00132 Acute Pain

Domain 12: comfort
Class 1: physical comfort
Diagnostic Code: 00132
Nanda label: acute pain
Diagnostic focus: pain
Approved 1996 • Revised 2013 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « acute pain » is defined as: unpleasant sensitive and emotional experience caused by a real or potential tissue lesion, or described in such terms (International Association for the Study of Pain ); Sudden or slow start of any slight to severe intensity with an anticipated or predictable ending, and with a duration of less than 3 months.

Definite characteristics

  • Alteration of physiological parameters
  • Change in appetite
  • Diaphoresis
  • Distraction behavior
  • Evidence of pain when using a standardized verification list of pain in those that cannot be communicated verbally
  • expressive behavior
  • Facial expression of pain
  • Desperateness
  • Focus narrowing
  • Pain avoidance posture
  • Protection behavior
  • Reports of nearby people about changes in activity
  • Reports of nearby people about pain behavior
  • Pupillary dilation
  • Informs intensity using standardized scales of pain assessment
  • Informs pain characteristics using a standardized pain assessment instrument
  • Attention centered on self

Related factors

  • Biological harmful agents
  • Inappropriate use of chemical agent
  • harmful agents

Suggestions of use

  • Acute pain can be diagnosed based solely on the patient’s report, since sometimes it is the only sign of acute pain.
  • None of the other defining characteristics would suffice on its own to diagnose acute pain. Related factors indicate that a patient may suffer from physical and psychological acute pain.
  • Adjectives should be added to this diagnosis to indicate the gravity, location and nature of pain. The following two are examples of adequate diagnoses: severe and sharp pain in the chest related to fracture of ribs and slight head pain related to sinus congestion.
  • It is important to distinguish between acute pain and chronic pain, since nursing activities have a different approach to each one. Acute pain (such as postoperative pain due to surgical incision) is usually a collaborative problem that is handled above all with the administration of narcotic analgesics. There are some independent nursing interventions for acute pain, such as teaching the patient to immobilize the incision when moving, even when these interventions do not offer for themselves an adequate pain relief. The nursing professional has a more active role by teaching patients the automanejo of chronic pain. When the pain is acute or causes a stressful factor that cannot be treated with a nursing intervention (surgical incision), it could be considered an etiology and not a problem, for example, liberation of ineffective space in the respiratory tract due to a slight cough caused by acute pain after a thorax incision.
  • Pain can also be the etiology (that is, a related factor) of other nursing diagnoses, such as impotence related to the inability to deal with acute pain and deficit of self -care: dress/bathroom, related to joint pain to joint pain to the perform movements.

Suggested alternative diagnostics

  • Comfort, deterioration of
  • Chronic pain

NOC Results

  • Pain control: personal actions to control pain
  • Comfort deterioration level: gravity of the mental or physical discomfort observed or reported
  • Pain level: gravity of pain observed or referred
  • Patient satisfaction: pain management: degree of positive perception of nursing care to relieve pain

Evaluation objectives and criteria

  • Demonstrates pain control, as manifested by the following indicators (specify from 1 to 5: never, rarely, sometimes, often or usually):
    • Recognize the appearance of pain
    • Apply preventive measures
    • Manifest pain control
  • Demonstrates pain level, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Facial expressions of pain
    • Meat or muscle tension
    • Duration of pain episodes
    • Complaints and crying
    • concern
  • Other examples

    The patient will be able to:

    • Demonstrate individualized relaxation techniques to achieve comfort
    • Maintain a pain level in (specify) or lower (on a scale of 0 to 10)
    • Manifest a state of physical and psychological well -being
    • Recognize causal factors and apply measures to modify them
    • Report pain to the health care provider
    • Properly use analgesic and non -analgesic measures
    • Do not experience problems in respiratory rhythm, heart rate or blood pressure
    • Keep a good appetite
    • Report that sleeps well
    • Manifest the ability to maintain their role performance and interpersonal relationships

    NIC Interventions

    • Administration of analgesics: use of pharmacological agents to reduce or eliminate pain
    • Medication administration: preparation, administration and evaluation of the effectiveness of prescribed and non -prescribed drugs
    • Patient controlled analgesia support (ACP): Facilitation of patient control over the administration and regulation of analgesics
    • Sedation management: sedative administration, patient response control and offering the necessary physiological assistance during a diagnostic or therapeutic procedure
    • Medicines management: facilitation of safe and effective use of prescribed medications without recipe
    • Pain management: relief or decrease in pain until an acceptable level of well -being for the patient
    • Surveillance: Collection, interpretation and synthesis of patient data, to make clinical decisions

