Nurseslabs » acute pain

Acute Pain — Inflammatory Bowel Disease Nursing Care Plans

Nurseslabs — Mon, 30 Apr 2012 13:53:32 +0000

NURSING DIAGNOSIS: Pain, acute

May be related to

Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation, fissures, fistulas

Possibly evidenced by

Reports of colicky/cramping abdominal pain/referred pain
Guarding/distraction behaviors, restlessness
Facial mask of pain; self-focusing

Desired Outcomes

Pain Level (NOC)

Report pain is relieved/controlled.
Appear relaxed and able to sleep/rest appropriately.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Encourage patient to report pain.	May try to tolerate pain rather than request analgesics.
Assess reports of abdominal cramping or pain, noting location, duration, intensity (0–10 scale). Investigate and report changes in pain characteristics	Colicky intermittent pain occurs with Crohn’s disease
Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues.	Body language/nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent/severity of the problem.
Review factors that aggravate or alleviate pain.	May pinpoint precipitating or aggravating factors (such as stressful events, food intolerance) or identify developing complications.
Encourage patient to assume position of comfort, e.g., knees flexed.	Reduces abdominal tension and promotes sense of control.
Provide comfort measures (e.g., back rub, reposition) and diversional activities.	Promotes relaxation, refocuses attention, and may enhance coping abilities.
Cleanse rectal area with mild soap and water/wipes after each stool and provide skin care, e.g., A&D ointment, Sween ointment, karaya gel, Desitin, petroleum jelly.	Protects skin from bowel acids, preventing excoriation.
Provide sitz bath as appropriate.	Enhances cleanliness and comfort in the presence of perianal irritation/fissures.
Observe for ischiorectal and perianal fistulas.	Fistulas may develop from erosion and weakening of intestinal bowel wall.
Observe/record abdominal distension, increased temperature, decreased BP.	May indicate developing intestinal obstruction from inflammation, edema, and scarring.
Implement prescribed dietary modifications, e.g., commence with liquids and increase to solid foods as tolerated.	Complete bowel rest can reduce pain, cramping.

Acute Pain — Inflammatory Bowel Disease Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Cholecystitis Nursing Care Plans

Nurseslabs — Sat, 28 Apr 2012 16:50:57 +0000

NURSING DIAGNOSIS: Pain, acute

May be related to

Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis

Possibly evidenced by

Reports of pain, biliary colic (waves of pain)
Facial mask of pain; guarding behavior
Autonomic responses (changes in BP, pulse)
Self-focusing; narrowed focus

Desired Outcomes

Report pain is relieved/controlled.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions	Rationale
Observe and document location, severity (0–10 scale), and character of pain (e.g., steady, intermittent, colicky).	Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions.
Note response to medication, and report to physician if pain is not being relieved.	Severe pain not relieved by routine measures may indicate developing complications/need for further intervention.
Promote bedrest, allowing patient to assume position of comfort.	Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, patient will naturally assume least painful position.
Use soft/cotton linens; calamine lotion, oil bath; cool/moist compresses as indicated.	Reduces irritation/dryness of the skin and itching sensation.
Control environmental temperature.	Cool surroundings aid in minimizing dermal discomfort.
Encourage use of relaxation techniques, e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities.	Promotes rest, redirects attention, may enhance coping.
Make time to listen to and maintain frequent contact with patient.	Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
Maintain NPO status, insert/maintain NG suction as indicated.	Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.
Administer medications as indicated:Anticholinergics, e.g., atropine, propantheline (Pro-Banthı-ne); Sedatives, e.g., phenobarbital; Narcotics, e.g., meperidine hydrochloride (Demerol), morphine sulfate; Monoctanoin (Moctanin); Smooth muscle relaxants, e.g., papaverine (Pavabid), nitroglycerin, amyl nitrite; Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall); Antibiotics.	Relieves reflex spasm/smooth muscle contraction and assists with pain management.Promotes rest and relaxes smooth muscle, relieving pain. Given to reduce severe pain. Morphine is used with caution because it may increase spasms of the sphincter of Oddi, although nitroglycerin may be given to reduce morphine-induced spasms if they occur. This medication may be used after a cholecystectomy for retained stones or for newly formed large stones in the bile duct. It is a lengthy treatment (1–3 wk) and is administered via a nasal-biliary tube. A cholangiogram is done periodically to monitor stone dissolution. Relieves ductal spasm. These natural bile acids decrease cholesterol synthesis, dissolving gallstones. Success of this treatment depends on the number and size of gallstones (preferably three or fewer stones smaller than 20 min in diameter) floating in a functioning gallbladder. To treat infectious process, reducing inflammation.

