Wednesday, August 27, 2014

Nursing Care Plan for Personal Hygiene

Definition of Personal Hygiene
  • Personal hygiene is derived from the Greek language which means individual personal hygiene and healthy means. Personal hygiene is an action to maintain the cleanliness and health of a person's physical well-being.
  • Personal hygiene is an individual effort in maintaining personal hygiene which includes cleanliness of hair, teeth and mouth, eyes, ears, nails, skin, and dressed in improving hygiene in optimal health (Effendi, 1997).
  • Personal Hygiene is an act of maintaining the cleanliness and health of a person's physical and psychological well-being. The size of a person's cleanliness or appearance in fulfilling the needs of Personal Hygiene Personal differences in pain due to an interruption fulfillment.

Purposes of Personal Hygiene
  • Improve the health of a person.
  • Illness and disability can affect immabolisasi.
  • Maintaining the cleanliness of a person.
  • Fixing personl hygiene is lacking.
  • Prevent disease.
  • Improving one's self-confidence.
  • Creating beauty (tarwoto, 2004).

Factors affecting the Personal Hygiene
  • Body image. Image individuals against themselves strongly influence personal hygiene, for example due to a physical change that is never an individual concerned about hygiene
  • Social practices. In the children are always spoiled in personal hygiene, may lead to a change in personal hygiene.
  • Socioeconomic status. Changes in hygiene requires tools and materials such as soap, toothpaste, shampoo, bath equipment, all of which require a fee to provide it.
  • Knowledge. Knowledge of personal hygiene is very important because of his extensive knowledge to improve health.
  • Culture. Most of the people if a certain sick individuals, it must not be bathed.
  • The habit of a person. There is a custom of someone who uses pruduk tertuntu in self-care such as the use of soap, etc. sampoh.
  • Physical state. In particular illness, diminished ability to care for themselves and perlumembantu to do so.

Various of Personal Hygiene

Maintenance of personal hygiene means maintaining cleanliness and hygiene measures a person's physical and psychological well-being. A person is said to have good personal hygiene when, the person can have good personal hygiene which includes cleanliness of the skin, teeth and mouth, hair, eyes, nose, and ears, feet and nails, genitalia, as well as the cleanliness and tidiness pakaiannya.Menurut Potter and Perry (2005 ) assorted personal hygiene and the aim is:

1 Skin Care

The skin is an active organ that serves as a protector of various germs or trauma, secretion, excretion, temperature regulator, and sensation, so that adequate care is needed in maintaining its function. The skin has three main layers of the epidermis, dermis, and subcutaneous. When patients are not able or do personal skin care the nurses provide help or teach families how to carry out personal hygiene. A patient who is unable to move freely due to illness will be at risk of skin damage. Body parts hanging and exposed to pressure from the bottom surface of the body (eg matrasi body casts or wrinkled linen lining), will reduce circulation to the affected part of the body that can lead to pressure sores. Moisture on the surface of the skin is a bacterial growth medium and cause local irritation, smoothes the epidermis cells, and can cause skin maceration. Sweat, urine, watery fecal material and wound drainage may accumulate on the surface of the skin and will cause skin damage and infection. Patients who use some kind of external devices such as a cast skin, clothes fastener, bandages, dressings, and orthopedic jacket can exert pressure or friction on the skin surface so as causing skin damage. The purpose of skin care is the patient will have the skin intact, free of body odor, the patient can maintain range of motion, feel comfortable and prosperous, and can berpartisifasi and understand methods of skin care.

