Pengkajian Tujuan dan Kriteria Hasil/ Rencana Intervensi/ Nursing Evidence Based Nursing
No Dx Nursing Outcomes Classification Intervention Classification Practice
DS DO
(NOC) (NIC) (EBN)
1 Pasien mengatakan 1. Tampak Nyeri akut Setelah dilakukan tindakan 1. Lakukan penilaian awal Determining location, temporal
nyeri abdomen secara kesakitan, berhubungan keperawatan selama 1x24 jam, terhadap nyeri, seperti aspects, pain intensity,
tiba tiba. nyeri berbaring dengan agen cedera tingkat nyeri berkurang, dengan lokasi nyeri, kualitas, characteristics, and the impact of
semakin parah seperti 2. Terdapat biologis kriteria hasil: onset / durasi, intensitas, pain on function and quality of
ditusuk nyeri tekan 1. Nyeri yang dilaporkan faktor yang memberatkan life are critical to determine the
tusuk skala nyeri 8 di di semua 1 2 3 4 5 dan meringankan, dan underlying cause of pain and
seluruh bagian lapang paru
efek rasa sakit terhadap effectiveness of treatment (Breivik
perut selama 2 hari. 3. VT nyeri
2. Panjangnya episode nyeri fungsi dan kualitas hidup. et al, 2008; McCaffery, Herr, &
goyang
1 2 3 4 5 Pasero, 2011; Ming Wah, 2008).
cervix.
This initial assessment
4. Nadi
3. Ketegangan otot includes all pain information that
100x/menit
1 2 3 4 5 the client can provide and
provides data for the development
4. Mengerinyit of the individualized pain
1 2 3 4 5 management plan. Self-report is
considered the single most
reliable indicator of pain
presence and intensity (APS,
5. Mual 2008; McCaffery, Herr, &
1 2 3 4 5 Pasero, 2011).
Cognitive-behavioral (mind-body)
strategies can restore the clients
4. Selain pemberian sense of self-control, personal
analgesik, dukung klien efficacy, and active participation
dengan penggunaan in his or her own care (APS,
metode nonfarmakologis 2008; Bruckenthal, 2010).
untuk membantu
mengendalikan rasa sakit,
seperti relaksasi, dan
aplikasi panas dan dingin. EBN: Pain causes cognitive
impairment (Pasero et al, 2011b).
5. Mengajarkan dan Nonpharmacological
menerapkan intervensi interventions should be used to
nonfarmakologis saat rasa supplement, not replace,
sakit, tetapi tidak pharmacological interventions
menjadikannya yang (APS, 2008).
utama.