Acute Pain Nursing Care Plans and Nursing Diagnosis

Last updated on December 28th, 2023

Introduction

In this article, you will learn about NANDA nursing diagnoses for Acute Pain. You will also learn how to develop acute pain nursing care plans that include intervention and rationales.

There are four different NANDA nursing diagnoses for pain. They fall under Domain 12, Class I, which is Comfort and Physical Comfort, respectively.  

Those four NANDA nursing diagnoses for pain are,
1. Acute pain

2. Chronic pain

3. Chronic pain syndrome

4. Labor pain

Definition of NANDA pain nursing diagnoses

Acute pain

NANDA nursing diagnosis for acute pain is defined as a sudden onset of pain which is less than 3 months. An injury, surgery, illness, trauma, or invasive medical procedures can all cause acute pain.

Chronic pain

Click here to see chronic pain nursing diagnosis and care plans.

Chronic pain syndrome

NANDA nursing diagnosis for chronic pain syndrome is defined as pains that recurs or persists for more than three months and have a significant impact on the daily functioning or well-being of the individual. Therefore, a chronic pain syndrome encompasses other nursing diagnoses, such as disturbed sleep patterns, fatigue, impaired physical mobility, or social isolation.

 Labor pain

NANDA nursing diagnosis for labor Pain is defined as pain related to labor and childbirth.

