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

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.