Acute Pain — Cholecystitis Nursing Care Plans Original source at: Nurseslabs

4 Appendectomy Nursing Care Plans

Nurseslabs — Sat, 21 Apr 2012 09:18:36 +0000

Appendectomy is the surgical removal of the appendix. Here are 4 nursing care plans for appendectomy.

An inflamed appendix may be removed using a laparoscopic approach with laser. However, the presence of multiple adhesions, retroperitoneal positioning of the appendix, or the likelihood of rupture necessitates an open (traditional) procedure.

Studies indicate that laparoscopic appendectomy results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, lower wound infection rate, and a faster return to normal activities than open appendectomy.

Diagnostic Studies for Appendectomy

WBC: Leukocytosis above 12,000/mm³, neutrophil count often elevated to greater than 75%.
Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith), localized ileus.
Ultrasound or CT scan: May be done for differentiation of appendicitis from other causes of abdominal pain (e.g., perforating ulcer, cholecystitis, reproductive organ infections) or to localize drainable abscesses.

Nursing Priorities for Appendectomy

Prevent complications.
Promote comfort.
Provide information about surgical procedure/prognosis, treatment needs, and potential complications.

Discharge Goals

Complications prevented/minimized.
Pain alleviated/controlled.
Surgical procedure/prognosis, therapeutic regimen, and possible complications understood.
Plan in place to meet needs after discharge.

4 Appendectomy Nursing Care Plans

4 Appendectomy Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Fracture Nursing Care Plans

Nurseslabs — Thu, 05 Apr 2012 05:34:22 +0000

Nursing Diagnosis: Acute Pain

May be related to

Muscle spasms
Movement of bone fragments, edema, and injury to the soft tissue
Traction/immobility device
Stress, anxiety

Possibly evidenced by

Reports of pain
Distraction; self-focusing/narrowed focus; facial mask of pain
Guarding, protective behavior; alteration in muscle tone; autonomic responses

Desired Outcomes

Verbalize relief of pain.
Display relaxed manner; able to participate in activities, sleep/rest appropriately.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions	Rationale
Maintain immobilization of affected part by means of bed rest, cast, splint, traction.	Relieves pain and prevents bone displacement/extension of tissue injury.
Elevate and support injured extremity.	Promotes venous return, decreases edema, and may reduce pain.
Avoid use of plastic sheets/pillows under limbs in cast.	Can increase discomfort by enhancing heat production in the drying cast.
Elevate bed covers; keep linens off toes.	Maintains body warmth without discomfort due to pressure of bedclothes on affected parts.
Evaluate/document reports of pain/discomfort, noting location and characteristics, including intensity (0–10 scale), relieving and aggravating factors. Note nonverbal pain cues (changes in vital signs and emotions/behavior). Listen to reports of family member/SO regarding patient’s pain.	Influences choice of/monitors effectiveness of interventions. Many factors, including level of anxiety, may affect perception of/reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain.
Encourage patient to discuss problems related to injury.	Helps alleviate anxiety. Patient may feel need to relive the accident experience.
Explain procedures before beginning them.	Allows patient to prepare mentally for activity and to participate in controlling level of discomfort.
Medicate before care activities. Let patient know it is important to request medication before pain becomes severe.	Promotes muscle relaxation and enhances participation.
Perform and supervise active/passive ROM exercises.	Maintains strength/mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues.
Provide alternative comfort measures, e.g., massage, back rub, position changes.	Improves general circulation; reduces areas of local pressure and muscle fatigue.
Provide emotional support and encourage use of stress management techniques, e.g., progressive relaxation, deep-breathing exercises, visualization/guided imagery; provide Therapeutic Touch.	Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period.
Identify diversional activities appropriate for patient age, physical abilities, and personal preferences.	Prevents boredom, reduces muscle tension, and can increase muscle strength; may enhance coping abilities.
Investigate any reports of unusual/sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.	May signal developing complications; e.g., infection, tissue ischemia, compartmental syndrome.
Apply cold/ice pack first 24–72 hr and as necessary.	Reduces edema/hematoma formation, decreases pain sensation. Note: Length of application depends on degree of patient comfort and as long as the skin is carefully protected.
Administer medications as indicated: narcotic and nonnarcotic analgesics, e.g., morphine, meperidine (Demerol), hydrocodone (Vicodin); injectable and oral nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., ketorolac (Toradol), ibuprofen (Motrin); and/or muscle relaxants, e.g., cyclobenzaprine (Flexeril), carisoprodol (Soma), diazepam (Valium). Administer analgesics around the clock for 3–5 days.	Given to reduce pain and/or muscle spasms. Studies of ketorolac (Toradol) have proved it to be effective in alleviating bone pain, with longer action and fewer side effects than narcotic agents.
Maintain/monitor IV patient-controlled analgesia (PCA) using peripheral, epidural, or intrathecal routes of administration. Maintain safe and effective infusions/equipment.	Routinely administered or PCA maintains adequate blood level of analgesia, preventing fluctuations in pain relief with associated muscle tension/spasms.

