- When the discomfort first began, what was the patient doing? What led to it? What makes it better or worse? What appears to set it off? Stress? Position? Specific actions?
- What relieves it? Medication, massage, heat or cold, position change, physical activity, and rest?
- What makes it worse? Moving, bending, lying down, walking, standing?
- What sensations do patients have? Use adjectives like “sharp,” “dull,” “stabbing,” “burning,” “crushing,” “throbbing,” “nauseating,” “shooting,” “twisting,” or “stretched” to express the discomfort.
- Where does the pain come from? Does the discomfort spread? Where? Does it appear to be moving or traveling? Did it begin somewhere else and have a localized origin now?
- On a pain scale of 0 to 10, with 0 being no pain and 10 being the highest and worst pain, how bad is the pain? Does it obstruct activities? What is the worst-case scenario? Does it make the patient sit, lie, or move more slowly? How long is a single episode?
- When exactly did the suffering begin? How much time did it take? Does it happen hourly, and how frequently? Daily? Weekly? Monthly? Is it abrupt or sluggish? When did the patient first encounter it? Did the patient typically experience it during the day? Night? Early in the day? Do patients ever get roused by it? Does it have any other consequences? Does it also exhibit additional symptoms and signs?
2. Ask the patient to rate the pain.
Pain scales can help better understand the patient’s pain. It also evaluates how well the treatment reduces the pain. The most commonly used pain scales go from 0 to 10. The pain scale ranges from 0 (no pain) to 10 (worst pain experienced). The pain scales can be quantitative, qualitative, or combined measurements. Quantitative scales ask, “How bad is the pain?” While qualitative pain scales characterize the nature of the pain. Some other examples of pain scales that are available are:
- Numerical rating scales (NRS) use numbers to rate the pain.
- Visual analog scales (VAS) allow patients to choose the image that most accurately describes their pain level.
- Categorical scales utilize a combination of words and numbers, colors, or places on the body.
3. Look for the underlying cause.
Pain results from an injury, trauma, surgery, or a triggering condition (such as herniated disk, migraine headache, or pancreatitis). Target the cause to alleviate the pain. Shortly after it starts, acute pain becomes prominent. It frequently follows an injury, disease, or medical procedure that is well-known and tends to happen suddenly.
If the underlying cause can be found, treating it is the most efficient way to relieve pain. In other circumstances, the injury or disease causing the discomfort may improve or resolve independently. The cause may require treatment with drugs, surgery, or other therapies. While the patient is awaiting treatment, pain management should be offered. If the source of the pain cannot be immediately found, pain management should still be offered as long as there are no contraindications.
4. Distinguish the type of pain.
Knowing the type of pain, can assist the nurse in determining an appropriate pain management plan. Actual tissue injury or stimuli with the potential to cause tissue damage are caused by nociceptive pain. While neuropathic pain can result from several nerve impulse problems.
5. Identify the aggravating factors.
Determine to what extent cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain. These influences alter the patient’s expression of the pain experienced by increasing or potentially decreasing the patient’s pain tolerance. For instance, loud and bright environments may exacerbate stress causing increased distress to a patient already experiencing severe pain.
6. Observe signs and symptoms.
Pain results in observable behavioral and physiological changes. It sets off the body’s fight-or-flight reaction. It causes faster breathing and pulse rates. Assess for changes in vital signs and conduct a physical exam.
7. Ask the patient about the use of non-pharmacological methods.
Assess the patient’s comfort level with non-pharmacological methods of pain relief. Some patients are unaware that non-pharmacological methods can be used with or instead of analgesic drugs. A more effective reduction in pain can be achieved using a combination of these therapies.
8. Assess the patient’s expectations for pain relief.
Some patients are satisfied with a reduction of pain, while others desire it to be eliminated. Discussing their expectations can affect their perception of the effectiveness of their pain control and willingness to participate in treatment.
Encourage the patient to decide how comfortable they need to attain their functional goals based on their current state of health. Sometimes, it is not possible to entirely eliminate pain so a reasonable goal should be discussed with the patient. To correctly set a patient’s comfort-function goal, nurses must first outline the crucial steps in the healing process and explain how pain management contributes to successful outcomes.
