Acute Pain - Nursing Care Plan LBP

Nursing Care Plan for Lower Back Pain

Nursing Diagnosis for Lower Back Pain : Acute pain related to the agent of injury (physical, musculo skeletal disorders and vascular nervous system).

Defining characteristics :
Verbal

• Took a deep breath, moaning.
• Complained of pain.

Motor

• Grinning face.
• Step struggling.
• Rigid posture / unstable.
• Movement is very slow or forced.

Autonomic response

• Changes in vital signs.

Goal :
Pain is reduced / lost

Outcome :

Levels of pain

• Reported pain reduced / lost.
• Frequency of pain reduced / lost.
• Long of pain pain reduced / lost.
• Oral expression is reduced / lost.
• Muscle tension is reduced / lost.
• Can rest.
• Pain scale decreased.

Control of pain

• Know the factors that cause.
• Know the onset of pain.
• Rarely / never done action / relief with non- analgesic.
• Rarely / never use of analgesics.
• Rarely / never reported pain to the healthcare team.
• Pain controlled.

Level of comfort

• Report needs a break - sleeping fulfilled.
• Reported good physical condition.
• Reported good psychological condition.

Interventions :


Pain Management

• Perform a comprehensive pain assessment (location, characteristics, duration, frequency, quality, and precipitation factors).
• Observation of non-verbal reactions of discomfort.
• Use therapeutic communication techniques to determine the client's experience of pain.
• Assess the culture that affects pain response.
• Evaluation of past painful experiences.
• Evaluation with clients and other health team about the ineffectiveness of pain control past.
• Help clients and families to seek and find support.
• Control environment that may affect pain (room temperature, lighting, and noise).
• Reduce pain precipitation factor.
• Choose and pain management (pharmacological, non-pharmacological and interpersonal).
• Assess the type and source of pain to determine the intervention.
• Teach about non-pharmacological techniques.
• Give analgesics to reduce pain.
• Evaluation of the effectiveness of pain control.
• Increase the break.
• Collaboration with doctors, if there is a complaint and the action of pain that did not work.
• Monitor client acceptance of pain management.

Analgesic Andministrasi

• Determine the location, quality characteristics, and the degree of pain as drug delivery.
• Check the doctor's instructions about the type of medication, dosage and frequency.
• Check history of allergy.
• Select the required analgesics or combination of analgesics when giving more than one.
• Determine analgesic choice , depending on the type and severity of pain.
• Determine the route of administration of analgesic options, and the optimal dose.
• Select the route of administration of intravenous / intramuscular, for the treatment of pain on a regular basis.
• Monitor vital signs before and after the administration of first analgesic.
• Give analgesic especially timely when severe pain.
• Evaluation of the analgesic effectiveness of signs and symptoms (side effects).