Acute Pain Nursing Care Plans and Nursing Diagnosis
In this article, you will learn about NANDA nursing diagnoses for Acute Pain. You will also learn how to develop acute pain nursing care plans that include intervention and rationales.
There are four different NANDA nursing diagnoses for pain. They fall under Domain 12, Class I, which is Comfort and Physical Comfort, respectively.
Those four NANDA nursing diagnoses for pain are,
1. Acute pain
3. Chronic pain syndrome
Definition of NANDA pain nursing diagnoses
Acute pain
NANDA nursing diagnosis for acute pain is defined as a sudden onset of pain which is less than 3 months. An injury, surgery, illness, trauma, or invasive medical procedures can all cause acute pain.
Chronic pain syndrome
NANDA nursing diagnosis for chronic pain syndrome is defined as pains that recurs or persists for more than three months and have a significant impact on the daily functioning or well-being of the individual. Therefore, a chronic pain syndrome encompasses other nursing diagnoses, such as disturbed sleep patterns, fatigue, impaired physical mobility, or social isolation.
Labor pain
NANDA nursing diagnosis for labor Pain is defined as pain related to labor and childbirth.
List of Acute Pain Nursing Diagnosis
Acute pain related to medical and surgical conditions
- Abdominal Distension:Acute pain related to retention of air, gastrointestinal secretions in the peritoneum, disease process as evidenced by verbal reports of pain, increased abdominal girth, facial grimace, guarding, shortness of breath, changes in vital signs.
- Abdominal Pain: Acute pain related to abdominal trauma, pathological process as evidenced by verbal reports of pain, increased abdominal girth, nausea, vomiting, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
- Abdominal Surgery: Acute pain related to surgical incision as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, changes in vital signs.
- Abdominal Trauma: Acute pain related to abdominal trauma, traumatized tissue and internal structures as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Acute Abdominal Pain: Acutepain related to pathological process as evidenced by verbal reports of pain, crying, moaning, diaphoresis, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Acute pain management: Acutepain related to injury or surgical procedure
- Amputation: Acutepain related to surgery, phantom limb sensation as evidenced by verbal reports of pain, facial grimace, guarding, changes in vital signs.
- Angina: Acutepain related to myocardial ischemia as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Appendicitis/Appendectomy: Acute pain related to inflammatory process, surgical incision as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs, abnormal CBC.
- Bell’s Palsy: Acutepain related to inflammation of facial nerve
- Burns: Acutepain related to burn injury, treatments as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs, presence of invasive catheters.
- Cellulitis:Acute pain related to inflammatory change in tissue from bacterial invasion as evidenced by edema, increase local temperature, verbal reports of pain.
- Chest Pain: Acutepain related to myocardial injury, ischemia, blunt trauma to chest, as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Cholecystectomy: Acutepain related to surgical procedure as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Cholecystitis: Acute pain related to inflammation of the gall bladder as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Cholelithiasis: Acutepain related to obstruction of bile flow, inflammation in gallbladder as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Cleft Palate: Acutepain related to surgical correction, elbow restraints as evidenced by changes in vital signs, crying, moaning.
- Colitis: Acutepain related to inflammation in colon as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Compartment Syndrome: Acutepain related to pressure in compromised body part as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Conjunctivitis: Acutepain related to inflammatory process as evidenced by verbal reports of pain, redness and discharge from affected eye.
- Constipation: Acute pain related to constipation as evidenced by verbal reports of pain, inability to empty bowel, moaning, crying, facial grimace, guarding, nausea, vomiting, changes in vital signs, radiologic confirmation of fecal impaction.
- Coronary Artery Bypass Grafting (CABG): Acutepain related to traumatic surgery as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Craniectomy/Craniotomy: Acutepain related to recent brain surgery, increased intracranial pressure as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Crohn’s Disease: Acutepain related to increased peristalsis as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, nausea, vomiting, diarrhea, changes in vital signs.
- Dislocation of Joint: Acutepain related to dislocation of a joint as evidenced by verbal reports of pain, presence of deformity (specify location), moaning, crying, facial grimace, guarding, changes in vital signs.
- Diverticulitis: Acutepain related to inflammation of bowel as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- DVT (Deep Vein Thrombosis): Acutepain related to vascular inflammation, edema as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, confusion, changes in vital signs.
- Dyspepsia: Acutepain related to gastrointestinal disease, consumption of irritating foods as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Dysuria: Acutepain related to infection/inflammation of the urinary tract as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, abdominal guarding, changes in vital signs.