9. Consider the age and developmental stage.
The client’s age, developmental stage, and present health should be considered. Their developmental stage or other diseases may alter their capacity to report pain parameters or their reaction to pain and management strategies. For instance, very young children are susceptible to pain due to decreased ability to report pain. Therefore age-appropriate pain rating scales and collaboration with caregivers should be used to manage pain.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with acute pain.
1. Administer the appropriately prescribed analgesic.
Analgesic drugs like NSAIDS, opioids, and local anesthetics pharmacologically reduce acute pain quickly and effectively.
- Painkillers available over the counter, such as acetaminophen, aspirin, or ibuprofen
- Prescription pain relievers, such as corticosteroids or specific COX-2 inhibitors
- Opioid drugs, which may be administered for severe pain after an operation or injury
- Specific neuropathic pain or functional pain syndromes may be treated with antidepressant or seizure medicines.
2. Follow the pain ladder.
The pain ladder is crucial for assessing the patient’s pain level and prescribing the appropriate drugs. The pain ladder comprises a three-step transition from non-opioids through mild opioids to potent opioids to provide adequate pain relief. It consists of three steps:
- Mild pain uses non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
- Moderate pain utilizes weak opioids (such as hydrocodone, codeine, and tramadol) with or without non-opioid pain relievers.
- Severe and persistent pain uses potent opioids with or without non-opioid painkillers. Potent opioids are morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, and oxymorphone.
3. Assess the appropriateness of a patient controlled analgesia (PCA) pump.
Assess if the patient is a PCA candidate. PCA is the IV infusion of opioids through a pump controlled by the patient. If the patient meets the criteria, this can be a more effective method of pain management. PCA enables patients to self-administer analgesia and gives the patient some degree of control over the dosage they receive. It is important to assess if the patient is both physically able and willing to hit the PCA button but also mentally competent to understand that doing so will relieve their discomfort.
4. Evaluate pain after interventions.
Reassess pain level after 30 minutes of interventions. It is essential to reassess pain following interventions to determine if those actions were practical and if the patient’s pain control goals have been met. Also take into consideration how long it will take the medication administered to reach its maximal effectiveness. Some medications such as those administered IV will take effect almost immediately, while others may not reach peak efficacy for hours.
5. Educate the patient about pain management.
Teach regarding effective timing of medication doses prior to activities that exacerbate pain and to avoid periods of intense pain. Patients can help effectively manage their pain with additional knowledge of when to request pain medication to maximize its effectiveness and prevent severe pain episodes.
If the patient is not able to verbally respond to questions, the nurse can request that the patient nod their head, squeeze their hand, move their eyes up and down, or raise their fingers, hand, arm, or leg to indicate the presence of discomfort. If applicable, provide the patient with writing materials, pain intensity charts, or numbers they can reference.
6. Encourage feedback from the patient.
Instruct the patient to assess the interventions’ effectiveness and report the effectiveness of different interventions to the care team. Feedback can assist the care team in modifying and improving pain control strategies. Ask the patient how much pain they were experiencing both before and after taking pain management. What were actions taken if the patient’s pain level was intolerable?
7. Respond immediately to reports of pain.
If the patient is experiencing an altered passage of time due to pain, fear of delayed pain relief can exacerbate the pain experience. Prompt responses to reports of pain reduce anxiety and promote trust.
8. Promote periods of rest for the patient.
Fatigue can contribute to pain. A quiet, darkened room with minimal noise and interruptions can promote rest and reduce pain.
9. Encourage the use of non-pharmacological therapy.
Use relaxation and breathing exercises and music therapy. These techniques help produce a sense of tranquility for the patient. The goal is to reduce pain related to tension or stress. Complementary therapies are:
- Biofeedback teaches the patient to control bodily functions like breathing actively.
- Acupressure or acupuncture stimulates particular pressure spots on the body to relieve pain.
