What is the priority nursing diagnosis for a patient experiencing a migraine headache

Use this guide to formulate your nursing care plans and nursing interventions for patients experiencing acute pain.

The unpleasant feeling of pain is highly subjective in nature that may be experienced by the patient. The International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Another great and influential definition of pain is from Margo McCaffery, a nurse expert on pain, who defined it as pain is whatever the person says it is and exists whenever the person says it does.

Acute pain provides a protective purpose to make the patient informed and knowledgeable about the presence of an injury or illness. The unexpected onset of acute pain reminds the patient to seek support, assistance, and relief. It has a duration of fewer than six months. The physiological signs of acute pain emerge from the bodys response to pain as a stressor.

Other factors such as the patients cultural background, emotions, and psychological or spiritual discomfort may contribute to acute pain. In older patients, assessment of pain can be challenging due to cognitive impairment and sensory-perceptual deficits. Assessment and management of the nursing diagnosis of acute pain are the main focus of this care plan.

• Common Signs and Symptoms of Acute Pain
• Patient Goals for Acute Pain
• Related Nursing Care Plans for Acute Pain
• Acute Pain Nursing Assessment
• Nursing Interventions for Acute Pain
• Recommended Resources
• See also
• References and Sources

Common Signs and Symptoms of Acute Pain

The following are the common manifestations of acute pain. Use these subjective and objective data to help guide you through the nursing assessment. Alternatively, you can check out the assessment guide for acute pain in the subsequent sections.

• The most common characteristic of acute pain is when the patient reports or complaints about it. It is also the most common chief complaint that brings patients to their health care providers.
  • Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker FACES scale, visual analog scale, numeric rating scale)
  • Self-report of pain characteristics (e.g., aching, burning, electric shock, pins, and needles, shooting, sore/tender, stabbing, throbbing) using standardized pain scales (e.g., McGill Pain Questionnaire, Brief Pain Inventory)
• Other signs of pain include:
  • Guarding behavior or protecting the body part
  • Facial mask of pain (e.g., grimaces)
  • Expression of pain (e.g., restlessness, crying, moaning)
• Autonomic response to pain:
  • Profuse sweating
  • Alteration in BP, HR, RR
  • Dilation of the pupils
• Proxy reporting pain and behavior/activity changes (e.g., family members, caregivers)

Patient Goals for Acute Pain

The following are the common nursing care planning goals and expected outcomes for Acute Pain:

• Patient demonstrates the use of appropriate diversional activities and relaxation skills.
• Patient describes satisfactory pain control at a level (for example, less than 3 to 4 on a rating scale of 0 to 10)
• Patient displays improved well-being such as baseline levels for pulse, BP, respirations, and relaxed muscle tone or body posture.
• Patient uses pharmacological and nonpharmacological pain-relief strategies.
• Patient displays improvement in mood, coping.

Diseases, medical conditions, and related nursing care plans for Acute Pain nursing diagnosis:

• Surgery (Perioperative Client)
• Brain Tumor
• Fracture
• Hypertension
• Tonsillitis
• Click here for more sample nursing care plans for the acute pain nursing diagnosis.

NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and followed by their specific rationale in the following line. Still, when writing nursing care plans, follow the format here.

Acute Pain Nursing Assessment

Proper nursing assessment of Acute Pain is imperative for the development of an effective pain management plan. Nurses play a crucial role in the assessment of pain, use these techniques on how to assess acute pain:

1. Perform a comprehensive assessment of pain. Determine the location, characteristics, onset, duration, frequency, quality, and severity of pain via assessment.
The patient experiencing pain is the most reliable source of information about their pain. Their self-report on pain is the gold standard in pain assessment as they can describe the location, intensity, and duration. Thus, assessment of pain by conducting an interview helps the nurse in planning optimal pain management strategies.

Alternatively, you can use the nursing mnemonic PQRST to guide you during pain assessment:

• Provoking Factors: What makes your pain better or worse?
• Quality (characteristic): Tell me what its exactly like. Is it a sharp pain, throbbing pain, dull pain, stabbing, etc?
• Region (location): Show me where your pain is.
• Severity: Ask your pain to rate pain by using different pain rating methods (e.g., Pain scale of 1-10, Wong-Baker Faces Scale).
• Temporal (onset, duration, frequency): Does it occur all the time or does it come and go?

