Nursing Care Plan 2: Acute Pain
Assessment
Diagnosis &
Inference
Planning
Nursing Intervention
Rationale
Evaluation
Date: September
26, 2023
Subjective:
“Kanang dugay
gud ko maghigda
ma’am, kay sakit
kaayo akong likod
samot na diri
(points at her
lower back)”, as
verbalized by the
patient.
P – aggravated
pain
Q – sharp pain
R – lower back
S – P/S of 8/10
T – worse after
lying in supine
position
Objectives:
Dx:
Acute pain related
to physical agent
(disease process),
as evidenced by
right lower back
pain and a pain
scale of 8/10
Inference:
Acute pain refers to
the unpleasant
sensory and
emotional
experience
associated with
actual or potential
tissue damage, or
described in terms
of such damage;
sudden or slow
onset of any
intensity from mild
to severe and with a
duration of less
General Objective:
To promote the
maintenance of
sensory function.
Specific Objective
Within 8 hours of
nursing intervention
the patient will be able
to:
● Report pain is
relieved or
controlled. Pain
scale of less than
4/10
● Demonstrate use
of relaxation skills
and diversional
activities, as
indicated, for
individual
Independent:
1. Determine and document
presence of possible
pathophysiological and
psychological causes of pain
2. Assess for potential types of
pain that may be affecting clients.
3. Perform pain assessment each
time pain occurs.
4. Monitor skin color and
temperature and vital signs
1. Acute pain is that which follows
an injury, trauma, or procedure
such as surgery, or occurs
suddenly with the onset of a
painful condition (e.g., herniated
disk, migraine, headache,
pancreatitis)
2. Potential types of pain will help
the patient understand the reason
for severity of pain associated with
the client's condition, and point
toward needed interventions for
pain management.
3. Assessing pain will demonstrate
improvement in status or to identify
worsening of underlying
condition/developing
complications.
4. Skin color and vital signs are
usually altered in acute pain.
Provides baseline for interventions
and teaching, provides opportunity
to allay common fears and
misconceptions, or to address
expected side effects of
GOALS MET
Within 8 hours of
nursing intervention,
the patient’s pain is
decreased as
evidenced by:
• Demonstrated use
of relaxation skills
and diversional
activities, as
indicated, for
individual situation
such as deep
breathing
exercises,
visualization,
guided imagery,
meditation, and
pain distraction
(such as counting
or solving)
• Verbalized sense
of control of
response to acute
situations and
positive outlook.
• Described
