Defibrillation is a nonsynchronized delivery of energy during any phase of the cardiac cycle, whereas cardioversion is the

delivery of energy that is synchronized to the large R waves or QRS complex. Defibrillation and cardioversion are
demonstrated in the videos below.
Electrical cardioversion has now become a routine procedure and is used electively or emergently to terminate cardiac
arrhythmias. The delivered shock in both defibrillation and cardioversion causes electric current to go from the negative to the
positive electrode of the defibrillator, passing the heart on its way. It causes all the heart cells to contract simultaneously,
thereby interrupting and terminating the abnormal electrical rhythm without damaging the heart, and thus allowing the sinus
node to resume normal pacemaker activity. This article illustrates the basic principles and techniques of these procedures and
clinical indications for their use.
Indications
Indications for synchronized electrical cardioversion include the following:
 Supraventricular tachycardia
 Atrial fibrillation
 Atrial flutter
 Ventricular tachycardia
 Any patient with reentrant tachycardia with narrow or wide QRS complex (ventricular rate >150) who is unstable (eg,
chest pain, pulmonary edema, hypotension)
Indications for defibrillation include the following:
 Pulseless ventricular tachycardia (VT)
 Ventricular fibrillation (VF)
 Cardiac arrest due to or resulting in VF
Contraindications include the following:
 Dysrhythmias due to enhanced automaticity such as in digitalis toxicity and catecholamine-induced arrhythmia
 Multifocal atrial tachycardia
For dysrhythmias due to enhanced automaticity such as in digitalis toxicity and catecholamine-induced arrhythmia, a
homogeneous depolarization state already exists. Therefore, cardioversion is not only ineffective but is also associated with a
higher incidence of postshock ventricular tachycardia/ventricular fibrillation (VT/VF).
Anesthesia
 Cardioversion is almost always performed under induction or sedation (short-acting agent such as midazolam). The
only exceptions are if the patient is hemodynamically unstable or if cardiovascular collapse is imminent. For more
information, see Procedural Sedation.
 Defibrillation is an emergent maneuver and when necessary should be promptly performed in conjunction with or
prior to administration of induction or sedative agents.
Equipment
Equipment includes the following:
 Defibrillators (automated external defibrillators [AEDs], semi-automated AED, standard defibrillators with monitors)
 Paddle or adhesive patch
 Conductive gel or paste
 ECG monitor with recorder
 Oxygen equipment
 Intubation kit
 Emergency pacing equipment
The use of hand-held paddle electrodes may be more effective than self-adhesive patch electrodes. The success rates are
slightly higher for patients assigned to paddled electrodes because these hand-held electrodes improve electrode-to-skin
contact and reduce the transthoracic impedance. [1]
Positioning
Paddle placement on the chest wall has 2 conventional positions: anterolateral and anteroposterior.
In the anterolateral position, a single paddle is placed on the left fourth or fifth intercostal space on the midaxillary line. The
second paddle is placed just to the right of the sternal edge on the second or third intercostal space.
In the anteroposterior position, a single paddle is placed to the right of the sternum, as above, and the other paddle is placed
between the tip of the left scapula and the spine. An anteroposterior electrode position is more effective than the anterolateral
position for external cardioversion of persistent atrial fibrillation. [2, 3, 4] The anteroposterior approach is also preferred in
patients with implantable devices, to avoid shunting current to the implantable device and damaging its system.
Technique
Emergent application, which may be lifesaving, and elective cardioversion should be used cautiously, with attention to patient
selection and proper techniques. Repetitive, futile attempts at direct current cardioversion should be avoided.
Advanced cardiac life support (ACLS) measures should be instituted in preparing the patient, such as obtaining intravenous
access and preparing airway management equipment, sedative drugs, and a monitoring device.
Monophasic vs biphasic waveforms

Defibrillators can deliver energy in various waveforms that are broadly characterized as monophasic or biphasic.

Monophasic defibrillation delivers a charge in only one direction, while biphasic defibrillation delivers a charge in
one direction for half of the shock and in the electrically opposite direction for the second half.

