Acute Pain | Nursing Care Plan for Spinal Cord Injury

Nursing diagnosis: acute Pain related to Physical injury; damage or dysfunction of nervous system, Traction apparatus

Possibly evidenced by
Verbal reports of pain; hyperalgesia immediately above level of injury, burning pain below level of injury (central pain), phantom pain, headaches
Muscle spasm, spasticity
Irritability; restlessness
Self-focusing
Sympathetic mediated responses—temperature, cold, changes of body position, hypersensitivity

Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Identify ways to manage pain.
Demonstrate use of relaxation skills and diversional activities as individually indicated.
Report relief or control of pain and discomfort.

Nursing intervention with rationale:
1. Assess for presence of pain. Help client identify and quantify pain, including, location, type of pain, and intensity on a scale of 0 to 10.
Rationale: Pain is a frequent problem in the majority of the SCI population and can occur not only above the level of injury but also at or below the level of injury and in both complete
and incomplete injuries. An individual with SCI is likely to experience many types of painful sensations at or below the level of injury that can be troublesome to categorize, making effective treatment difficult. Pain can be neuropathic (resulting from abnormal processing of sensory input); can be due to musculoskeletal disorders caused from injury at the time of SCI; or be associated with organ complications such as ulcers or constipation. Pain can also be “segmental,” felt at the level of injury in a bandlike pattern (Turner et al, 2001). Client often reports pain above the level of injury, such as chest, back, or headache, possibly from stabilizer apparatus. After resolution of spinal shock phase, client may also report muscle spasms and radicular pain, described as a burning or stabbing pain radiating in a dermatomal pattern—associated with injury to peripheral nerves. Onset of this pain is within days to weeks after SCI and may become chronic.

2. Evaluate increased irritability, muscle tension, restlessness, and unexplained vital sign changes.
Rationale: Nonverbal cues indicative of pain or discomfort require timely intervention.

3. Assist client in identifying precipitating factors.
Rationale: Burning pain and muscle spasms can be precipitated or aggravated by multiple factors, such as anxiety, tension, external temperature extremes, sitting for long periods, and bladder distention.

4. Provide comfort measures, such as position changes, massage, ROM exercises, and warm or cold packs, as indicated.
Rationale: Alternative measures for pain control reduce need for pharmacological agents and provide emotional support.

5. Encourage use of relaxation techniques, such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities—television, radio, telephone, and unlimited visitors, as appropriate.
Rationale: Relaxation and diversional activities refocus attention, promote sense of control, and possibly enhance coping abilities.

6. Administer medications, as indicated, for example: muscle relaxants, such as dantrolene (Dantrium) and baclofen (Lioresal); analgesics; anti-anxiety agents, such as, alprazalam (Xanax), and diazepam (Valium).
Rationale: These medications relieve muscle spasm and pain associated with spasticity. They also alleviate anxiety and promote rest.