Nursing diagnosis: acute/chronic Pain related to injuring agents—biological, chemical, physical, psychological
Possibly evidenced by
Changes in appetite and eating, sleep pattern
Guarding, protective behavior; restlessness, moaning, crying, irritability
Desired Outcomes/Evaluation Criteria—Child Will
Report or indicate pain is relieved or controlled.
Manifest decreased restlessness and irritability.
Demonstrate age-appropriate blood pressure (BP), pulse, and respiratory rates.
Pain Disruptive Effects
Participate in usual activities within level of ability.
Nursing intervention with rationale:
1. Perform routine comprehensive pain assessment, including location, characteristics, onset, duration, frequency, quality, and severity using some type of rating scale, such as numbers or visual analog, facial expressions, or color scale.
Rationale: Assessment of children involves observational skills and may require enlisting the aid of parent or caregiver to clarify cues and verbalizations. Choice of rating scale is dependent on age and developmental level (Suresh, 2002).
2. Accept child’s description of pain, noting precipitating, exacerbating, and relieving factors.
Rationale: Pain is subjective and cannot be experienced by others. Note: In presence of chronic pain situation, use of a pain diary may be appropriate for adolescents (Suresh, 2002).
3. Investigate changes in frequency or description of pain.
Rationale: May signal worsening of condition or development of complications.
4. Observe for guarding, rigidity, crying, and restlessness.
Rationale: Nonverbal expressions, body movement, and behavioral state may signal pain or changes in pain severity, especially in infants and younger children (Suresh, 2002).
5. Monitor heart rate, BP using correctly sized cuff, and respiratory rate, noting age-appropriate normals and variations.
Rationale: Changes in autonomic responses may indicate increased pain before child verbalizes. Note: Autonomic responses change with acute pain, not chronic pain. BP may be lower than normal or higher than normal.
6. Note location and type of surgical incisions or trauma.
Rationale: Influences degree and severity of pain manifestations.
7. Identify ways to avoid or minimize pain, such as splinting surgical incisions during coughing, sleeping on a firm mattress, or wearing brace on sprains.
Rationale: Many factors may reduce pain intensity based on specific situation. Child can quickly learn and use such pain management techniques, enhancing sense of control as well as comfort.
8. Review procedures and expectations and tell child when it will hurt. Provide distraction during painful procedures, such as deep breathing or counting, or looking at something that interests child.
Rationale: Although the procedure may still be stressful, child will find it easier to handle if he or she knows what to expect and has developed coping strategies.
9. Collaborate in treatment of underlying conditions or disease process.
Rationale: Treating cause, when possible, can eliminate pain.
10. Administer medications, such as opioid and nonsteroidal analgesics, as indicated. Use multiple routes to deliver analgesia, such as oral, nebulized, transdermal, or patientcontrolled analgesia (PCA), as indicated by current situation.
Rationale: Depending on the cause and type of pain, as well as its chronicity, various means of pain management may be needed to overcome or control pain.