List of Acute Pain Nursing Diagnosis

Acute pain related to medical and surgical conditions

1. Abdominal Distension: Acute pain related to retention of air, gastrointestinal secretions in the peritoneum, disease process as evidenced by verbal reports of pain, increased abdominal girth, facial grimace, guarding, shortness of breath, changes in vital signs.
2. Abdominal Pain: Acute pain related to abdominal trauma, pathological process as evidenced by verbal reports of pain, increased abdominal girth, nausea, vomiting, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
3. Abdominal Surgery: Acute pain related to surgical incision as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, changes in vital signs.
4. Abdominal Trauma: Acute pain related to abdominal trauma, traumatized tissue and internal structures as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
5. Acute Abdominal Pain: Acute pain related to pathological process as evidenced by verbal reports of pain, crying, moaning, diaphoresis, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
6. Acute pain management: Acute pain related to injury or surgical procedure
7. Amputation: Acute pain related to surgery, phantom limb sensation as evidenced by verbal reports of pain, facial grimace, guarding, changes in vital signs.
8. Angina: Acute pain related to myocardial ischemia as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
9. Appendicitis/Appendectomy: Acute pain related to inflammatory process, surgical incision as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs, abnormal CBC.
10. Bell’s Palsy: Acute pain related to inflammation of facial nerve
11. Burns: Acute pain related to burn injury, treatments as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs, presence of invasive catheters.
12. Cellulitis: Acute pain related to inflammatory change in tissue from bacterial invasion as evidenced by edema, increase local temperature, verbal reports of pain.
13. Chest Pain:  Acute pain related to myocardial injury, ischemia, blunt trauma to chest, as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
14. Cholecystectomy: Acute pain related to surgical procedure as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
15. Cholecystitis: Acute pain related to inflammation of the gall bladder as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
16. Cholelithiasis: Acute pain related to obstruction of bile flow, inflammation in gallbladder as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
17. Cleft Palate: Acute pain related to surgical correction, elbow restraints as evidenced by changes in vital signs, crying, moaning.
18. Colitis: Acute pain related to inflammation in colon as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
19. Compartment Syndrome: Acute pain related to pressure in compromised body part as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
20. Conjunctivitis: Acute pain related to inflammatory process as evidenced by verbal reports of pain, redness and discharge from affected eye.
21. Constipation: Acute pain related to constipation as evidenced by verbal reports of pain, inability to empty bowel, moaning, crying, facial grimace, guarding, nausea, vomiting, changes in vital signs, radiologic confirmation of fecal impaction.
22. Coronary Artery Bypass Grafting (CABG): Acute pain related to traumatic surgery as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
23. Craniectomy/Craniotomy: Acute pain related to recent brain surgery, increased intracranial pressure as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
24. Crohn’s Disease: Acute pain related to increased peristalsis as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, nausea, vomiting, diarrhea, changes in vital signs.
25. Dislocation of Joint: Acute pain related to dislocation of a joint as evidenced by verbal reports of pain, presence of deformity (specify location), moaning, crying, facial grimace, guarding, changes in vital signs.
26. Diverticulitis: Acute pain related to inflammation of bowel as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
27. DVT (Deep Vein Thrombosis): Acute pain related to vascular inflammation, edema as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, confusion, changes in vital signs.
28. Dyspepsia: Acute pain related to gastrointestinal disease, consumption of irritating foods as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
29. Dysuria: Acute pain related to infection/inflammation of the urinary tract as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, abdominal guarding, changes in vital signs.
30. Fracture: Acute pain related to muscle spasm, edema, trauma as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
31. Gastric ulcers: Acute pain related to irritated mucosa from acid secretion as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
32. Gastroenteritis: Acute pain related to increased peristalsis causing cramping as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, diarrhea, confusion, changes in vital signs.
33. Gastroesophageal Reflux (GERD): Acute pain related to irritation of esophagus from gastric acids as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
34. Glomerulonephritis: Acute pain related to edema of kidney as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
35. Headache: Acute pain related to lack of knowledge of pain control techniques or methods to prevent headaches
36. Hemophilia: Acute pain related to bleeding into body tissues as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, confusion, changes in vital signs.
37. Hemorrhoidectomy: Acute pain related to surgical procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
38. Hepatitis: Acute pain related to edema of liver, bile irritating skin as evidenced by verbal reports of pain, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
