Pulmonary Tuberculosis (TB) - 3 Nursing Diagnosis, Interventions and Rational

Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the accumulation of purulent secretions in the airway.

Goal: Airway clearance back effectively.

Nursing Interventions:

• Assess respiratory function, for example; breath sounds, speed and rhythm.
• Give the patient semi-Fowler's position or high Fowler effectively assist the patient to cough and deep breathing exercises.
• Maintain fluid intake at least 2500 ml / day, except, contra indications.
• Collaboration for the administration of drugs according to indications, mucolytic drugs.

Rational:

• Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of secretions inability to clean the airway.
• The position helps maximize lung expansion and lower respiratory effort.
• High input of fluids helps to thin the secretions, making it easily removed.
• Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning.

Nursing Diagnosis for Plan Tuberculosis (TB) : Imbalanced Nutrition Less than Body Requirements related to the production of sputum, anorexia.

Goal: Demonstrate increased weight.

Nursing Interventions:

• Record the patient's nutritional status, record of skin turgor, weight and degree of underweight, ability / inability to swallow, a history of nausea-vomiting.
• Supervise the input or output and weight periodically.
• Provide oral care before and after the act of breathing.
• Encourage eating little and often with foods high in calories and high in protein.
• Collaboration with a nutritionist to determine the composition of the diet.

Rational:

• Useful in defining the degree / problems in determining appropriate intervention options.
• Useful in measuring the effectiveness of nutrition and fluid support.
• Lowering bad taste because the rest of the sputum or leftover medicines.
• Maximize nutrient inputs as energy needs and decrease gastric irritation.
• Provide assistance in planning a diet with adequate nutrients for metabolic and dietary needs.

Nursing Diagnosis for Plan Tuberculosis (TB) : Knowledge Deficit: on the conditions, rules of action and displacement.

Goal: To declare understanding of disease processes / prognosis and treatment needs.

Nursing Interventions:

• Assess the patient's ability to learn. Example: the problem of weakness, the level of participation and the best environment.
• Emphasize the importance of maintaining a high protein and carbohydrate diet and adequate fluid intake.
• Explain the drug dose, frequency, expected work and long treatment reasons
• Emphasize to not drink alcohol and do not smoke.

Rational:

• Learning depends on the emotional and physical readiness improved in individual stages.
• Meet the metabolic needs, help minimize the weaknesses and improve healing.
• Increase cooperation in the treatment program and prevent withdrawal of the drug.

Risk for Injury - NCP for Cesarean Section

Nursing Care Plan for Cesarean Section

Nursing Diagnosis : Risk for Injury related to biochemical function or regulation, the effects of anesthesia, tissue trauma.

Goal:

• Demonstrate behaviors to reduce risk factors and / or self-protection.
• Free from complications.

Itervention:

1. Review the prenatal and intra prenatal record, the factors of clients in complications.
Rationale: The presence of risk factors such as fatigue miometrial, excessive uterine distension, slow oxytocin stimulation, or thrombophlebitis a prenatal, allowing clients more susceptible to post-operative complications.

2. Monitor blood pressure, pulse and temperature. Note the skin is cold, wet, weak pulse and subtle, changes in behavior, delayed capillary refill, or cyanosis.
Rationale: High blood pressure can indicate the occurrence or continuation of hypertension. Hypotension and tachycardia may indicate dehydration and hypovolemia but may not occur until the circulating blood volume has been decreased to 35% - 50%, pyrexia may indicate infection.

3. Inspection bandage against excessive bleeding.
Rationale: Surgical wounds with drain, can dampen the bandage, but seepage is usually not visible and can indicate the occurrence of complications.

4. Note the catheter and amount of lochia flow and consistency of the fundus.
Rationale: The flow of lochia should not be much or contains clots. Fundus must remain contracted, firmly on the umbilicus. Protrusion of the uterus resulting in increased blood flow and loss.

5. Encourage exercise foot / ankle and early ambulation.
Rationale: Increased venous return, preventing ataxia / buildup on the lower extremities, lower the risk of phlebitis.

5. Inspection incision regularly, note the slowdown, or a change in healing.
Rationale: Excessive Stretching the incision, slowing the healing can cause clients tend to tissue separation and possible hemorrhage.

6. Replace lost fluids intravenously, according to the program.
Rationale: Average blood loss typically 600-800 ml, but prenatal physiological edema, increasing the need for replacement of large fluid volumes.

7. Monitor hemoglobin / hematocrit Post-surgery, compared with preoperative levels.
Rationale: Clients with a hematocrit of 33% or greater and an increase in the plasma with respect to pregnancy can tolerate the actual blood loss.

8. Increase the oxytocin infusion if uterine relaxation and / or heavy lochia.
Rationale: Stimulate miometrial contractility and decrease blood loss.

Acute Pain - Nursing Care Plan for Cesarean Section

Nursing Diagnosis for Cesarean Section : Acute pain related to surgical trauma, anesthesia, hormonal effects, distended bladder / abdomen.

Goal:

• Identify and use interventions to treat pain / discomfort appropriately.
• Reveal a reduction in pain.
• Relaxed able to sleep / rest.

Intervention:

1. Determine the characteristics and location of discomfort. Pay attention to verbal and non-verbal cues such as grimacing, stiffness, and limited movement or protect.
Rationale: The client may not be verbally reported pain and discomfort directly. Distinguish specific characteristics of pain and postoperative pain helps distinguish from complications.

2. Evaluation of blood pressure and pulse, note the change in behavior change.
Rationale: Pain can cause restlessness and increased blood pressure and pulse.

