Nursing Diagnosis for Lower Back Pain : Acute pain related to the agent of injury (physical, musculo skeletal disorders and vascular nervous system).
Defining characteristics :
Verbal
- Took a deep breath, moaning.
- Complained of pain.
- Grinning face.
- Step struggling.
- Rigid posture / unstable.
- Movement is very slow or forced.
- Changes in vital signs.
Goal :
Pain is reduced / lost
Outcome :
Levels of pain
- Reported pain reduced / lost.
- Frequency of pain reduced / lost.
- Long of pain pain reduced / lost.
- Oral expression is reduced / lost.
- Muscle tension is reduced / lost.
- Can rest.
- Pain scale decreased.
- Know the factors that cause.
- Know the onset of pain.
- Rarely / never done action / relief with non- analgesic.
- Rarely / never use of analgesics.
- Rarely / never reported pain to the healthcare team.
- Pain controlled.
- Report needs a break - sleeping fulfilled.
- Reported good physical condition.
- Reported good psychological condition.
Interventions :
Pain Management
- Perform a comprehensive pain assessment (location, characteristics, duration, frequency, quality, and precipitation factors).
- Observation of non-verbal reactions of discomfort.
- Use therapeutic communication techniques to determine the client's experience of pain.
- Assess the culture that affects pain response.
- Evaluation of past painful experiences.
- Evaluation with clients and other health team about the ineffectiveness of pain control past.
- Help clients and families to seek and find support.
- Control environment that may affect pain (room temperature, lighting, and noise).
- Reduce pain precipitation factor.
- Choose and pain management (pharmacological, non-pharmacological and interpersonal).
- Assess the type and source of pain to determine the intervention.
- Teach about non-pharmacological techniques.
- Give analgesics to reduce pain.
- Evaluation of the effectiveness of pain control.
- Increase the break.
- Collaboration with doctors, if there is a complaint and the action of pain that did not work.
- Monitor client acceptance of pain management.
Analgesic Andministrasi
- Determine the location, quality characteristics, and the degree of pain as drug delivery.
- Check the doctor's instructions about the type of medication, dosage and frequency.
- Check history of allergy.
- Select the required analgesics or combination of analgesics when giving more than one.
- Determine analgesic choice , depending on the type and severity of pain.
- Determine the route of administration of analgesic options, and the optimal dose.
- Select the route of administration of intravenous / intramuscular, for the treatment of pain on a regular basis.
- Monitor vital signs before and after the administration of first analgesic.
- Give analgesic especially timely when severe pain.
- Evaluation of the analgesic effectiveness of signs and symptoms (side effects).
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