Monday, April 28, 2014

Acute Pain - Nursing Care Plan for Coronary Artery Disease

Nursing Diagnosis and Interventions for Coronary Artery Disease : Acute Pain

Coronary artery disease is coronary artery pathological condition characterized by abnormal accumulation of lipids or fatty material and fibrous tissue in the walls of blood vessels resulting in changes in the structure and function of arteries and reduced blood flow to the heart (Brunner and Suddarth)

The main cause of coronary artery disease is atherosclerosis. Atherosclerosis is the hardening of the artery walls. Arteriosclerosis characterized by the accumulation of fat, cholesterol, intimate layer of the artery. This heap is called atheroma or plaque.

Nursing Diagnosis for Coronary Artery Disease : Acute Pain related to a decrease in myocardial blood flow, increased cardiac workload / oxygen consumption

  • Stating chest pain disappeared / controlled.
  • Demonstrating the use of relaxation techniques.
  • Showed reduced tension, relaxed, easy to move.


1. Monitor / record the characteristics of pain, note the verbal report, nonverbal cues, and the hemodynamic response (grimacing, crying, restlessness, sweating, gripping his chest, rapid breathing, BP / heart rate change).

Rational: Variations in the appearance and behavior of the patient as pain occurs as the assessment findings. Most patients with acute myocardial infarction looks sick, distraction and focus on the pain. Verbal history and education in the precipitating factors should be postponed until the pain is gone. Breathing may be increased as a result of pain and is associated with anxiety, stress cause temporary loss of catecholamines will increase the heart rate and BP.

2. Take full assessment of the patient's pain at the site; intensity (0-10); duration; quality (shallow / spread) and deployment.

Rational : Pain as a subjective experience and should be described by the patient. Help the patient to assess pain by comparing it with other experiences.

3. Review the history of previous angina, pain resembling angina, or myocardial infarction pain. Discuss family history.

Rational : There can compare the pain of the previous pattern, according to widespread identification of complications such as infarction, pulmonary embolism, or pericarditis.

4. Instruct the patient to report pain immediately.

Reporting delay distribution of pain inhibiting pain / need improvement. Doses of the drug. In addition, severe pain can cause shock to stimulate the sympathetic nervous system, resulting in further damage and interfere with diagnostic and pain relief.

5. Provide a quiet environment, the activity slowly, and the action comfortable. Approach calmly and with patient trust.

Rational: Lowering external stimuli in which anxiety and heart strain and limited coping abilities and judgment of the current situation.

6. Aids patients relaxation techniques, eg deep breathing / slow, behavioral distraction, visualization, guided imagery.

Rational: Assist in the reduction in the perception / pain response. Giving control of the situation, increase positive behavior.

7. Check vital signs before and after drug administration.

Rational: Hypotension / respiratory depression can occur as a result of drug administration. This problem can increase the damage miokardia the presence of ventricular failure.

8. Provide supplemental oxygen by nasal cannula or mask as indicated.

Rational: Increase the amount of oxygen available for myocardial consumption and reduce discomfort with respect to tissue ischemia.

Monday, April 21, 2014

Nursing Care Plan for Acute Pain (Impaired sense of comfort)

Definition of Pain

Pain is defined as a condition that affects a person's mind and the extensions if someone ever experienced. Pain means lead to feelings and reactions that are less fun. However, we all realize that the pain is often useful, among others, as a sign of danger; a sign that there are unfavorable changes in man.

Classification of Pain

1. Based on the source

a. Cutaneous / superficial: the pain of the skin / subcutaneous tissue. Usually burning.
Example: exposed tip of a knife or scissors.

b. Deep somatic / pain in: pain that arises from the ligament, cleanin. Blood, tendons and nerves, pain spreading and for longer than cutaneous.
Example: joint sprain.

c. Visceral (the internal organs): stimulation of pain receptors within the abdominal cavity, cranium and thoracic. It usually occurs due to muscle spasm, ischemia, tissue strain.