- Fracture: Acutepain related to muscle spasm, edema, trauma as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Gastric ulcers: Acutepain related to irritated mucosa from acid secretion as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Gastroenteritis: Acutepain related to increased peristalsis causing cramping as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, diarrhea, confusion, changes in vital signs.
- Gastroesophageal Reflux (GERD): Acutepain related to irritation of esophagus from gastric acids as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Glomerulonephritis: Acutepain related to edema of kidney as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Headache: Acutepain related to lack of knowledge of pain control techniques or methods to prevent headaches
- Hemophilia: Acutepain related to bleeding into body tissues as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, confusion, changes in vital signs.
- Hemorrhoidectomy: Acutepain related to surgical procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Hepatitis: Acutepain related to edema of liver, bile irritating skin as evidenced by verbal reports of pain, guarding, shortness of breath, nausea, vomiting, confusion, changes in vital signs.
- Hip fracture: Acutepain related to injury, surgical procedure, movement as evidenced by x-ray confirmation of hip fracture, verbal reports of pain, impaired walking, changes in vital signs.
- IBD: Acutepain related to abdominal cramping and anal irritation as evidenced by verbal reports of pain, facial grimace, guarding, shortness of breath, nausea, vomiting, changes in vital signs.
- Ileus: Acutepain related to pressure, abdominal distention as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, guarding.
- Inguinal Hernia Repair: Acutepain related to surgical procedure as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Intermittent Claudication:Acute pain related to decreased circulation to extremities with activity as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Interstitial Cystitis: Acutepain related to inflammatory process as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- JRA (Juvenile Rheumatoid Arthritis): Acutepain related to swollen or inflamed joints, restricted movement, physical therapy as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Kawasaki Disease: Acute pain related to enlarged lymph nodes; erythematous skin rash that progresses to desquamation, peeling, denuding of skin
- Kidney Stone: Acutepain related to obstruction from kidney calculi as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, distended bladder, guarding.
- Lyme disease: Acutepain related to inflammation of joints, urticaria, rash as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Mastectomy: Acutepain related to surgical procedure as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shortness of breath.
- Mastitis: Acutepain related to infectious disease process, swelling of breast tissue
- Meningitis/ Encephalitis: Acutepain related to biological injury
- MI (Myocardial Infarction): Acutepain related to myocardial tissue damage from inadequate blood supply
- Nephrectomy: Acutepain related to surgical incision as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shortness of breath.
- Osteoarthritis: Acutepain related to movement as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
- Osteomyelitis: Acutepain related to inflammation in affected extremity as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
- Osteoporosis: Acutepain related to fracture, muscle spasms as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, refusal to move.
- Otitis media: Acutepain related to inflammation, infectious process as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Pacemaker: Acutepain related to pacemaker insertion, transcutaneous pacing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in pulse and blood pressure.
- Pancreatitis: Acutepain related to irritation and edema of the inflamed pancreas as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, nausea, vomiting.
- Paralytic Ileus: Acutepain related to pressure, abdominal distention, presence of nasogastric tube as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning.
- Pericardial Friction Rub: Acutepain related to inflammation, effusion breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shallow breathing, shortness of breath.
- Peripheral neuropathy: Acutepain related to stimulation of affected nerve endings, inflammation of sensory nerves as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Peritonitis: Acutepain related to inflammation and infection of gastrointestinal system as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, nausea, vomiting.
- Pleural Effusion: Acutepain related to inflammation, fluid accumulation as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning, shallow breathing, shortness of breath.
- Pneumothorax: Acutepain related to recent injury, coughing, deep breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, shallow breathing, shortness of breath.
- Postoperative surgery: Acute pain related to inflammation or injury in surgical area as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
- Pressure ulcers (bedsore): Acute pain related to tissue destruction, exposure of nerves as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning.
- Pulmonary embolism (PE): Acutepain related to biological injury, lack of oxygen to cells as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, confusion, shortness breath.
- Pyelonephritis: Acutepain related to inflammation and irritation of urinary tract as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning.
- Radial Nerve Dysfunction: Acutepain related to trauma to hand or arm as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs.
- Rectocele Repair: Acutepain related to surgical procedure as evidenced by facial grimacing, restlessness, changes in vital signs, moaning.
- Rib Fracture: Acutepain related to movement, deep breathing as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, shallow breathing, moaning.
- Scoliosis: Acute pain related to musculoskeletal restrictions, surgery, reambulation with cast or spinal rod as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, guarding, moaning, refusal to mobilize.
- Sickle Cell Anemia: Acutepain related to viscous blood, tissue hypoxia as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, shortness of breath, moaning.