2 Bath

Bathing the patient is a total hygienic care. Bath, can be categorized as a cleansing or therapeutic. Bath, in bed complete necessary for patients with total dependence and requires total personal hygiene. Breadth bathing patients and methods used for bathing is based on the patient's physical abilities and needs of the required level of hygiene. Patients who rely in meeting personal hygiene needs, lying in bed and not being able to reach all members of the body can obtain most of the bath in bed. The purpose of bathing patients in bed is to maintain the cleanliness of the body, reduce infections caused by dirty skin, improving blood circulation system, and increase patient comfort. Bath can eliminate microorganisms from the skin and body secretions, eliminates bad odor, improve blood circulation to the skin, and make the patient feel more relaxed and refreshed. Patients can be bathed every day in the hospital. However, if the patient's skin dry, the bath may be limited once or twice a week so it will not add to the skin to become dry. Nurses or family members may need to help the patient to walk to the bathroom or the back of the bathroom. Nurse or family member must be there to help the patient flushed or dry out if necessary clean or replace clothes after bathing. Sometimes patients can bathe themselves in bed or they need the assistance of a nurse or family member to bathe the back or legs. Sometimes patients can not bathe themselves and the nurse or family member to bathe the patient in bed.

3. Oral hygiene

Patient immobilization is too weak to perform oral care, as a result, the mouth becomes too dry or irritated and cause unpleasant odors. These problems can be increased due to disease or medication used by the patient. Oral care should be done every day and depend on the state of the patient's mouth. Teeth and mouth is an important part of cleanliness must be maintained through this organ for a variety of germs can enter. Oral hygiene helps maintain the health status of the mouth, teeth, gums, and lips, scrub clean the teeth of food particles, plaque, bacteria, memasase gums, and reduce discomfort resulting from the smell and taste that is uncomfortable. Some diseases that may arise as a result of dental care and poor oral is caries, gingivitis (gum inflammation), and thrush. Good oral hygiene provide a sense of sound and further stimulate appetite. The purpose of oral hygiene care patient is a patient will have an intact oral mucosa are well hydrated and to prevent the spread of diseases that are transmitted through the mouth (eg typhoid, hepatitis), diseases of the mouth and teeth prevent, increase endurance, achieve a sense of comfort, understanding oral hygiene practices and able to perform their own oral hygiene care properly.

4. Eye, nose, and ears care

Special attention is given to cleaning the eyes, nose, and ears during bathing patients. Normally there is no special care needed for the eye because it is continuously cleaned by water eyes, eyelids and eyelashes to prevent the entry of foreign particles into the eye. Normally, the ears do not actually need cleaning. However, patients with too much wax, ears need to be cleaned either independently or performed by nurses and family. Ear hygiene has implications for auditory acuity. If the foreign body assembled on the outer ear canal, it will interfere with the conduction of sound. The nose serves as the sense of smell, monitor the temperature and humidity of inhaled air, and prevent the entry of foreign particles into the respiratory system. Patients who have limited mobilization need help nurses or family members for treatment of eyes, nose, and ears. Treatment goals eyes, nose, and ears are the patient will have a normal functioning of sensory organs, eyes, nose, and ears of the patient will be free from infection, and the patient will be able to make eye care, nose, and ears everyday.

5. Hair Care

Appearance and well-being often depends on the way the look and feel of the hair. Illness or disability prevents a person to maintain day-to-day hair care. Brush, comb and shampoo are basic hygienic ways of hair care, hair distribution pattern can be an indicator of general health status, hormonal changes, emotional and physical stress, aging, infections and certain diseases or drugs can affect the characteristics of the hair. Hair is part of the body which have a function as protection and temperature control, through hair changes in health status itself can be identified. Illness or disability makes the patient can not maintain the daily hair care. Patient immobilization hair tends to look wrinkled. Brushing, combing, and shampoo the hair higyene basis for all patients. Patients should also be allowed to shave when conditions permit. Patients who are able to perform self-care should be motivated to maintain their daily hair care. Whereas in patients who have limited mobilization need help nurse or the patient's family in doing higyene hair. The purpose of hair care is the patient will have the hair and scalp clean and healthy, the patient will achieve a sense of comfort and self-esteem, and the patient can berpartisifasi in hair care practices.

6. Foot and nail care

Feet and nails often need special attention to prevent infection, odor, and injury to the tissue. But often people are not aware of foot problems and nail until there is pain or discomfort. Maintain cleanliness of nails is important in maintaining personal hygiene due to a variety of germs can enter the body through the nail. Therefore, the nail should remain healthy and clean. Treatments can be combined for a shower or at separate times. The purpose of the foot and nail care is the patient will have the intact skin and soft surface of the skin, the patient feels comfortable and clean, the patient will understand and perform foot and nail care methods correctly.

