Skip to main content

Nanda Acute Pain

Acute pain related to ischemic tissue

Goal: decrease pain / no pain

Expected outcomes:
1. Patients verbally say, pain is reduced / lost.
2. Patients can perform the methods or actions to overcome or reduce pain.
3. Expanding patient movement.
4. No cold sweat, vital signs within normal limits. (Temperature: 36 to 37.5 0C, Pulse: 60 - 80 x / min, blood pressure: 100-130 mmHg, RR: 18 - 20 x / min).

 Nanda Acute Pain - Action plan:
1. Assess the level, frequency, and reaction to pain experienced by patients.
Rational: to find out how many patients experienced severe pain.
2. Explain to the patient about the causes of pain.
Rational: the patient's understanding of the causes of pain that occurs will reduce the tension of patients and allows patients to be invited to cooperate in taking measures.
3. Create a calm environment.
Rational: Rangasangan excess of the environment will aggravate the pain.
4. Teach distraction and relaxation techniques.
Rational: distraction and relaxation techniques can reduce the perceived pain patients.
5. Adjust the position of the patient as comfortable as possible according to patient preference.
Rational: a comfortable position will help provide the opportunity for relaxation in the muscles as optimal as possible.
6. Do massage and compress the wound with the BWC as wound care.
Rational: massage can increase spending vaskulerisasi and pussy while the BWC as a disinfectant that can provide comfort.
7. Collaboration with physicians for the administration of analgesics.
Rational: analgesic drugs may help reduce patients' pain.
Labels:

Popular posts from this blog

NANDA Ineffective Health Maintenance

NANDA Definition: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior;  reported or observed lack of equipment, financial, and/or other resources;  reported or observed impairment of personal support systems;  expressed interest in improving health behaviors;  demonstrated lack of knowledge regarding basic health practices;  demonstrated lack of adaptive behaviors to internal and external environmental changes;  reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills);  lack of or significant alteration in communication skills (written, verbal, or gestural);  unachieved developmental tasks;  lack of material resources;  dysfunctional ...
Read more

Activity Intolerance NIC NOC

Insufficient physiological or psychological energy to endure or complete required or desired daily activities Defining Characteristics: Verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, exertional discomfort or dyspnea, electrocardiographic changes reflecting dysrhythmias or ischemia Related Factors: Bed rest or immobility; generalized weakness; sedentary lifestyle; imbalance between oxygen supply and demand NOC Suggested NOC Labels Endurance Energy Conservation Activity Tolerance Self-Care: Activities of Daily Living (ADLs) Client Outcomes Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor patterns (rhythm and ST segment) within normal limits States symptoms of adverse effects of exercise and reports onset of symptoms immediately Maintains normal skin color and skin is warm and dry with activity Verbalizes an understa...
Read more

Ineffective Breastfeeding Nursing Interventions and Rationales

Nursing Interventions and Rationales Refer to care plan for Effective Breastfeeding 1. Assess for presence/absence of related factors or conditions that would preclude breastfeeding. Some conditions (e.g. certain maternal drugs, maternal HIV-positive status, infant galactosemia) may preclude breastfeeding, in which case the infant needs to be started on a safe alternative method of feeding (Riordan, Auerbach, 2000; Lawrence, 2000). 2. Assess breast and nipple structure. Normal nipple and breast structure or early detection and treatment of abnormalities with continuing support are important for successful breastfeeding (Vogel, Hutchison, Mitchell, 1999). 3. Evaluate and record the mother's ability to position, give cues, and help the infant latch on. Correct positioning and getting the infant to latch on is critical for getting breastfeeding off to a good start and contributes to breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews, Kvale, 1998)...
Read more