Nursing Care Plan for Pain - NANDA
The Casic Concept of Pain
1. Definition of Pain
Pain is a subjective sensory and emotional experience unpleasant tissue damage associated with actual or potential or perceived in the events where the damage occurred.
Another definition of pain is a subjective experience, greatly influenced by private educational, cultural, and cognitive meaning of the situation.
2. Type of pain based on the duration and length
Pain is usually divided into two major types are acute and chronic pain. Both can be distinguished from the onset, duration and cause pain.
a) Acute pain
Acute pain occurs after an acute injury, illness or surgical intervention and has a rapid onset, with varying intensity (mild to severe) and lasts for a short time (Meinhart and Mc Caffery, 1983, NIH 1986 in Potter and Perry, 1997).
By Bonica in 1987, acute pain as a collection of unpleasant experiences associated with sensory, perceptual and emotional responses related to the autonomic, emotional and behavioral.
Acute pain is usually a new event, a sudden and short duration. It is associated with acute illness, surgery or medical procedures or trauma and pain can help to determine its location. Another characteristic is the sense of pain can usually be identified, the pain was quickly reduced / lost, are clear and likely to end up / missing.
b) Chronic Pain
Chronic pain is pain that lasts a long, varied in intensity and usually lasts more than six months (Mc Caffery, 1986 in Potter and Perry, 1997). On clients with chronic pain often experience periods of remission (partial or complete loss of symptoms) and exacerbation (increased severity). The nature of this chronic pain can not be predicted which makes the client often leads to frustration and psychological depression.
Chronic pain is a situation or circumstance that experience persistent pain / continuously for several months / years after the healing phase of an acute illness / injury. Characteristics of chronic pain is not easily identifiable area of pain, reduced pain intensity difficult, the pain usually increases, its nature is less obvious and less likely to heal / disappear.
Chronic pain can be categorized into two: chronic pain of malignant and non malignant. Malignant chronic pain can be described as pain associated with cancer or other progressive diseases. Non-malignant chronic pain is usually associated with pain due to non-progressive tissue damage, or have experienced healing.
3. Type of pain based on the intensity
The intensity of pain a person can be known from the assessment tools used. In the verbal descriptions of pain, the individual is the best assessor of the pain they experienced and should therefore be asked to describe and make level. Obtained pain intensity was measured using a scale of them; simple descriptive pain intensity scale, a scale of 0-10 numerical pain intensity and visual analogue scale (VAS). Scale used to describe the intensity / severity of pain.
a. Simple descriptive pain intensity scale
Pain intensity scale of this simple descriptive pain using six images of different facial expressions, showing a happy face to sad face, which is used to express pain. This scale can be used from children age 3 (three) years.
b. Numeric pain intensity scale: 0 -10
Severity of pain or pain made into measurable with subjective pain make objective opinion. Numerical scale, was used from 0 to 10, zero (0) is a state with no or a pain-free, while ten (10), a very great pain.
c. Visual analog scale (VAS)
Similar scale is a straight line, without figures. Be free to express pain, to the left to no pain, unbearable pain in the right direction, with the center about which pain is. Clients asked to indicate the position of pain on the line between these two extreme values.
Pain Definition - Nanda
Feeling and an unpleasant emotional experience arising from tissue damage or a description of actual and potential damage. It can occur suddenly or slowly, the intensity of light or heavy. With predictions of healing time is approximately less than 6 months.
- Reports of verbal and nonverbal
- Observation reports
- Position the patient to be careful to avoid the pain
- Movement to protect themselves
- Cautious behavior
- Face mask
- Sleep disturbances (glazed eyes, looked tired, which is difficult or chaotic movement, smirk)
- Focus on self-
- The focus narrows (decreasing the perception of time, damage fikir process, decreasing the interaction with people and the environment)
- Distracting activity (a walk, meet other people or activities, repetitive activities)
- Response autonomy (diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils).
- Autonomy in response to changes in muscle tone (visible from the weak to stiff)
- Expressive behavior (restlessness, moaning, crying, alert, iritabel, deep breath, sigh)
- Changes in appetite, drinking
a. Injury agents (biological, chemical, physical, psychological)
- Not performed at all
- Rarely do
- Sometimes done
- Often do
- Always do
- Pain Management
Interventions and Rational:
- Perform a comprehensive assessment
- Observation of nonverbal reactions and discomfort
- Use therapeutic communication to know the experience of pain
- Assess the culture that affect the pain response
- Evaluation of past experience of pain
- Assist patients and families to seek and find support
- Environmental control
- Reduce the Pain of precipitation factor
- Select and doing pain management (pharmacologic, non-pharmacological and interpersonal)
- Assess the source and type of pain to determine intervention
- Teach about non-pharmacological techniques
- Give analgesics for pain relief
- Increase breaks
- Collaboration with a physician if there are complaints of pain and the action does not work
- Monitor the patient acceptance of pain management.