2. Based on the causes

a. Physical: It could happen because of a physical stimulus.
Example: fracture of the femur.
b. Psycogenic: Occurs for reasons unclear / difficult is identified, sourced from emotional / psychological and usually insidious.
Example: people who get angry, suddenly felt pain in his chest.

3. Based on the long / duration.

a. Acute pain: pain that arises suddenly and disappear quickly, which does not exceed 6 months and is characterized by an increase in muscle tension.

b. Chronic pain: pain that arises slowly, usually taking place in a long time, ie more than 6 months. Are included in the category of chronic pain is pain terminal, chronic pain syndromes, and psychosomatic pain.

Pain Stimulus

A person can tolerate, withstand pain (pain tolerance), or can identify the amount of pain stimulation, before feeling pain (pain threshold).

There are several types of painful stimuli, including:
  1. Trauma to the tissues of the body, such as surgery due to tissue damage and irritation directly to the receptor.
  2. Disturbances in body tissues, such as edema due to an emphasis on pain receptors.
  3. Tumors, can also suppress the pain receptors.
  4. Ischemia in the tissue, such as occurs blockade on coronary artery which stimulates pain receptors due to lactic acid during egress.
  5. Muscle spasm, can stimulate mechanics.

Factors that Affect Pain

The experience of pain in a person can be influenced by several factors, among which are:

1. Meaning of pain.
The meaning of pain for a person to have a lot of differences and almost most of the meaning of pain is negative, such as harm, damage etc.. This situation is influenced by various factors, such as age, sex, socio-cultural background, environment, and experience.

2. Perception of pain.
The perception of pain is a subjective assessment sngat place in the cortex (the evaluative cognitive function). This perception is influenced by factors that can trigger nociceptor stimulation.

3. Tolerance of pain.
Tolerance is closely related to the intensity of pain that can affect one's ability to withstand pain. Factors that can affect an increase in pain tolerance, among others, alcohol, drugs, hypnosis, friction, or scratching, shifting attention, strong beliefs, etc.. While a number of factors that lower the tolerance, among others, fatigue, anger, boredom, anxiety, pain that does not go away, pain etc..

4. Reaction to pain.
Reaction to pain is a form of an individual's response to pain, such as fear, anxiety, worry, crying, and screaming. All of this is a form of pain response to dipengaruhioleh several factors, such as the meaning of pain, degree of pain perception, past experience, cultural values​​, social expectations, physical and mental health, fear, anxiety, age, etc..


Assessment of pain that is factual (current), complete and accurate to facilitate nurses in the basic data set, enforce appropriate nursing diagnosis, planning therapy / treatment matching, and facilitate nurses in evaluating the client's response to therapy that is given.

Nursing actions that need to be done in assessing patients for acute pain are:
  1. Assess the client's feelings (psychological response that appears).
  2. Establish client's physiological response to pain and pain location.
  3. Assessing the severity and quality of pain.

During episodes of acute pain assessment should not be done while the client in a state of alert (attention to pain), nurses should strive to reduce the client's anxiety before attempting to assess the quantity of clients to pain perception. As for patients with chronic pain better then the assessment is to focus on the dimensions of behavioral assessment, affective, cognitive (NIH, 1986; McGuire, 1992).

Characteristics of Pain (Method P, Q, R, S, T).

1) Originator factor (Q: Provocate),
The nurse examines the causes or pain stimuli on the client, in this case nurses can also observe the body parts injured.

2) Quality (Q: Quality),
Quality is something subjective pain expressed by the client. Example sentences: sharp, dull, throbbing, moving, such as crushed, sore, and punctured.

3) Location (R: Region),
To assess pain location then the nurse asks the client to show all the parts or areas that felt uncomfortable by the client.

4) Severity (S: Severe),
The severity of the patient's pain is the most subjective characteristic. In this assessment the client is asked to describe the pain he felt as pain mild, moderate or severe pain.

5) Duration (Time).
The nurse asks the patient to determine the onset, duration, and sequence of pain