Related Factors Injuring agents (biological, chemical, physical, psychological) Dening Characteristics SUBJECTIVE Verbal report of pain; coded

report [may be less from clients younger than age 40, men, and some cultural groups] Changes in appetite OBJECTIVE Observed evidence of pain Guarding behavior; protective gestures; positioning to avoid pain Facial mask; sleep disturbance (eyes lack luster, beaten look, xed or scattered movement, grimace) Expressive behavior (e.g.,restlessness,moaning,crying,vigilance, irritability, sighing) Distraction behavior (e.g., pacing, seeking out other people and/or activities, repetitive activities) Change in muscle tone (may span from listless *accid+ to rigid) Diaphoresis; change in blood pressure/heart rate/respiratory rate; pupillary dilation Self-focusing;narrowed focus (altered time perception,impaired thought process, reduced interaction with people and envi- ronment) Desired Outcomes/Evaluation CriteriaClient Will: Report pain is relieved/controlled. Follow prescribed pharmacological regimen. Verbalize nonpharmacologic methods that provide relief. Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation. Actions/Interventions NURSING PRIORITY NO.1.To assess etiology/precipitating contrib- utory factors: Note clients age/developmental level and current condition (e.g.,infant/child,critically ill,ventilated/sedated,or cognitively impaired client) affecting ability to report pain parameters. Determine/document presence of possible pathophysiologi- cal/psychological causes of pain (e.g., inammation; tissue Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 499

Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. acute PAIN FABK021-C04[70-780].qxd 11/27/07 7:15 PM Page 499 RAJESH Wiley 1:Users:pinn trauma/fractures; surgery; infections; heart attack/angina; abdominal conditions [e.g.,appendicitis,cholecystitis]; burns; grief; fear/anxiety; depression; and personality disorders). Note location of surgical procedures,as this can inuence the amount of postoperative pain experienced; for example, vertical/diagonal incisions are more painful than transverse or S-shaped. Presence of known/unknown complication(s) may make the pain more severe than anticipated. Assess for referred pain, as appropriate, to help determine possibility of underlying condition or organ dysfunction requiring treatment. Note clients attitude toward pain and use of pain medica- tions, including any history of substance abuse. Note clients locus of control (internal/external). Individuals with external locus of control may take little or no respon- sibility for pain management. Assist in thorough

evaluation, including neurological and psychological factors (pain inventory, psychological inter- view), as appropriate, when pain persists. NURSING PRIORITY NO. 2.To evaluate clients response to pain: Obtain clients assessment of pain to include location,charac- teristics,onset/duration,frequency,quality,intensity,and precipitating/aggravating factors. Reassess each time pain occurs/is reported. Note and investigate changes from previ- ous reports to rule out worsening of underlying condi- tion/development of complications. Use pain rating scale appropriate for age/cognition (e.g., 0 to 10 scale; facial expression scale [pediatric, nonverbal+; pain assessment scale for dementing elderly *PADE+; behavioral pain scale *BPS+). Accept clients description of pain. Acknowledge the pain experience and convey acceptance of clients response to pain. Pain is a subjective experience and cannot be felt by others. Observe nonverbal cues/pain behaviors (e.g., how client walks, holds body, sits; facial expression; cool ngertips/toes, which can mean constricted blood vessels) and other objec- tive Dening Characteristics, as noted, especially in persons who cannot communicate verbally. Observations may/may not be congruent with verbal reports or may be only indica- tor present when client is unable to verbalize. Ask others who know client well (e.g.,spouse,parent) to iden- tify behaviors that may indicate pain when client is unable to verbalize. 500 Cultural Collaborative Community/Home Care Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. acute PAIN FABK021-C04[70-780].qxd 11/27/07 7:15 PM Page 500 RAJESH Wiley 1:Users:pinn Note cultural and developmental inuences affecting pain response. Verbal and/or behavioral cues may have no direct relationship to the degree of pain perceived (e.g., client may deny pain even when feeling uncomfortable,or reactions can be stoic or exaggerated,reecting cultural/familial norms. Monitor skin color/temperature and vital signs (e.g., heart rate, blood pressure, respirations), which are usually altered in acute pain. Ascertain clients knowledge of and expectations about pain management. Review clients previous experiences with pain and methods found either helpful or unhelpful for pain control in the past. NURSING PRIORITY NO. 3.To assist client to explore methods for alleviation/control of pain: Determine clients acceptable level of pain/pain control goals. Varies with individual and situation. Determine factors in clients lifestyle (e.g., alcohol/other drug use/abuse) that can affect responses to analgesics and/or choice of interventions for pain management. Note when pain occurs (e.g., only with ambulation, every evening) to medicate prophylactically, as appropriate. Collaborate in treatment of underlying condition/disease processes causing pain and proactive management of pain (e.g., epidural analgesia, nerve blockade for postoperative pain). Provide comfort measures (e.g., touch, repositioning, use of heat/cold packs, nurses presence), quiet environment, and calm activities to promote nonpharmacological pain man- agement. Instruct in/encourage use of relaxation techniques, such as focused breathing, imaging, CDs/tapes (e.g., white noise, music,instructional) to distract attention and reduce tension. Encourage diversional activities (e.g., TV/radio, socialization with others). Review procedures/expectations and tell client when treat- ment may cause pain to reduce concern of the unknown and associated muscle tension. Encourage verbalization of feelings about the

pain. Use puppets to demonstrate procedure for child to enhance understanding and reduce level of anxiety/fear. Suggest parent be present during procedures to comfort child. Identify ways of avoiding/minimizing pain (e.g., splinting incision during cough;using rm mattress/proper supporting shoes for low back pain; good body mechanics). Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 501

Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. acute PAIN FABK021-C04[70-780].qxd 11/27/07 7:15 PM Page 501 RAJESH Wiley 1:Users:pinn Work with client to prevent pain. Use ow sheet to document pain, therapeutic interventions, response, and length of time before pain recurs. Instruct client to report pain as soon as it begins as timely intervention is more likely to be successful in alleviating pain. Administer analgesics, as indicated, to maximum dosage, as needed, to maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal. Demonstrate/monitor use of selfadministration/patient- controlled analgesia (PCA) for management of severe, persistent pain. Evaluate/document clients response to analgesia, and assist in transitioning/altering drug regimen,based on individual needs. Increasing/decreasing dosage, stepped program (switching from injection to oral route, increased time span as pain lessens) helps in self-management of pain. Instruct client in use of transcutaneous electrical stimulation (TENS) unit, when ordered. NURSING PRIORITY NO. 4.To promote wellness (Teaching/ Discharge Considerations): Encourage adequate rest periods to prevent fatigue. Review ways to lessen pain,including techniques such as Ther- apeutic Touch (TT),biofeedback,self-hypnosis,and relaxation skills. Discuss impact of pain on lifestyle/independence and ways to maximize level of functioning. Provide for individualized physical therapy/exercise program that can be continued by the client after discharge. Promotes active, not passive, role and enhances sense of control. Discuss with SO(s) ways in which they can assist client and reduce precipitating factors that may cause or increase pain (e.g., participating in household tasks following abdominal surgery). Identify specic signs/symptoms and changes in pain charac- teristics requiring medical follow-up.