Acute Pain | Nursing Diagnosis for Leukemia

Nursing diagnosis: Acute pain related to physical agents—enlarged organs and lymph nodes, bone marrow packed with leukemic cells, chemical agents—antileukemic treatments, psychological manifestations—anxiety, fear

Possibly evidenced by
Reports of pain—bone, nerve, headaches, and so forth
Guarding or distraction behaviors, facial grimacing, alteration in muscle tone
Autonomic responses

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep and rest appropriately.
Pain Control
Demonstrate behaviors to manage pain.

Nursing intervention with rationale:
1. Investigate reports of pain. Note changes in degree (use scale of 0 to 10) and site.
Rationale: Helpful in assessing need for intervention and may indicate developing complications.

2. Monitor vital signs and note nonverbal cues, such as muscle tension and restlessness.
Rationale: May be useful in evaluating verbal comments and effectiveness of interventions.

3. Provide quiet environment and reduce stressful stimuli: noise, lighting, and constant interruptions.
Rationale: Promotes rest and enhances coping abilities.

4. Place in position of comfort, and support joints and extremities with pillows and other padding.
Rationale: May decrease associated bone and joint discomfort.

5. Reposition periodically and provide or assist with gentle range-of-motion (ROM) exercises.
Rationale: Improves tissue circulation and joint mobility.

6. Provide comfort measures, such as massage, cool packs, and psychological support, including encouragement and presence, as appropriate.
Rationale: Enhances effects of medication.

7. Review and promote client’s own comfort interventions— position and physical activity or nonactivity.
Rationale: Successful management of pain requires client involvement. Use of effective techniques provides positive reinforcement, promotes sense of control, and prepares client for interventions to be used after discharge.

8. Evaluate and support client’s coping mechanisms.
Rationale: Using own learned perceptions and behaviors to manage pain can help client cope more effectively.

9. Encourage use of stress management techniques, such as deep-breathing exercises, guided imagery, visualization, and therapeutic touch.
Rationale: Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.

10. Assist with or provide diversional activities and relaxation techniques.
Rationale: Helps with pain management by redirecting attention.