7 Genital care

Genitalia care is part of a complete bath. Patients who need care the most rigorous genitalia is the biggest risk patients acquired the infection. Patients who are able to perform self-care can be allowed to do their own. Nurses may be embarrassed to provide care genitalia, especially in patients of the opposite sex. Can be helpful to have a nurse of the same sex with the patient in the room at the time of treatment genitalia. The goal of treatment is to prevent the occurrence of genital infections, genital hygiene maintaining, improving comfort and maintaining personal hygiene.

Tuesday, August 26, 2014

Nursing Care Plan for Encephalitis - Assessment, Diagnosis and Interventions

Nursing Care Plan for Encephalitis

  • Encephalitis is an infection of the CNS caused by a virus or other microorganism that non-purulent.
  • Encephalitis is an infection of the brain tissue by a variety of microorganisms. Encefalopati terminology that was used for the same symptoms, no signs of infection are now no longer in use. (Abdoerrachman, et al, 1985).


A wide variety of organisms can cause encephalitis, such as bacteria, protozoa, worms, fungi, spirokaeta, and viruses. The most common cause is a virus. Infection can occur due to virus attacks the brain directly or acute inflammatory reaction due to systemic infection or previous vaccination. Encephalitis can also be caused by the direct invasion of the cerebrospinal fluid during a lumbar puncture. Various types of viruses can cause encephalitis, despite similar clinical symptoms. According to the type of virus and its epidemiology, known to a wide variety of viral encephalitis.

Signs and Symptoms
  • The clinical symptoms of encephalitis is not specific, depending on the cause and extent of the areas affected by the infection. Generally obtained sudden temperature rise, before consciousness decreased, often complain of headache, vomiting frequently found, lethargi, photofobi, sometimes a stiff neck desertai if infection of the meninges.
  • Children appear irritable, agitated sometimes accompanied by changes in behavior. May be accompanied by impaired vision, hearing, speech, and seizures. Seizures may be general or focal or just twitching alone. Seizures can last for hours, diverse cerebral symptoms may occur individually or together, such as paresis or paralysis, aphasia, and so on.
  • Cerebrospinal liquor often within normal limits, sometimes found little elevation cell count, protein or glucose levels.
  • Cerebrospinal fluid examination: Colors are clear pleocytosis ranges from 50 to 2000 cells. Where lymphocyte cells are the dominant cell, the protein rather increased, whereas glucose within normal limits.
  • EEG: Shows a diffuse inflammatory process "Bilateral" with low activity.
  • Other signs and symptoms that often arise are: Nuchal rigidity, Kernig's signs, Ataxia, Muscle weakness, Diplopia, Confusion, Irritability, Coma.

  • Encephalitis can also occur as a complication of measles, mumps or chickenpox.
  • Complications include encephalitis beginning of the cardiovascular system, respiratory and neurologic usually the brain stem.
  • Encephalitis can cause residual neurologic defects after recovery.

Assessment for Encephalitis

Symptoms may occur gradually, but may also occur in acute
  • Headaches.
  • High temperature.
  • Ridgiditas nuchal.
  • Kernig's signs.
  • Ataxia.
  • Muscle weakness.
  • Paralysis.
  • Diplopia.
  • Confusion.
  • Irritability.
  • Lethargy.
  • Coma.

Nursing Diagnosis and Interventions for Encephalitis

1. Ineffective Cerebral Tissue Perfusion related to inflammatory processes, increased ICP.

  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Monitor the signs of the rise of ICT (elevated BP, peurunan pulse, irregular breath, anxiety, changes in pupil).
  • Elevate head of bed 30 °.
  • Keep the neck and head straight to improve venous return.
  • Teach children to avoid the Valsalva manuever (coughing, sneezing).
  • Monitor signs / symptoms of septic shock (hypotension, increased temperature, increased RR, confusion, disorientation, peripheral vasoconstriction).

