Definition of the NANDA label
Unpleasant sensory and emotional experience caused by a real or potential tissue injury or described in such terms, of sudden or slow onset, of any intensity from mild to severe, with a predictable end and a duration of less than 6 months.
Unpleasant sensory and emotional experience associated with 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 with a duration of less than 3 months.
• Verbal expression and gesturing of pain.
• Observation of evidence.
• Protection and defense behavior:
– Touching the painful area.
– Changes in posture (antalgic) or in gait.
• Facies of pain (dejected appearance, dull eyes, grimaces of pain).
• Positive response to palpation.
• Distracting behavior (moaning, crying, walking, looking for other people, doing activities).
• Autonomous vegetative responses to pain (changes in blood pressure and pulse rate, increased or decreased respiratory rate, diaphoresis, pupillary dilation).
• Anxiety and restlessness.
• Social isolation.
• Expressive behavior (crying, sighing, irritability, agitation, alertness, moaning).
• Alteration of thought processes.
• Alteration of the perception of the passage of time.
• Focus your attention on yourself.
• Alteration of muscle tone (from laxity to rigidity).
• Changes in appetite and intake.
• Pain control.
• Pain: harmful effects.
• Comfort level.
• Pain level.
• Medication management.
• Emotional Support.
• Pain management.
• Administration of analgesics.
• Assistance in patient-controlled analgesia.
• Conscious sedation.