Nursing diagnosis: acute Pain related to Injuring agents—biological, physical, psychological—muscle spasms, surgical procedure, preexisting chronic joint diseases, elderly age, anxiety
Possibly evidenced by
Reports of pain; distraction, guarding behaviors
Narrowed focus, self-focusing
Alteration in muscle tone; autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Report pain relieved or controlled.
Appear relaxed, able to rest or sleep appropriately.
Demonstrate use of relaxation skills and diversional activities, as indicated by individual situation.
Nursing intervention with rationale:
1. Perform comprehensive assessment of pain, noting intensity (scale of 0–10), duration, and location. Determine if pain is at operative or different site, associated with ROM or weightbearing, associated with vascular compromise or fever.
Rationale: Provides information on which to base and monitor effectiveness of interventions.
2. Maintain proper position of operated extremity.
Rationale: Reduces muscle spasm and undue tension on new prosthesis and surrounding tissues.
3. Provide comfort measures—frequent repositioning, back rub—and diversional activities. Encourage stress management techniques, such as progressive relaxation, guided imagery, visualization, and meditation. Provide Therapeutic Touch, as appropriate.
Rationale: Reduces muscle tension, refocuses attention, promotes sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period.
4. Medicate on a regular schedule and before activities or procedures.
Rationale: Reduces muscle tension, improves comfort, and facilitates participation.
5. Investigate reports of sudden, severe joint pain with muscle spasms and changes in joint mobility, or sudden, severe chest pain with dyspnea and restlessness.
Rationale: Early recognition of developing problems, such as dislocation of prosthesis or blood or fat pulmonary emboli, provides opportunity for prompt intervention and prevention of more serious complications.
6. Administer medications as indicated, around the clock, such as: Opioids—instruct in and monitor use of patient-controlled analgesia (PCA), epidural administration, and/or pain ball
Rationale: Relieves surgical pain and reduces muscle tension and spasm, which contribute to overall discomfort. Opioid infusion (including epidural) may be given during the first 24 to 48 hours. The ON-Q PainBuster® ball provides continuous infusion of local anesthetic directly into surgical site for up to 5 days, thus decreasing need for opioids, and allows for earlier ambulation than epidural administration.
7. Analgesics, such as, oxycodone (Percocet), hycodone and acetaminophen (Vicodin), and muscle relaxants
Rationale: Oral analgesics are added to pain management program as the client progresses. Note: Use of ketorolac (Toradol) or other nonsteroidal anti-inflammatory drug (NSAID) is contraindicated when client is receiving enoxaparin (Lovenox) therapy.
8. Apply ice packs, as indicated.
Rationale: Promotes vasoconstriction to reduce bleeding and tissue edema in surgical area and lessens perception of discomfort.
9. Initiate and maintain extremity mobilization, such as, ambulation, physical therapy, exerciser, or continuous passive motion (CPM) device.
Rationale: Increases circulation to affected muscles. Minimizes joint stiffness; relieves muscle spasms related to disuse.