Acute Pain — Fracture Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Burns Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 11:30:21 +0000

Nursing Diagnosis: Pain, acute

May be related to

Destruction of skin/tissues; edema formation
Manipulation of injured tissues, e.g., wound debridement

Possibly evidenced by

Reports of pain
Narrowed focus, facial mask of pain
Alteration in muscle tone; autonomic responses
Distraction/guarding behaviors; anxiety/fear, restlessness

Desired Outcomes

Report pain reduced/controlled.
Display relaxed facial expressions/body posture.
Participate in activities and sleep/rest appropriately.

Nursing Interventions	Rationale
Cover wounds as soon as possible unless open-air exposure burn care method required.	Temperature changes and air movement can cause great pain to exposed nerve endings.
Elevate burned extremities periodically.	Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures.
Provide bed cradle as indicated.	Elevation of linens off wounds may help reduce pain.
Wrap digits/extremities in position of function (avoiding flexed position of affected joints) using splints and footboards as necessary.	Position of function reduces deformities/contractures and promotes comfort. Although flexed position of injured joints may feel more comfortable, it can lead to flexion contractures.
Change position frequently and assist with active and passive ROM as indicated.	Movement and exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury.
Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings.	Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
Assess reports of pain, noting location/character and intensity (0–10 scale).	Pain is nearly always present to some degree because of varying severity of tissue involvement/destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (e.g., limb ischemia) or herald improvement/return of nerve function/sensation.
Provide medication and/or place in hydrotherapy (as appropriate) before performing dressing changes and debridement.	Reduces severe physical and emotional distress associated with dressing changes and debridement.
Encourage expression of feelings about pain.	Verbalization allows outlet for emotions and may enhance coping mechanisms.
Involve patient in determining schedule for activities, treatments, drug administration.	Enhances patient’s sense of control and strengthens coping mechanisms.
Explain procedures/provide frequent information as appropriate, especially during wound debridement.	Empathic support can help alleviate pain/promote relaxation. Knowing what to expect provides opportunity for patient to prepare self and enhances sense of control.
Provide basic comfort measures, e.g., massage of uninjured areas, frequent position changes.	Promotes relaxation; reduces muscle tension and general fatigue.
Encourage use of stress management techniques, e.g., progressive relaxation, deep breathing, guided imagery, and visualization.	Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency.
Provide diversional activities appropriate for age/condition.	Helps lessen concentration on pain experience and refocus attention.
Promote uninterrupted sleep periods.	Sleep deprivation can increase perception of pain/reduce coping abilities.
Administer analgesics (narcotic and nonnarcotic) as indicated, e.g., morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone(OxyContin, Percocet).	The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.

Acute Pain — Burns Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Angina (Coronary Artery Disease) Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 04:37:43 +0000

Nursing Diagnosis: Acute Pain

May be related to

Decreased myocardial blood flow
Increased cardiac workload/oxygen consumption

Possibly evidenced by

Reports of pain varying in frequency, duration, and intensity (especially as condition worsens)
Narrowed focus
Distraction behaviors (moaning, crying, pacing, restlessness)
Autonomic responses, e.g., diaphoresis, blood pressure and pulse rate changes, pupillary dilation, increased/decreased respiratory rate

Desired Outcomes

Pain Level (NOC)
Report anginal episodes decreased in frequency, duration, and severity.
Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness

