Nursing Diagnosis and Nursing Intervention

Acute Pain related to Ischemia


Ischemia is a symptom of reduced blood flow that can lead to functional changes in normal cells. Ischemia is a restriction in blood supply to the tissues, causing lack of oxygen and glucose needed for cell metabolism. Ischemic generally caused by problems with the blood vessels, with the result of tissue damage or dysfunction. It also means local anemia in a particular part of the body is sometimes caused by congestion (such as vasoconstriction, thrombosis or embolism).

The brain is the most sensitive tissues to ischemia to ischemic episodes were very short on neurons will induce a series of metabolic pathways that ends with apoptosis. Brain ischemia is classified into two subtypes, namely the global and focal ischemia. In global ischemia, at least two, or four cervical vessels impaired blood circulation immediately recovered some time later. In focal ischemia, the circulation of blood in the middle of the brain arteries are generally hampered by thrombus clot allowing reperfusion occurs. Simtoma impaired blood circulation by vascular occlusion clot called a thrombus.

Nursing Intervention:

1 Assess the level, frequency, and the reaction of pain experienced by the patient.
Rational: to find out how severe the pain experienced by the patient.

2 Explain to patients about the causes of the onset of pain.
Rationale: The patient's understanding of the causes of pain that occurs will reduce the strain of patients and allows patients to be invited to cooperate in taking action.

3 Create a quiet environment.
Rationale: Excessive stimulation of the environment will aggravate pain.

4 Teach distraction and relaxation techniques.
Rational: distraction and relaxation techniques can reduce the pain felt by the patient.

5. Adjust the position of the patient as comfortable as possible.
Rationale: a comfortable position will help provide opportunities for relaxation in the muscles optimally.

6 Perform massage and compress the wound with the current BWC wound care.
Rational: massage can increase spending vaskulerisasi and pussy while BWC as a disinfectant that can provide a sense of comfort.

7 Collaboration with physicians for analgesia.
Rational: analgesic medications can help reduce the patient's pain.
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