2. Risk for injury related to disorientation, seizures, and the unfamiliar environment.

  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Maintain a calm and comfortable environment.
  • Limit the number of visitors.
  • Teach ROM exercises (passive, active) as recommended and regularly.
  • Collaboration of anticonvulsants.

3. Altered thought processes related to changes in the level of consciousness

  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Monitor the signs of the rise of ICT.
  • Speak slowly and clearly.
  • Maintain a calm and comfortable environment.
  • Limit the number of visitors.

4. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, fatigue, nausea, and vomiting

  • Ask the patient's favorite food.
  • Provide the recommended diet.
  • Serve food in small portions but frequently.
  • Encourage to eat slowly.
  • Allow families to provide food for children.
  • Monitor body weight per day.
  • Create a pleasant environment.
  • Encourage family members to accompany the child during meals.
  • Limit fluid intake during meals.
  • Give good oral care.

5. Acute pain related to irritation encephalon

  • Assess the level of pain.
  • Evaluation indicators of pain (facial expression, crying), location, duration, spread, intensity, and precipitating factors.
  • Take action to support comfort (change position, imagination, distraction, massage, cold compresses).
  • Instruct child to menghindarigerakan that can improve ICT (coughing, sneezing, bending, straining).
  • Limit visitors.
  • Collaboration of analgesics.

Nursing Care Plan for Impaired Sense of Comfort : Pain

Nursing Care Plan for Pain

Pain is the most common reason a person seek medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very annoying and difficult many people. Nurses can not see and feel the pain experienced by the client, because pain is subjective (between one individual to another individual is different in addressing the pain). Nurses provide nursing care to clients in a variety of situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is a basic requirement that the client is the purpose of nursing care. The statement was supported by Kolcaba who said that comfort is a state of fulfillment of basic human needs have.

  • According to the International Association for the Study of Pain (IASP), pain is a subjective sensory and emotional obtained unpleasant associated with actual or potential tissue damage or described the condition of the occurrence of the damage.
  • Specificity theory "suggest" states that pain is a specific sensory arise because of the injury and the information obtained through the peripheral and central nervous system through the pain receptors in the peripheral nerves and specific pain in the spinal cord.
  • Coffery mc (1979): a condition that affects a person, its existence is known only to the folks if they'd ever experienced.
  • Feurst W. Wolf (1974): a feeling of physical and mental suffering or feelings that cause tension.
  • Arthur C. Emilion (1983): a mechanism for the production of the body, arises when tissue is damaged and causes the individual to react to relieve pain.


1. Trauma. Trauma is also divided into several kinds. The cause of the trauma is divided into:
  • Mechanics. The pain caused by this mechanical arising from free nerve endings were damaged. Examples of this pain is due to mechanical trauma due to impact, friction, and other injuries.
  • Thermal. Painful as this arises because the nerve endings gets receptor stimulation caused by heat, cold, such as fire and water.
  • Chemist. Pain caused by contact with chemicals that are strong acids or bases.
  • Electric. Pain is caused by the influence of a strong electric current on the pain receptors that cause muscle spasms and burns.
2. Neoplasms. This neoplasm is also divided into two, namely:
  • Benign neoplasms.
  • Malignant neoplasm.
3. Disorders of blood circulation, and blood vessel abnormalities. This can be exemplified in patients with acute myocardial infarction or angina pectoris that is felt is the typical chest pain.
4. Inflammation. Pain is caused due to damage to nerve endings receptor due to inflammation or pinched by swelling. An example is the pain due to abscess.
5. Psychological trauma.

Signs and Symptoms

Behavioral responses to pain may include:
  • Verbal statements (moan, cry, Shortness of Breath, Snoring).
  • Facial expressions (Wince, gritted teeth, biting lip).
  • Body movements (Restless, immobilization, muscle tension, increase finger and hand movements.
  • Contact with other people / social interaction (conversational Avoiding, Avoiding social contact.
  • Decreased attention span, focus on pain-relieving activity.
  • Individuals who experience a sudden onset of pain may react very differently to pain that lasts for a few minutes or become chronic. Pain can cause fatigue and make people too tired to moan or cry. Patients can sleep, even with severe pain. Patients may seem to relax and engage in the activity because it becomes adept at diverting attention to pain.