Nursing Interventions	Rationale
Instruct patient to notify nurse immediately when chest pain occurs.	Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and release of thromboxane A₂. This potent vasoconstrictor causes coronary artery spasm, which can precipitate, complicate, and/or prolong an anginal attack. Unbearable pain may cause vasovagal response, decreasing BP and heart rate.
Assess and document patient response/effects of medication.	Provides information about disease progression. Aids in evaluating effectiveness of interventions, and may indicate need for change in therapeutic regimen.
Identify precipitating event, if any; frequency, duration, intensity, and location of pain.	Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina. (Stable angina usually lasts 3–15 min and is often relieved by rest and sublingual nitroglycerin (NTG); unstable angina is more intense, occurs unpredictably, may last longer, and is not usually relieved by NTG/rest.)
Observe for associated symptoms, e.g., dyspnea, nausea/vomiting, dizziness, palpitations, desire to micturate.	Decreased cardiac output (which may occur during ischemic myocardial episode) stimulates sympathetic/parasympathetic nervous system, causing a variety of vague sensations that patient may not identify as related to anginal episode.
Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side).	Cardiac pain may radiate, e.g., pain is often referred to more superficial sites served by the same spinal cord nerve level.
Place patient at complete rest during anginal episodes.	Reduces myocardial oxygen demand to minimize risk of tissue injury/necrosis.
Elevate head of bed if patient is short of breath.	Facilitates gas exchange to decrease hypoxia and resultant shortness of breath.
Monitor heart rate/rhythm.	Patients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress.
Monitor vital signs every 5 min during initial anginal attack.	Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls.
Stay with patient who is experiencing pain or appears anxious.	Anxiety releases catecholamines, which increase myocardial workload and can escalate/prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness.
Maintain quiet, comfortable environment; restrict visitors as necessary.	Mental/emotional stress increases myocardial workload.
Provide light meals. Have patient rest for 1 hr after meals.	Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack.
Provide supplemental oxygen as indicated.	Increases oxygen available for myocardial uptake/reversal of ischemia.
Administer antianginal medication(s) promptly as indicated:Nitroglycerin: sublingual (Nitrostat), buccal, or oral tablets, metered-dose spray; or sublingual isosorbide dinitrate (Isordil) Sustained-release tablets, caplets (Nitrong, Nitrocap T.D.), chewable tablets (Isordil, Sorbitrate), patches, transmucosal ointment (Nitro-Dur, Transderm-Nitro) Beta-blockers, e.g., acebutolol (Sectral), atenolol (Tenormin), nadolol (Corgard), metroprolol (Lopressor), propranolol (Inderal) Calcium channel blockers, e.g., bepridil (Vascor), amlodipine (Norvasc), nifedipine (Procardia), felodipine (Plendil), isradipine (DynaCirc), diltiazem (Cardizem) Analgesics, e.g., acetaminophen (Tylenol) Morphine sulphate (MS)	Nitroglycerin has been the standard for treating and preventing anginal pain for more than 100 yr. Today it is available in many forms and is still the cornerstone of antianginal therapy. Rapid vasodilator effect lasts 10–30 min and can be used prophylactically to prevent, as well as abort, anginal attacks. Long-acting preparations are used to prevent recurrences by reducing coronary vasospasms and reducing cardiac workload. May cause headache, dizziness, light-headedness—symptoms that usually pass quickly. If headache is intolerable, alteration of dose or discontinuation of drug may be necessary. Note: Isordil may be more effective for patients with variant form of angina. Reduces frequency and severity of attack by producing prolonged/continuous vasodilation. Reduces angina by reducing the heart’s workload. (Refer to ND: Cardiac Output, risk for decreased, following, p. 000.) Note: Often these drugs alone are sufficient to relieve angina in less severe conditions. Produces relaxation of coronary vascular smooth muscle; dilates coronary arteries; decreases peripheral vascular resistance. Usually sufficient analgesia for relief of headache caused by dilation of cerebral vessels in response to nitrates. Potent narcotic analgesic may be used in acute onset because of its several beneficial effects, e.g., causes peripheral vasodilation and reduces myocardial workload; has a sedative effect to produce relaxation; interrupts the flow of vasoconstricting catecholamines and thereby effectively relieves severe chest pain. MS is given IV for rapid action and because decreased cardiac output compromises peripheral tissue absorption.
Monitor serial ECG changes.	Ischemia during anginal attack may cause transient ST segment depression or elevation and T wave inversion. Serial tracings verify ischemic changes, which may disappear when patient is pain-free. They also provide a baseline against which to compare later pattern changes.