39. Hip fracture: Acute pain related to injury, surgical procedure, movement as evidenced by x-ray confirmation of hip fracture, verbal reports of pain, impaired walking, changes in vital signs.
40. IBD: Acute pain related to abdominal cramping and anal irritation as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
41. Ileus: Acute pain related to pressure, abdominal distention as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, guarding.
42. Inguinal Hernia Repair: Acute pain related to surgical procedure as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
43. Intermittent Claudication: Acute pain related to decreased circulation to extremities with activity as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
44. Interstitial Cystitis: Acute pain related to inflammatory process as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
45. JRA (Juvenile Rheumatoid Arthritis): Acute pain related to swollen or inflamed joints, restricted movement, physical therapy as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
46. Kawasaki Disease: Acute pain related to enlarged lymph nodes; erythematous skin rash that progresses to desquamation, peeling, denuding of skin
47. Kidney Stone: Acute pain related to obstruction from kidney calculi as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, distended bladder, guarding.
48. Lyme disease: Acute pain related to inflammation of joints, urticaria, rash as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
49. Mastectomy: Acute pain related to surgical procedure as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shortness of breath.
50. Mastitis: Acute pain related to infectious disease process, swelling of breast tissue
51. Meningitis/ Encephalitis: Acute pain related to biological injury
52. MI (Myocardial Infarction): Acute pain related to myocardial tissue damage from inadequate blood supply
53. Nephrectomy: Acute pain related to surgical incision as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shortness of breath.
54. Osteoarthritis: Acute pain related to movement as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
55. Osteomyelitis: Acute pain related to inflammation in affected extremity as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
56. Osteoporosis: Acute pain related to fracture, muscle spasms as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
57. Otitis media: Acute pain related to inflammation, infectious process as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
58. Pacemaker: Acute pain related to pacemaker insertion, transcutaneous pacing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in pulse and blood pressure.
59. Pancreatitis: Acute pain related to irritation and edema of the inflamed pancreas as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, nausea, vomiting.
60. Paralytic Ileus: Acute pain related to pressure, abdominal distention, presence of nasogastric tube as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning.
61. Pericardial Friction Rub: Acute pain related to inflammation, effusion breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shallow breathing, shortness of breath.
62. Peripheral neuropathy: Acute pain related to stimulation of affected nerve endings, inflammation of sensory nerves as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
63. Peritonitis: Acute pain related to inflammation and infection of gastrointestinal system as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, nausea, vomiting.
64. Pleural Effusion: Acute pain related to inflammation, fluid accumulation as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shallow breathing, shortness of breath.
65. Pneumothorax: Acute pain related to recent injury, coughing, deep breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, shallow breathing, shortness of breath.
66. Postoperative surgery: Acute pain related to inflammation or injury in surgical area as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
67. Pressure ulcers (bedsore): Acute pain related to tissue destruction, exposure of nerves as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning.
68. Pulmonary embolism (PE): Acute pain related to biological injury, lack of oxygen to cells as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, confusion, shortness breath.
69. Pyelonephritis: Acute pain related to inflammation and irritation of urinary tract as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning.
70. Radial Nerve Dysfunction: Acute pain related to trauma to hand or arm as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs.
71. Rectocele Repair: Acute pain related to surgical procedure as evidenced by facial grimacing, restlessness, changes in vital signs, moaning.
72. Rib Fracture: Acute pain related to movement, deep breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, shallow breathing, moaning.
73. Scoliosis: Acute pain related to musculoskeletal restrictions, surgery, reambulation with cast or spinal rod as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, refusal to mobilize.
74. Sickle Cell Anemia: Acute pain related to viscous blood, tissue hypoxia as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, shortness of breath, moaning.
75. Small Bowel Obstruction: Acute pain related to pressure from distended abdomen as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, increased abdominal girth, nausea, vomiting, abdominal guarding.
76. Spina bifida: Acute pain related to stimulation of affected nerve endings, inflammation of sensory nerves as evidenced by facial grimacing, restlessness, changes in vital signs, moaning.
77. Trigeminal Neuralgia: Acute pain related to irritation of trigeminal nerve as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.

