Acute Pain is characterized by the following signs and symptoms:

Patient complains of pain

Appetite changes
Self-focused
Guarding behavior, protecting body part
Intolerant (e.g., altered time perception, withdrawal from social or
physical contact)
Facial mask of pain
Autonomic responses (e.g., diaphoresis, an alteration in BP, HR,
pupillary dilation; alteration in RR; pallor; nausea)
Change in muscle tone: lethargy or weakness; rigidity or tightness
Relief or distraction behavior (e.g., pacing, seeking out other people or
activities)
Expressive behavior (e.g., restlessness, moaning, crying)
Hopelessness
Observed evidence of pain using standardized pain behavior checklist
For those unable to communicate; refer to the appropriate assessment
tool (e.g., Behavioral Pain Scale, Neonatal Infant Pain Scale, Pain
Assessment Checklist for Seniors with Limited Ability to Communicate)
Positioning to avoid pain
Protective gestures
Proxy reporting pain and behavior/activity changes (e.g., family
members, caregivers)
Self-report of intensity using standardized pain intensity scales (e.g.,
Wong-Baker FACES scale, visual analogue scale, numeric rating scale)
Self-report of pain characteristics (e.g., aching, burning, electric shock,
pins and needles, shooting, sore/tender, stabbing, throbbing) using
standardized pain scales (e.g., McGill Pain Questionnaire, Brief Pain
Inventory)

Goals and Outcomes

The following are the common goals and expected outcomes for Acute Pain.

Patient describes satisfactory pain control at a level less than 3 to 4 on

a rating scale of 0 to 10.
Patient displays improved well-being such as baseline levels for pulse,
BP, respirations, and relaxed muscle tone or body posture.
Patient uses pharmacological and nonpharmacological pain-relief
strategies.
Patient displays improvement in mood, coping.

Nursing Assessment

Proper assessment of Acute Pain is imperative for the development of an

effective pain management plan. Nurses play a crucial role in the assessment of
pain, owing to the nature of their relationship with patients.

Assessment Rationales

Assess pain characteristics:

Quality (e.g., burning,

sharp, shooting)
Assessment of pain experience is the first
Severity (scale of 0 or step in planning pain management
no pain to 10 or most strategies. The most reliable source of
information about the pain is the patient.
severe pain)
Descriptive scales such as a visual analogue
Location (anatomical
can be utilized to distinguish the degree of
description)
pain.
Onset (gradual or
sudden)
Duration (how long;
intermittent or
continuous)
 Precipitating or relieving
factors
Assess for signs and symptoms
relating to pain.
Assess to what degree cultural,
environmental, intrapersonal,
and intrapsychic factors may
contribute to pain or pain relief.
Assess the patents anticipation
for pain relief.
Assess the patients willingness
or ability to explore a range of
techniques aimed at controlling
pain.
Assess the suitability of the
patient as a PCA candidate
Some people deny the existence of pain.
Attention to associated signs may help the
nurse in evaluating pain. An increase in BP,
HR, and temperature may be present in a
patient with acute pain. The patients skin
may be pale and cool to touch. Restlessness
and inability to concentrate are also some
manifestations.
Such variables play a big role in modifying
the patients expression of pain. Some
cultures simply express feelings, whereas
others hold such expression. Nevertheless,
health care providers should not prejudge
any patient response but rather evaluate
the unique response of each individual.
Some patients may be satisfied when pain is
no longer massive; others will demand
complete elimination of pain. This influences
the perceptions of the effectiveness of the
treatment of the treatment modality and
their eagerness to engage in further
treatments.
Other patients may be overlooking of the
effectiveness of nonpharmacological
methods and may be willing to try them,
either with or instead of traditional
analgesic medications. Often a combination
of therapies (e.g., mild analgesics with
distraction or heat) may be more effective.
Some patients will feel uncomfortable
exploring alternative methods of pain relief.
However, patients need to be acquainted
that there are other approaches to manage
pain.
PCA is the IV infusion of an opioid
(usually morphine or Demerol) through an
infusion pump that is controlled by the
patient. This allows the patient to manage
pain relief within prescribed limits. The
criteria for implementing PCA include:
 No allergy to opioid analgesics
No history of substance abuse
No history of renal, hepatic, or
respiratory disease
No history of major psychiatric
disorder
Clear sensorium
Cooperative and motivated about
use
Manual dexterity

In the hospice or home setting, a nurse or

caregiver may be needed to assist the
patient in managing the infusion.

If the patient is on PCA, assess the following:

If requests for medication are quite
frequent, the patients dosage may need to
Weigh the amount of pain
be increased to promote pain relief. if
medication the patient is using
requests are very low, the patient may
to his or her reports of pain.
require further guidance to correctly use
PCA.
Potential PCA complications
such as excessive sedation;
Early assessment of complication is required
respiratory distress; urinary
to prevent serious adverse reactions to
retention; nausea and
opioid analgesics.
vomiting; constipation; and IV
site pain, or swelling
If the patient is receiving epidural analgesia, assess the following:
Tingling in the extremities, These symptoms may be indicators of an
numbness, a metallic taste in allergic response to the anesthesia agent or
the mouth of incorrect catheter placement.
Potential epidural analgesia
Respiratory depression and intravascular
complications such as extreme
infusion of anesthesia (resulting from
sedation, respiratory
catheter migration) can be potentially life
distress, urinary retention, or
threatening.
catheter migration

Evaluate the patients response
to pain and management
strategies.
Evaluate what the pain suggests
to the patient.
It is essential to assist patients express as
factually as possible (i.e., without the effect
of mood, emotion, or anxiety) the effect of
pain relief measures. Inconsistencies
between behavior or appearance and what
the patient says about pain relief (or lack of
it) may be more a reflection of other
methods the patient is using to cope with
the pain rather than pain relief itself.
The meaning of pain will directly determine
the patients response. Some patients,
especially the dying, may consider that the
act of suffering meets a spiritual need.