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CHAPTER 46 / Pain Management 1223

■ Were the client’s beliefs, expectations, and values about pain

CLINICAL ALERT therapy considered?
The statement “Please tell me how I can best help you control your pain” ■ Did the client understate the pain experience for some reason?
sends a couple of subtle messages that are an important part of treat- ■ Were appropriate instructions provided to allay misconcep-
ment planning and evaluation of care. First, it places the ownership and tions about pain management?
responsibility for controlling pain on the client. Second, it acknowledges
■ Did the client and support people understand the instructions
that the client may be the best judge of what is needed, respecting the
cultural meaning of pain and acceptable ways of expressing/controlling about pain management techniques?
pain. Third, it establishes the nurse’s role in helping the client be more ■ Is the client receiving adequate support for both physical
comfortable and in control of his or her condition. ■ pain and emotional distress?
■ Has the client’s physical condition changed, necessitating
modifications in interventions?
If outcomes are not achieved, the nurse and client need to ex-
■ Should selected intervention strategies be reevaluated?
plore the reasons before modifying the care plan. The nurse
might consider the following questions: See the Nursing Care Plan and the Concept Map.
■ Is adequate analgesic being given? Would the client benefit
from a change in dose or in the time interval between doses?

CRITICAL THINKING CHECKPOINT

Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. 1. What conclusions, if any, can be drawn about Mrs. Lundahl’s pain
She has a 15-cm midline incision that is covered with a dry and intact status?
surgical dressing. Upon assessing Mrs. Lundahl you note that she is per- 2. Does Mrs. Lundahl’s rating her pain as 5 mean that she is not ex-
spiring, lying in a rigid position, holding her abdomen, and grimacing. periencing pain severe enough to warrant intervention?
Her blood pressure is 150/90, heart rate 100, and respiratory rate 32. 3. What type of pain is Mrs. Lundahl experiencing?
When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates 4. What interventions, in addition to pain medication, may be use-
her pain as 5 as long as she remains perfectly still. There is a sharp area ful in reducing Mrs. Lundahl’s pain?
of pain at her incision; however, the most bothersome pain is crampy 5. How will you know if your interventions have been effective in
and dull, like she was “kicked in the stomach” with severe exacerbations reducing Mrs. Lundahl’s pain?
that come in unpredictable waves.
See Critical Thinking Possibilities in Appendix A.

NURSING CARE PLAN Acute Pain

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*
Nursing Assessment Acute Pain related to tissue in- Pain Control [1605] as evi-
Mr. C. is a 57-year-old businessman who was admitted to the sur- jury secondary to surgical inter- denced by often demonstrating
gical unit for treatment of a possible strangulated inguinal hernia. vention (as evidenced by ability to
Two days ago he had a partial bowel resection. Postoperative or- restlessness; pallor; elevated ■ Use analgesics appropriately
ders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr pulse, respirations, and systolic ■ Use nonanalgesic relief
left arm, nasogastric tube to low intermittent suction. Mr. C. is in a blood pressure; dilated pupils; measures
dorsal recumbent (supine) position and is attempting to draw up and report of 7/10 abdominal ■ Report uncontrolled
his legs. He appears restless and is complaining of abdominal pain) symptoms to health care
pain (7 on a scale of 0–10). professional

Pain Level [2102] As evi-

Physical Examination Diagnostic Data denced by mild to no
Height: 188 cm (6′ 3′′) Chest x-ray and urinalysis neg- ■ Reported pain
Weight: 90.0 kg (200 lb) ative, WBC 12,000 ■ Protective body positioning
Temperature: 37°C (98.6°F) ■ Restlessness
Pulse: 90 BPM ■ Pupil dilation
Respirations: 24/minute ■ Perspiration
Blood pressure: 158/82 mm Hg ■ Change in BP, HR, R from
Skin pale and moist, pupils di- normal baseline data
lated. Midline abdominal inci-
sion, sutures dry and intact.

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1224 UNIT X / Promoting Physiologic Health

NURSING CARE PLAN Acute Pain continued

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Pain Management [1400]

Perform a comprehensive assessment of pain to include location, Pain is a subjective experience and must be described by the
characteristics, onset, duration, frequency, quality, intensity or client in order to plan effective treatment.
severity, and precipitating factors of pain.

Consider cultural influences on pain response (e.g., cultural beliefs Each person experiences and expresses pain in an individual
about pain may result in a stoic attitude). manner using a variety of sociocultural adaptation techniques.

Reduce or eliminate factors that precipitate or increase Mr. C.’s Personal factors can influence pain and pain tolerance. Factors
pain experience (e.g., fear, fatigue, monotony, and lack of that may be precipitating or augmenting pain should be reduced
knowledge). or eliminated to enhance the overall pain management program.

Teach the use of nonpharmacologic techniques (e.g., relaxation, The use of noninvasive pain relief measures can increase the re-
guided imagery, music therapy, distraction, and massage) before, lease of endorphins and enhance the therapeutic effects of pain
after, and if possible during painful activities; before pain occurs or relief medications.
increases; and along with other pain relief measures.

