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    Nyeri Akut (00132) : Kenyamanan

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    Quurma Mala
    This document contains a nursing care plan for acute pain management. It includes the nursing diagnosis of acute pain related to factors like anxiety, tissue trauma, and temperature changes. The goal is to eliminate or reduce pain. Interventions include comprehensive pain assessment, monitoring for nonverbal discomfort signs, ensuring analgesic care, controlling environmental factors, proper body positioning, patient controlled analgesia, education on pain causes and management, and teaching non-pharmacological and pharmacological pain relief techniques. Collaboration with the patient and other providers is also emphasized. Outcomes include using analgesics as recommended and reporting controlled or uncontrolled symptoms.

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    Nyeri Akut (00132) : Kenyamanan

    Uploaded by

    Quurma Mala
    50 views3 pages
    This document contains a nursing care plan for acute pain management. It includes the nursing diagnosis of acute pain related to factors like anxiety, tissue trauma, and temperature changes. The goal is to eliminate or reduce pain. Interventions include comprehensive pain assessment, monitoring for nonverbal discomfort signs, ensuring analgesic care, controlling environmental factors, proper body positioning, patient controlled analgesia, education on pain causes and management, and teaching non-pharmacological and pharmacological pain relief techniques. Collaboration with the patient and other providers is also emphasized. Outcomes include using analgesics as recommended and reporting controlled or uncontrolled symptoms.

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    ncp

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    1. Ncp Nyeri Akut

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    This document contains a nursing care plan for acute pain management. It includes the nursing diagnosis of acute pain related to factors like anxiety, tissue trauma, and temperature changes. The goal is to eliminate or reduce pain. Interventions include comprehensive pain assessment, monitoring for nonverbal discomfort signs, ensuring analgesic care, controlling environmental factors, proper body positioning, patient controlled analgesia, education on pain causes and management, and teaching non-pharmacological and pharmacological pain relief techniques. Collaboration with the patient and other providers is also emphasized. Outcomes include using analgesics as recommended and reporting controlled or uncontrolled symptoms.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    50 views3 pages

    Nyeri Akut (00132) : Kenyamanan

    Uploaded by

    Quurma Mala
    This document contains a nursing care plan for acute pain management. It includes the nursing diagnosis of acute pain related to factors like anxiety, tissue trauma, and temperature changes. The goal is to eliminate or reduce pain. Interventions include comprehensive pain assessment, monitoring for nonverbal discomfort signs, ensuring analgesic care, controlling environmental factors, proper body positioning, patient controlled analgesia, education on pain causes and management, and teaching non-pharmacological and pharmacological pain relief techniques. Collaboration with the patient and other providers is also emphasized. Outcomes include using analgesics as recommended and reporting controlled or uncontrolled symptoms.

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    You are on page 1of 3

    Universitas Muhammadiyah Surakarta

    Program Profesi NERS 2018

    RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLAN)


    KENYAMANAN : Nyeri Akut (00132)
    Domain : 12 (kenyamanan) Kelas : 1 (kenyamanan fisik)

    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 ( 1400) Pain Control (1605 )

    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 :

    Page 1 of 3
    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 )

    Page 2 of 3
    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)
    *NANDA 2015-2017 edisi 10

    Perawat primer Kepala Ruang

    (……………………….) (……………………)

    Page 3 of 3

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