1. Acute Pain / Chronic Pain related to vasospasm / reperfusion disorders, ischemic / tissue damage.Goal: Pain is reduced and tissue damage is not widespread.
Intervention:
- Record the characteristics of pain and paresthesias.
- Check the patient's vital signs.
- Discuss with the patient, how and why the pain inflicted.
- Help the patient identify trigger factor or situation example: smoking, exposure to cold and how to handle.
- Encourage the use of stress management techniques, entertainment activities.
- Soak the affected area in warm water.
- Give the room a warm, draft-free air, for example ventilation, air-conditioning, keep doors closed as indicated.
- Monitor drug effects and action.
- Collaboration: the medications as indicated, prepare surgical intervention when necessary.
Rational:
- Knowing the pain level.
- To monitor the general state of the client.
- That patients understand how to process pain.
- That patients understand the factors that influence pain.
- Used to divert the attention of the client.
- Warm water will make the blood vessels will dilate and blood flow.
- Avoid infection and keep the air hot.
- Determine the level of effectiveness of the drug.
- Administration of drugs to relieve pain.
2. Ineffective Tissue Perfusion is related to cessation of arterial blood flow
Intervention:
- Observation of skin color on the sick.
- Note the decrease in pulse.
- Evaluation of pain sensation parts, for example: sharp / shallow, hot / cold.
- View and examine the skin for ulceration, lesions, gangrene area.
- Recommended for proper nutrition and vitamins.
- Collaboration: the medications as indicated (vasodilator), example: drainage lesions for culture or sensitivity.
Rational:
- To see cyanosis or redness of the skin.
- Identify the severity of the cessation of arterial blood flow.
- Knowing levels, flavors, and forms of pain.
- Seeing how big a part that had gangrene.
- Proper nutrition and vitamin requirements are complete will increase the body's immune system.
- Giving obta vasodilator make the arteries dilate and blood flow.
3. Knowledge Deficit: the need to learn about the condition, treatment needs related to lack of knowledge / resources are not familiar with, wrong perception / misunderstood.
Intervention:
- Provide information to patients about the disease.
- Encourage clients to ask questions about the disease.
- Instruct to avoid exposure to cold.
- Preserve the environment at a temperature above 20.9 C eliminate cold flow.
- Discuss the possibility of moving to a warmer climate.
- Emphasize the importance of stopping smoking, provide information on local clinics / support group.
- Help the patient to create a method to avoid or alter discuss stress relaxation techniques.
- Emphasize the importance of viewing each day and do the right skin care.
Rational:
- Increase patients' knowledge about the disease.
- Knowing the client's level of curiosity about the disease.
- Cold temperatures make the constriction of the blood vessels and will aggravate the blockage of blood flow.
- Hot temperature makes blood vessels to maintain a state of dilatation.
- Avoid the severity of which will happen.
- That patients know and understand that smoking is a major contributing factor to the occurrence trombongitis.
- Distraction and relaxation techniques to make the patient more calm in responding.
- Avoid skin injury.
4. Anxiety related to the action procedure to be performed
Intervention:
- Describe the action procedure to be performed.
- Explain the importance of actions to be taken.
- Observation of vital signs.
- Give comfort to the patient.
- Reassure the patient that the action to be performed is the best course of action.
- Reassure the patient that the procedure acts to be performed safely.
- Collaboration with physicians for the provision of drugs.
- Increase patients' knowledge about action procedure.
- In order for patients to understand why the need for that action.
- Knowing the general state of the client.
- Patients will feel calm and do not worry with action procedures to be performed.
- Reduce the level of anxiety on the client.
- Reduce negarif thinking about an act procedures.
- To create a calm and reduce anxiety levels.