    Nursing Activities

    Valuations

    • Apply the self -report as the first option to obtain evaluation information
    • Ask the patient to qualify their pain or discomfort on a scale from 0 to 10 (0 = absence of pain or discomfort, 10 = the greatest pain)
    • Use a pain flow diagram to monitor pain relief due to analgesics and possible side effects
    • Assess the impact of religion, culture, beliefs and circumstances on the pain and responses of the patient
    • When assessing the patient’s pain, use a vocabulary appropriate to the age and level of development of the patient
    • (NIC) Pain management.
      • Make a complete pain assessment that includes location, characteristics, appearance and duration, frequency, quality, intensity or severity of pain, as well as precipitating factors
      • Observe nonverbal signs of discomfort, especially in people who are not able to communicate effectively

    Patient and family education

    • When registering, including in the instructions the specific medications that must be taken, the frequency of administration, the possible side effects, the possible interactions with other medications, the specific precautions that must be taken when taking the medication (for example , limitations of physical activity, diet restrictions) and the name of the person to whom it should be notified if the pain does not decrease
    • Indicate the patient to inform the nursing staff if the pain does not decrease
    • Inform the patient about the procedures that can increase pain and suggest ways to face it
    • Correct erroneous ideas about opioid analgesics (such as addiction and overdose risks)
    • (NIC) Pain management: Offer information about pain, such as causes, its duration and discomfort derived from procedures
    • (NIC) Pain management.
      • Teach the use of non -pharmacological techniques (for example, bioretro -food, transcutaneous electric stimulation or tens massages) before, after and, if possible, during painful activities; before the pain occurs or increases, and together with other measures to relieve pain

    Collaboration activities

    • Manage immediate postoperative pain with the established opioid (for example, every four hours for 36 hours) or patient controlled analgesia, PCA
    • (NIC) Pain management.
      • Use pain control measures before pain worse
      • Inform the doctor if the measures do not take effect or if the current complaint implies a significant change in the previous patient’s pain experience

    Others

    • Adjust the dose frequency as indicated after evaluating pain and side effects
    • Help the patient identify the comfort measures that previously worked, such as distraction, relaxation or application of cold or heat
    • To meet comfort needs and perform other activities that help relaxation, including the following measures:
      • Offer a change of position, a back massage and relaxation
      • Change the bedding, as required
      • Provide care without hurry and comprehensively
      • Involve the patient in decisions about care activities
    • Help the patient focus on activities rather than pain and discomfort when providing fun through television, radio, videos and visits
    • Take a positive attitude to optimize the patient’s response to analgesics (for example, “this will help to relieve pain”)
    • Explore feelings of fear of addiction; reassure the patient by saying: “If I didn’t feel this pain, still would I want to take this drug?”
    • (NIC) Pain management.
      • Involve the family in pain relief, if possible
      • Control the environmental factors that can influence the patient’s response to discomforts (such as room temperature, lighting, and noise)

    At home

    • above interventions can adapt to home care
    • Teach the patient and relatives to apply the technology needed to administer medications (for example, venoclysis pumps, transcutaneous electric stimulation units, or tens)

    Babies and Children

    • Be aware that children are as sensitive to pain as adults. Use topical anesthetics (for example, EMLA cream) before performing a venopunction; In the case of newborns, use Oral Sucrosa
    • To assess pain in young children, use the facial scale of pain or other image scale

    Older people

    • Keep in mind that older people have greater sensitivity to the analgesic effects of opioids, with a higher peak effect and a longer duration of pain relief
    • Be alert to the possible interactions of different drugs and drugs and diseases in the case of older people, since they usually present multiple conditions and take many medications
    • Recognize that pain is not a normal part of the aging process
    • Reduce the usual dose of opioids for older people, since they are more sensitive to this type of medicines
    • Avoid the use of meperidine (demerol) and dextropropoxyphen (Darvon) or other drugs that are mainly metabolized in the kidney
    • Avoid the use of drugs with a long half -life due to a greater probability of toxicity due to the accumulation of drugs
    • When talking about pain, make sure the patient can hear and see any written pain scale
    • By offering information about medicines, repeating information as many times as necessary; Leave information in writing to the patient
    • Value drug interactions, including medications without recipe