 Patients who demand pain medications at more

Report to the physician when interventions are
frequent intervals than prescribed may actually
unsuccessful and ineffective.
require higher doses or more potent analgesics.

Patient may give up trying to cope with pain

Remind the patient that pain is limited and that
when he or she perceives pain as everlasting
there are other approaches to minimizing pain.
and unresolvable.

If the patient is on PCA:

Restrict the use of an IV line for PCA only; ask

 a pharmacist before combining other drugs Unexpected IV incompatibilities may occur.
with opioids being infused.

If the patient is receiving epidural analgesia:

Label all tubing (e.g., epidural catheter, IV

tubing to epidural catheter) clearly to prevent Improper use of an epidural catheter can result
the accidental administration of unseemly to neurological injury or infection.
fluids or drugs into the epidural space.

For the patient with PCA or epidural analgesia:

Place a “No additional analgesia” warning

This prevents inadvertent analgesic overdosing.
over the bed.

Keep Narcan or other opioid-reversing These drugs reverse the opioid effect in case of
agents readily available. respiratory depression.

References and Sources

Recommended resouces and further study for Acute Pain nursing diagnosis:

Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M.
(2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.
[Link]
Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins. [Link]
Herr, K., Titler, M. G., Schilling, M. L., Marsh, J. L., Xie, X., Ardery, G., … & Everett, L. Q. (2004).
Evidence-based assessment of acute pain in older adults: current nursing practices and perceived
Thisbarriers. The cookies
website uses Clinicaltojournal ofan
give you pain , 20(5),
optimal 331-340.
browsing [Link] By continued used of this site, you agree to our
experience.
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Urden, L. D., Stacy, K. M., & Lough, M. E. (2006).  . critical care nursing: diagnosis and

management (pp. 918-966). Maryland Heights, MO: Mosby.

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Last updated on March 24, 2019 
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 TAGS acute pain chronic pain Nursing Diagnosis Pain Management

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Gil Wayne, BSN, R.N.
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https://nurseslabs.com
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Gil Wayne graduated in 2008 with a bachelor of science in nursing and during the same year, earned his
license to practice as a registered nurse. His drive for educating people stemmed from working as a
community health nurse where he conducted first aid training and health seminars and workshops to
teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is
now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His
goal is to expand his horizon in nursing-related topics, as he wants to guide the next generation of nurses
to achieve their goals and empower the nursing profession.

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