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Acute Pain: Unpleasant sensory and emotional experience arising from actual

or potential tissue damage or described in terms of such damage; sudden or


slow onset of any intensity from mild to severe with anticipated or predictable
end and a duration of <6 months.

May be related to

 Distension of intestinal tissues by inflammation


 Presence of surgical incision

Possibly evidenced by

 Reports of pain
 Facial grimacing, muscle guarding; distraction behaviors
 Expressive behavior (restlessness, moaning, crying, vigilance,
irritability, sighing)
 Autonomic responses

Desired Outcomes

 Report pain is relieved/controlled.


 Appear relaxed, able to sleep/rest appropriately.
 Demonstrate use of relaxation skills and diversional activities, as
indicates, for individual situation.

Nursing Interventions Rationale

Useful in monitoring effectiveness of


Assess pain, noting location, medication, progression of healing.
characteristics, severity (0–10 scale). Changes in characteristics of pain may
Investigate and report changes in pain as indicate developing abscess or peritonitis,
appropriate. requiring prompt medical evaluation and
intervention.

Provide accurate, honest information to Being informed about progress of situation


Nursing Interventions Rationale

patient and SO. provides emotional support, helping to


decrease anxiety

To lessen the pain. Gravity localizes


inflammatory exudate into lower abdomen
Keep at rest in semi-Fowler’s position.
or pelvis, relieving abdominal tension,
which is accentuated by supine position.

Promotes normalization of organ


function (stimulates peristalsis and
Encourage early ambulation.
passing of flatus, reducing abdominal
discomfort).

Refocuses attention, promotes relaxation,


Provide diversional activities
and may enhance coping abilities.

Decreases discomfort of early


Keep NPO and maintain NG suction
intestinal peristalsis, gastric irritation and
initially.
vomiting.

Relief of pain facilitates cooperation with


Administer analgesics as indicated. other therapeutic interventions
(ambulation, pulmonary toilet).

Soothes and relieves pain through


Place ice bag on abdomen periodically desensitization of nerve endings. Note: Do
during initial 24–48 hr, as appropriate. not use heat, because it may cause tissue
congestion.

Never apply heat to the right lower


This may cause the appendix to rupture.
abdomen.

Watch closely for possible surgical Continuing pain and fever may signal an
complications. abscess.