Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Injuring agents (biological, chemical, physical, psychological)
· Verbal or coded report [may be less from clients younger than age 40, men, and some cultural groups]
· Changes in appetite and eating
· [Pain unrelieved and/or increased beyond tolerance]
· Guarded/protective behavior ; antalgic position/gestures
· Facial mask; sleep disturbance (eyes lack luster , beaten look, fixed or scattered movement, grimace)
· Expressive behavior (restlessness, moaning, crying, vigilance, irritability, sighing)
· Distraction behavior (pacing, seeking out other people and/or activities, repetitive activities)
· Autonomic alteration in muscle tone (may span from listless [flaccid] to rigid)
· Autonomic responses (diaphoresis; blood pressure, respiration, pulse change; pupillary dilation)
· Narrowed focus (altered time perception, impaired thought process, reduced interaction with people and environment)
The patient will
• Rate pain on a scale of 1–10.
• Articulate factors that intensify pain and will modify behaviors accordingly.
• State and carry out appropriate interventions for relief of pain.
• Decrease amount and frequency of pain medication needed.
• Express feeling of comfort and relief from pain.
• Perform relaxation exercises at bedtime.
Interventions And Rationales:
Determine: Assess descriptive characteristics of pain, including location, quality and intensity on a scale of 1–10, temporal factors and sources of relief; pain tolerance; ethnicity; attitude and values. Descriptions about the particulars of pain will help determine what goals are realistic for the patient.
Perform: Make changes in the environment at the patient’s suggestion that will promote sleep. This allows patient to have an active role in treatment.
Apply heat or cold as prescribed to minimize or relieve pain. Reposition patient and use pillows to splint or support painful areas, as appropriate to reduce muscle spasm and to redistribute pressure on body parts. Administer analgesic medications in a collaborative mode with the patient when alternative methods are not sufficient to make the pain tolerable. Gaining the patient’s trust and involvement helps ensure compliance and make reduce medication intake.
Provide patient with sleep aids, such as pillows, bath before sleep, and reading materials. Milk and some high-protein snacks, such as cheese and nuts, contain L-tryptophan and are also sleep promoters. Personal hygiene and prebedtime rituals promote sleep in some patients. Comfort measures act as distracters from pain, reduce muscle tension or spasm, and redistribute pressure on body parts.
Inform: Teach patient relaxation techniques such as guided imagery, deep breathing, meditation, aromatherapy, and progressive muscle relaxation. Practice with the patient frequently and especially at bedtime. Purposeful relaxation efforts usually help promote sleep.
Instruct patient to eliminate or reduce caffeine and alcohol intake and avoid foods that interfere with sleep (e.g., spicy foods). Foods and beverages containing caffeine consumed fewer than 4 hours before bedtime may interfere with sleep. Alcohol disrupts normal sleep, especially when ingested immediately before retiring.
Attend: Listen to patient’s description of pain. Allow time for the patient to talk about his or her frustration. Listening attentively gives the patient a feeling that the nurse is interested. It also helps determine progress in alleviating the pain.
Ask patient each day to describe the quality of his or her sleep. Discomfort associated with pain may prevent the patient from sleeping well.
Encourage activities that provide distraction, such as reading, crafts, television, and visits to help patient focus on non-pain-related matters.
Manage: When possible, allow patient to use alternative pain treatments common in his or her culture (such as acupuncture) as a substitute or a complement to Western treatments to promote nonpharmacologic pain management
Refer to case manager/social worker to ensure that follow-up is provided.
DeJong, A. E., & Gamel, C. (2006, June). Use of simple relaxation technique in burn care: Literature review. Journal of Advanced Nursing, 54(6), 710–721