Biphasic waveforms defibrillate more effectively and at lower energies than monophasic waveforms. [5, 6, 7]
Energy selection for defibrillation or cardioversion
 Synchronized electrical cardioversion begins with 25-50 J (or the biphasic equivalent, which is generally one half of
that required with monophasic waveforms) to treat atrial flutter and 50-100 J (or the biphasic equivalent) to treat atrial

fibrillation for patients in stable condition, as shown below. ECG strip shows a
atrial fibrillation terminated by a synchronized shock (synchronization marks [arrows] in the apex of the QRS
complex) to normal sinus rhythm.
 Rapid polymorphic ventricular tachycardia (rate >150 bpm) associated with hemodynamic instability should be
treated with immediate, direct-current, nonsynchronized defibrillation with energies of 200-360 J (or biphasic
equivalent [100-200 J]).
 Monomorphic ventricular tachycardia should be treated with a synchronized discharge of 100-200 J (or biphasic
equivalent [50-100 J]).
 Ventricular fibrillation should be treated with unsynchronized electrical countershock with at least 200-360 J (or
biphasic equivalent [100-200 J]) administered as rapidly as possible, as shown below.

Ventricular fibrillation terminated by an unsynchronized shock (arrows) to normal

sinus rhythm
Complications

The most common complications are harmless arrhythmias, such as atrial, ventricular, and junctional premature beats.

Serious complications include ventricular fibrillation (VF) resulting from high amounts of electrical energy, digitalis
toxicity, severe heart disease, or improper synchronization of the shock with the R wave. [8, 9]

Thromboembolization is associated with cardioversion in 1-3% of patients, especially in patients with atrial
fibrillation who have not been anticoagulated prior to cardioversion.

Myocardial necrosis can result from high-energy shocks. ST segment elevation can be seen immediately and usually
lasts for 1-2 minutes. ST segment elevation that lasts longer than 2 minutes usually indicates myocardial injury
unrelated to the shock.

Pulmonary edema is a rare complication of cardioversion and is probably due to left ventricular dysfunction or
transient left atrial standstill.

Painful skin burns can occur after cardioversion or defibrillation; they are moderate to severe in 20-25% of patients.
They most likely are due to improper technique and electrode placement. [10]

What is Elder Abuse

Each year hundreds of thousands of older persons are abused, neglected, and exploited. Many victims are people
who are older, frail, and vulnerable and cannot help themselves and depend on others to meet their most basic
needs. Abusers of older adults are both women and men, and may be family members, friends, or “trusted others.”

In general, elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other
person that causes harm or a serious risk of harm to a vulnerable adult. Legislatures in all 50 states have passed
some form of elder abuse prevention laws. Laws and definitions of terms vary considerably from one state to
another, but broadly defined, abuse may be:
  Physical Abuse—inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by
physical or chemical means.
 Sexual Abuse—non-consensual sexual contact of any kind.
 Neglect—the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable
elder.
 Exploitation—the illegal taking, misuse, or concealment of funds, property, or assets of a senior for
someone else's benefit.
 Emotional Abuse—inflicting mental pain, anguish, or distress on an elder person through verbal or
nonverbal acts, e.g. humiliating, intimidating, or threatening.
 Abandonment—desertion of a vulnerable elder by anyone who has assumed the responsibility for care or
custody of that person.
 Self-neglect—characterized as the failure of a person to perform essential, self-care tasks and that such
failure threatens his/her own health or safety.

What are the warning signs of elder abuse?

While one sign does not necessarily indicate abuse, some tell-tale signs that there could be a problem are:

 Bruises, pressure marks, broken bones, abrasions, and burns may be an indication of physical abuse,
neglect, or mistreatment.
 Unexplained withdrawal from normal activities, a sudden change in alertness, and unusual depression may
be indicators of emotional abuse.
 Bruises around the breasts or genital area can occur from sexual abuse.
 Sudden changes in financial situations may be the result of exploitation.
 Bedsores, unattended medical needs, poor hygiene, and unusual weight loss are indicators of possible
neglect.
 Behavior such as belittling, threats, and other uses of power and control by spouses are indicators of verbal
or emotional abuse.
 Strained or tense relationships, frequent arguments between the caregiver and elderly person are also signs.

