Acute pain is sudden and usually linked to an injury, surgery, or illness. Pain is whatever the client says it is. Good care means assessing well, treating early, and checking that it worked.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Acute Pain
Related to
- Surgical incision, injury, or inflammation
As evidenced by
- Pain rating of 6/10
- Guarding
- Grimacing, restlessness, or increased heart rate
Short-term goals
- Client reports pain at or below their goal (for example 3/10) within 1 hour of intervention
Long-term goals
- Client manages pain well enough to walk, cough, and sleep
- Pain using a scale that fits the client: numeric, Wong-Baker FACES, or FLACC
- OLD CARTS: onset, location, duration, character, aggravating factors, relieving factors, timing, severity
- Sedation level and respiratory rate with opioids
| INTERVENTION | RATIONALE |
|---|---|
| Give pain medication as ordered, before pain is severe | Pain is easier to control when treated early. |
| Use non-drug measures like positioning, ice or heat as ordered, and distraction | These add relief and can lower medication needs. |
| Reassess within 30 to 60 minutes | Confirms the intervention worked. |
| Hold opioids and report if the client is very drowsy or breathing slowly | Prevents opioid-induced respiratory depression. |
EVALUATION
- Pain is at or below the client's goal
- Client walks and coughs without severe pain
Quick answers
What is a SMART goal for pain?
Specific, measurable, achievable, relevant, and time-bound. For example: "Client will report pain at 3/10 or less within 1 hour of receiving medication."
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.