Cellulitis is an infection by Staphylococcus, Streptococcus, or by both of them in the deepest layers of the skin. Bacteria can enter the body through the other parts of the skin of a cut, scratch, or bite. Usually if the skin is infected, affected only the top layer and will disappear on their own with proper care. But in cellulitis, skin tissue becomes infected parts in red, hot, inflamed and painful. Cellulitis usually occurs on the face and lower legs.
While according to Neville, Oral and Maxillofacial Pathology, explains that the term cellulitis used an oedematous deployment of acute inflammation on the surface of the soft tissues and is diffuse. Cellulitis can occur in all places where there is soft tissue and loose connective tissue, especially on the face and neck, because usually in the area of defense against infection is less than perfect.
The main causes of facial cellulitis is Staphylococcus aureus and Streptococcus b- hemolyticus, whereas Staphylococcus epidermidis is a normal inhabitant of the skin and rarely fight infections. Pyoderma predisposing factor is the lack of hygiene, immune deficiencies, and other diseases have been found in the skin.
Cellulitis are not contagious, usually begins as a small, inflamed, pain, swelling, heat, and redness of the skin. When the milking area began to spread, the child will feel pain and discomfort, fever, and can be accompanied by chills and sweating. Swollen lymph nodes in the folds are sometimes found on the nearby skin infections.
Nursing Diagnosis and Interventions :
Acute Pain related to local inflammatory response of subcutaneous tissue.
Goal : The client expressed pain decreased after nursing care.
Expected outcomes :
Stable pain scale (0-3).
Showed no pain / controlled.
Looks relaxed, able to sleep / rest and participate in activities according to ability.
Following the recommended pharmacological program.
Intervention :
1. Observation pain scale (0-10), the characteristics of pain, and pain location.
Rational : assist in determining the need for pain management, and program effectiveness.
2. Let the patient take a comfortable position and increase bed rest as indicated.
Rational : to limit the pain.
3. Give a gentle massage.
Rational : increase relaxation / reduce muscle tension.
4. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, guidance imagination, self hypnosis, and breath control.
Rational : increase relaxation, gives a sense of control, and may improve coping skills.
Collaboration
5. Give the medicine before the activity / exercise is planned, according to the instructions.
Rational : increase relaxation, reduce muscle tension / spasm, easy to participate in therapy.
6. Apply ice or a cold pack if necessary.
Rational : the cold can relieve pain and swelling during the acute period.
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.
Urinary retention is the inability to empty the bladder completely during the process of urine. (Brunner and Suddarth. (2010). Text Book Of Medical Surgical Nursing 12th Edition. Thing in 1370).
Causes of urinary retention, among others, diabetes, enlarged prostate gland, urethral abnormalities (tumor, infection, calculus), trauma, childbirth or neurological disorders (stroke, spinal cord injury, multiple sclerosis and Parkinson's). Some medications can cause urinary retention either by inhibiting bladder contractions or increased resistance of the bladder. (Karch, 2008)
Signs and Symptoms
Beginning with a slow flow of urine.
Then there are the longer polyuria became worse because of inefficient bladder emptying.
Abdominal distention occurs due to dilatation of the bladder.
Feels no pressure, pain and sometimes feel the urge to urinate.
In severe retention could reach 2000 -3000 cc.
The diagnostic checks that can be performed on urine retention is as follows:
Examination of the urine specimen.
Decision: sterile, random, midstream.
General retrieval: pH, BJ, Culture, Protein, Glucose, hemoglobin, ketones and Nitrite.
Cystoscopy (examination of the bladder).
IVP (Intravenous pyelogram) / X-ray with contrast material.
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. Is a major cause of acute excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen.
Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in ribbon or reconstruction of the gastrointestinal tract.
Cause of chronic gastritis is infection with bacteria, primarily Helicobacter pylori''''. Certain diseases, such as pernicious anemia, chronic bile reflux, stress and certain autoimmune disorders can cause gastritis as well.
The most common symptom is abdominal upset or pain. Other symptoms are indigestion, flatulence, nausea, and vomiting.
Some people may have a feeling of fullness or burning in the upper abdomen. A gastroscopy, blood test, complete blood count tests, or stool tests can be used to diagnose gastritis. Treatment includes taking antacids or other medications, such as proton pump inhibitors or antibiotics, and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections are given.
Nursing Diagnosis - Acute Pain related to Gastritis
Acute Pain related to inflammation of the mucosal lining of the stomach (gastric)
Goal:
Pain is reduced with no inflammation or irritation of the gastric mucosa.
