Nursing diagnosis: acute Pain 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/Evaluation Criteria—Client Will
Verbalize relief of pain.
Display relaxed manner, able to participate in activities, and sleep and rest appropriately.
Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation.
Nursing intervention with rationale:
1. Maintain immobilization of affected part by means of bedrest, cast, splint, and traction. (Refer to ND: risk for Trauma.)
Rationale: Relieves pain and prevents bone displacement/extension of tissue injury.
2. Elevate and support injured extremity.
Rationale: Promotes venous return, decreases edema, and may reduce pain.
3. Avoid use of plastic sheets/pillows under limbs in cast.
Rationale: Can increase discomfort by enhancing heat production in the drying cast.
4. Elevate bed covers and keep linens off toes.
Rationale: Maintains body warmth without discomfort due to pressure of bedclothes on affected parts.
5. Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (scale of 0–10), relieving, and aggravating factors. Note nonverbal pain cues, such as changes in vital signs and emotions or behavior. Listen to reports of family member/significant other (SO) regarding client’s pain.
Rationale: Influences choice of, and monitors effectiveness of, interventions. Many factors, including level of anxiety, may affect perception of and reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain.
6. Encourage client to discuss problems related to injury.
Rationale: Helps alleviate anxiety. Client may feel need to relive the accident experience.
7. Explain procedures before beginning them.
Rationale: Allows client to prepare mentally for activity and to participate in controlling level of discomfort.
8. Medicate before care activities. Let client know it is important to request medication before pain becomes severe.
Rationale: Promotes muscle relaxation and enhances participation.
9. Perform and supervise passive or active ROM exercises.
Rationale: Maintains strength and mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues.
10. Provide emotional support and encourage use of stress managements techniques—progressive relaxation, deepbreathing exercises, and visualization or guided imagery; provide therapeutic touch.
Rationale: 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.