Physiological Respon to Pain

A. Sympathetic stimulation (mild pain, moderate, and superficial)
  • Bronchial tract dilatation and increased respiration rate.
  • The increase in heart rate.
  • Peripheral vasoconstriction, increased BP.
  • Increased blood sugar values​​.
  • Diaphoresis.
  • Increased muscle strength.
  • Dilated pupils.
  • Decreased GI motility.
B. Stimulus parasympathetic (severe pain and in)
  • Pallor.
  • Hardened muscles.
  • Decreased HR and BP.
  • Rapid breathing and irregular.
  • Nausea and vomiting.
  • Fatigue and exhaustion.

Meinhart & McCaffery describe the 3 phases of the experience of pain:

Anticipation phase: occurs before pain received
This phase may not be the most important phase, because this phase can affect the other two phases. In this phase allows one to learn about the pain and the effort to relieve pain. The role of the nurse in this phase is very important, especially in providing information to the client.
Example: prior to surgery, the nurse describes the pain that will be experienced by the client after the surgery, so the client will be better prepared with the pain that will be encountered.

Sensation Phase : occurs when the pain feels.
This phase occurs when the client feel the pain, because the pain is subjective, then each person in dealing with the pain also varies. Tolerance to pain will also vary from one person to another person. People who have a high level of tolerance to pain will not complain of pain with a small stimulus, whereas people low tolerance to pain will be easier to feel pain with small painful stimulus. Clients with a high level of tolerance to pain is able to withstand the pain without help, otherwise people who have a low tolerance to pain is to find ways to prevent pain before the pain came.
The presence of enkephalins and endorphins help explain how different people feel the pain level of the same stimulus. Endorphin levels differ for each individual, individual with a little high endorphins pain endorphins and individuals with slightly greater pain.
Clients can express the pain in various ways, ranging from facial expressions, vocalizations and body movements. Expression of clients indicated that nurses used to identify patterns of behavior that indicate pain. Nurses should review carefully when clients express a bit of pain, not necessarily because people who do not express the pain was not experiencing pain. Such cases it would require the help of a nurse to help clients effectively communicate pain.

Aftermath phase: occurs when the pain is reduced or stopped
This phase occurs when the pain is reduced or lost. In this phase, the client still needs the control of the nurse, because pain is a crisis, thus allowing clients to experience residual symptoms after pain. If the client is experiencing recurrent episodes of pain, then the response due to the (aftermath) can be a serious health problem. Nurses play a role in helping to gain self control to minimize the fear of the possibility of recurring pain.

Classification of pain can be divided into:

1. According to the location of pain
  • Peripheral Pain. Peripheral pain is pain that is divided into 3 surface (superficial pain), pain in the (deep pain), pain appropriation (reffered pain). This appropriation means pain is pain felt in an area that is not a source of pain.
  • Central Pain. This pain occurs because of stimulation of the central nervous system, spinal cord, brain stem.
  • Psychogenic Pain. This pain is felt in the absence of an organic cause, but the result of psychological trauma.
  • Phantom Pain. Phantom Pain is a feeling on the part of the body that no longer exists, for example in amputation. Phantom pain arising from severe dendrite stimulation compared to stimulation of receptors normally. Therefore, the person will feel pain at the areas that have been raised.
  • Pain radiating. Pain is felt at the source which extends into the surrounding tissue.

2 According to the nature of pain.
  • Incidental. That is the nature of pain which arise from time to time and then disappear.
  • Steady. That is the nature of pain arising settled and felt in a long time.
  • Paroxysmal. That is the pain of high intensity and very strong and usually persists for 10-15 minutes, then disappears and then comes back.
  • Pain intractable. That is the nature of pain resistant to treatment or reduced. Example in arthritis, administration of narcotic analgesics is contraindicated due to the length of the disease that can lead to addiction.

