List of Nursing Diagnosis

Acute coronary syndrome (ACS) refers to a group of conditions due to decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies. The most common symptom is chest pain, often radiating to the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Acute coronary syndrome usually occurs as a result of one of three problems: ST elevation myocardial infarction (30%), non ST elevation myocardial infarction (25%), or unstable angina (38%).

Nursing Care Plan for Acute Coronary Syndrome

Nursing Diagnosis : Acute Pain related to tissue ischemia secondary to coronary artery occlusion.

Goal: pain experienced by the patient can be reduced.

Expected outcomes:

• The client states chest pain is gone / controlled.
• The client can demonstrate relaxation techniques.
• The client may indicate reduced tension, relaxed and easy to move.

Nursing Interventions:

1. Provide a comfortable environment, calm, and give slow activity.
R /: Lowering external stimuli in which anxiety and heart strain and limited coping skills and decisions on the current situation.

2. Assist the client in relaxation techniques such deep breaths / slowly, distraction, visuallisasi, guidance imagination.
R /: Helps in reducing the pain response.

3. Provide supplemental oxygen by nasal cannula or mask as indicated.
R /: Increase the amount of oxygen available for the use of the myocardium and also reduces discomfort with respect to tissue ischemia.

4. Give the drug as indicated.
R /: To control pain and increase peace of patients to the healing process runs smoothly.

Nursing Diagnosis for Encephalitis : Acute Pain related to irritation of the brain lining.

Goal :
Patients seen decreases pain / pain control.

Outcomes :

• Patients can sleep.
• Saying decrease pain.

Interventions :
1. Try to create a safe and quiet environment.
Rationale : Lowering the reaction to external stimuli or sensitivity to light and encourage patients to rest.

2. Cold compress to the head and a cool cloth on the eye.
Rationale : Can cause vasoconstriction of blood vessels of the brain.

3. Perform active or passive motion exercise in accordance with the conditions of tender and careful.
Rationale : Can help to relax tense muscles and may decrease pain / disconfort.

collaboration :
4. Give analgesics.
Rationale : It may be necessary to decrease pain.


Nursing Diagnosis for Encephalitis : Risk for Injury related to the presence of seizures, altered mental status and decreased level of consciousness.

Goal :
Patients free from injury caused by seizures and loss of consciousness.

1. Monitor spasms in hands, feet, mouth and other facial muscles.
Rationale : Require evaluation in accordance with the appropriate interventions to prevent complications.

2. Prepare a safe environment such as bed boundaries, safety boards, and suction devices have always been close to the patient.
Rationale : Protecting patients when seizures occur.

3. Maintain total bedrest during the acute phase.
Rationale : Reduce the risk of falls / injured if vertigo, sincope, and ataxia occurred.

4. Give appropriate therapy doctors advice.
Rationale : To prevent or reduce seizures.

Nursing Care plan for Hypertensive Heart Disease

Nursing Diagnosis : Acute Pain : headache related to an increase in cerebral vascular pressure.

Goal : Pain is reduced

Outcomes :

• Client reported pain / discomfort disappeared / controlled.

Interventions :

1. Maintaining bed rest during the acute phase.
2. Give non-pharmacological measures to relieve headaches, for example; cold compress on the forehead, back and neck massage, a quiet, dim room light, relaxation techniques (imagination, distraction ) and leisure time activities.
3. Eliminate / minimize vasoconstriction activity that can improve headaches, for example; straining during defecation, coughing and bending length.
4. Assist patients in ambulation as needed.
5. Give liquids, soft foods, regular oral care in case of nose bleeds or compress the nose has been done to stop the bleeding.
6. Collaboration of drugs ; analgesic, anti- anxiety.

Rationale : 

1. Minimizing stimulation / increase relaxation.
2. Actions that decreases cerebral vascular pressure and the slow / block the sympathetic response is effective in relieving headaches and complications.
3. Activities that increase vasoconstriction cause headaches in an increase in cerebral vascular pressure.
4. Dizziness and blurred vision often associated with headache, patients may also experience episodes of postural hypotension.
5. Increase the general comfort, compress the nose may interfere with the ingestion or require breathing with the mouth, causing stagnation and drying oral secretions of mucous membranes.
6. Lose / control pain and decrease the sympathetic nervous system stimulation.
7. Can reduce tension and discomfort aggravated by stress.

Nursing Care Plan for Diabetes Mellitus

Nursing Diagnosis : Acute Pain related to injury of biological agents (decreased peripheral tissue perfusion)

NOC :

• level of pain
• pain controlled
• level of comfort

Clients can :
1 Controlling pain, with indicators :

• Know the factors that cause.
• Know the onset of pain.
• Non-pharmacological aid measures.
• Analgesic use.
• Reported pain symptoms to the health care team.
• Pain controlled.

2. Shows the level of pain, the indicator :

• Reported pain.
• Frequency of pain.
• The duration of pain episodes.
• The expression of pain ; face.
• Changes in respiration rate.
• Changes in blood pressure.
• Loss of appetite.

