Acute Pain Nursing Diagnosis

Daytonite, BSN, RN · Oct 5, 2009

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during your assessment of the patient. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

so, i am confused. you say "it is policy not to medicate for pain if it is rated as less than a 4/10". does that also apply to the information that you put on your care plan? does this care plan that you are writing get placed on this patient's chart or turned in to your instructors?

i went through the information you posted and i came up with data that is usable, although not measurable. however, it is not your fault that the staff nurses didn't do a stellar job of documenting his level of pain, is it? you should make a note of this in your care plan: "the level of pain was only documented as severe by the staff nurses on duty".

in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .

severe post-op chest pain
has a history of cardiac conditions - what cardiac conditions? this is important to know because it will have an impact on the pathophysiology of the pain. most chest pain is first ruled out to be of cardiac origin (tissue perfusion problem). once that is ruled out then musculoskeletal or gi sources of the chest pain are considered. if he was not given nitroglycerin for his chest pain, then the docs didn't think it was a heart problem. it could be a lung problem. it could be swelling from the surgery (which you haven't mentioned) pressing on internal structures causing pain. ii could have been due to the way he was placed on the surgical table and this is merely a musculoskeletal pain. since you didn't mention any of his other problems or the type of surgery he had, i can't help you on this, but you need to figure out a cause of why his chest would be hurting for the "related to" part of your nursing diagnostic statement and it probably lies in the type of surgery that was done.
he described that it was a feeling of throbbing and tightness located in the left side of his chest
when i assessed his pain it was decreased to a 2 out of 10 (this was after receiving pain medication?)

secondly, determine your nursing problem from the abnormal data. . .

acute pain r/t ??? aeb a feeling of throbbing and tightness located in the left side of his chest which he describes as 2 out of 10. [this is based on your assessment at the time you took care of the patient]

this is probably musculoskeletal pain. if it were cardiac in origin he would be getting nitroglycerin for the pain and your nursing diagnosis would be decreased cardiac output r/t ischemia.

cjcsoon2bnp, MSN, RN, NP · Oct 5, 2009

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)
problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during your assessment of the patient. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
so, i am confused. you say "it is policy not to medicate for pain if it is rated as less than a 4/10". does that also apply to the information that you put on your care plan? does this care plan that you are writing get placed on this patient's chart or turned in to your instructors?

i went through the information you posted and i came up with data that is usable, although not measurable. however, it is not your fault that the staff nurses didn't do a stellar job of documenting his level of pain, is it? you should make a note of this in your care plan: "the level of pain was only documented as severe by the staff nurses on duty".

in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .

severe post-op chest pain
has a history of cardiac conditions - what cardiac conditions? this is important to know because it will have an impact on the pathophysiology of the pain. most chest pain is first ruled out to be of cardiac origin (tissue perfusion problem). once that is ruled out then musculoskeletal or gi sources of the chest pain are considered. if he was not given nitroglycerin for his chest pain, then the docs didn't think it was a heart problem. it could be a lung problem. it could be swelling from the surgery (which you haven't mentioned) pressing on internal structures causing pain. ii could have been due to the way he was placed on the surgical table and this is merely a musculoskeletal pain. since you didn't mention any of his other problems or the type of surgery he had, i can't help you on this, but you need to figure out a cause of why his chest would be hurting for the "related to" part of your nursing diagnostic statement and it probably lies in the type of surgery that was done.
he described that it was a feeling of throbbing and tightness located in the left side of his chest
when i assessed his pain it was decreased to a 2 out of 10 (this was after receiving pain medication?)
secondly, determine your nursing problem from the abnormal data. . .
acute pain r/t ??? aeb a feeling of throbbing and tightness located in the left side of his chest which he describes as 2 out of 10. [this is based on your assessment at the time you took care of the patient]
this is probably musculoskeletal pain. if it were cardiac in origin he would be getting nitroglycerin for the pain and your nursing diagnosis would be decreased cardiac output r/t ischemia.

thanks daytonite for all of your help i really appreciate it! let me see if i can give some information to help clear some things up.