Provide Mr. C. optimal pain relief with prescribed analgesics. Each client has a right to expect maximum pain relief. Optimal
pain relief using analgesics includes determining the preferred
route, drug, dosage, and frequency for each individual. Medica-
tions ordered on a prn basis should be offered to the client at
the interval when the next dose is available.
Medicate before an activity to increase participation, but evaluate Turning and ambulation activities will be enhanced if pain is con-
the hazard of sedation. trolled or tolerable. Assessing level of sedation should precede the
activity to ensure necessary safety precautions are put in place.
Evaluate the effectiveness of the pain control measures used Research shows that the most common reason for unrelieved
through ongoing assessment of Mr. C.’s pain experience. pain is failure to routinely assess pain and pain relief. Many
clients silently tolerate pain if not specifically asked about it.

Analgesic Administration [2210]

Check the medical order for drug, dose, and frequency of anal- Ensures that the nurse has the right drug, right route, right
gesic prescribed. dosage, right client, right frequency.
Determine analgesic selections (narcotic, nonnarcotic, or NSAID) Various types of pain (e.g., acute, chronic, neuropathic, nocicep-
based on type and severity of pain. tive) require different analgesic approaches. Some types of pain
respond to nonopioid drugs alone, while others can be relieved
by combining a low-dose opioid with a nonopioid.
Institute safety precautions as appropriate if Mr. C. receives nar- Side effects of opioid narcotics include drowsiness and sedation.
cotic analgesics.

Instruct Mr. C. to request prn pain medication before the pain is Severe pain is more difficult to control and increases the client’s
severe. anxiety and fatigue. The preventive approach to pain manage-
ment can reduce the total 24-hour analgesic dose.
Evaluate the effectiveness of analgesic at regular, frequent inter- The analgesic dose may not be adequate to raise the client’s
vals after each administration and especially after the initial doses, pain threshold or may be causing intolerable or dangerous side
also observing for any signs and symptoms of untoward effects effects or both. Ongoing evaluation will assist in making neces-
(e.g., respiratory depression, nausea and vomiting, dry mouth, and sary adjustments for effective pain management.
constipation).

Document Mr. C.’s response to analgesics and any untoward effects. Documentation facilitates pain management by communicating
effective and noneffective pain management strategies to the
entire health care team.

Implement actions to decrease untoward effects of analgesics Constipation is a common side effect of opioid narcotics, and a
(e.g., constipation and gastric irritation). treatment plan to prevent occurrence should be instituted at the
beginning of analgesic therapy. For Mr. C., constipation could re-
sult from his primary condition or his analgesia. Assess for overall
GI functioning, possible complications of surgery (e.g., ileus), as
well as opioid-induced constipation or NSAID-induced gastritis.
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NURSING CARE PLAN Acute Pain continued

NURSING INTERVENTIONS/SELECTED ACTIVITIES* RATIONALE

Simple Relaxation Therapy [6040]
Consider Mr. C.’s willingness and ability to participate, preference, The client must feel comfortable trying a different approach to
past experiences, and contraindications before selecting a specific pain management. To avoid ineffective strategies, the client
relaxation strategy. should be involved in the planning process.
Elicit behaviors that are conditioned to produce relaxation, such as Relaxation techniques help reduce skeletal muscle tension, which
deep breathing, yawning, abdominal breathing, or peaceful imaging. will reduce the intensity of the pain.
Create a quiet, nondisruptive environment with dim lights and Comfort and a quiet atmosphere promote a relaxed feeling and
comfortable temperature when possible. permit the client to focus on the relaxation technique rather than
external distraction.
Individualize the content of the relaxation intervention (e.g., by Each person may find different images or approaches to relax-
asking for suggestions about what Mr. C. enjoys or finds relaxing). ation more helpful than others. The nurse should have a variety
of relaxation scripts or audiovisual aids to help clients find the
best one for them.
Demonstrate and practice the relaxation technique with Mr. C. Return demonstrations by the participant provide an opportunity
for the nurse to evaluate the effectiveness of teaching sessions.
Evaluate and document his response to relaxation therapy. Conveys to the health care team effective strategies in reducing
or eliminating pain.

EVALUATION
Outcomes partially met. The client verbalizes pain and discomfort, requesting analgesics at onset of pain. States “the pain is a 2” (on a
scale of 0–10) 30 minutes after a parenteral analgesic administration. Requests analgesic 30 minutes before ambulation. States willing-
ness to try relaxation techniques; however, has not attempted to do so.

*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention.
Outcomes, indicators, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individu-
alized for each client.

APPLYING CRITICAL THINKING

1. Is there any other assessment data you would want to gather to 3. What kind of data would you gather prior to having a discus-
help plan Mr. C.’s pain management? sion with the primary care provider about options for improv-
2. Mr. C. does not have a PCA. What nursing interventions are im- ing pain control in this client?
portant?
See Critical Thinking Possibilities in Appendix A.