Nursing Diagnosis: Pain, acute/chronic
May be related to
- Tissue inflammation/destruction: infections, internal/external cutaneous lesions, rectal excoriation, malignancies, necrosis
- Peripheral neuropathies, myalgias, and arthralgias
- Abdominal cramping
Possibly evidenced by
- Reports of pain
- Self-focusing; narrowed focus, guarding behaviors
- Alteration in muscle tone; muscle cramping, ataxia, muscle weakness, paresthesias, paralysis
- Autonomic responses; restlessness
Desired Outcomes
- Report pain relieved/controlled.
- Demonstrate relaxed posture/facial expression.
- Be able to sleep/rest appropriately.
| Nursing Interventions | Rationale |
| Assess pain reports, noting location, intensity (0–10 scale), frequency, and time of onset. Note nonverbal cues, e.g., restlessness, tachycardia, grimacing. | Indicates need for/effectiveness of interventions and may signal development/resolution of complications. Note:Chronic pain does not produce autonomic changes; however, acute and chronic pain can coexist. |
| Instruct/encourage patient to report pain as it develops rather then waiting until level is severe. | Efficacy of comfort measures and medications is improved with timely intervention. |
| Encourage verbalization of feelings. | Can reduce anxiety and fear and thereby reduce perception of intensity of pain. |
| Provide diversional activities, e.g., reading, visiting, radio/television. | Refocuses attention; may enhance coping abilities. |
| Perform palliative measures, e.g., repositioning, massage, ROM of affected joints. | Promotes relaxation/decreases muscle tension. |
| Instruct patient in/encourage use of visualization, guided imagery, progressive relaxation, deep-breathing techniques, meditation, and mindfulness. | Promotes relaxation and feeling of well-being. May decrease the need for narcotic analgesics (CNS depressants) when a neuro/motor degenerative process is already involved. May not be successful in presence of dementia, even when dementia is minor. Note:Mindfulness is the skill of staying in the here and now. |
| Provide oral care. (Refer to ND: Oral Mucous Membrane, impaired.) | Oral ulcerations/lesions may cause severe discomfort. |
| Apply warm/moist packs to pentamidine injection/IV sites for 20 min after administration. | These injections are known to cause pain and sterile abscesses |
| Administer analgesics/antipyretics, narcotic analgesics. Use patient-controlled analgesia (PCA) or provide around-the-clock analgesia with rescue doses prn. | Provides relief of pain/discomfort; reduces fever. PCA or around-the-clock medication keeps the blood level of analgesia stable, preventing cyclic undermedication or overmedication. Note: Drugs such as Ativan may be used to potentiate effects of analgesics. |
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