Friday, April 11, 2014

Nursing Care Plan for Chest Pain

Chest pain is feeling pain / bad that disrupt the chest area and often the pain is projected on the chest wall.

Chest pain varies from person to person. It may feel like a sharp, stabbing pain or a dull ache. While chest pain may be a sign of a serious heart-related problem, it may also have other common, non–life-threatening causes.

Causes of Chest Pain
  • heart attack
  • angina—chest pain due to blockages in the blood vessels leading to your heart
  • pericarditis—inflammation of the sac around the heart
  • myocarditis—inflammation of the heart muscle
  • cardiomyopathy—heart muscle disease
  • aortic dissection—a rare condition involving rupture of the heart’s main artery

Signs and symptoms that commonly accompany chest pain are:
  • Heartburn
  • Headache
  • Pain is projected to arms, neck, back
  • Diaphoresis / cold sweat
  • Shortness of breath
  • Tachycardia
  • Pale Skin
  • Difficulty sleeping (insomnia)
  • Nausea, Vomiting, Anorexia
  • Anxiety, restlessness, focus on yourself
  • Weakness
  • Tense face, moaning, crying

Primary assessment

a. Airway
  • How airway patency?
  • Is there a blockage / buildup of secretions in the airway?
  • How breath sounds?
b. Breathing
  • How breathing pattern? Frequency? The depth and rhythm?
  • Is using a respirator muscles?
  • Are there additional breath sounds?
c. Circulation
  • What about the peripheral and carotid pulse? Quality (content and voltage)
  • How Capillary refillnya, if there akral cold, cyanosis or oliguric?
  • Is there a loss of consciousness?
  • How vital signs? blood pressure, temperature, pulse, respiration?

Secondary assessment

Important things that need to be studied further in chest pain (coronary):

a. Location of pain.
Where to place the start, spreading (coronary chest pain: from sternal spread to the neck, chin or shoulder to the left forearm ulna).

b. The nature of the pain.
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..

c. Characteristic pain.
The degree of pain, duration, number of times arise within a certain period.

d. Chronology of pain.
Early pain relief and development sequentially.

e. Circumstances at the time of the attack
Are arise at times / circumstances.

f. Factors that reinforce / relieve pain such as attitude / position of the body, movement, pressure, etc..

g. Other symptoms that may be present or not relations with chest pain.

Nursing Diagnosis for Chest Pain
  1.  Acute pain r / t tissue ischemia secondary to arterial occlusion, tissue inflammation.
  2. Ineffective Tissue perfusion (heart muscle) r / t decrease in blood flow.
  3.  Activity intolerance r / t imbalance between oxygen supply and tissue metabolic needs.

  • Bed rest with Fowler position / semi-Fowler.
  • Perform a 12 lead ECG, 24-lead if necessary.
  • Observing vital signs.
  • Collaboration of O2 and administration of analgesic medications, tranquilizers, nitroglycerin, calcium antagonists and observation of drug side effects.
  • Installing a drip and give peace to the client.
  • Taking blood samples.
  • Reduce environmental stimuli.
  • Calm in the works.
  • Observing signs of complications.

Saturday, March 1, 2014

Acute Pain Nursing Interventions for Peptic Ulcers

Nursing Care Plan for Peptic Ulcers

Peptic ulcer is a condition in which the unbroken continuity of the gastric mucosa and extends below the epithelium. Mucosal damage does not extend all the way down
epithelial erosion, although often considered as well as ulcers. (eg ulcers due to stress).

Chronic peptic ulcer is different premises acute, because it has a scarring of the ulcer base. By definition, peptic ulcer can be found on any part of the gastrointestinal tract that is exposed to stomach acid sap, namely the esophagus, stomach, duodenum, and after gastroduodenal, too jejunum. Although the activity of peptic digestion by gastric an important aetiological factor, there is evidence that this is only one factor of many factors that play a role in the pathogenesis of peptic ulcer.

Ulcer symptoms can disappear for days, weeks, or months and can even disappear only to look back, often with no identifiable cause. Many individuals have symptoms of ulcer, and 20-30% had perforation or haemorrhage which precedes manifestation absence.

1. Pain: usually patients with ulcers complain of dull pain, like stabbing or burning sensation in the epigastric middle or at the back. It is believed that the pain occurs when the acidic contents of the stomach and duodenum increased erosion and stimulates nerve endings exposed. Another theory suggests that the lesion contact with acids stimulate the local reflex mechanism mamulai surrounding smooth muscle contraction.

The pain is usually relieved by eating, because eating neutralize acid or by using alkali, but when the stomach is empty or unused alkali back pain arises. Sharp local tenderness can be removed by gentle pressure on the epigastric or slightly to the right of the center line. Some symptoms decreased with the local pressure on the epigastrium.

2. Pyrosis (heartburn): some patients experience a burning sensation in the esophagus and stomach, which rose to mouth, sometimes accompanied eruktasi acid. Eructation or belching is common when the patient's stomach is empty.

3. Vomiting: although rarely in uncomplicated duodenal ulcer, vomiting can be a symptom of peptic ulcer. This is attributed to the formation of scar tissue or acute swelling of the inflamed mucous membrane surrounding the acute ulcer. Vomiting may occur or without preceded by nausea, severe pain are usually removed after the ejection of gastric acid content.

4. Constipation and bleeding: constipation may occur in patients with ulcers, possibly as a result of diet and medication. Patients may also come with a small portion of gastrointestinal bleeding due to ulcer patients who have previously experienced acute complaints, but they show symptoms afterwards.

Nursing Diagnosis:

Acute pain related to irritation of the mucosa and muscle spasm.

Goal: The client expresses pain diminished or disappeared.


1. Give drug therapy in accordance with the program:

2. Instruct to avoid drugs are sold freely especially those containing salicylates.
R /: Medicines containing salicylates may irritate the gastric mucosa.

3. Instruct the client to avoid foods / drinks that irritate the gastric mucosa: caffeine and alcohol.
R /: to stimulate the secretion of hydrochloric acid.

4. Encourage clients to use food and snacks at regular intervals.
R /: Schedule regular meals helps retain food particles in
which helps neutralize stomach acidity of gastric secretion.

5. Instruct the patient to stop smoking.
R /: Smoking can stimulate ulcer recurrence.