Acute Pain | Nursing Care Plan for Fecal Diversions

Nursing diagnosis: acute pain related to Physical factors—disruption of skin or tissues (incisions, drains), Biological factors—activity of disease process (cancer, trauma), Psychological factors—fear, anxiety

Possibly evidenced by
Reports of pain, self-focusing
Guarding and distraction behaviors, restlessness
Autonomic responses—changes in vital signs

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize that pain is relieved or controlled.
Appear relaxed and able to sleep or rest appropriately.
Pain Control
Demonstrate use of relaxation skills and general comfort measures, as indicated for individual situation.

Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and intensity (such as 0–10 scale).
Rationale: Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Note: Pain in anal area associated with abdominal-perineal resection may persist for months.

2. Encourage client to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with client, and giving appropriate information.
Rationale: Reduction of anxiety and fear can promote relaxation and comfort.

3. Provide comfort measures, such as mouth care, back rub, and repositioning. Assure client that position change will not injure stoma.
Rationale: Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities.

4. Encourage use of relaxation techniques such as guided imagery and visualization. Provide diversional activities.
Rationale: Helps client rest more effectively and refocuses attention, thereby reducing pain and discomfort.

5. Assist with range-of-motion exercises and encourage early ambulation. Avoid prolonged sitting position.
Rationale: Reduces muscle and joint stiffness. Ambulation returns organs to normal position and promotes return of usual level of functioning. Note: Presence of edema, packing, and drains (if perineal resection has been done) increases discomfort and creates a sense of needing to defecate. Ambulation and frequent position changes reduce perineal pressure.

6. Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.
Rationale: Suggestive of peritoneal inflammation, which requires prompt medical intervention.

7. Administer medication, such as opioids, analgesics, and patient-controlled analgesia (PCA), as indicated.
Rationale: Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair.

8. Provide sitz baths.
Rationale: Relieves local discomfort, reduces edema, and promotes healing of perineal wound.

9. Apply and monitor effects of transcutaneous electrical nerve stimulator unit.
Rationale: Cutaneous stimulation may be used to block transmission of pain stimulus.