- Small Bowel Obstruction: Acutepain related to pressure from distended abdomen as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, abdominal guarding, moaning, increased abdominal girth, nausea, vomiting, abdominal guarding.
- Spina bifida: Acutepain related to stimulation of affected nerve endings, inflammation of sensory nerves as evidenced by facial grimacing, restlessness, changes in vital signs, moaning.
- Trigeminal Neuralgia: Acutepain related to irritation of trigeminal nerve as evidenced by verbal reports of pain, facial grimacing, restlessness, changes in vital signs, moaning.
Acute pain related to obstetric and genecology
- Abruptio Placentae: Acutepain related to irritable uterus, hypertonic uterus as evidenced by verbal reports of pain, moaning, crying, facial grimace, abdominal guarding, shortness of breath, changes in vital signs.
- Breasts engorgement: Acute pain related to distention of breast tissue as evidenced by verbal reports of pain, hard and tender breasts, moaning, crying, facial grimace.
- C section: Acutepain related to surgical incision as evidenced by verbal reports of pain, diaphoresis, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
- D & C: Acutepain related to uterine contractions, surgical procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Dysmenorrhea: Acutepain related to cramping from hormonal effects as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Ectopic pregnancy: Acutepain related to stretching or rupture of implantation site as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, confusion, changes in vital signs, sonographic confirmation of rupture.
- Endometriosis: Acutepain related to onset of menses with distention of endometrial tissue
- Endometritis: Acutepain related to infectious process in reproductive tract
- Episiotomy: Acutepain related to tissue trauma as evidenced by verbal reports of pain, moaning, facial grimace, inability to sit properly, changes in vital signs.
- Induced Abortion: Acutepain related to surgical intervention as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- PID (Pelvic Inflammatory Disease): Acutepain related to biological injury; inflammation, edema, congestion of pelvic tissues as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- PMS (Premenstrual Syndrome): Acutepain related to hormonal stimulation of gastrointestinal structures as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, nausea, vomiting, diarrhea, changes in vital signs.
- Postpartum Hemorrhage: Acutepain related to nursing and medical interventions to control bleeding as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, confusion, changes in vital signs.
- Postpartum: Acutepain related to episiotomy, lacerations, bruising, breast engorgement, headache, sore nipples, epidural or intravenous site, hemorrhoids as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Sore Nipples: Acutepain related to cracked nipples as evidenced by verbal reports of pain, redness and cracked nipple, moaning, crying, facial grimace.
- Spontaneous Abortion: Acutepain related to uterine contractions, surgical intervention as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
Acute pain related to invasive procedures
- Bone Marrow Biopsy: Acute pain related to bone marrow aspiration, invasive procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
- Chest Tubes: Acutepain related to presence of chest tubes, injury as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Intubation, Endotracheal or Nasogastric Tube: Acutepain related to presence of tube as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
- Lumbar Puncture: Acutepain related to possible loss of cerebrospinal fluid as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Percutaneous Nephrostomy: Acutepain related to invasive procedure as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Thoracotomy: Acutepain related to surgical procedure, coughing, deep breathing as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, shallow breathing, changes in vital signs.
- Tracheostomy: Acutepain related to edema, surgical procedure as evidenced by reports of pain, moaning, crying, facial grimace, guarding, changes in vital signs.
- Traction and Casts: Acutepain related to immobility, injury, or disease as evidenced by verbal reports of pain, moaning, crying, facial grimace, guarding, shortness of breath, changes in vital signs.
Labor Pain Nursing Diagnosis
Labor pain related to uterine contractions, cervical and birth canal stretching, expulsion of the fetus.
Chronic Pain Syndrome Nursing Diagnosis
Chronic pain syndrome related to persistent pain affecting daily living (specify condition; eg: spinal cord injury).
Chronic pain syndrome related to long-term opioid use.
Acute Pain Care Plan Examples
Nursing care plan for acute pain related to MI
Nursing Diagnosis
Acute pain related to decreased blood flow to the myocardium, myocardial ischemia or infarct, increased cardiac workload, and oxygen consumption as evidenced by changes in ECG (specify ECG changes, eg; ST-segment elevation on leads), elevated cardiac enzymes, verbal report of pain (specify location, character, intensity), moaning, restlessness, facial grimacing, diaphoresis, changes in blood pressure, tachycardia, tachypnoea, dyspnea, dizziness.
Goal/ Expected Outcome
The patient verbalizes a pain reduction of no more than 3 to 4 on a standardized pain scale of 0 to 10 (0 indicating no pain and 10 indicating most severe pain) within 1 to 2 hours of receiving analgesics.
Demonstrate pain relief by maintaining stable vital signs and avoiding muscle tension and restlessness.