Acute Pain — Angina (Coronary Artery Disease) Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Appendectomy Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 03:08:12 +0000

Nursing Diagnosis: Acute Pain

May be related to

Distension of intestinal tissues by inflammation
Presence of surgical incision

Possibly evidenced by

Reports of pain
Facial grimacing, muscle guarding; distraction behaviors
Autonomic responses

Desired Outcomes

Report pain is relieved/controlled.
Appear relaxed, able to sleep/rest appropriately.

Nursing Interventions	Rationale
Assess pain, noting location, characteristics, severity (0–10 scale). Investigate and report changes in pain as appropriate.	Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis, requiring prompt medical evaluation and intervention.
Provide accurate, honest information to patient/SO.	Being informed about progress of situation provides emotional support, helping to decrease anxiety
Keep at rest in semi-Fowler’s position.	Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.
Encourage early ambulation.	Promotes normalization of organ function, e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort.
Provide diversional activities	Refocuses attention, promotes relaxation, and may enhance coping abilities.
Keep NPO/maintain NG suction initially.	Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.
Administer analgesics as indicated.	Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet.
Place ice bag on abdomen periodically during initial 24–48 hr, as appropriate.	Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion.

Acute Pain — Appendectomy Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Benign Prostatic Hyperplasia Nursing Care Plans

Nurseslabs — Wed, 28 Mar 2012 11:10:01 +0000

Nursing Diagnosis: Acute Pain

May be related to

Mucosal irritation: bladder distension, renal colic; urinary infection; radiation therapy
Possibly evidenced by
Reports of pain (bladder/rectal spasm)
Narrowed focus; altered muscle tone, grimacing; distraction behaviors, restlessness
Autonomic responses

Desired Outcomes

Report pain relieved/controlled.
Appear relaxed.
Be able to sleep/rest appropriately.

Nursing Interventions	Rationale
Assess pain, noting location, intensity (scale of 0–10), duration.	Provides information to aid in determining choice/effectiveness of interventions.
Tape drainage tube to thigh and catheter to the abdomen (if traction not required).	Prevents pull on the bladder and erosion of the penile-scrotal junction.
Recommend bedrest as indicated.	Bedrest may be needed initially during acute retention phase; however, early ambulation can help restore normal voiding patterns and relieve colicky pain.
Provide comfort measures, e.g., back rub, helping patient assume position of comfort. Suggest use of relaxation/deep-breathing exercises, diversional activities.	Promotes relaxation, refocuses attention, and may enhance coping abilities.
Encourage use of sitz baths, warm soaks to perineum.	Promotes muscle relaxation.
Insert catheter and attach to straight drainage as indicated.	Draining bladder reduces bladder tension and irritability.
Instruct in prostatic massage.	Aids in evacuation of ducts of gland to relieve congestion/inflammation. Contraindicated if infection is present.
Administer medications as indicated: Narcotics, e.g., meperidine (Demerol); Antibacterials, e.g., methenamine hippurate (Hiprex); Antispasmodics and bladder sedatives, e.g., flavoxate (Urispas), oxybutynin (Ditropan).	Given to relieve severe pain, provide physical and mental relaxation. Reduces bacteria present in urinary tract and those introduced by drainage system. Relieves bladder irritability.

Acute Pain — Benign Prostatic Hyperplasia Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Pneumonia Nursing Care Plans

Nurseslabs — Tue, 27 Mar 2012 13:36:06 +0000

Nursing Diagnosis: Pain, acute

May be related to

Inflammation of lung parenchyma
Cellular reactions to circulating toxins
Persistent coughing

Possibly evidenced by

Reports of pleuritic chest pain, headache, muscle/joint pain
Guarding of affected area
Distraction behaviors, restlessness

Desired Outcomes

Verbalize relief/control of pain.
Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.

