NURSING DIAGNOSIS: Pain, acute
May be related to
Injuring agents (biological, chemical, physical, psychological)
Possibly evidenced by
Changes in appetite and eating, sleep pattern
Guarded/protective behavior; restlessness, moaning, crying, irritability
DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL:
Pain Level (NOC)
Report pain is relieved/controlled.
Manifest decreased restlessness/irritability.
Demonstrate age-appropriate blood pressure, pulse and respiratory rates.
Pain Management (NIC)
Perform routine comprehensive pain assessment,
including location, characteristics, onset/duration,
frequency, quality, severity (using 0–10 scale, facial
expressions, or color scale).
Accept child’s description of pain.
Investigate changes in frequency or description of pain.
Observe for guarding, rigidity, and restlessness.
Monitor heart rate, blood pressure (BP) (using correctly
sized cuff), and respiratory rate, noting age-appropriate
Note location/type of surgical incisions, injuries/trauma.
Provide comfort measures, e.g., repositioning, back rub,
use of heat/cold.
Encourage diversional activities, e.g., TV, music, reading,
playing quiet games.
Review procedures/expectations and tell patient when it