3. Change the position of the client, reduce harmful stimuli, and give a back rub. Encourage the use of breathing techniques, relaxation and distraction.
Rationale: muscle relaxes and distracts from the pain sensors.

4. Encourage early ambulation, Instruct to avoid gas-forming foods or liquids.
Rationale: Lower gas formation and increase the peristaltic to relieve discomfort due to gas accumulation.

5. Encourage the use of the left lateral recumbent position.
Rationale: Allows the gas increases from descending colon to the sigmoid, ease spending.

6. Palpate bladder, note the presence of the pain.
Rationale: Restore normal bladder function requires 4-7 days and overdistention of the bladder, creating a feeling of encouragement and discomfort.

7. Provide information for breastfeeding patients, the increased frequency of feeding, giving the exact position of the baby and mother's milk issued manually.
Rationale: This action can help the client lactation, stimulates milk flow and eliminates static and tension. Pillow helps support and protect the incision baby in a sitting position or tilted.

8. Encourage clients starting breastfeeding.
Rationale: The first strong sucking response and possible pain. Start breastfeeding may reduce pain and promote healing.

9. Collaboration of analgetic every 3-4 hours, continuing from the IV / intramuscular to the oral route. Give the drugs to clients who breastfeed 48-60 minutes before feeding.
Rationale: Improves comfort and correct the psychological status and improve mobility. Wise use of the drug, allowing the mother to enjoy the benefits of breastfeeding with no side effects in infants.

Bronchopneumonia - Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis and Interventions for Bronchopneumonia -

1. Ineffective airway clearance related to accumulation of secretions.

Goal: Airway clearance back effectively.

Outcomes: secretions can come out.

Interventions:

• Monitor respiratory status every 2 hours, assess the increase in respiratory and abnormal breath sounds.
• Do suction as indicated.
• Give oxygen therapy every 6 hours.
• Create an environment / convenient so patients can sleep.
• Give a comfortable position for the patient.
• Monitor blood gas analysis to assess respiratory status.
• Perform chest percussion.
• Provide sputum for culture / sensitivity test.

2. Impaired gas exchange related to changes in alveolar capillaries.

Goal: back to normal gas exchange.

Outcomes: The client showed improved ventilation, gas exchange and oxygenation optimally adequately.

Interventions:

• Observation of level of consciousness, respiratory status, signs cianosis.
• Give appropriate sleeping position fowler / semi-Fowler.
• Give oxygen according to the program.
• Monitor blood gas analysis.
• Ciprtakan comfortable environment.
• Help prevent fatigue.

3. Fluid volume deficit related to excessive output.

Goal: Client will maintain normal body fluid.

Outcomes: no sign of dehydration.

Interventions:

• Record intake and output of fluids (fluid balance).
• Encourage the mother to continue to provide oral fluid.
• Monitor fluid balance, mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
• Maintain a drip infusion accuracy.
• Observation of vital signs (pulse, temperature, respiration).

4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.

Goal: The nutritional requirements are met.

Outcomes: The client can maintain / improve nutritional intake.

Intervetions:

• Assess the client's nutritional status.
• Perform a physical examination of the abdomen (auscultation, percussion, palpation, and inspection).
• Measure the client's body weight every day.
• Assess for nausea and vomiting.
• Give the diet a little but often.
• Provide food in a warm state.
• Collaboration with the nutrition team.

5. Increased body temperature related to the infection process.

Goal: There is an increase in body temperature.

Outcomes: Hyperthermia / increase in temperature can be resolved with no infection process.

Interventions:

• Observation of vital signs.
• Provide and encourage families to provide water compress on the forehead area and armpits.
• Involve the family in every action.
• Give drink orally.
• Replace wet clothing with sweat.
• Collaboration with doctors in febrifuge.

6. Knowledge Deficit : parents, about the care of clients related to a lack of information.

Goal: Knowledge parents about the child's illness increased after the act of nursing.

Outcomes: Parents know about the child's illness.

Interventions:

• Assess the level of parental knowledge about the child's illness.
• Assess the client's level of parental education.
• Help parents to develop a plan of nursing care in the hospital such as: diet, rest and activity accordingly.
• Emphasize the need to protect children ..
• Explain to the client's family about the definition, causes, signs and symptoms, treatment, and prevention of complications by providing health education.
• Give parents the opportunity to ask clients about things not yet understood.

7. Anxiety children related to the effects of hospitalization.

Goal: Anxious children is reduced / lost.

Outcomes: The client can be quiet, anxious lost, comfortable feeling fulfilled after the act of nursing.

Interventions:

• Assess the client's level of anxiety.
• Encourage the mother / family to give suport to the child by way of the mother is always near to the client.
• Facilitating a sense of comfort by way of participating mothers caring for their children.
• Make a visit, contact with clients.
• Encourage other family visiting clients.
• Give A toy according client's home.

Evaluation

The evaluation is expected in patients with Brochopneumonia are:

1. Normal gas exchange.
2. Effective airway clearance.
3. Intake and output balance.
4. Adequate nutritional intake.
5. Body temperature within normal limits.
6. Increase family knowledge.
7. Anxiety resolved.

Nursing Care Plan for Encephalitis - Assessment, Diagnosis and Interventions

Nursing Care Plan for Encephalitis

Definition

• 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).

Etiology

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.

Complications

• 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.

Intervention:

• 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.

Intervention:

• 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

Intervention:

• 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

Intervention:

• 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

Intervention:

• 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.


Definition

• 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.

Etiology

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

Assessment

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.

Pattern
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.

Interventions:
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)

Goal:
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.

Interventions:
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).

Intervention

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.