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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.
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