Outcomes:
Pain scale is reduced
Do not feel pain in the epigastric
Not grimace (no abdominal tenderness)
Interventions:
Record complaints of pain, including the location, duration, intensity (scale of 0-10)
Review the factors that increase or decrease pain
Give food a little but often as an indication for patients
Assistive range of motion exercises active / passive
Provide frequent oral care and comfort measures (back massage, change of positions)
Collaboration:
Give medication as indicated
Rational:
Pain is not always there but if there is to be compared with the previous patient's symptoms of pain, which can help diagnose the etiology and occurrence of bleeding complications.
Assist in making the diagnosis and therapeutic needs.
Have the effect of neutralizing acidic foods, it also destroyed the womb gaster.Makan little gastrin prevent distension and output
Acute Pain NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of <6 months (NANDA).
Defining Characteristics:
Subjective
Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).
Objective
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.
Related Factors:
Actual or potential tissue damage (mechanical [e.g., incision or tumor growth], thermal [e.g., burn], or chemical [e.g., toxic substance])
·Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities)
·Describes how unrelieved pain will be managed
·Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects
·Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)
·States an ability to obtain sufficient amounts of rest and sleep
·Describes a nonpharmacological method that can be used to control pain
NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels
·Conscious Sedation
·Patient-Controlled Analgesia (PCA) Assistance
Nursing Interventions and Rationales
·Determine whether client is experiencing pain at the time of the initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).
·Ask client to describe past experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how he or she expresss pain. A number of concerns (barriers) may affect patients' willingness to report pain and use analgesics (Ward et al, 1993).
·Describe adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).
·Tell client to report location, intensity (using a pain rating scale), and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).
·Determine client's current medication use. To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992).
·Explore the need for both opioid (narcotic) and non-opioid analgesics. Pharmacological interventions are the cornerstone of pain management (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
·Obtain a prescription to administer a non-opioid (acetaminophen, Cox-2 inhibitor, or a nonsteroidal antiinflammatory drug [NSAID]), unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain impulses (Dahl, Kehlet, 1991). Unless contraindicated, all patients with acute pain should receive a non-opioid ATC (Acute Pain Management Guideline Panel, 1992). The analgesic regimen should include a non-opioid, even if pain is severe enough to require the addition of an opioid (Jacox et al, 1994; McCaffery, Pasero, 1999).
·Obtain a prescription to administer opioid analgesia if indicated, especially for severe pain. Opioid analgesics are indicated for the treatment of moderate to severe pain (Jacox et al, 1994; McCaffery, Pasero, 1999).
·Administer opioids orally or intravenously, not intramuscularly. Use a preventive approach to keep pain at or below an acceptable level. Provide PCA and intraspinal routes of administration when appropriate and available. The least invasive route of administration capable of providing adequate pain control is recommended. The intramuscular (IM) route is avoided because of unreliable absorption, pain, and inconvenience. The intravenous (IV) route is preferred for rapid control of severe pain. For ongoing pain, give analgesia ATC. PRN dosing is appropriate for intermittent pain (Jacox et al, 1994; McCaffery, Pasero, 1999).
·Discuss client's fears of undertreated pain, overdose, and addiction. A number of concerns may affect clients' willingness to report pain and use opioid analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (Jacox et al, 1994; McCaffery, Pasero, 1999). Addiction is extremely unlikely after patients use opioids for acute pain (Acute Pain Management Guideline Panel, 1992).
·When opioids are administered, assess pain intensity, sedation, and respiratory status at regular intervals. Opioids may cause respiratory depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the respiratory centers of the brain. Because even more opioid is required to produce respiratory depression than is required to produce sedation, patients with clinically significant respiratory depression are usually also sedated. Respiratory depression can be prevented by assessing sedation and decreasing the opioid dose when the patient is arousable but has difficulty staying awake (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).
·Review client's flow sheet and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the past 24 hours. Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).
·Administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for supplementary opioid doses between regular doses is an essential backup (American Pain Society, 1999).
·Obtain prescriptions to increase or decrease opioid doses as needed; base prescriptions on client's report of pain severity and response to the previous dose in terms of relief, side effects, and ability to perform the activities of recovery. Increase or decrease the dose of opioid based on assessment of the patient's response. Patients' responses, and therefore their requirements, vary widely, so it is less important to focus on the amount given than on the response (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).
·When client is able to tolerate oral analgesics, obtain a prescription to change to the oral route; use an equianalgesic chart to determine initial dose. (See Appendix E for an equianalgesic chart.) The oral route is preferred because it is the most convenient and cost-effective (Jacox et al, 1994). Use of equianalgesic doses when switching from one opioid or route of administration to another will help to prevent loss of pain control from underdosing and side effects from overdosing (McCaffery, Pasero, 1999).
·In addition to use of analgesics, support client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore the clients' sense of self-control, personal efficacy, and active participation in own care (Jacox et al, 1994).
·Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992).
·Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999).
·Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, these side effects should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).
Geriatric
·Always take the elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999).
·When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials.
