Nursing Diagnosis: Acute Pain with NANDA, NOC, nic

Nursing Diagnosis: Acute Pain
Chris Pasero and Margo McCaffery

NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of <6 months (NANDA)

Defining Characteristics:

Subjective

Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.

Related Factors: Actual or potential tissue damage (mechanical [e.g., incision or tumor growth], thermal [e.g., burn], or chemical [e.g., toxic substance])

NOC Outcomes (Nursing Outcomes Classification

Suggested NOC Labels

·         Pain Level, Pain Control, Comfort Level

·         Pain: Disruptive Effects

 Client Outcomes

·         Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities)

·         Describes how unrelieved pain will be managed

·         Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects

·         Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)

·         States an ability to obtain sufficient amounts of rest and sleep

·         Describes a nonpharmacological method that can be used to control pain

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Conscious Sedation

·         Patient-Controlled Analgesia (PCA) Assistance

 Nursing Interventions and Rationales

·         Determine whether client is experiencing pain at the time of the initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

·         Ask client to describe past experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how he or she expresss pain. A number of concerns (barriers) may affect patients' willingness to report pain and use analgesics (Ward et al, 1993).

·         Describe adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).

·         Tell client to report location, intensity (using a pain rating scale), and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

·         Determine client's current medication use. To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992).

·         Explore the need for both opioid (narcotic) and non-opioid analgesics. Pharmacological interventions are the cornerstone of pain management (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

·         Obtain a prescription to administer a non-opioid (acetaminophen, Cox-2 inhibitor, or a nonsteroidal antiinflammatory drug [NSAID]), unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain impulses (Dahl, Kehlet, 1991). Unless contraindicated, all patients with acute pain should receive a non-opioid ATC (Acute Pain Management Guideline Panel, 1992). The analgesic regimen should include a non-opioid, even if pain is severe enough to require the addition of an opioid (Jacox et al, 1994; McCaffery, Pasero, 1999).

·         Obtain a prescription to administer opioid analgesia if indicated, especially for severe pain. Opioid analgesics are indicated for the treatment of moderate to severe pain (Jacox et al, 1994; McCaffery, Pasero, 1999).

·         Administer opioids orally or intravenously, not intramuscularly. Use a preventive approach to keep pain at or below an acceptable level. Provide PCA and intraspinal routes of administration when appropriate and available. The least invasive route of administration capable of providing adequate pain control is recommended. The intramuscular (IM) route is avoided because of unreliable absorption, pain, and inconvenience. The intravenous (IV) route is preferred for rapid control of severe pain. For ongoing pain, give analgesia ATC. PRN dosing is appropriate for intermittent pain (Jacox et al, 1994; McCaffery, Pasero, 1999).

·         Discuss client's fears of undertreated pain, overdose, and addiction. A number of concerns may affect clients' willingness to report pain and use opioid analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (Jacox et al, 1994; McCaffery, Pasero, 1999). Addiction is extremely unlikely after patients use opioids for acute pain (Acute Pain Management Guideline Panel, 1992).

·         When opioids are administered, assess pain intensity, sedation, and respiratory status at regular intervals. Opioids may cause respiratory depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the respiratory centers of the brain. Because even more opioid is required to produce respiratory depression than is required to produce sedation, patients with clinically significant respiratory depression are usually also sedated. Respiratory depression can be prevented by assessing sedation and decreasing the opioid dose when the patient is arousable but has difficulty staying awake (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).

·         Review client's flow sheet and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the past 24 hours. Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).

·         Administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for supplementary opioid doses between regular doses is an essential backup (American Pain Society, 1999).

·         Obtain prescriptions to increase or decrease opioid doses as needed; base prescriptions on client's report of pain severity and response to the previous dose in terms of relief, side effects, and ability to perform the activities of recovery. Increase or decrease the dose of opioid based on assessment of the patient's response. Patients' responses, and therefore their requirements, vary widely, so it is less important to focus on the amount given than on the response (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).

·         When client is able to tolerate oral analgesics, obtain a prescription to change to the oral route; use an equianalgesic chart to determine initial dose. (See Appendix E for an equianalgesic chart.) The oral route is preferred because it is the most convenient and cost-effective (Jacox et al, 1994). Use of equianalgesic doses when switching from one opioid or route of administration to another will help to prevent loss of pain control from underdosing and side effects from overdosing (McCaffery, Pasero, 1999).

·         In addition to use of analgesics, support client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore the clients' sense of self-control, personal efficacy, and active participation in own care (Jacox et al, 1994).

·         Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992).

·         Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999).

·         Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, these side effects should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).

Geriatric

·         Always take the elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999).

·         When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials.

·         Handle client's body gently. Allow client to move at own speed.

·         Use acetaminophen and NSAIDs with low side-effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid), and watch for side effects, such as GI disturbances and bleeding problems. Elderly people are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992).

·         Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). The higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

·         Use opioids with caution in the elderly client. The elderly are more sensitive to the analgesic effects of opioid drugs because they experience a higher peak effect and a longer duration of pain relief. Reduce the initial recommended adult starting opioid dose by 25% to 50%, especially if the client is frail and debilitated; then increase the dose if safe and necessary (Acute Pain Management Guideline Panel, 1992).

·         Avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet), in elderly clients. Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

Multicultural

·         Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Have scale translated into client's native language if necessary.. Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999).

·         Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level. Regardless of the patient's cultural background, pain rated at (4 on a 0 to 10 pain rating scale interferes significantly with daily function. Perceived quality of life appears to be comparable across cultures, with pain ratings of >6 interfering markedly with a person's ability to enjoy life (McCaffery, 1999; McCaffery, Pasero, 1999).

·         Assess for the influence of cultural beliefs, norms, and values on the client's perception and experience of pain. The client's experience of pain may be based on cultural perceptions (Leininger, 1996).

·         Assess for the role of fatalism on the client's beliefs regarding their current state of comfort. Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).

·         Incorporate folk health care practices and beliefs into care whenever possible. Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).

·         Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients. Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).

·         Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client. Culturally diverse clients may express pain differently than clients from the majority culture. The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).

·         Ensure that directions for medications are available in the client's language of choice and are understood by client and caregiver. Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).

·         Validate the client's feelings and emotions regarding current health status. Validation lets the client know the nurse has heard and understands what was said, and it promotes the nurse-client relationship. (Stuart, Laraia, 2001;Giger, Davidhizer, 1995).

Home Care Interventions

·         Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).

·         Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).

·         Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).

·         If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).

·         Assess knowledge base of client and family for highly technological medication administration. Teach as necessary. Be sure clients know when, how, and who to contact if analgesia is unsatisfactory. Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).

Client/Family Teaching

·               NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.

·         Provide written materials on pain control such as the Agency for Health Care Policy and Research (AHCPR) pamphlet, Pain Control: Patient Guide.

·         Discuss the various discomforts encompassed by the word pain, and ask client to give examples of previously experienced pain. Explain pain assessment process and purpose of the pain rating scale.

·         Teach client to use the pain rating scale to rate intensity of past or current pain. Ask client to set a comfort/function goal by selecting a pain level on the rating scale that makes it easy to perform recovery activities (e.g., turn, cough, deep breathe). If pain is above this level, client should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)

·         Demonstrate medication administration and use of supplies and equipment. If PCA is ordered, determine client's ability to press appropriate button. Remind client and staff that the PCA button is for patient-only use.

·         Reinforce importance of taking pain medications to keep pain under control.

·         Reinforce that taking opioids for pain relief is not addiction and that addiction is very unlikely to occur.

·         Demonstrate use of appropriate nonpharmacological approaches for controlling pain, such as heat, cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music, and television.