Most importantly, be alert. The suffering is often in silence. If you notice changes in a senior’s personality or
behavior, you should start to question what is going on.
 TNM classification of breast cancer

Discharge Instructions after mitral valve replacement

It is important upon discharge to notify your local cardiologist that you are now home. Your local doctor will oversee the
management of your routine medications, diet and exercise regimen. Also, any problems that develop at home should first be
referred to your local physician, unless it concerns your incisions. The information on the following pages comes from years
of experience working with patients who have recovered successfully from open heart surgery. Please let us know at your
follow-up appointment if these suggestions have been helpful.
 
Activity
A sensible balance of rest and activity is the key to a good recovery. Mild exercise will hasten your mobility. When you get
home, try to balance periods of activity with periods of rest. Gradually increase your activity level. Do something everyday.
 
Walking is one of the best overall exercises you can do. It improves circulation, muscle tone, strength and the way your feel
about yourself. As a form of conditioning, walking should be done daily with a gradual increase in distance and speed.
Walking should feel comfortable, that is, you should feel like you are doing something—but not overworking. For some,
walking with other people is more fun, try contacting your local mall or YMCA to find out if there are organized walking
groups you can join. Some general guidelines for walking include:
 Wear comfortable shoes, soft absorbent socks, and loose fitting clothing. In cold weather, dress warmly and wear you
can remove as you warm up.
 Take a few deep breaths at the beginning and end of each walk. If you still you’re your incentive spirometer from the
hospital you can use it to help with your deep breathing.
 Take several short walks with rest periods in between, rather than one long walk.
 Begin walking on a flat surface such as a shopping mall, athletic track, or your own neighborhood. Keep moving and
do not stop to window shop until after you have completed your walk.
 Avoid temperature extremes such as hot humid summer afternoons, or cold, rainy, windy winter days. These weather
extremes can increase your fatigue. If weather is inclement, try walking at an indoor location.
 
Do those light chores around the house that you are accustomed to doing. Avoid heavy chores such as vacuuming and
shoveling for three months. If you find an activity tiring, stop and rest.
 
Do not resume activity that requires pushing or pulling (i.e., elliptical machine) or more strenuous exercise such as golf,
tennis, jogging, swimming, contact sports, sit-ups, push-ups, digging, heavy gardening or returning to work until you have
checked with your doctor at the follow-up appointment.
 
Stairs are ok. There is no reason to avoid stairs; however, climbing stairs does require more energy than walking. Before you
leave the hospital, climb stairs with the physical therapist to ensure that you can do so safely. Take your time and go slow.
You may want to pause and rest at the mid-point or whenever you feel tired. Use the handrail only for balance; do not pull
yourself up the stairs.
 
Lifting anything over 10 pounds, including children, pets, grocery bags, suitcases or briefcases is PROHIBITED for SIX
WEEKS after your surgery. In addition, do not attempt to open stuck windows, unscrew tight jar lids, push open heavy doors
or move furniture. Do not do anything that would stress or twist the sternum (breast bone) until you have had your follow-up
appointment with your surgeon and received the “go ahead” for these activities. We consider the breastbone to be fully healed
in three months time and recommend not lifting anything over 20 lbs for a full three months.
 
Keep in mind that these are guidelines for activity. It is difficult to say how quickly or slowly your strength will return. Your
own body will be the best indicator that you are overdoing an activity. Doing too little activity can delay return of muscle tone
and stamina. Increase your activity level gradually by doing a little more each day. Full recovery is an individual experience.
 
Rest and Sleep
During the initial recovery period, your body considers all activity as “work.” Therefore, routine activities such as bathing,
shaving, or brushing your hair can be tiring. This simply means you need more rest during this time. Plan or build rest periods
into your day. By balancing periods of activity with periods of rest, you will not get over tired.
 
Try to get a usual night’s sleep each night. Avoid staying up late one night and trying to “catch up” the next. If you are having
difficulty sleeping at night, you may be taking too many naps during the day. However, it is not uncommon for patients to
have some restlessness when they return home.
 
Your incision may be sore – especially when you lie flat and turn from side to side. For some patients it is more comfortable
to sleep in a reclining chair for a period of time, until their chest is less sore. Other patients prefer to sleep in bed with a wedge
or reading pillow to allow them to sleep at an angle instead of completely flat. You may want to take some Tylenol or your
prescription pain medication about 30 minutes before going to bed. This frequently relieves muscle soreness and allows you to
sleep in a more comfortable position. If sleeplessness persists, call your primary care doctor.
 