basically, the patient was brought to this hospital to go for an ent related surgery (with a surgical scar around the ear) and was expected to go home the same day. when the patient was brought into the pacu the patient started complaining of "severe chest pain, nausea, shortness of breath and tingling in both arms" and the patient had an ekg done and blood work drawn (including cardiac enzymes) and based upon that the physician noted in his report that he "did not believe that the chest pain was cardiac in nature" but booked a telemetry bed so the patient could be observed "because of the patient's history of medical conditions especially those that are cardiac in nature" and so the chest pain and nausea could be treated. this patient has a history of coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, crohn's disease, acid reflux disease and has had cardiac catherization showing mild heart failure, angioplasty with stent insertion, pacemaker insertion for left bundle branch block. the patient is being treated with a nitro patch and has percocet available prn. but if the physician "did not believe the pain was cardiac in nature" then why would they prescribe the nitro patch. it was suggested to me that the physician may believe that the pain could be both cardiac and gi in nature and that's why it was being treated with both (because the patient does receive some pain relief from the nitro patch but the patient still has pain which he believe is from his gi conditions too.)

so when i was first assigned the patient i came in and did my vital signs as soon as i came on shift which including a pain assessment. the patient informed me that their pain "was much better since the night nurse had given me pain medication about an hour and a half ago" i asked the patient to describe and rate their pain at that current time when i was in the room and it was a "throbbing and tightness in the left side of the chest which they described as a 2 out of 10". i informed the nurse that i was working with and she told me that "the policy is to not give pain medication for pain less than a 4 out of 10" so i went back to the room and discussed with the patient that since he had already received pain medication only an hour an a half before he did not have any other pain medication available at this time and that normally the policy is not medicate for pain less then a 4 out of 10. i said that if the patient felt like he needed more pain medication i could speak with his physician and we discussed non-pharmacologic pain management techniques, he did not think he needed more pain medication but he decided to try some relaxation, listening to music and i also did some distraction techniques by sitting and talking with the patient. i would say that at about an hour after i first assessed the patients pain i asked again if he was in pain after trying the non-pharmacologic pain management techniques and he reported that he was in no pain at that time. the care plan i am making is not going into the patient's chart it is being turned into my instructor. now what i was wondering is when i make this care plan can i base it on the pain assessment i did with the patient and how his pain went from a 2/10 to a 0/10? i did not do the previous assessment or administer the pain medication to him so i didn't think that should be put in my care plan. i just feel that if i put that he was given pain medication by the other nurse and the pain went to a 2/10 then it does not focus on the results of my interventions and i would not be able to give the original pain rating from the night nurse since i wasn't there. i mean i can still use the "acute pain" nursing diagnosis even if the patient only reports the pain as a 2/10 right? that's still pain and discomfort for the patient. i would just have the goal to be free of pain (which he was when i assessed his pain for the second time.)

!chris :specs:

Daytonite, BSN, RN · Oct 5, 2009

i mean i can still use the "acute pain" nursing diagnosis even if the patient only reports the pain as a 2/10 right? that's still pain and discomfort for the patient.

yes. the diagnosis is based on the presence of the symptoms which is pain of 2/10. the definition of

acute pain

is

unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

i would just have the goal to be free of pain

goals quite simply can be what you expect will happen when your nursing interventions are performed. they don't necessarily have to be the complete obliteration of the patient's pain. nursing interventions are of four types:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
care/perform/provide/assist (performing actual patient care)
teach/educate/instruct/supervise (educating patient or caregiver)
manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

if you have teaching interventions your goals that relate to them will not necessarily have to do with the patient being free of pain but with the patient performing some return demonstration perhaps to indicate that a teaching was learned properly.

cjcsoon2bnp, MSN, RN, NP · Oct 7, 2009

Ok I'm sorry to be a pain but I have another question. The physician put in his notes that he "does not believe that the pain is cardiac in nature" and yet the patient is still being treated with Nitro. so should I put my diagnosis as "Acute Pain R/T decreased myocardial oxygenation" or should I put "Acute Pain R/T unknown pathological process"? I mean the pain does not have the diagnosis of Angina in their chart anywhere and the pain did not have a clear diagnosis and yet the patient has a Nitro. patch. I really don't want to put "Acute Pain R/T unknown pathological process" but the part where the physician put that he "does not believe the pain is cardiac in nature" so I'm not really sure what to do.

!Chris :specs:

Daytonite, BSN, RN · Oct 7, 2009

You assessed and saw the patient. What do you think is going on? Did his chest pain respond to the nitroglycerin or the other pain medication? This is a nursing problem, not a medical one.

He has CAD. Did you look up information about this disease? It is why he is getting the nitroglycerin.