Interventions (NIC)

Pain Management :

• Perform a comprehensive pain assessment includes the location, characteristics, duration, frequency , quality and ontro precipitation.
• Observation of nonverbal reactions of discomfort.
• Use therapeutic communication techniques to determine the client's experience of pain before.
• Environmental controls that affect pain such as room temperature, lighting, noise.
• Reduce pain ontro precipitation.
• Choose and pain management (pharmacological / non- pharmacological).
• Teach non- pharmacological techniques ( relaxation , distraction, etc.) to mengetasi pain.
• Give analgesics to reduce pain.
• Evaluation of pain -reducing action / ontrol pain.
• Collaboration with a physician if there are complaints about the administration of analgesics to no avail.
• Monitor client acceptance of pain management.

Analgesics Administration :

• Check program providing analogetik ; the type, dosage, and frequency.
• Check history of allergy.
• Determine the analgesic of choice, the optimal route of administration and dose.
• Monitor vital signs before and after the administration of analgesics.
• Give analgesic especially timely when the pain arises.
• Evaluation of the effectiveness of analgesics, signs and symptoms of side effects.

Nursing Care Plan for Lower Back Pain

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.

Motor

• Grinning face.
• Step struggling.
• Rigid posture / unstable.
• Movement is very slow or forced.

Autonomic response

• 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.

Control of pain

• 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.

Level of comfort

• 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).

Nursing Care Plan for Atherosclerosis

Atherosclerosis is a slow disease in which your arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries.

Signs and Symptoms:

Many times, people with atherosclerosis don't have any symptoms until an artery is 40% clogged with plaque. Symptoms vary depending upon which arteries are affected.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.

Goal: reduced pain

Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.

Intervention and Rational:

1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
Rationale: Helps reduce external stimuli that can add to the tranquility so patients can rest in peace and the power of the heart is not too hard.

4. Teach relaxation techniques with a sigh
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
Rationale: Knowing the patient's progress, after being given the drug.

Nursing Diagnosis for Hydatidiform Mole: Acute Pain

Objective: Clients will show pain reduced / lost

Expected outcomes:

• Clients say the pain is reduced / lost
• Calm facial expression
• Vital signs are within normal limits

Nursing Intervention:

1. Assess the level of pain, location and scale of pain, perceived client.
Rationale: Knowing the level of pain that is felt so it can help determine appropriate interventions.

2. Observation of vital signs every 8 hours
Rationale: Changes in vital signs, especially temperature and pulse rate is one indication of increased pain experienced by the client.

3. Instruct client to perform relaxation techniques
Rationale: Relaxation techniques can make the client feel comfortable and a little distraction to divert the attention of clients to pain so that they can help children reduce the pain.

4. Give a comfortable position
Rationale: a comfortable position to avoid an emphasis on the area of ​​injury / pain.

5. Collaboration of analgesic
Rational: analgesic drugs block the pain receptors so that the pain can not be perceived.

Nursing Diagnosis for Hypertension:

Acute Pain (headache) related to increased cerebral vascular pressure

Purpose:

• Having given nursing care, pain expectancy is reduced / controlled.

Expected outcomes:

• Clients reported pain / discomfort disappeared / controlled.

Nursing Intervention for Hypertension - Acute Pain :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to relieve headaches eg, a cold compress on the forehead, neck and back massage, quiet, Dim the room lights room lights, relaxation techniques (your imagination, diktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Berikancairan, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

6. Collaboration of analgesic drugs.

Rational:

1. Minimizing stimulation / enhance relaxation.

2. Measures that reduce cerebral vascular pressure and that slow / block sympathetic responses are effective in eliminating the headaches and complications.

3. Activities that enhance vasoconstriction causing headaches in the increased cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain also experience episodes kepala.pasien postural hypotension.

5. Improve comfort umum.kompres nose can disrupt the ingestion or require breath with your mouth, causing stagnation oral secretions and mucous membranes dry out.

6. Lose / control pain and reduce sympathetic nervous system stimulation.

Nursing Diagnosis and Interventions for Acute Pain 

Acute Pain related to Biological and Physical Agents Injury 

NOC and Indicators

NOC: pain control, after the intervention of care, reduced patient pain

Indicators:

• Using a pain scale to identify the level of pain
• Patient states pain is reduced
• Patients are able to rest / sleep
• Using non-pharmacological techniques

NIC and Activities

1. Management of pain

• Activity:
• Perform an assessment of pain, location, characteristics and factors that may increase the pain.
• Observe non-verbal cues about restless.
• Facilitation comfortable environment.
• Give painkillers.
• Help patients find a comfortable position.
• Teach techniques without the use of medication (eg, relaxation, distraction, massage, guidet imageri).
• Compress the chest while coughing exercises.

2. Manage analgesic :  Determine the location, karaketristik, quality
3. Relaxation therapy
4. Environmental management

Rational

• To determine appropriate interventions and the effectiveness of a given therapy.
• Assist in identifying the degree of discomfort.
• Increase comfort.
• Reduce pain and allow patients to mobilize without pain.
• Elevation of the arm causes the patient to relax.
• Increase relaxation and help to focus attention so as to improve coping resources.
• Facilitate participation in the activity without discomfort arises.