Acute pain related to obstetric and genecology

1. Abruptio Placentae: Acute pain related to irritable uterus, hypertonic uterus as evidenced by verbal reports of pain, moaning, crying, facial grimace, abdominal guarding, shortness of breath, changes in vital signs.
2. Breasts engorgement: Acute pain related to distention of breast tissue as evidenced by verbal reports of pain, hard and tender breasts, moaning, crying, facial grimace.
3. C section: Acute pain related to surgical incision as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
4. D & C: Acute pain related to uterine contractions, surgical procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
5. Dysmenorrhea: Acute pain related to cramping from hormonal effects as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
6. Ectopic pregnancy: Acute pain related to stretching or rupture of implantation site as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, confusion, changes in vital signs, sonographic confirmation of rupture.
7. Endometriosis: Acute pain related to onset of menses with distention of endometrial tissue
8. Endometritis: Acute pain related to infectious process in reproductive tract
9. Episiotomy: Acute pain related to tissue trauma as evidenced by verbal reports of pain, moaning, facial grimace, inability to sit properly, changes in vital signs.
10. Induced Abortion: Acute pain related to surgical intervention as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
11. PID (Pelvic Inflammatory Disease): Acute pain related to biological injury; inflammation, edema, congestion of pelvic tissues as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
12. PMS (Premenstrual Syndrome): Acute pain related to hormonal stimulation of gastrointestinal structures as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, nausea, vomiting, diarrhea, changes in vital signs.
13. Postpartum Hemorrhage: Acute pain related to nursing and medical interventions to control bleeding as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, confusion, changes in vital signs.
14. Postpartum: Acute pain related to episiotomy, lacerations, bruising, breast engorgement, headache, sore nipples, epidural or intravenous site, hemorrhoids as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
15. Sore Nipples: Acute pain related to cracked nipples as evidenced by verbal reports of pain, redness and cracked nipple, moaning, crying, facial grimace.
16. Spontaneous Abortion: Acute pain related to uterine contractions, surgical intervention as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.

Acute pain related to invasive procedures

1. Bone Marrow Biopsy: Acute pain related to bone marrow aspiration, invasive procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
2. Chest Tubes: Acute pain related to presence of chest tubes, injury as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
3. Intubation, Endotracheal or Nasogastric Tube: Acute pain related to presence of tube as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
4. Lumbar Puncture: Acute pain related to possible loss of cerebrospinal fluid as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
5. Percutaneous Nephrostomy: Acute pain related to invasive procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
6. Thoracotomy: Acute pain related to surgical procedure, coughing, deep breathing as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, shallow breathing, changes in vital signs.
7. Tracheostomy: Acute pain related to edema, surgical procedure as evidenced by reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
8. Traction and Casts: Acute pain related to immobility, injury, or disease as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.