3 According to the severity of pain.
  • Mild pain is pain that is located in a low intensity.
  • Moderate pain is pain that causes a physiological reaction and psychological reactions.
  • Heavy pain is pain that is located in a high intensity.
4 According to the time of the attack.
  • Acute Pain. Acute pain is usually short-lived, such as pain at the fracture. Clients who experience acute pain will generally show symptoms include: increased respiration, heart rate and increased blood pressure, and pallor.
  • Chronic Pain. Chronic pain develops more slowly and occurs in a longer time and in general, people are often hard to remember since when the pain began to be felt.

Nursing Care Plan for Pain


Accurate assessment of pain is important for effective pain management efforts.
Pain is a subjective experience and perceived differently in each individual, the nurse needs to assess all the factors that affect pain, such as psychological factors, physiological, behavioral, emotional, and sociocultural. Assessment of pain consists of two main components, namely:

Nursing care of clients experiencing pain:

History of pain to get the data from the client
Direct observations on the behavioral and physiological responses of clients. The purpose of the assessment is to obtain objective understanding of the subjective experience.

Characteristics of pain (PQRST)
  • P (Provocative): factors that affect the severity of distress and pain.
  • Q (Quality): What kind; sharp, blunt, or broken.
  • R (Region): the journey of pain.
  • S (Severity / pain scale): severity / intensity of pain.
  • T (Time): long / time or frequency of pain attacks.

The things that need to be assessed:

1 Location
To determine the specific location of pain ask the client to indicate the area of pain, can with the help of images. Clients can mark parts of the body that is experiencing pain.

2 Intensity of pain
Use of pain intensity scale is an easy and reliable method to determine the patient's pain intensity.

3 Quality of pain
Sometimes the pain can feel like a pounded or tingling. Nurses need to record the words used to describe pain clients. For information have a big impact on the diagnosis and etiology of pain.

4 Patterns
The pattern of pain include the time of onset, duration, and recurrence intervals or pain. Therefore, nurses need to assess when the pain started, how long the pain lasts, whether recurrent pain, and pain at last appeared.

5. Factor precipitation
Sometimes, certain activities can trigger pain as an example, physical activity can cause severe chest pain. In addition, environmental factors (environment very cold or very hot), and emosionaljuga physical stressors can trigger pain.

Quality of pain

Sometimes the pain can feel like a pounded or tingling. Nurses need to record the words used to describe pain clients. For information have a big impact on the diagnosis and etiology of pain.

The pattern of pain include the time of onset, duration, and recurrence intervals or pain. Therefore, nurses need to assess when the pain started, how long the pain lasts, whether recurrent pain, and pain at last appeared.

Symptoms that accompany
Symptoms include nausea, vomiting, dizziness, and diarrhea. These symptoms may be caused by the onset of pain or pain itself.

Influence on daily activities
By knowing the extent to which pain affects the client's daily activities will help nurses understand the client's perspective on pain. Some aspects of life that need to be examined in regard to pain is sleep, appetite, concentration, work, interpersonal relationships, marriage relationships, activities at home, at a time when leisure activity and emotional status.

Sources coping
Each individual has a different coping strategies in the face of pain. The strategy can be influenced by the experience of previous pain or influence of religion or culture.

Affective response
Client affective response to pain varies, depending on the situation, degree, and duration of pain, the interpretation of pain, and many other factors. Nurses need to assess the feelings of anxiety, fear, fatigue, depression, or feelings of failure on the client.

Observation of behavioral and physiological responses

Non-verbal responses that can be used as indicators of pain. One of the most important is the facial expression.
Behavior such as eyes tightly shut or wide open, biting the lower lip, and sneer face may indicate pain.

In addition to facial expressions, other behavioral responses that are indicative of pain is the vocalization (eg moans, crying, screaming), immobilization of the body that are experiencing pain, body movement without purpose (eg, kicking, flipping the mattress over the body reversal), etc..

While the physiological response to pain varies, depending on the source and duration of pain.
In the early onset of acute pain, the physiological response may include increased blood pressure, pulse, and breathing, diaphoresis, dilated pupils due srta terstimulasinya the sympathetic nervous system.
However, if the pain lasts longer, and the sympathetic nerve has been adapted, the physiological response may be reduced or even non-existent. Therefore, it is important for nurses to assess more than one response could be fisiolodis because the response is a poor indicator for pain.