2. Assess the location of the pain by asking to point to the site that is discomforting.
Using charts or drawings of the body can help the patient, and the nurse determines specific pain locations. For clients with a limited vocabulary, asking to pinpoint the location helps in clarifying your pain assessment - this is especially important when assessing pain in children.

3. Perform history assessment of pain
Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.

4. Determine the clients perception of pain.
In taking a pain history, provide an opportunity for the client to express in their own words how they view the pain and the situation to gain an understanding of what the pain means to the client. You can ask, What does having this pain mean to you?, Can you describe specifically how this pain is affecting you?.

5. Pain should be screened every time vital signs are evaluated.
Many health facilities set pain assessment as the fifth vital sign and should be added to routine vital signs assessment.

6. Pain assessments must be initiated by the nurse.
Pain responses are unique for each person, and some clients may be reluctant to report or voice out their pain unless asked about it.

7. Use the Wong-Baker FACES Rating Scale to determine pain intensity.
Some clients (e.g., children, language constraints) may not relate to numerical pain scales and may need to use the Wong-Baker Faces Rating Scale. Pain assessment tools help translate the patients subjective experience of pain into objective numbers or descriptors.

 8. Investigate signs and symptoms related to pain.
An accurate assessment of pain is crucial in providing an individualized plan of care. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain. In some instances, the existence of pain is disregarded by the patient.

9. Determine the patients anticipation for pain relief.
Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.

10. Assess the patients willingness or ability to explore a range of techniques to control pain.
Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., the use of analgesics). A combination of both therapies may be more effective, and the nurse has the duty to inform the patient of the different methods to manage pain.

11. Determine factors that alleviate pain.
Ask clients to describe anything they have done to alleviate the pain. These may include, for example, meditation, deep breathing exercises, praying, etc. Information on these alleviating activities can be integrated into planning for optimal pain management.

12. Evaluate the patients response to pain and management strategies.
It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may reflect other methods the patient is using to cope with the pain rather than pain relief itself.

13. Provide ample time and effort regarding the patients report of their pain experience.
Patients may be reluctant to report their pain as they may perceive staff to be very busy and have competing demands on their time from other nurses, doctors, and patients (Manias et al., 2002). Interruptions during pain management can prevent nurses from assessing and managing the patients pain experience.

14. Evaluate what the pain suggests to the patient.
The meaning of pain will directly determine the patients response. Some patients, especially the dying, may consider that the act of suffering meets a spiritual need.

Nursing Interventions for Acute Pain

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time treating patients. The following are the therapeutic nursing interventions for your acute pain care plan:

1. Provide measures to relieve pain before it becomes severe.
It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required. An example would be preemptive analgesia, which is administering analgesics before surgery to decrease or relieve pain after surgery. The preemptive approach is also useful before painful procedures like wound dressing changes, physical therapy, postural drainage, etc.

2. Acknowledge and accept the clients pain.
Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.

3. Provide nonpharmacologic pain management.
Nonpharmacologic methods in pain management may include physical, cognitive-behavioral strategies, and lifestyle pain management. See methods below: 

3.1. Provide cognitive-behavioral therapy (CBT) for pain management.
These methods are used to provide comfort by altering psychological responses to pain. Cognitive-behavioral interventions include:

• Distraction. This technique involves heightening ones concentration upon non-painful stimuli to decrease ones awareness and experience of pain. Drawing the person away from the pain lessens the perception of pain. Examples include reading, watching TV, playing video games, and guided imagery.
• Eliciting the Relaxation Response. Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, and deep breathing.
• Guided imagery. Involves the use of mental pictures or guiding the patient to imagine an event to distract from the pain.
• Repatterning Unhelpful Thinking. Involves patients with strong self-doubts or unrealistic expectations that may exacerbate pain and result in failure in pain management.
• Other CBT techniques include Reiki, spiritually directed approaches, emotional counseling, hypnosis, biofeedback, meditation, and relaxation techniques.

