Acute Pain Nursing Care Plan

Subjective (OLDCARTS): Onset 2 h post-op; Location right lower quadrant; Duration constant; Character sharp with movement; Aggravated by ambulation and coughing; Relieved partially by splinting; Timing worse on inspiration; Severity 8/10 at rest, 9/10 with movement. Patient's functional goal: "I want to be able to walk to the bathroom."

Objective: HR 108, BP 152/90, RR 24 shallow, guarding, grimacing, refuses to cough and deep-breathe, diaphoretic, incisional site clean and dry, FLACC 6 in a nonverbal patient.

1. Acute pain related to surgical tissue trauma AEB self-report of 8/10, HR 108, guarding, and refusal to perform incentive spirometry.
2. Ineffective breathing pattern AEB shallow RR 24 and splinting (pain-limited ventilation).
3. Impaired physical mobility related to pain AEB refusal to ambulate.
4. Risk for constipation (opioid therapy).
5. Anxiety related to fear of uncontrolled pain.

• Pain ≤ 3/10 (or patient's stated functional goal) within 60 minutes of intervention.
• Patient performs incentive spirometry ≥ 10 times/hour while awake within 12 h.
• Patient ambulates 50 feet with one assist within 24 h.
• HR < 100 and RR 12–20 within 4 h.
• Bowel movement within 48 h of opioid initiation.

• Assess pain with a validated tool every 4 h and 30–60 min after every intervention — reassessment is the single most-missed documentation element and is what proves the intervention worked.
• Use multimodal analgesia: scheduled acetaminophen + NSAID (if not contraindicated) + opioid PRN for breakthrough — multimodal regimens lower total opioid dose, nausea, sedation, and length of stay.
• Medicate 30 minutes before ambulation, dressing changes, and physical therapy — pre-emptive dosing prevents the pain spiral that makes patients refuse mobility.
• Non-pharmacological adjuncts: repositioning, splinting a pillow for cough, cold/heat per order, distraction, guided imagery — additive analgesia with no respiratory risk.
• Monitor sedation with POSS or RASS and RR before each opioid dose — sedation precedes respiratory depression; a sedation scale detects it earlier than RR alone.
• Start a scheduled bowel regimen (stimulant laxative ± softener) with the first opioid dose — opioid-induced constipation is preventable, not treatable-after-the-fact.
• Accept the patient's self-report as the standard — clinician estimation systematically under-treats pain, especially in Black patients and in patients with substance use history.
• Teach the functional goal model of pain control — "pain that lets you cough, walk, and sleep" is a more achievable target than zero.

Sixty minutes after multimodal dosing: pain 3/10, HR 88, RR 16 with deep excursion, patient completes 10 incentive-spirometry breaths and ambulates 60 feet with one assist. Bowel movement documented at hour 36. All five outcomes met.