If you have a waterbed, you may not be able to get in and out of it for several weeks. Try to arrange to sleep on a conventional
mattress for the first month or two after surgery.
 
Driving
You will not be able to drive for at least 3 to 4 weeks from the date of your surgery. Reasons for not driving include:
 Decreased concentration and reflex time.
 Limited shoulder, arm and leg flexibility due to stiffness and soreness.
 Impaired braking time if you have leg incisions.
 Twisting movement of the chest when driving.
 
Always wear a seatbelt when riding in a car. When traveling longer distances, stop every hour and walk around for five or ten
minutes. This will improve circulation in your legs and help prevent swelling. Check with your local cardiologist or primary
care doctor before going on any lengthy car trips during the first month after surgery.
 
Diet
You are urged to maintain a heart-healthy low salt and low fat diet. However, calories from food are important to help heal
your incision. Some patients report that it takes a while to regain their appetite. You might feel better eating smaller meals
more frequently during the day than three big meals. Your cardiologist can recommend specific guidelines for you when you
follow-up after surgery.
 
If you are accustomed to having a drink before dinner or a glass of wine with your meals, you may continue this practice.
 
Medications
Any medications you may need will be carefully explained to you. The purpose and effects of each drug will be discussed.
The nurses will help you to establish a timetable of when to take your medication. Please note that certain pain medication can
be constipating. If you should become constipated, increase your intake of high fiber foods. These include fruits, vegetables
and bran products. Also, drink plenty of water. If necessary, you may take a laxative.
 
Some patients will be sent home with blood-thinning medication called warfarin or Coumadin. Those patients must have
regular blood tests to check their INR level. In most cases, your local cardiologist will follow the INR level and prescribe any
changes to your warfarin/Coumadin dosage. It is important that patients taking Coumadin report any signs of bleeding,
excessive nose bleeds, or blood in the urine or stool.
 
Weight
Check your weight each morning and record it for two weeks. Call your doctor if you notice a rapid weight gain or weight loss
of 3-4 pounds from one day to the next, and notice if you have any swelling of your hands or feet. Swelling or edema is a sign
that you are retaining fluid. Continued weight loss below your pre-operative weight may be a sign that you are losing too
much fluid. Some patients are sent home on a diuretic, a medicine that helps the body eliminate excess fluid. This medicine,
typically Lasix (furosemide), may need to be adjusted if you are losing or gaining significant amounts of weight.
 
Care of Incision
Once you are home, you may shower daily, and use soap to wash your incisions. Do not use a sponge or washcloth on the
incision at this time, as those materials may be too rough. Apply soapy water with your fingertips and allow the shower water
to run down your chest to rinse. The use of powder, lotion and ointment is discouraged until your incisions are full healed.
This can take four to six weeks. If you experience any redness, drainage or breakage of the skin along the incision line, please
call your surgeon’s office immediately.
 
Incisional Discomfort
You may experience non-cardiac chest pain related to the incision down the center of the breast bone or to the ribs on either
side of the sternum. This pain will diminish in time but may reoccur when there is an adverse change in the weather or when
you over exert physically. The pain may be aggravated by coughing, sneezing, or sudden changes in body position. This pain
will become less frequent and bothersome as time goes by. Do not hesitate to use pain medication as ordered.
 
Sexual Activity
Sexual activity may generally be resumed once you are discharged from the hospital. The stress and fatigue of your surgery
may initially lessen your interest in sex. But, as with any activity, your desire will return with your increased strength and
feeling of well being. If you are hesitant or fearful about resuming sexual activity it is often helpful to discuss these feelings
with your partner.
 
Initially it is advisable to place as little pressure on the sternal area as possible. If some incisional pain is experienced, a
change of position may be required. If you experience shortness of breath or extreme fatigue, wait a period of time before
resuming.
 
