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Kelompok II PSIK A

1. Dina Susanti 201410420311013


2. St. Annisa Al Kamilah 201410420311014
3. Moh. Syaifi Akbar 201410420311015
4. Sefty Kasanah 201410420311016
5. Sigit Andrianto 201410420311017
6. Rizka Amalia Syamsudin 201410420311018
7. Muhammad Khoirul Anuwar 201410420311019
8. Nur Khaulah 201410420311020
9. Mutmin Ansari 201410420311021
10. Yuliana 201410420311022
11. Gina Riska Yulianti 201410420311023
Diagnosa Medis: Curiga KET

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).

2. Kaji tingkat intensitas The first step in pain assessment


nyeri pada klien is to determine if the client can
menggunakan skala ukur provide a self-report. Ask the
nyeri yang valid dan dapat client to rate pain intensity or
dipercaya, seperti skala select descriptors of pain intensity
penilaian nyeri 0-10 using a valid and reliable self-
report pain tool (Breivik et al,
2008; McCaffery, Herr, &
Pasero, 2011; Pasero, 2009a).

EB: Single-dimension pain


ratings are valid and reliable as
measures of pain intensity level
(Breivik et al, 2008; McCaffery,
Herr, & Pasero, 2011).

CEB & EBN: Investigation of


nursing attitudes and beliefs
about pain assessment revealed
that effective use of pain rating
scales is often determined by the
nurses personal attitude about its
effectiveness (LaymanYoung,
Horton, & Davidhizar, 2006;
McCaffery, Herr, & Pasero,
2011).

The relationship between


3. Minta klien untuk pain level and functional goals
mengidentifikasi tujuan should be a major focus of the
fungsi dari kenyamanan, development of individualized
tingkat rasa sakit, yang pain management plans
akan memungkinkan klien (McCaffery, Herr, & Pasero,
melakukan aktivitas yang 2011).
diperlukan atauyang EB: Effective pain relief with
diinginkan dengan mudah. function such as mobilization,

coughing, and deep breathing is


critical for decreasing risk factors
for cardiopulmonary and
thromboembolic complications
after surgery (Breivik et al, 2008).
CEB & EBN: Immobilization and
poorly managed acute pain also
are risk factors for persistent
(chronic) post-surgical and post-
trauma pain syndromes (Pasero,
2011; Stubhaug & Breivik, 2007).

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.