Labor Pain Nursing Diagnosis

Labor pain related to uterine contractions, cervical and birth canal stretching, expulsion of the fetus.

Chronic Pain Syndrome Nursing Diagnosis

Chronic pain syndrome related to persistent pain affecting daily living (specify condition; eg: spinal cord injury).

Chronic pain syndrome related to long-term opioid use.

Acute Pain Care Plan Examples

See Chronic Pain Care Plan Examples

Nursing care plan for acute pain related to MI

Nursing Diagnosis

Acute pain related to decreased blood flow to the myocardium, myocardial ischemia or infarct, increased cardiac workload, and oxygen consumption as evidenced by changes in ECG (specify ECG changes, eg; ST-segment elevation on leads), elevated cardiac enzymes, verbal report of pain (specify location, character, intensity), moaning, restlessness, facial grimacing, diaphoresis, changes in blood pressure, tachycardia, tachypnoea, dyspnea, dizziness.

Goal/ Expected Outcome

The patient verbalizes a pain reduction of no more than 3 to 4 on a standardized pain scale of 0 to 10 (0 indicating no pain and 10 indicating most severe pain) within 1 to 2 hours of receiving analgesics.

Demonstrate pain relief by maintaining stable vital signs and avoiding muscle tension and restlessness.

Nursing intervention for acute pain with rationales

Nursing Interventions	Rationales
Independent Assess chest pain for onset, quality, location, severity, duration, and relieving factors, as well as other symptoms such as pallor, diaphoresis, pain radiating, nausea, vomiting, shortness of breath, and changes in vital signs.	Variations in specific complaints and behavior may differ from patient to patient. Atypical MI symptoms are common in older patients, women, patients with diabetes mellitus, and patients with heart failure. But, most MI patients appear to be acutely ill and can only concentrate on their pain. Anxiety and pain may cause an increase in respiration. Increased catecholamines, stress, and pain can all cause an increase in heart rate, which can also lead to an increase in blood pressure. A thorough initial assessment is essential for early treatment, preserving myocardium, and obtaining baseline data for future comparisons.
Obtain a description of pain intensity on a pain scale ranging from 0 to 10, with 0 representing no pain and 10 representing the most severe pain experienced.	Pain is a subjective experience that is unique to each patient. Intensity scales can be used to assess whether a patient perceives improvement or deterioration.
Inquire about the onset of the current pain.	If the initial onset of pain is less than 6 hours, the patient may be a candidate for IV thrombolytic therapy, if there is an acute ST-segment elevation or new left bundle branch block on ECG
Obtain a previous history of past cardiac episodes and a family history of cardiac disease.	This provides data that may be useful in differentiating current pain from previous ones, as well as identifying new problems and complications.
Assess any prior treatment for present pain.	The nurse should document any treatment that the patient received prior to hospitalization. Because the patient may have tried a variety of pain relief methods, such as antacids and sublingual NTG.
Place the patient on continuous cardiac monitoring and assess cardiac arrhythmias.	Patients with MI are more likely to experience acute life-threatening dysrhythmias (particularly in the first 24 hours), which develop as a result of ischemia alterations and stress hormones.
Advise patient to report new onset of pain immediately	Delays in reporting pain hinder pain alleviation and may necessitate an increase in medication dosage to get relief. Also, intense pain can cause a shock by activating the sympathetic nervous system, causing additional damage, and interfering with diagnostics and pain treatment.
Frequently monitor vital signs and every 15 minutes during pain episodes.	Blood pressure may rise initially due to sympathetic activation and subsequently fall if cardiac output is decreased. Tachycardia can also occur as a result of sympathetic stimulation and may persist as a compensatory response if cardiac output falls.
Monitor serial biomarkers with 12 lead ECGs	Necrotic cardiac cells release creatinine kinase – myocardial bound (CK-MB), troponin, and myoglobin into the circulation. Myoglobin and CK-MB are the first to be detected, while troponin is more sensitive and specific to myocardial damage, remaining elevated for 10 – 14 days. Because there is no cellular death in unstable angina, enzyme and protein levels do not rise.
Monitor heart rate and blood pressure throughout a pain episode and when administering medicine.	Pain increases sympathetic stimulation, which raises the heart’s oxygen demand. During pain and anxiety, tachycardia and elevated blood pressure are observed. With the administration of nitrates and morphine, hypotension is observed. With the administration of morphine and beta-blocker bradycardia is observed.
Continuously reassess the chest pain and response to treatment. If the recommended drug doses do not relieve cardiac symptoms, report the physician for evaluation for thrombolytic therapy, angioplasty, coronary angiography, or bypass surgery revascularization.	Persistent pain may indicate extended cardiac ischemia, necessitating prompt intervention.
Ensure uninterrupted bed rest and sleep in a comfortable position. The nurse should remain with the patient throughout pain if the patient appears anxious.	Reduces oxygen use and demand; alleviates fear and promotes a safe and caring environment.
Collaborative Administer oxygen, use a nasal cannula or mask as indicated. Observe the oxygen saturation levels.	Supplemental oxygen can improve available oxygen and reduce pain related to myocardial infarction ischemia.
Administer analgesics as prescribed, such as morphine sulfate, meperidine (Demerol), or Dilaudid IV.	Morphine is the medicine of choice for controlling MI pain, however other analgesics may be used to alleviate pain while reducing the burden on the heart. IM injections should be avoided since they can affect cardiac enzymes and are poorly absorbed in non- or under-perfused tissue.
Administer beta-blockers as prescribed (eg, atenolol, pindolol, and propranolol)	These medications suppress sympathetic activation, decreasing heart rate and systolic blood pressure, as well as myocardial oxygen demand. Because of their negative inotropic effects, beta-blockers should not be used in patients with severely compromised contractility.
Administer calcium-channel blockers as prescribed (eg, verapamil, diltiazem, or nifedipine).	These drugs can improve coronary blood flow and collateral circulation, lower preload, and myocardial oxygen demands, and thereby alleviate ischemia pain.
Administer angiotensin-converting enzymes (ACE) inhibitors or angiotensin receptor blockers (ARBs).	These drugs reduce the risk of recurrent MI, progression of heart failure, and death, particularly in diabetics and patients with LV dysfunction.
Administer thrombolytic drugs according to the facility’s guidelines.	Thrombolytic medications are enzymes that convert plasminogen to plasmin, a fibrinolytic protein. These medications dissolve fibrin clots and restore myocardial tissue perfusion through previously occluded coronary arteries. IV therapy is used since it is the quickest. According to AHA guidelines, the period from door to thrombolytic therapy should be no more than 30 minutes.

Nursing care plan for acute pain related to surgery (general NCP)

Nursing Diagnosis

Acute pain may be related to surgical incision; disruption of skin, tissue, and muscle integrity; musculoskeletal or bone injury; presence of tubes or drains as evidenced by verbal reports of pain, restlessness, crying, moaning, facial grimace, guarding, confusion, changes in vital signs.

Goal/Expected Outcome

The patient verbalizes a pain decrease as evidenced by reports of pain no more than 3 to 4 on a standardized pain scale of 0 to 10, with 0 indicating no pain and 10 indicating most severe pain.

Demonstrates pain relief as evidenced by normal vital signs and non-verbal behavior such as muscle relaxation.