- Massage relieves tension and pain by pressure and rubbing the muscles or other soft tissues.
- Meditation releases tension and stress by concentrating on thoughts in specific ways during meditation.
- Yoga or tai chi combines slow and intentional movements with deep breaths to relax the muscles.
- Natural relaxation practices continuous muscle relaxation where the patient can contract and relax various muscles.
- Guided imagery can picture something comforting for the patient, diverting them from pain.
10. Remove the stimuli.
Divert away the patient’s attention from the painful stimuli using effective distractors that can reduce the pain the patient perceives. Provide appropriate and engaging distractions for the patient to redirect their attention. Diversional therapy involves using the mind to redirect the attention to something else. The patient can put the pain on hold and concentrate instead on things like playing games, counting, practicing breathing exercises, and many other things.
11. Monitor for side effects of medications.
Monitoring for side effects is also essential to maintain the patient’s comfort and safety. Drugs have varying effects based on each person’s metabolism, and efficacy should be evaluated case by case. Sedation, mental fogginess, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression are typical adverse effects of opioid treatment. Watch out for physical dependence that may put the patient at risk for overdosage and poor pain management.
12. Anticipate the need for pain relief.
Pain is most effectively managed by preventing it. Intervening as soon as possible can decrease the total amount of analgesic needed to provide adequate pain control.
13. Refer to therapies.
Physical therapy could ease the pain brought on by illnesses like multiple sclerosis or arthritis, as well as injuries. While occupational therapy may teach patients how to modify their routines and environments to minimize pain.
14. Apply a compress.
To relieve uncomfortable swelling and inflammation brought on by injuries or persistent illnesses like arthritis, apply an ice pack or cold pack wrapped in a towel. While using heating pads or a warm bath relieves cramps, pain, or muscle stiffness.
15. Follow RICE for minor injuries.
For minor injuries that do not require medical attention, follow RICE:
- Rest the affected area.
- Ice the affected area with a towel-wrapped cold pack for 10 to 20 minutes to reduce swelling.
- Compress by wrapping the affected area with an elastic bandage to provide support. It should be applied tightly enough to prevent numbness.
- Elevate the affected area above the heart to encourage venous return.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for acute pain.
Acute pain care plans should always be individualized to the patient. The care planning process should assess contributing factors to the patient’s pain, the appropriateness of the planned interventions, and effective methods for evaluating the patient’s response.
Care Plan #1
Diagnostic statement:
Acute pain related to an orthopedic surgical procedure of the left lower extremity can be caused by a bone fracture and inflammation, as evidenced by a heart rate of 112 bpm, guarding of the left lower extremity, reports of pain, and pain scale of 8/10.
Expected outcomes:
- Patient will report a reduced pain scale from 8 up to less than 3/10 within 4 hours.
- Patient will verbalize increased pain tolerance while moving at the end of the shift.
- Patient will be able to ambulate independently with tolerable pain at the end of the shift.
- Patient will be able to appear well-rested at the end of the shift.
Assessment:
1. Characterize the pain.
It is typical to experience pain or discomfort following orthopedic surgery as the patient heals. Pain indicates that the patient’s body is actively trying to heal. Each pain feels different, and it varies in intensity. The nurse should perform a full PQRST pain assessment to better understand the pain and to make a plan to address the pain.
2. Determine the patient’s healing process.
The pain level may vary during the healing process following orthopedic surgery. After surgery, the discomfort often peaks in the first week.
3. Ask the patient about the pain at night.
Pain experienced after orthopedic surgery is worst at night. Stress, the effects of some drugs on sleep, sleep disturbances, body’s normal cycles of activity and rest are likely contributing reasons to the experienced pain at night.
4. Assess the patient’s comfort level with non-pharmacological methods.
Non-pharmacological pain management techniques are simple and have fewer adverse effects than pharmacological therapies.
5. Determine if PCA is needed.
Patient-controlled analgesia (PCA) reduces pain. However, it has side effects that may hinder recovery and the ability of the patient who has undergone orthopedic surgery to ambulate.
