Nursing Diagnosis: Acute Pain
May be related to
- Muscle spasms
- Movement of bone fragments, edema, and injury to the soft tissue
- Traction/immobility device
- Stress, anxiety
Possibly evidenced by
- Reports of pain
- Distraction; self-focusing/narrowed focus; facial mask of pain
- Guarding, protective behavior; alteration in muscle tone; autonomic responses
Desired Outcomes
- Verbalize relief of pain.
- Display relaxed manner; able to participate in activities, sleep/rest appropriately.
- Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
8 Fracture Nursing Care Plan (NCP)
- Risk for Trauma — Fracture Nursing Care Plan (NCP)
- Acute Pain — Fracture Nursing Care Plan (NCP)
- Risk for Peripheral Neurovascular Dysfunction — Fracture Nursing Care Plan (NCP)
- Risk for Impaired Gas Exchange — Fracture Nursing Care Plan (NCP)
- Impaired Physical Mobility — Fracture Nursing Care Plan (NCP)
- Impaired Skin Integrity — Fracture Nursing Care Plan (NCP)
- Risk for Infection — Fractures Nursing Care Plan (NCP)
- Knowledge Deficit — Fractures Nursing Care Plan (NCP)
Acute Pain — Fracture Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Maintain immobilization of affected part by means of bed rest, cast, splint, traction. | Relieves pain and prevents bone displacement/extension of tissue injury. |
| Elevate and support injured extremity. | Promotes venous return, decreases edema, and may reduce pain. |
| Avoid use of plastic sheets/pillows under limbs in cast. | Can increase discomfort by enhancing heat production in the drying cast. |
| Elevate bed covers; keep linens off toes. | Maintains body warmth without discomfort due to pressure of bedclothes on affected parts. |
| Evaluate/document reports of pain/discomfort, noting location and characteristics, including intensity (0–10 scale), relieving and aggravating factors. Note nonverbal pain cues (changes in vital signs and emotions/behavior). Listen to reports of family member/SO regarding patient’s pain. | Influences choice of/monitors effectiveness of interventions. Many factors, including level of anxiety, may affect perception of/reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain. |
| Encourage patient to discuss problems related to injury. | Helps alleviate anxiety. Patient may feel need to relive the accident experience. |
| Explain procedures before beginning them. | Allows patient to prepare mentally for activity and to participate in controlling level of discomfort. |
| Medicate before care activities. Let patient know it is important to request medication before pain becomes severe. | Promotes muscle relaxation and enhances participation. |
| Perform and supervise active/passive ROM exercises. | Maintains strength/mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. |
| Provide alternative comfort measures, e.g., massage, back rub, position changes. | Improves general circulation; reduces areas of local pressure and muscle fatigue. |
| Provide emotional support and encourage use of stress management techniques, e.g., progressive relaxation, deep-breathing exercises, visualization/guided imagery; provide Therapeutic Touch. | Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period. |
| Identify diversional activities appropriate for patient age, physical abilities, and personal preferences. | Prevents boredom, reduces muscle tension, and can increase muscle strength; may enhance coping abilities. |
| Investigate any reports of unusual/sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics. | May signal developing complications; e.g., infection, tissue ischemia, compartmental syndrome. |
| Apply cold/ice pack first 24–72 hr and as necessary. | Reduces edema/hematoma formation, decreases pain sensation. Note: Length of application depends on degree of patient comfort and as long as the skin is carefully protected. |
| Administer medications as indicated: narcotic and nonnarcotic analgesics, e.g., morphine, meperidine (Demerol), hydrocodone (Vicodin); injectable and oral nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., ketorolac (Toradol), ibuprofen (Motrin); and/or muscle relaxants, e.g., cyclobenzaprine (Flexeril), carisoprodol (Soma), diazepam (Valium). Administer analgesics around the clock for 3–5 days. | Given to reduce pain and/or muscle spasms. Studies of ketorolac (Toradol) have proved it to be effective in alleviating bone pain, with longer action and fewer side effects than narcotic agents. |
| Maintain/monitor IV patient-controlled analgesia (PCA) using peripheral, epidural, or intrathecal routes of administration. Maintain safe and effective infusions/equipment. | Routinely administered or PCA maintains adequate blood level of analgesia, preventing fluctuations in pain relief with associated muscle tension/spasms. |