Ackley: Nursing Diagnosis Handbook, 11th Edition

Acute Pain

Acute Pain
Maureen F. Cooney DNP, FNP-BC, Chris Pasero MS, RN-BC, FAAN, Denise Sullivan MSN, ANP-BC

NANDA-I

Definition

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage (); sudden or slow onset of any intensity from mild to severe with an
anticipated or predictable endInternational Association for the Study of Pain, 1979

Defining Characteristics

Appetite change; change in physiological parameter (e.g., blood pressure, heart rate, respiratory rate,
oxygen saturation, and end-tidal CO); diaphoresis; distraction behavior; evidence of pain using
standardized pain behavior checklist for those unable to communicate verbally (e.g., Neonatal Infant Pain
Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate); expressive behavior
(e.g., restlessness, crying, vigilance); facial expression of pain (e.g., eyes lack luster, beaten look, fixed or
scattered movement, grimace); guarding behavior; hopelessness; narrowed focus (e.g., time, perception,
thought processes, interaction with people and environment); positioning to ease pain; protective
behavior; proxy report of pain behavior/activity changes (e.g., family member, caregiver); pupil dilation;
self-focused; self-report of intensity using standardized pain scale (e.g., Wong-Baker FACES scale, visual
analog scale, numerical rating scale); self-report of pain characteristics using standardized pain
instrument (e.g., McGill Pain Questionnaire, Brief Pain Inventory)

Related Factors (r/t)

Biological injury agent (e.g., infection, ischemia, neoplasm); chemical injury agent (e.g., burn, capsaicin,
methylene chloride, mustard agent); physical injury agent (e.g., abscess, amputation, burn, cut, heavy
lifting, operative procedure, trauma, overtraining)

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Pain Control; Pain Level; Pain: Adverse Psychological Response

Example NOC Outcome

Pain Level as evidenced by severity of observed or reported pain.

N: Pain Level is the NOC Outcome label; this text recommends use of the self-report numerical pain
rating scale in place of the NOC indicator scales because of the amount of research supporting its use.

Client Outcomes
Client Will (Specify Time Frame)

For the client who is able to provide a self-report

 Use a self-report pain tool to identify current pain intensity level and establish a comfort-
function goal

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Analgesic Administration; Pain Management; Patient-Controlled Analgesia (PCA) Assistance

Example NIC Activities—Pain Management

Ensure client attentive analgesic care; Perform a comprehensive assessment of pain to include location,
characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors

Nursing Interventions and Rationales

 During the initial assessment and interview, if the client is experiencing pain, conduct and document a
comprehensive pain assessment, using appropriate pain assessment tools. CEB:Determining location,
temporal aspects, pain intensity, characteristics, and the impact of pain on function and quality of
life are critical to determine the underlying cause of pain and effectiveness of treatment
(McCaffery, 1968;McCaffery et al, 2011). The initial assessment includes all pain information that
the client can provide for the development of the individualized pain management plan
(McCaffery et al, 2011).
 Assess if the client is able to provide a self-report of pain intensity, and if so, assess pain intensity level
using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale. CEB: Self-
report is considered the single most reliable indicator of pain presence and intensity and single-dimension
pain ratings are valid and reliable as measures of pain intensity level (McCaffery et al,
2011).EB:Regularly and routinely assess the client for pain presence during activity and rest and with
interventions or procedures likely to cause painCEB:Self-report is considered the single most reliable
indicator of pain presence and intensity and single-dimension pain ratings are valid and reliable
as measures of pain intensity level (McCaffery et al, 2011).EB:Regularly and routinely assess the
client for pain presence during activity and rest and with interventions or procedures likely to
cause painCEB:Acute pain should be reliably assessed both at rest (important for comfort) and
during movement (important for function and decreased client risk for cardiopulmonary and
thromboembolic events) (McCaffery et al, 2011).
 Using a self-report pain tool, ask the client to identify a comfort-function goal that
will allow the client to perform necessary or desired activities easily. EBN:The
comfort-function goal provides the basis for individualied pain management plans and assists in
determining effectiveness of pain management interventions (McCaffery et al, 2011).

Client/Family Teaching and Discharge Planning

Note: To avoid the negative connotations associated with the words “drugs” and “narcotics,” use the term
“pain medicine” when teaching clients.

 Discuss the various discomforts encompassed by the word “pain” and ask the client to give
examples of previously experienced pain. Explain the pain assessment process and the purpose
of the pain rating scale. CEB:It is often difficult for clients to understand the concept of pain and
 describe their pain experience. Using alternative words and providing a complete description of
the assessment process, including the use of scales, ensures that an accurate treatment plan is
developed (McCaffery et al, 2011).
 Teach the client to use the self-report pain tool to rate the intensity of past or current pain. Ask the
client to set a comfort-function goal by selecting a pain level on the self-report tool that will allow
performance of desired or necessary activities of recovery with relative ease (e.g., turn, cough,
deep breathe, ambulate, participate in physical therapy). If the pain level is consistently above the
comfort-function goal, the client should take action that decreases pain or notify a member of the
health care team so that effective pain management interventions may be implemented
promptly. CEB:The use of comfort-function goals provides the basis for the direction and
modification of the treatment plan (McCaffery et al, 2011).