Almost everyone experiences acute pain, a highly subjective and unpleasant feeling.
A nursing diagnosis for Acute Pain is defined as an unpleasant emotional and sensory experience resulting from actual or potential damage to body tissue.
It can be sudden or have a slow onset, ranging from mild to severe. The duration can vary from a few seconds to up to six months.
Chronic pain is defined as long-term pain experienced for more than six months.
Various pain assessment tools are available for evaluating acute pain, such as the Brief Pain Inventory, Wong-Baker Faces Pain Scale, FLACC, visual analog scale, PQRST pain assessment, numerical rating pain scale, and the Indiana Polyclinic Combined Pain Scale.
Non-pharmacological pain relief methods, such as visualization exercises and heat/cold applications, can be employed to augment pain relief efforts.
Additionally, changing positions to relieve pressure and allowing patients ample time to report pain can further enhance pain management outcomes.
When non-pharmacological measures fail to alleviate pain, pain medications become essential in managing acute pain.
Types of pain medication include analgesics and nonsteroidal anti-inflammatory drugs, which can be used to treat mild to moderate pain and are often combined with other pain management techniques for increased effectiveness.
Nursing Diagnosis: Impaired Physical Mobility related to acute pain
Related Factors/Causes:
Expected Outcomes:
Nursing Interventions with Rationales:
Nursing Diagnosis: Anxiety related to acute pain
Related Factors/Causes:
Expected Outcomes:
Question 1:
A patient presents with acute abdominal pain. The nurse suspects appendicitis. Which assessment finding supports this suspicion?
A) Radiating chest pain
B) Rebound tenderness in the right lower quadrant
C) Bilateral leg swelling
D) Increased urine output
Answer: B) Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis. It occurs when pressure is applied to the area and then quickly released, resulting in increased pain.
Question 2:
A postoperative patient is experiencing acute pain. Which non-pharmacological intervention would be most effective in providing relief?
A) Administering oral analgesics
B) Applying cold packs to the surgical site
C) Providing distraction with music or games
D) Assisting with relaxation techniques
Answer: D) Assisting with relaxation techniques
Rationale: Non-pharmacological interventions such as relaxation techniques, including deep breathing exercises and guided imagery, can help reduce acute pain and promote relaxation, allowing the patient to experience relief.
Question 3:
A patient with a leg fracture reports severe pain. The nurse understands that pain can lead to which physiological response?
A) Decreased heart rate
B) Increased blood pressure
C) Decreased respiratory rate
D) Decreased oxygen saturation
Answer: B) Increased blood pressure
Rationale: Severe pain activates the sympathetic nervous system, increasing stress hormone release. This response causes vasoconstriction, increasing blood pressure as a compensatory mechanism.
Question 4:
A patient with acute pancreatitis is experiencing severe pain. Which medication is the most appropriate for the nurse to administer?
A) Acetaminophen (Tylenol)
B) Ibuprofen (Advil)
C) Morphine sulfate
D) Aspirin
Answer: C) Morphine sulfate
Rationale: Acute pancreatitis is a severe and painful condition. Morphine sulfate, an opioid analgesic, is the most appropriate medication to relieve severe pain in this situation.
Question 5:
A patient with acute respiratory distress syndrome (ARDS) is experiencing severe pain due to rib fractures. Which nursing intervention should take priority?
A) Administering supplemental oxygen
B) Applying ice packs to the fractured ribs
C) Administering intravenous fluids
D) Providing distraction with music or games
Answer: A) Administering supplemental oxygen
Rationale: In a patient with ARDS, maintaining adequate oxygenation is crucial. Administering supplemental oxygen takes priority as it helps meet the patient’s respiratory needs and promotes adequate oxygen saturation, supporting healing and alleviating pain associated with rib fractures.
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare. 2023; 11(1):34. https://doi.org/10.3390/healthcare11010034
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
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This is an excellent reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnoses, it also helps guide the nurse to match the nursing diagnosis to the patient assessment and diagnosis.
This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.
All introductory chapters in this updated version of a ground-breaking text have been completely rewritten to give nurses the knowledge they require to appreciate assessment, its relationship to diagnosis and clinical reasoning, and the goal and use of taxonomic organization at the bedside.
It contains more than 200 care plans that adhere to the newest evidence-based recommendations.
Additionally, it distinguishes between nursing and collaborative approaches and highlights QSEN competencies.
Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.