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RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLAN)

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KENYAMANAN : Nyeri Akut
COMFORT : Acute Pain

Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain
related to anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature,
functional organ damage, functional damage to body tissue )

Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

Pain Management ( Perawatan Nyeri ) Pain Control (Kontrol nyeri )

Observasi 1. Menggunakan non analgesics untuk bantuan ( uses non


1. Lakukan pengkajian komprehensif meliputi lokasi, karakteristik, analgesic relief measure )
durasi, frekuensi, kualitas,intensitas/beratnya nyeri dan factor
pencetus ( perform a comprehensive assessment of pain to include 2. Menggunakan analgesik seperti yang dianjurkan( uses
location,characteristics, onset, frequency, quality,intensity or severity analgesic as recommended )
of pain and precipitating factors) 3. Laporan gejala tidak terkontrol kepada profesi
2. Observasi tanda ketidaknyamanan nonverbal terutama dengan
kesehatan( report uncontrolled symptoms to health
ketidakmampuan komunikasi efektif ( observe for non verbal of
professional )
discomport, especially in unable to communicate effectively)
Treatment 4. Laporan nyeri terkontrol( reports pain controlled )
3. Pastikan pasien mendapatkan perawatan analgesic ( assure patient
attentive analgesic care)

Tanggal/ Jam :

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KPWT/0165-18/RAK/13/Rev.2
Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain related to
anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature, functional
organ damage, functional damage to body tissue )

Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

4. Control factor lingkungan yang dapat meningkatkan respon Measurement Scale ( Skala pengukuran )
ketidaknyamanan pasien ,contoh temperature ruangan, cahaya dan
1= never demonstrated ( Tidak pernah menunjukan )
keributan ( control environmental factor that may influence the
patient response to discomport ,e.g room temperature, lighting, 2= rarely demonstrated ( Jarang menunjukan )
noise)
5. Posisi sejajar tubuh yang tepat untuk mengurangi tekanan pada saraf 3= sometimes demonstrated ( kadang Menunjukan )
dan jaringan( Position the body aligned the right to reduce the pressure on
4= often demonstrated ( Sering menunjukan )
the nerves and tissues )
6. Melakukan tindakan PCA ( implement the use patient controlled 5= consistently demonstrated ( Konsisten menunjukan )
analgecia)
Education
7. Memberikan informasi tentang penyebab nyeri,berapa lama
terjadinya dan antisipasi ketidaknyamanan dari prosedur ( provide
information about the pain, causes of the pain, how long it and
anticipated discomports from procedure)
8. Ajarkan prinsip dari manajemen nyeri ( teach principles of pain
management)

Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain
related to anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature,
functional organ damage, functional damage to body tissue )

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Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

9. Ajarkan penggunaan teknik non pharmakologi ( hypnosis,relaksasi


music terapi ,distraksi, terapi bermain,terapi aktivitas,kompres
panas /dingin, pijatan ) selama,sesudah,sebelum ,pada saat
peningkatan nyeri )( teach the use nonpharmacological techniques
( hypnosis,relaxation, music therapy,distraction, play therapy, activity
therapy, cold/hot application, massage) during , after, before, or
increases pain )
10. Ajarkan tentang metode farmakologi dari gambaran nyeri ( teach
about pharmacological method of pain relief )
Collaboration
11. Kolaborasi dengan pasien dan tenaga kesehatan lainnya untuk
memilih dan meimplementasikan terapi nonfarmakologi ( Collaborate
with the patient and other health propessionals to select and
implement non pharmacological .
12. Kolaborasi dengan dokter jika pengobatan tidak berhasil dan
mengalami keluhan ulangan dari pengalaman nyeri pasien .( Notify
psysician if measure are unsuccessfull and current complaints from
past experience of pain)
Nama perawat Koordinator/PJ shift

(……………………….) (……………………)

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