Acute Pain Nursing Diagnosis and Care Plan
Those patients who suffer from acute pain require acute pain nursing diagnosis and corresponding nursing care plan. The definition of Nanda presents acute pain as the individual state of uncomfortable sensations and severe discomfort lasting for the period from one second to half a year. The pain gains the status of chronic if it lasts for more than six months.
Thus, a specific feature of an acute pain care plan is that the patient demonstrates signs of discomfort, in particular itching, nausea, pain, or vomiting. There are a number of accompanying signs other from baseline vitals, including a guarded position, moaning, facial pain mask, crying, and others.
There are different reasons for acre pain; for instances, the patient may have such musculoskeletal disorders as arthritis or fractures, as well as traumas from accidents and burns.
A good nursing care plan for those patients who have acute pain covers acute pain nursing diagnosis, performing a number of interventions, and setting specific goals.
How is it possible to define a nursing care plan? What is the procedure of developing such a plan? What guidance can be helpful when a nursing care plan is under development?
Here is a sample of an acute pain nursing care plan as an illustrative example of the approach of a RN or LPN nurse to treating a patient.
Please note that the presented plan is given only as a sample for educational purposes and an example to study. It should not be used as a basis for treatment provided to the patients as the approaches may change in each individual case. Besides, the formats for care plans may differ.
Formatting is not the main aspect of care plans as different medical jobs or nursing establishments may adhere to different formats. It may be a common practice for certain hospitals to present the information digitally, while others use the templates. Note that the key aspect is the content of the plan which serves as a basis for the care program a nurse uses.
Acute Pain Nursing Care Plan for the Patients
It is easier to develop an acute pain nursing care plan after watching a video tutorial; however, a written guidance is also helpful.
A 69-year-old man gets to the hospital with hypertension. Although the blood pressure has been taken under control, the patient feels acute pain in his big toe of the left foot. The toe is warm and red. The patient cannot tolerate when someone touches the toe. He claims that it is painful both to move the toe and to get it touched by clothes or blankets. The crushing pain gets more intense at night. The patient describes it as throbbing. The doctor diagnoses the patient’s state as gout. Using a 1-10 scale, the patient rates the ache as 8. He says that he has never experienced such pain, but his mother used to have gout attacks.
The diagnosis is acute pain as a result of spasms in reflex muscle and tissue trauma caused by gout with the evidence of pain and rating 8 of the patient given with the use of 1-10 scale.
According to the patient, it is painful to get the toe touched by clothes, sheets, or blankets. Besides, it is painful to move the toe. According to him, the pain persists at night, and the description presents the pain as crushing and throbbing. According to the family history presented by the patient, his mother used to have gout attacks; however, he feels this intense pain for the first time. The rating of the pain is 8 as per the 1-10 scale used by the patient for evaluation.
A 69-year-old man gets to hospital with hypertension. Although the blood pressure has been taken under control, the patient feels acute pain in his big toe of the left foot. The toe is warm and red. The patient cannot tolerate when someone touches the toe, as it is painful.
Nursing Expected Outcomes
- As for the care plan for chronic pain, the care plan for acute pain also has its expected outcomes.
- The rating of the experienced pain done by the patient on the 1-10 scale will be lower than 4 after the medication taken (within 24 hours).
- It is expected that the patient will take Colichine within 48 hours to be able not to feel pain moving his big toe on his left foot.
- The patient will be aware of five symptoms and early signs that demonstrate a pending attack of gout.
- The patient will know at least six kinds of food which can ensure prevention of the attacks.
- The patient will know the procedure of taking Colichine properly before discharge.
- The patient will know how to use four main non-pharmacological methods of pain decrease in the course of gout attacks. That is a long term goal for acute pain intervention.
Interventions in Nursing
- Assessment of the patient’s pain level will be done by the nurse every two hours when the patient is not sleeping. It is expected to be done from the acute pain nursing diagnosis till the time when the rating given by the patient according to the 1-10 scale is 4 or lower.
- According to the instructions, the patient will get the 0.5mg Colichine BID per md to address the swelling and pain from gout.
- The nurse will do the assessment of the ability of the patient to move the toe 48 hours after he has started taking Colichine.
- The nurse will teach the patient how to see the early symptoms of gout attacks and recognize the five main signs.
- The nurse will teach the patient how to ensure the prevention of gout attacks with the use of six kinds of food.
- The nurse will tell the patient how to take Colichine effectively before the discharge.
- The nurse will demonstrate to the patient how he can ensure decrease in pain with the help of four non-pharmacological methods for gout attacks.