·Handle client's body gently. Allow client to move at own speed.
·Use acetaminophen and NSAIDs with low side-effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid), and watch for side effects, such as GI disturbances and bleeding problems. Elderly people are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992).
·Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). The higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
·Use opioids with caution in the elderly client. The elderly are more sensitive to the analgesic effects of opioid drugs because they experience a higher peak effect and a longer duration of pain relief. Reduce the initial recommended adult starting opioid dose by 25% to 50%, especially if the client is frail and debilitated; then increase the dose if safe and necessary (Acute Pain Management Guideline Panel, 1992).
·Avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet), in elderly clients. Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
Multicultural
·Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Have scale translated into client's native language if necessary.. Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999).
·Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level. Regardless of the patient's cultural background, pain rated at (4 on a 0 to 10 pain rating scale interferes significantly with daily function. Perceived quality of life appears to be comparable across cultures, with pain ratings of >6 interfering markedly with a person's ability to enjoy life (McCaffery, 1999; McCaffery, Pasero, 1999).
·Assess for the influence of cultural beliefs, norms, and values on the client's perception and experience of pain. The client's experience of pain may be based on cultural perceptions (Leininger, 1996).
·Assess for the role of fatalism on the client's beliefs regarding their current state of comfort. Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
·Incorporate folk health care practices and beliefs into care whenever possible. Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).
·Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients. Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).
·Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client. Culturally diverse clients may express pain differently than clients from the majority culture. The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).
·Ensure that directions for medications are available in the client's language of choice and are understood by client and caregiver. Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).
·Validate the client's feelings and emotions regarding current health status. Validation lets the client know the nurse has heard and understands what was said, and it promotes the nurse-client relationship. (Stuart, Laraia, 2001;Giger, Davidhizer, 1995).
Home Care Interventions
·Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).
·Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).
·Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).
·If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).
·Assess knowledge base of client and family for highly technological medication administration. Teach as necessary. Be sure clients know when, how, and who to contact if analgesia is unsatisfactory. Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).
Client/Family Teaching
·NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.
·Provide written materials on pain control such as the Agency for Health Care Policy and Research (AHCPR) pamphlet, Pain Control: Patient Guide.
·Discuss the various discomforts encompassed by the word pain, and ask client to give examples of previously experienced pain. Explain pain assessment process and purpose of the pain rating scale.
·Teach client to use the pain rating scale to rate intensity of past or current pain. Ask client to set a comfort/function goal by selecting a pain level on the rating scale that makes it easy to perform recovery activities (e.g., turn, cough, deep breathe). If pain is above this level, client should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)
·Demonstrate medication administration and use of supplies and equipment. If PCA is ordered, determine client's ability to press appropriate button. Remind client and staff that the PCA button is for patient-only use.
·Reinforce importance of taking pain medications to keep pain under control.
·Reinforce that taking opioids for pain relief is not addiction and that addiction is very unlikely to occur.
·Demonstrate use of appropriate nonpharmacological approaches for controlling pain, such as heat, cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music, and television.
Vertigo is a subtype of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to an asymmetric dysfunction of the vestibular system in the inner ear.It is often associated with nausea and vomiting as well as a balance disorder, causing difficulties standing or walking. There are three types of vertigo:
Objective− the patient has the sensation that objects in the environment are moving;
Subjective− patient feels as if he or she is moving; Pseudovertigo− intensive sensation of rotation inside the patient's head.
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Nine areas of the head and neck have these pain-sensitive structures, which are the cranium (the periosteum of the skull), muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes.
Nursing Diagnosis for Vertigo / Headache: Pain (acute / chronic)
related to
stress and tension,
irritation / pressure nerves,
vasospasm,
increased intracranial
characterized by:
states that pain is influenced by factors such as:
position changes, changes in sleep patterns, anxiety.
1. Monitor vital signs, the intensity / pain scale.
Rationale: Identify and facilitate the conduct of nursing actions.
2. Encourage clients to rest in bed.
Rational: the break to reduce the intensity of pain.
3. Adjust the position of the patient as comfortable as possible
Rational: the right position to reduce stress and prevent muscle tension and reduce pain.
4. Teach relaxation and deep breathing techniques
Rational: relaxation to reduce tension and create a feeling more comfortable.
5. Collaboration for providing analgesic.
Rational: useful analgesic to relieve pain so that patients become more comfortable.
Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.
Defining Characteristics
Patient reports pain
Guarding behavior, protecting body part
Self-focused
Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
Facial mask of pain
Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
Related Factors:
Postoperative pain
Cardiovascular pain
Musculoskeletal pain
Obstetrical pain
Pain resulting from medical problems
Pain resulting from diagnostic procedures or medical treatments
Pain resulting from trauma
Pain resulting from emotional, psychological, spiritual, or cultural distress
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
Comfort Level
Medication Response
Pain Control
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
Analgesic Administration
Conscious Sedation
Pain Management
Patient-Controlled Analgesia Assistance
Expected Outcomes
Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.