Determination of Diagnosis
According to NANDA (2009-2011), nursing diagnosis for clients who are experiencing pain:
Acute Pain
Chronic pain

Nursing Diagnosis
  1. Acute Pain related to physical injury, reduction of blood supply, process of giving birth.
  2. Chronic pain related to the process of malignancy.
  3. Anxiety related to pain that is felt.
  4. Ineffective individual coping related to chronic pain.
  5. Impaired physical mobility related to musculoskeletal pain.
  6. Risk for injury related to lack of perception to pain.
  7. Disturbed sleep pattern related to low back pain.

Nurses develop a plan of nursing diagnoses that have been made​​. Nurses and clients together to discuss realistic expectations of action to overcome the pain, the degree of pain relief that is expected, and the effects are to be anticipated in lifestyle and client functions. Expected outcomes and objectives of nursing and nursing diagnoses are selected based on the client's condition. In general, the purpose of nursing care clients with pain are as follows:
  • Clients feel healthy and comfortable.
  • Clients retain the ability to perform self-care.
  • Clients maintain physical and psychological function held today.
  • Clients describe factors that cause pain.
  • Clients using the therapy given safely at home.
Nursing Diagnosis : Acute pain r / t physical injury (surgery)

Pain level, pain control and comfort level with the expected outcomes:
  • Using a pain scale to identify the perceived pain.
  • Describing how to manage pain.
  • Expressing ability to sleep and rest.
  • Describing nonpharmacological therapy to control pain.
  • Vital signs within normal limits.
Pain management:
  • Assess pain experienced by clients (including PQRST).
  • Observation of nonverbal discomfort to pain.
  • Assess the client's experience of the past to pain.
  • Create a comfortable environment for clients.
  • Collaboration of analgesics.
  • Teach nonpharmacological techniques to cope with pain.
  • Etc. (see more fully in the NIC).

Pain management consists of:
a. Pharmacological (collaboration); analgesic use.
Interfere with the reception / pain stimuli and its interpretation by pressing a function of the thalamus and cerebral cortex.
b. Non-pharmacological (standalone)
Therapeutic touch. This theory says that individuals who have a healthy balance between the body's energy with the outside environment. Sick people means there is an imbalance of energy, with a touch on the client, there is expected to transfer energy from the nurse to the client.
Acupressure. Giving emphasis on pain centers.
Guided imagery. Ask the client to imagine imagining things fun, this action requires an atmosphere and a quiet room and the concentration of clients. If the client is experiencing anxiety, action must be stopped. This action is done when the client feel comfortable and not in acute pain.
Distraction. Turning his attention to pain, effective for mild to moderate pain. Visual distraction (see TV or a football game), audio distraction (listening to music), touch distraction (massase, holding a toy), intellectual distraction (assembling puzzles, play chess)

Anticipatory guidence. Directly modify anxiety associated with pain. Examples of actions: the client before undergoing a surgical procedure, the nurse gives an explanation / information to the client about the surgery, so the client has no idea and will be better prepared for pain.
Hypnotize. Help change the perception of pain by affecting positive suggestions.

Biofeedback. Behavioral therapy is done by providing individual information about the physiological response to pain and how to train the voluntary control of the response. This therapy is effective for migraine and muscle tension, by placing electrodes on the temples.
Cutaneous stimulation. The workings of this system is still unclear, one is thinking this way can release endorphins, which can block pain stimulation. Could do with massase, warm baths, compresses with ice bags and transcutaneous electrical nerve stimulation (TENS / transcutaneus electrical nerve stimulation). TENS is a stimulation of the skin using a mild electrical current is delivered through the outer electrode.

The role of nurses in pain management:
  1. Identifying the cause of pain.
  2. Collaboration with other KES team for the treatment of pain.
  3. Provide pain relief intervention.
  4. Evaluating the effectiveness of pain relief.
  5. Acting as an advocate if pain relief is not effective.
  6. As educators keluarga§ and patients about pain management.
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