Interventions:
1. Administer the appropriately prescribed analgesic.
It is important to educate the patient about the pain medication they are using and how to manage their breakthrough pain when they leave the hospital.
2. Reevaluate pain after interventions.
Following therapies, it is critical to reevaluate pain to see if the patient’s pain control goals and interventions were beneficial.
3. Educate about pain management.
Pain management also involves the proper use of several pain medications. Teach about safe pain management approaches after orthopedic surgery that minimize adverse effects. The nurse should also educate the patient about timing of pain medication as well as any potential side effects of pain medication such as constipation.
4. Combine non-pharmacological and pharmacological therapy.
Managing pain after orthopedic surgery without the use of drugs is an option. These non-traditional approaches to pain management are frequently combined with painkillers.
Care Plan #2
Diagnostic statement:
Acute pain related to acute bronchitis can be caused by a viral infection, as evidenced by patient reports of chest and throat soreness, a pain scale of 8/10, lack of appetite, and grimacing while coughing and speaking.
Expected outcomes:
- Patient will report decreased pain scale from 8 up to less than 3/10 within 4 hours of nursing interventions.
- Patient will verbalize decreased pain when breathing within 4 hours of nursing interventions.
- Patient will manifest respiratory rate within normal limits within 2 hours of nursing interventions.
- Patient will be able to appear well-rested at the end of the shift.
Assessment:
1. Assess pain characteristics.
Chest pain and throat soreness is usually found in patients with acute bronchitis. It is due to inflammation of the lining of the main airways of the lungs (bronchi) resulting in a forceful cough.
2. Observe how the patient coughs.
The patient engages various abdominal, back, and chest muscles during coughing. These muscles might become exhausted after a severe cough or several days of coughing, feeling sore or painful, particularly when one massages the affected area. Usually, the pain worsens during a cough before improving between them.
3. Identify the viral cause.
Most of the time, the same viruses that cause the common cold or flu also cause bronchitis. Millions of microscopic droplets released from the mouth and nose during a cough or sneeze carry the virus.
Interventions:
1. Administer antitussive medication as ordered.
Antitussive medication should be administered PRN as directed. It can assist in stopping coughing and ease discomfort from painful stimuli in acute bronchitis.
2. Ask the patient for feedback.
Feedback can enhance the pain care plan. Ask the patient to evaluate and report the effects of the pain interventions in a patient with acute bronchitis.
3. Teach the patient proper coughing and breathing exercises.
Stretching and building respiratory muscles with breathing exercises assist patients in recovering from acute bronchitis.
4. Cautiously administer corticosteroids.
A corticosteroid helps the patient relieve coughing, promote healing, and lessen inflammation, especially in cases of severe bronchitis.
Care Plan #3
Diagnostic statement:
Acute pain related to psychological distress can be caused by anxiety and fear, as evidenced by the patient verbalizing pain, moaning and crying, narrowed focus and altered passage of time, and pallor.
Expected outcomes:
- Patient will demonstrate a reduction in crying within 1 hour of nursing interventions.
- Patient will report a decreased pain scale of less than 3/10 within 4 hours of nursing interventions.
- Patient will appear well-rested at the end of the shift.
Assessment:
1. Determine the contributing factors.
Determine the extent to which societal, environmental, intrapersonal, and psychological factors may be causing pain. It can gauge how each patient will respond differently.
2. Identify the trigger.
Know which triggering incident causes anxiety and fear in the patient, resulting in pain and psychological distress. Exposure to the trigger can alleviate the pain.
3. Check the psychological and emotional status.
Assessing psychological and emotional status of the patient to help look for ways to eliminate distress, improve health status, and relieve the accompanying pain.
Interventions:
1. Be with the patient.
Fear of a long wait for pain relief can worsen the patient’s impression of time passing differently because of their agony. Rapid responses to complaints of pain lower anxiety and increase trust.
2. Allow rest periods.
Pain can be a result of fatigue. Encourage the patient to take rest periods. Promote a calm and peaceful environment conducive to resting and sleeping.