Miscellaneous
NO SMOKING! If you have been a smoker it is mandated that you abstain from cigarette, pipe and cigar smoking. This is
absolutely necessary in the early convalescent period. Smoking not only stresses the heart but also predisposes you to lung and
vascular disease. If you have smoked in the past, regardless of how long, by stopping immediately, you can still reverse
harmful effects of smoking on your heart and lungs. There are many products available to help patients stop smoking. Speak
with your local clinician if you need assistance with smoking cessation.
 Female patients may have some alteration in their monthly menstrual cycle. This is generally a temporary disruption.
You will reestablish your normal cycle in a short time.
 Certain valves are characterized by an audible clicking noise. This is normal and not a cause for alarm.
 For three months following surgery you should not have any elective dental work done. If an emergency occurs and
you must undergo dental work you must take a course of antibiotics. Contact your local physician or cardiologist for
the exact antibiotic and the amount to be taken.
 Communication tips for physicians

If you walked into a room and wanted to listen to the radio, you would first have to plug it in to a power source. Similarly,
when you walk into the exam room to communicate with your older patients, the first thing you have to do is “plug in,” that is,
make a connection with them physically and emotionally. Once you’ve made that connection, you can then begin to
communicate necessary information and instructions. Below is a list of tips to help you achieve this.

1. Allow extra time for older patients. Studies have shown that older patients receive less information from physicians
than younger patients do, when, in fact, they desire more information from their physicians.7,8 Because of their
increased need for information and their likelihood to communicate poorly, to be nervous and to lack focus, older
patients are going to require additional time. Plan for it, and do not appear rushed or uninterested. Your patients will
sense it and shut down, making effective communication nearly impossible.
2. Avoid distractions. Patients want to feel that you have spent quality time with them and that they are important.
Researchers recommend that if you give your patients your undivided attention in the first 60 seconds, you can “create
the impression that a meaningful amount of time was spent with them.”9 Of course, you should aim to give patients
your full attention during the entire visit. When possible, reduce the amount of visual and auditory distractions, such
as other people and background noise.10,11

3. Sit face to face. Some older patients have vision and hearing loss, and reading your lips may be crucial for them to
receive the information correctly.12 Sitting in front of them may also reduce distractions. This simple act sends the
message that what you have to say to your patients, and what they have to say to you, is important. Researchers have
found that patient compliance with treatment recommendations is greater following encounters in which the physician
is face to face with the patient when offering information about the illness.13

4. Maintain eye contact. Eye contact is one of the most direct and powerful forms of nonverbal communication. It tells
patients that you are interested in them and they can trust you. Maintaining eye contact creates a more positive,
comfortable atmosphere that may result in patients opening up and providing additional information.10

5. Listen. The most common complaint patients have about their doctors is that they don’t listen.14 Good
communication depends on good listening, so be conscious of whether you are really listening to what older patients
are telling you. Many of the problems associated with noncompliance can be reduced or eliminated simply by taking
time to listen to what the patient has to say.10 Researchers have reported that doctors listen for an average seconds
before they interrupt, causing miss important information patients are trying to tell them.15

6. Speak slowly, clearly and loudly. The rate at which an older person learns is often much slower than that of a younger
person. Therefore, the rate at which you provide information can greatly affect how much your older patients can take
in, learn and commit to memory.10,12 Don’t rush through your instructions to these patients. Speak clearly and loudly
enough for them to hear you, but do not shout.

7. Use short, simple words and sentences. Simplifying information and speaking in a manner that can be easily
understood is one of the best to ensure that your patients will follow your instructions. Do not use medical jargon or
technical terms that are difficult for the layperson to understand In addition, do not assume that patients will
understand even basic medical terminology. Instead, make sure you use that are “familiar and comfortable” to your
patients.9

8. Stick to one topic at a time. Information overload can confuse patients. avoid this, instead of providing a long,
detailed explanation to a patient, try the information in outline form. This allow you to explain important information
in a series of steps. For example, first talk about the heart; second, talk about blood pressure; and third, talk about
treating blood pressure.16

9. Simplify and write down your instructions. When giving patients instructions, avoid making them overly complicated
or confusing. Instead, write down your instructions in a basic, easy-to-follow format. Writing is a more permanent
form of communication than speaking and provides the opportunity for the patient to later review what you have said
in a less stressful environment.10
 One way to accomplish this is to provide an information sheet that summarizes the most important points of the visit
and explains what the patient needs to do after he or she leaves your office. (See an example.) For example, instead of
just telling older patients to take their medication and get some exercise, you can give them a visit summary to take
home that includes detailed instructions, such as “Take a pill when you first get up in the morning,” “Walk around the
block in the morning,” and “Walk around the block in the afternoon.”

