ACUTE PAIN

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSI EXPLANATION INTERVENTIONS
S
SUBJECTIVE: ACUTE Unpleasant sensory SHORT TERM: 1. Assess pain 1. Assessment of the SHORT
 “intermitten PAIN related and emotional After 4 hours of characteristic pain experience is TERM:
t right knee to joint experience arising nursing the first step in After 4 hours of
pain inflammatio from actual or interventions, the planning pain nursing
associated n associated potential tissue client will be able management interventions,
with with damage or to identify the strategies. The the client shall
arthritis” increased described in terms management patient is the most have been able
 “occur on disease of such damage; strategies and reliable source of to identify the
cold or activity as sudden or slow verbalize decrease information about management
rainy days manifested onset of any in pain. his or her pain strategies and
and by arthritis intensity from mild 2. Assess for 2. Some people deny verbalize
extended pain to severe with an LONG TERM: signs and the experience of decrease in
walking or anticipated or After 2 days of symptoms pain when it is pain.
sitting.” predictable end and nursing associated with present. Attention Pain level 5/10
 Described a duration of less interventions, the pain to associated signs
as a bad than 6 months client will be able may help the nurse LONG TERM:
ache to exhibit in evaluating pain. After 2 days of
OBJECTIVE: increased The patient in acute nursing
 Restlessness comfort. pain may have an interventions,
 Pain scale: 7 elevated BP, HR, the client shall
out of 10 and temperature. have been able
 Duration: 30 The patient’s skin to exhibit
minutes to 1 may be pale and increased
hour cool to touch. The comfort.
patient may be “I can tolerate
restless and have the pain a little
difficulty more now with
concentrating. the massage
3. Evaluate the 3. It is important to techniques you
patient’s help patient express gave me”
response to as factually as
pain and pain possible the effect
 management of pain relief
strategies measures.
Discrepancies
between behavior
or appearance and
what the patient
says about pain
relief may be more
a reflection of other
methods the patient
is using to cope
with the pain rather
than pain relief
4. Evaluate what itself.
the pain means 4. The meaning of the
to the patient pain will directly
influence the
patient’s response.
Some patients,
especially the
dying, may feel that
the “act of
suffering” meets a
5. Assess the spiritual need
patient’s 5. Some patients may
expectations be content to have
for pain relief pain decreased;
other will expect
complete
elimination of pain.
This affects their
perceptions of the
effectiveness of the
treatment modality
and their
willingness to
 participate in
additional
6. Assess the treatments
patient’s 6. Some patients may
willingness or be unaware of the
ability to effectiveness of
explore a range nonpharmacologica
of techniques l methods and may
aimed at be willing to try
controlling them, either with or
pain instead of
traditional analgesic
medications. Often
a combination of
therapies may be
more effective.
Some patients will
feel uncomfortable
exploring
alternative methods
of pain relief.
However, patients
need to be informed
that there are
multiple ways to
7. Anticipate the manage pain
need for pain 7. One can most
relief effectively deal
with pain by
preventing it. Early
intervention may
decrease the total
amount of analgesic
8. Respond required
immediately to 8. In the midst of
reports of pain painful experiences,
 a patient’s
perception of time
may become
distorted. Anxiety
and fear about
delayed pain relief
can exacerbate the
pain experience.
Prompt responses to
reports of pain may
result in decreased
anxiety in the
patient.
Demonstrated
concern for the
patient’s welfare
and comfort fosters
the development of
a trusting
9. Eliminate relationship
stressors or 9. Patients may
sources of experience an
discomfort exaggeration in
whenever pain or a decreased
possible ability to tolerate
painful stimuli if
environmental,
intrapersonal, or
intrapsychic factors
are further stressing
10. Provide rest them.
periods to 10. The patient’s
facilitate experiences of pain
comfort, sleep, may become
and relaxation 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
11. Determine the rest
appropriate 11. Unless
pain relief contraindicated, all
method patients with acute
pain should receive
a nonopioid
analgesic around-
12. Give analgesics the-clock
as ordered, 12. Pain medications
evaluating their are absorbed and
effectiveness metabolized
and observing differently by
for any signs patients, so their
and symptoms effectiveness must
of untoward be evaluated
effects individually by the
patient. Analgesics
may cause side
effects that range
from mild to life
threatening.