Sie sind auf Seite 1von 3


Pain: 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 or more
than six (6) months.

Classification of Pain
Acute Pain duration of less than six months.
Chronic Pain duration of more than six months.

Defining Characteristics
Pain is characterized by the following signs and symptoms:
Patient complains of pain
Appetite changes
Guarding behavior, protecting body part
Intolerant (e.g., altered time perception, withdrawal from social or physical contact)
Facial mask of pain
Autonomic responses (e.g., diaphoresis, an alteration in BP, HR, pupillary dilation; alteration in RR;
pallor; nausea)
Change in muscle tone: lethargy or weakness; rigidity or tightness
Relief or distraction behavior (e.g., pacing, seeking out other people or activities)
Expressive behavior (e.g., restlessness, moaning, crying)
Observed evidence of pain using standardized pain behavior checklist
For those unable to communicate; refer to the appropriate assessment tool (e.g., Behavioral Pain
Scale, Neonatal Infant Pain Scale, Pain Assessment Checklist for Seniors with Limited Ability to
Positioning to avoid pain
Protective gestures
Proxy reporting pain and behavior/activity changes (e.g., family members, caregivers)
Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker FACES scale, visual
analogue scale, numeric rating scale)
Self-report of pain characteristics (e.g., aching, burning, electric shock, pins and needles, shooting,
sore/tender, stabbing, throbbing) using standardized pain scales (e.g., McGill Pain Questionnaire, Brief
Pain Inventory).

Goals And Outcomes

The following are the common goals and expected outcomes for Pain : Patient displays improved well-
being such as baseline levels for pulse, BP, respirations, and relaxed muscle tone or body posture.

Nursing Interventions

Nurses are not to judge whether the pain is real or not. As a nurse, we should spend more time treating

1. Preventing the pain is one thing that a patient experiencing it can consider. Early intervention may
decrease the total amount of analgesic required.
2. Ones perception of time may become distorted during painful experiences. Pain can be
aggravated with anxiety and fear especially when pain is delayed. An immediate response to
reports of pain may decrease anxiety in the patient. Demonstrated concern for the patients welfare
and comfort fosters the development of trusting relationship.
3. Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if
environmental, intrapersonal, or intrapsychic factors are further stressing them.
4. Ones experiences of pain may become exaggerated as a result of exhaustion. Pain may result
in fatigue, which may result in exaggerated pain. A peaceful and quiet environment may facilitate
5. Patients with acute pain should be given a nonopioid analgesic around-the-clock unless
Assallammualaikum wr. wb. let me introduce, my name is Rezha Rakhmad Try Putra and my call
name is Rezha.
Good Afternoon all of my friends and honorable Mr. Juno as the lecturer of this subject.
In this time Id like to present about Nursing Interventions or Care Plans of Pain.
Well, like you see on my slide the topic is about Nursing Interventions or Care Plans.
Well I think thats all of my presentation. Thank you very much for your attention.
I say, Assallamualaikum wr. wb.
Well audience. Please, any questions?

Keterangan :
Etc. : et cetera
E. g : Example given (Contoh)
Source of : sumber dari
By from : Menurut dari