3.2. Provide cutaneous stimulation or physical interventions
Cutaneous stimulation provides effective pain relief, albeit temporary. The way it works is by distracting the client away from painful sensations through tactile stimuli. Cutaneous stimulation techniques include:

• Massage. When appropriate, massaging the affected area interrupts the pain transmission, increases endorphin levels, and decreases tissue edema. Massage aids in relaxation and decreases muscle tension by increasing superficial circulation to the area. Massage should not be done in areas of skin breakdown, suspected clots, or infections.
• Heat and cold applications. Cold works by reducing pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. Cold is best when applied within the first 24 hours of injury while heat is used to treat the chronic phase of an injury by improving blood flow to the area and through reduction of pain reflexes.
• Acupressure. An ancient Chinese healing system of acupuncture wherein the therapist applies finger pressure points that correspond to many of the points used in acupuncture.
• Contralateral stimulation. Involves stimulating the skin in an area opposite to the painful area. This technique is used when the painful area cannot be touched.
• Transcutaneous Electrical Nerve Stimulation (TENS). Is the application of low-voltage electrical stimulation directly over the identified pain areas or along with the areas that innervate pain.
• Immobilization. Restriction of movement of a painful body part is another nonpharmacologic pain management. To do this, you need splints or supportive devices to hold joints in the position optimal for function. Note that prolonged immobilization can result in muscle atrophy, joint contracture, and cardiovascular problems. Check with the agency protocol.
• Other cutaneous stimulation interventions include therapeutic exercises (tai-chi, yoga, low-intensity exercises, ROM exercises), and acupuncture.

4. Provide pharmacologic pain management as ordered.
Pain management using pharmacologic methods involves using opioids (narcotics), nonopioids (NSAIDs), and coanalgesic drugs.

The World Health Organization (WHO) published guidelines on the logical usage of analgesics to treat cancer using a three-step ladder approach - also known as the analgesic ladder. The analgesic ladder focuses on aligning the proper analgesics with the intensity of pain.

• Step 1: For mild pain (1 to 3 pain rating), the WHO analgesic ladder suggests the use of nonopioid analgesics with or without coanalgesics. If pain persists or increases despite providing full doses, then proceed to the next step.
• Step 2: For moderate pain (4 to 6 pain rating), opioid, or a combination of opioid and nonopioid is administered with or without conanalgesics.
• Step 3: For severe pain (7 to 10), the opioid is administered and titrated in ATC scheduled doses until the pain is relieved.

4.1. Provide nonopioids including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, as ordered. 
NSAIDs work in peripheral tissues. Some block the synthesis of prostaglandins, which stimulate nociceptors. They are effective in managing mild to moderate pain. All NSAIDs have anti-inflammatory (except for acetaminophen), analgesic, and antipyretic effects. They work by inhibiting the enzyme cyclooxygenase (COX), a chemical activated during tissue damage, resulting in decreased synthesis of prostaglandins. NSAIDs also have a ceiling effect. Once the maximum analgesic benefit is achieved, additional amounts of the same drug will not produce more analgesia and may risk the patient for toxicity.

Common side effects of NSAIDs include heartburn or indigestion. There is also a possibility of forming a small stomach ulcer due to platelet aggregation. To prevent these side effects, clients should be taught to take NSAIDs with food and a full glass of water.

Common NSAIDs include:

• Aspirin. It can prolong bleeding time and should be stopped a week before a client undergoes any surgical procedure. Should never be given to children below 12 years of age due to the possibility of Reyes syndrome. May cause excessive anticoagulation if the client is taking warfarin.
• Acetaminophen (Tylenol). May have serious hepatotoxic side effects and possible renal toxicity with high dosages or with long-term use. Limit acetaminophen usage to 3 grams per day.
• Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side effects than COX-1 NSAIDs.

4.2. Administer opioids as ordered.
Opioids are indicated for severe pain and can be administered orally, IV, PCA systems, or epidurally.

• Opioids for moderate pain. These include codeine, hydrocodone, and tramadol (Ultram) which are combinations of nonopioid and opioid.
• Opioids for severe pain. These include morphine, hydromorphone, oxycodone, methadone, and fentanyl. Most of these are controlled substances due to potential misuse. These drugs are indicated for severe pain, or when other medications fail to control pain.

