Acute Pain NANDA Definition : 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 less than 6 months
- Patient reports pain
- Guarding behavior, protecting body part
- Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
- Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
- Facial mask of pain
- Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
- Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
Pain is reduced / no pain
- Report: no pain / controlled
- Demonstrate use of relaxation skills.
- Another method to improve comfort
Nursing Interventions Acute Pain Nursing Care Plan for Peritonitis
1. Investigate reports of pain, noting location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant)
Rationale: The change in location / intensity not common but may indicate the occurrence of complications. Pain tends to be constant, more intense, and spread upward, pain can occur if local abscess.
2. Maintain semi-Fowler's position as indicated
Rationale: Facilitate drainage of fluids / injury, because of gravity and helps minimize the pain due to movement.
3. Provide comfort measures, sample the back massage, deep breathing, relaxation or visualization exercises.
Rationale: Increase relaxation and may enhance the patient's coping abilities by refocusing attention.
4. Provide oral care. Eliminate unpleasant environmental stimuli.
Rational: Lowering nausea / vomiting that can increase the pressure or pain intrabdomen.
Give medications as indicated:
Rational: Lowering the metabolic rate and irritable bowel because of toxin circulating / local, which helps relieve pain and improve healing.
Reduces nausea / vomiting, which can increase abdominal pain
Lowering of discomfort related to fever or chills.