Nursing intervention for acute pain with rationales

Nursing Interventions	Rationales
Obtain thorough medical history and intraoperative course, including incision size and location, drain placement, and anesthetic agents utilized.	The approach to postoperative pain management is dependent on a variety of variable elements, particularly drugs used to treat chronic pain.
Examine the intraoperative and recovery room records for the kind of anesthesia and analgesia administered.	Some anesthetics have anesthetic properties, whilst others do not have analgesic effects. Furthermore, the duration of intraoperative local and regional blocks varies according to the drug used and the dose. Patients with muscular diseases/conditions may require more time to recover (eg, postpolio)
Assess pain frequently (eg, every 30 minutes including, intensity, location, and characteristics) in the initial postoperative phase using a standardized pain assessment tool.	Provides information on the need for and efficacy of interventions. It is important to note that eliminating pain is not always possible; however, analgesics should reduce pain to a manageable level. A frontal and/or occipital headache may occur 24 to 72 hours after spinal anesthesia, requiring a recumbent position, and increased fluid intake. Also, notify the anesthesiologist of a different pain treatment plan.
Recognize the presence of anxiety and how it relates to the nature of the procedure and the preparation for it.	Concern over the unknown, such as the outcome of a biopsy or insufficient preparation due to an emergency procedure, can heighten the patient’s feeling of pain.
Examine potential sources of discomfort other than the surgery.	Other causes can induce or exacerbate pain (For example, an indwelling catheter causing bladder pain, an NG tube causing stomach fluid and gas buildup, or parenteral lines that have infiltrated IV fluids or drugs).
Educate regarding the temporary nature of the discomfort as appropriate.	Understanding the reason for transitory discomfort provides emotional reassurance (for example, achy muscles following succinylcholine administration, which can last up to 48 hours postoperatively; sinus headache caused by nitrous gas; or sore throat caused by intubation).
Reposition as needed, for example, semi-or Fowler’s lateral Sims’	It is possible that it will reduce pain and improve circulation. The semi-Fowler position improves abdominal muscular strain as well as arthritic back muscle strain, whereas the lateral Sims position relieves dorsal pressures.
Offer supplementary comfort measures such as backrub and heat or cold compress.	Improves circulation and lowers pain-related muscle tension and anxiety. Improves sense of well-being.
Teach non-pharmacological pain-relieving techniques such as deep breathing exercises, diversion of thought, or music.	Enhances coping abilities and relieves muscle and emotional stress.
Perform regular oral care and offer sips or ice chips as tolerated.	Diminishes throat discomfort caused by anesthetic agents and hydrates oral mucosa.
Assess sedation and respiratory status. Take note of analgesia’s effectiveness as well as any side effects.	When opioids are administered, respirations may decrease, and synergistic effects with anesthetic drugs may develop. It should be noted that the migration of epidural analgesia into the head may result in respiratory depression or severe sedation.
Collaborative Administer IV analgesics as prescribed.	Analgesics administered intravenously reach the pain centers immediately, providing more effective relief with lower doses of medication.
Avoid administering analgesic medications intramuscularly.	Intramuscular administration is not advised due to the potential for significant pain and unpredictable absorption.
Administer regional anesthetics, such as epidural block as needed.	To prevent extreme pain, analgesics may be administered into the surgical site, or nerves to the site may be kept blocked in the initial postoperative phase.
Administer NSAIDs, such as ketorolac (Toradol), diflunisal (Dolobid), or naproxen (Anaprox), acetaminophen (Tylenol) as prescribed.	They are useful for mild to moderate pain in adults and children, or as adjuncts to opioid therapy in moderate to severe pain. Allows for a lower opioid dosage, lowering the risk of side effects. Use an alternating schedule for NSAIDs administered between opioid doses to ensure that the peak effect occurs at a different time.

See Chronic Pain Nursing Diagnosis & Care Plan Examples

Conclusion

To recap, you learnt about acute pain NANDA nursing diagnosis in this post. You’ve also seen sample acute pain nursing diagnoses for various diseases, as well as sample acute pain nursing care plans.

Recommended Readings & Reference

Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.

Axton, S., & Fugate, T. (2009). PEDIATRIC NURSING CARE PLANS FOR THE HOSPITALIZED CHILD (3rd ed.). Pearson Prentice Hall.

Comer, S. and Sagel, B. (1998). CRITICAL CARE NURSING CARE PLANS. Skidmore-Roth Publications.

Doenges, M., Murr, A., & Moorhouse, M. (2019). NURSING CARE PLANS: Guidelines for Individualizing Client Care Across the Life Span (10th ed.). F. A. Davis Company.

Gulanick, M. and Myers, J. (2014). NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes (8th ed.). Elsevier/Mosby.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Luxner, K. (1999). MATERNAL-INFANT NURSING CARE PLANS. Skidmore-Roth Pub.

Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.