4.3. Administer coanalgesics (adjuvants), as ordered. 
Coanalgesics are medications that are not classified as pain medication but have properties that may reduce pain alone or in combination with other analgesics. They may also relieve other discomforts, increase the effectiveness of pain medications, or reduce the pain medications side effects. Commonly used coanalgesics include: 

• Antidepressants. Is a common coanalgesic that helps in increasing pain relief, improving mood, and reducing excitability.
• Local Anesthetics. These drugs block the transmission of pain signals and are used for pain in specific areas of nerve distribution.
• Other coanalgesics. Include anxiolytics, sedatives, and antispasmodics to relieve other discomforts. Stimulants, laxatives, and antiemetics are other coanalgesics that reduce the side effects of analgesics.

5. Manage acute pain using a multimodal approach. 
A multimodal approach is based on using two or more distinct methods or drugs to enhance pain relief (rather than resorting to opioid use or other pain management strategies alone). Different combinations of analgesic medications, adjuvants, and procedures can act on different sites and pathways in an additive or synergistic fashion. Combining medications and techniques allows the lowest effective dose of each drug to be administered, resulting in reduced side effects. 

6. Administer analgesia before painful procedures whenever possible.
Doing so will help prevent pain caused by relatively painful procedures (e.g., wound care, venipunctures, chest tube removal, endotracheal suctioning, etc.).

7. Perform nursing care during the peak effect of analgesics. 
Oral analgesics typically peak in 60 minutes, and intravenous analgesics in 20 minutes. Performing nursing tasks during the peak effect of analgesics optimizes client comfort and compliance in care. 

8. Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects.
The patients effectiveness of pain medications must be evaluated individually since they are absorbed and metabolized differently.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurses Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patients care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors - this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canales Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If youre looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

References and Sources

Recommended resources and to further your study for this acute pain nursing care plan.

1. Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.
2. Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins.
3. Hartrick, C. T. (2004). Multimodal postoperative pain management. American Journal of Health-System Pharmacy, 61(suppl_1), S4-S10.
4. Herr, K., Titler, M. G., Schilling, M. L., Marsh, J. L., Xie, X., Ardery, G., … & Everett, L. Q. (2004). Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers. The Clinical journal of pain, 20(5), 331-340.
5. Hsieh, L. L. C., Kuo, C. H., Lee, L. H., Yen, A. M. F., Chien, K. L., & Chen, T. H. H. (2006). Treatment of low back pain by acupressure and physical therapy: randomized controlled trial. Bmj, 332(7543), 696-700.
6. Khan, K. A., & Weisman, S. J. (2007). Nonpharmacologic pain management strategies in the pediatric emergency department. Clinical Pediatric Emergency Medicine, 8(4), 240-247.
7. Loeser, J. D., & Treede, R. D. (2008). The Kyoto protocol of IASP basic pain terminology☆. Pain, 137(3), 473-477.
8. Loggia, M. L., Juneau, M., & Bushnell, M. C. (2011). Autonomic responses to heat pain: Heart rate, skin conductance, and their relation to verbal ratings and stimulus intensity. PAIN®, 152(3), 592-598.
9. Manias, E., Botti, M., & Bucknall, T. (2002). Observation of pain assessment and management− the complexities of clinical practice. Journal of clinical nursing, 11(6), 724-733.
10. McCaffery, M. (1990). Nursing approaches to nonpharmacological pain control. International Journal of nursing studies, 27(1), 1-5.
11. Reid, C., & Davies, A. (2004). The World Health Organization three-step analgesic ladder comes of age.
12. Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelans critical care nursing: diagnosis and management (pp. 918-966). Maryland Heights, MO: Mosby.
13. Treede, R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain reports, 3(2).
14. Pasero, C., & McCaffery, M. (1999). Pain: clinical manual (Vol. 9). St. Louis: Mosby.
15. Urba, S. G. (1996). Nonpharmacologic pain management in terminal care. Clinics in geriatric medicine, 12(2), 301-311.
16. Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid?: Twenty-four years of experience. Canadian Family Physician, 56(6), 514-517.

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