With such a list, the patient can mentally check off each item as it is completed each day. Posting the information on
the refrigerator or a bulletin board can help keep instructions fresh in the patient’s mind.10

10. Use charts, models and pictures. Visual aids will help patients better understand their condition and treatment.
Pictures can be particularly helpful since patients can take home a copy for future reference. 12 You can find free
images online in Medem’s Medical Library at http://www.medem.com/medlb/medlib_entry.cfm. Click on “Anatomy
and Medical Illustrations” under the heading “Diseases and Conditions.”
11. Frequently summarize the most important points. As you discuss the most important points with your patients, ask
them to repeat your instructions. If after hearing what the patient has to say you conclude that he or she did not
understand your instructions, simply repeating them may work, since repetition leads to greater recall. 16 The National
Council on Patient Information and Education recommends having a nurse or pharmacist repeat instructions for taking
medications, and it advises always combining written and oral instructions.17 However, be aware that if patients
require a second or third repeat, they may become frustrated and disregard the information altogether. An effective
technique to try at that point is to rephrase the message, making it shorter and simpler. You may also want elderly
patients to bring a family member or friend in during the consultation to ensure information is understood.12

12. Give patients an opportunity to ask questions and express themselves. Once you have explained the treatment and
provided all the necessary information, give your patients ample opportunity to ask questions. This will allow them to
express any apprehensions they might have, and through their questions you will be able to determine whether they
completely understand the information and instructions you have given.12 If you have doubts, you may want to have
a staff person contact the patient in 24 hours to review educational points.
 Nursing Measures in Epistaxis Cases
1. Place patient in an upright position, leaning forward to reduce venous pressure
2. Avoiding the patient to talk and let to breathe through his mouth
3. Tell the Patient to firmly grasp and pinch his entire nose between the thumb and fingers for at least 10
minutes
4. Compress the soft outer portion of the nose against the midline septum for about 5-10 minutes continuously
5. Keep the head of the bed elevated 30 to 45 degrees for the next 4 hours.
6. Tell to the patient not to blow his/her nose for several hours and to avoid lifting objects or bending at the
waist for the next 24 hours.
7. If symptoms persist assist the physician, They will do or order some of following treatments: application of
topical anesthetic vasoconstrictor solution, such as a 4% lidocaine and topical epinephrine; topical chemical
cauterization with silver nitrate; nasal tampon insertion; or insertion of up to 36 to 72 inches (90 to 180 cm)
of ½ inch petroleum gauze packing into the nostril.
8. Care of the gauze packing pack inside the nose and be remove after 24 hours
9. Psychological support to the patient specially if packing is applied as he feels uncomfortable
Nursing Diagnosis

1. Risk for Bleeding

Goal: minimize bleeding
Expected Outomes: No bleeding, vital signs within normal limits, no anemis.
Interventions:
 Monitor the patient's general condition
 Monitor vital signs
 Monitor the amount of bleeding patients
 Monitor the event of anemia
 Collaboration with the doctor about the problems that occur with bleeding: transfusion, medication.
2. Ineffective airway clearance
Goal: to be effective airway clearance
Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory
muscles, dyspnoea and cyanosis does not occur.
Independent
 Assess the sound or the depth of breathing and chest movement.
Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of
secretions.
 Note the ability to remove mucous / coughing effectively
Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.
 Give Fowler's or semi-Fowler position.
Rational: Positioning helps maximize lung expansion and reduce respiratory effort.
  Clean secretions from the mouth and trachea
Rational: To prevent obstruction / aspiration.
 Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.
Rational: Helping dilution of secretions.

Collaboration
 Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.
Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce
bronchial spasms and analgesics are given to reduce discomfort.
3. Acute pain
Goal: pain diminished or disappeared
Expected Outcomes:
 Clients express the pain diminished or disappeared
 Clients do not grimace in pain

Interventions:
 Assess client's level of pain
Rational: Knowing the client's level of pain in determining further action.
 Explain the causes and consequences of pain to the client and his family.
Rational: The causes and consequences of pain the client is expected to participate in treatment to reduce
pain.
 Teach relaxation and distraction techniques.
Rational: The client knows the distraction, and relaxation techniques can be practiced so as if in pain.
 Observation of vital signs and client complaints.
Rational: Knowing the prevailing circumstances and conditions of client development.