There are many things that can cause a person pain and different people have different tolerances for types of pain. Someone with a low tolerance may find many things very painful. Someone with a higher tolerance may be able to withstand these things.
There is the pain of a headache and there are many kinds of headaches that produce vaious degrees and quality of pain. There is organ pain when something is wrong inside and muscle pain when they are pushed beyond the norm either by exercise or emergency. Pain can be mild and a mere annoyance, or brutal and debilitating.
Acute pain is a pain that is recent, a sudden onset of pain, something that has been caused by an accident, a fall, an injury, or something of that nature. Acute pain is usually quite strong and ranges from a sharp nerve pain or shooting pain, to a very strong ache. It can be made worse by certain movements and may restrict you from doing things.
These are some of the obvious things that cause instant pain but sometimes acute pain seems to appear out of nowhere. For example, the sudden onset of lower back pain or neck spasms.
Generally the majority of acute pain conditions are caused by muscle spasms. Sure they may feel like they are incredibly painful because when muscles spasm they can also entrap and irritate nerves. Acute pain conditions are generally easy to treat and do not leave any residual problems. Massage therapy is the treatment used to alleviate muscular problems. Remedial massage acts by stimulating the muscles that are in spasm so they release. By stimulating the right muscles the body will then correct itself, releasing the muscle spasms and bringing your body back to normal.
Acute Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.
Nursing Diagnosis for Pain – Chronic
Chronic Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.
Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.
Acute pyelonephritis is a potentially organ- and/or life-threatening infection that characteristically causes scarring of the kidney. An episode of acute pyelonephritis may lead to significant renal damage; kidney failure; abscess formation (eg, nephric, perinephric); sepsis; or sepsis syndrome, septic shock, and multiorgan system failure.
Acute pyelonephritis is complex, and there is no consistent set of signs and symptoms that is both sensitive and specific for the diagnosis. Therefore, clinicians must maintain a high index of suspicion.
In contrast to the plethora of data available for the treatment of cystitis, less substantial data are available regarding the appropriate antibiotic choice or duration of therapy for acute pyelonephritis. An additional cause for concern is the growing resistance of uropathogens to standard agents. Nevertheless, useful recommendations can be made. (emedicine)
Nursing Care Plan for Pyelonephritis
Nursing Diagnosis for Pyelonephritis : Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.
Evaluation criteria: no pain when urinating, no pain on percussion of the pelvis.
Nursing Interventions and Rational for Pyelonephritis
Independent
1. Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor the results of repeated urinalysis.
Rational: To identify indications of progress or deviations from expected results.
2. Record the location, duration, intensity scale (1-10) the spread of pain.
Rational: To help evaluate the obstroksi and cause pain.
3. Provide comfort measures, such as back massage, environment, rest, sleep.
Rational: Increase relaxation, reduce muscle tension.
4. Help or encourage the use of focused relaxation breathing.
Rational: Helps to redirect attention and for muscle relaxation.
5. Give perianal care.
Rational: To prevent contamination of the urethra.
6. If mounted catheter, catheter care provided 2 times per day.
Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.
Collaboration
1. Consul doctor if: previous urine yellow, ivory, yellow urine, dark orange, hazy or cloudy. Micturition pattern changes, frequent urination in small amounts, feeling the urge to urinate. Persistent pain or increasing pain.
Rational: These findings could signal further tissue damage and needs extensive examination.
2. Give analgesics as needed and evaluate its success.
Rational: Analgesic block the path of pain, thereby reducing pain.
3. Giving antibiotics. Create a variety of drink preparations, including fresh water. Provision of water to 2400 ml / day.
Rational: As a result of urine output makes it easy to urinate often and help flush urinary tract.
A uterine fibroid is a leiomyoma (benign (non-cancerous) tumor from smooth muscle tissue) that originates from the smooth muscle layer (myometrium) of the uterus. Fibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. The malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma.
Other common names are uterine leiomyoma,myoma, fibromyoma, fibroleiomyoma.
Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare. (wikipedia)
Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus
Objectives:
Pain can be reduced or lost
Expected outcomes are:
Pain scale (1-10) = 1-3.
Respiration = 16-24 beats / minute.
Pulse = 60 -100 beats / min.
Expression showed no signs of pain and seemed to relax.
Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.
2. Find the area, location, and intensity of pain
Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications
3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client
Rational: It can provide comfort to the client.
4. Give instruction in relaxation techniques and deep breathing techniques
Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client
5. Encourage clients to use a warm compress
Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.
6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.
Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.
7. Provide information about the use of analgesics that are prescribed or not prescribed
Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.
8. Evaluation of vital signs.
Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.
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