3. Promote a non-pharmacological approach.
Music therapy, breathing exercises, and relaxation techniques give the patient a feeling of serenity. The intention is to lessen tension- or stress-related pain.
Care Plan #4
Diagnostic statement:
Acute pain related to skin and tissue damage caused by chemical burns, as evidenced by patient reports of burning pain rated 6/10, restlessness when lying down, and antalgic positioning to avoid pressure on the back.
Expected outcomes:
- Patient will report pain less than 3/10 pain scale within 4 hours of nursing interventions.
- Patient will verbalize relief of pain within 4 hours of nursing interventions.
- Patient will appear well-rested at the end of the shift.
Assessment:
1. Assess the extent of the affected area.
A minor burn could be painful and can heal within a few days. However, a more severe burn may take weeks or even months to recover. The skin damage brought on by a burn may result in an infection.
2. Ask about the patient’s expectations for pain relief.
Patients may perceive their pain management as more effective and more likely to participate in therapy if their expectations are discussed.
3. Note the presence of blisters.
Burns can occasionally have blisters. It can create skin damage that may cause severe pain and may put the patient at risk for infection.
Interventions:
1. Advise the patient to stay away from chemical stimuli.
Based on the extent of the injury, chemical burns are similar to other burns. Experiencing chemical burns affect the skin, eyes, mouth, and internal organs.
2. Decontaminate.
Decontamination uses water irrigation on the affected site to remove the chemicals causing the burn.
3. Relieve the pain.
Assess the efficacy of analgesics and watch for any adverse effects. Different patients may metabolize analgesics differently.
4. Teach the patient when to seek medical attention.
Initiate basic first aid when the patient encounters a harmful substance. If unsure whether the substance is dangerous, contact the Poison Control department. If there is shortness of breath, chest discomfort, dizziness, or other symptoms all over the body, seek medical attention immediately.
References
- Doenges, M. E., Moorhouse, M. F., Murr, A. C., & Geissler-Murr, A. (2005). Nursing diagnosis manual: Planning, individualizing, and documenting client care. F A Davis Company.
- Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.
- Herdman, T. H., & Kamitsuru, S. (2018). NANDA international, Inc. Nursing diagnoses: Definitions & classification 2018-2020. Thieme Medical Publishers.
- HSS. (2020, August 18). Managing pain after orthopedic surgery. https://www.hss.edu/playbook/managing-pain-after-orthopedic-surgery/
- Johns Hopkins Medicine. (2021, August 8). Acute bronchitis. Johns Hopkins Medicine, based in Baltimore, Maryland. https://www.hopkinsmedicine.org/health/conditions-and-diseases/acute-bronchitis
- MedlinePlus. (n.d.). Pain. MedlinePlus – Health Information from the National Library of Medicine. Retrieved February 2023, from https://medlineplus.gov/pain.html
- Occupational Safety and Health Administration. (n.d.). Biological agents – Overview | Occupational safety and health administration. https://www.osha.gov/biological-agents
- Physiology, pain – StatPearls – NCBI bookshelf. (2021, July 26). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK539789/
- PubMed Central (PMC). (n.d.). A systematic review of non-pharmacological interventions used for pain relief after orthopedic surgical procedures. Retrieved February 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480131/
- SpringerLink. (n.d.). World Health Organization analgesic ladder. Retrieved February 2023, from https://link.springer.com/chapter/10.1007/978-3-030-87266-3_67
- Union Health. (n.d.). Pain management after orthopedic surgery terre haute, Indiana (IN), union health. Retrieved February 2023, from https://www.myunionhealth.org/blogs/pain-management-after-orthopedic-surgery
- WebMD. (2007, January 1). Chemical burns. Retrieved February 2023, from https://www.webmd.com/first-aid/chemical-burns#091e9c5e80010a27-3-10
Shelly Caruso is a bachelor-prepared registered nurse in her fifth year of practice. She began her career as a nursing assistant and has worked in acute care for nearly eight years. In addition to her hospital and trauma center experience, Shelly has also worked in post-acute, long-term, and outpatient settings.
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
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