Nursing Interventions	Rationale
Determine pain characteristics, e.g., sharp, constant, stabbing. Investigate changes in character/location/intensity of pain.	Chest pain, usually present to some degree with pneumonia, may also herald the onset of complications of pneumonia, such as pericarditis and endocarditis.
Monitor vital signs.	Changes in heart rate or BP may indicate that patient is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.
Provide comfort measures, e.g., back rubs, change of position, quiet music or conversation. Encourage use of relaxation/breathing exercises.	Nonanalgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Patient involvement in pain control measures promotes independence and enhances sense of well-being.
Offer frequent oral hygiene.	Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort.
Instruct and assist patient in chest splinting techniques during coughing episodes.	Aids in control of chest discomfort while enhancing effectiveness of cough effort.
Administer analgesics and antitussives as indicated.	These medications may be used to suppress nonproductive/paroxysmal cough or reduce excess mucus, thereby enhancing general comfort/rest.

Acute Pain — Pneumonia Nursing Care Plans Original source at: Nurseslabs

Acute Pain — Cancer Nursing Care Plans

Nurseslabs — Mon, 26 Mar 2012 13:05:48 +0000

Nursing Diagnosis: Pain [acute]/chronic

May be related to

Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)
Side effects of various cancer therapy agents

Possibly evidenced by

Reports of pain
Self-focusing/narrowed focus
Alteration in muscle tone; facial mask of pain
Distraction/guarding behaviors
Autonomic responses, restlessness (acute pain)

Desired Outcomes

Report maximal pain relief/control with minimal interference with ADLs.
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions	Rationale
Determine pain history, e.g., location of pain, frequency, duration, and intensity using numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report.	Information provides baseline data to evaluate need for/effectiveness of interventions. Pain of more than 6 mo duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.
Determine timing/precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, IV, or patch medications.	Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.
Evaluate/be aware of painful effects of particular therapies, i.e., surgery, radiation, chemotherapy, biotherapy. Provide information to patient/SO about what to expect.	A wide range of discomforts are common (e.g., incisional pain, burning skin, low back pain, headaches), depending on the procedure/agent being used. Pain is also associated with invasive procedures to diagnose/treat cancer.
Provide nonpharmacological comfort measures (e.g., massage, repositioning, backrub) and diversional activities (e.g., music, television)	Promotes relaxation and helps refocus attention.
Encourage use of stress management skills/ complimentary therapies (e.g., relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch).	Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases patient’s focus on self, which in turn increases the level of pain.
Provide cutaneous stimulation, e.g., heat/cold, massage.	May decrease inflammation, muscle spasms, reducing associated pain. Note: Heat may increase bleeding/edema following acute injury, whereas cold may further reduce perfusion to ischemic tissues.
Be aware of barriers to cancer pain management related to patient, as well as the healthcare system.	Patients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; beliefs that pain has meaning, such as “God wills it,” they should overcome it, or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances/patient addiction, inadequate reimbursement/ cost of treatment modalities.
Evaluate pain relief/control at regular intervals. Adjust medication regimen as necessary.	Goal is maximum pain control with minimum interference with ADLs.
Inform patient/SO of the expected therapeutic effects and discuss management of side effects	This information helps establish realistic expectations, confidence in own ability to handle what happens.
Discuss use of additional alternative/complementary therapies, e.g., acupuncture/acupressure.	May provide reduction/relief of pain without drug-related side effects.
Administer analgesics as indicated, e.g.: Opioids, e.g., codeine, morphine (MS Contin), oxycodone (oxycontin) hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic); oxymorphone (Numorphan);Acetaminophen (Tylenol); and nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (Motrin, Advil); peroxicam (Feldene); indomethacin (Indocin); Corticosteroids, e.g., dexamethasone (Decadron);	A wide range of analgesics and associated agents may be employed around the clock to manage pain. Note: Addiction to or dependency on drug is not a concern. Effective for localized and generalized moderate to severe pain, with long-acting/controlled-release forms available. Routes of administration include oral, transmucosal, transdermal, nasal, rectal, and infusions (subcutaneous, IV, intraventricular), which may be delivered via PCA. IM use is not recommended because absorption is not reliable, in addition to being painful and inconvenient. Note: Research is in process for oral transmucosal agent (fentenyl citrate [oralet]) to control breakthrough pain in patients using fentanyl patch. Adjuvant drugs are useful for mild to moderate pain and can be combined with opioids and other modalities.May be effective in controlling pain associated with inflammatory process (e.g., metastatic bone pain, acute spinal cord compression and neuropathic pain).

Acute Pain — Cancer Nursing Care Plans Original source at: Nurseslabs