SOP PENGKAJIAN DAN MANAJEMEN NYERI

PENGERTIAN Mengetahui kondisi nyeri seseorang dan menentukan cara

dalam menurunkan dan meringankan nyeri sampai tingkat
kenyamanan yang dapat dirasakan oleh pasien
TAHAP PRA 1. Menyiapkan alat ( kertas pengkajian nyeri dan alat tulis),
INTERAKSI 2. Membaca catatan medis keperawatan,
3. Mengeksplorasi kekuatan dan kelemahan dalam diri saya,
4. Mencuci tangan 6 langkah, dan bertemu dengan klien

TAHAP ORIENTASI 1. Mengucapkan salam “ assalamualaikum”

2. Memperkenalkan diri “perkenalkan ibu nama saya fistalina
sukmianti, saya mahasiswa praktek keperawatan Dari
STIKES Mataram”
3. Menentukan identitas klien dan memverifikasi dengan
nama yang ada direkam medis “Ny. P umur 53 tahun
alamat Kekalik Mataram”
4. Menjelaskan prosedur dan tujuan“pada pagi ini saya akan
menanyakan terkait dengan nyeri atau rasa sakit pada dada
yang ibu rasakan ya ibu, dan saya nanti dengan terapi obat
dan relaksasi saya In SyaAllah akan membantu meredakan
nyeri yang ibu rasa sehingga nanti ibu akan merasa
nyaman saat nyeri itu berkurang”
5. Kontrak waktu “ baik ibu untuk prosedurnya nanti
dibutuhkan waktu kurang lebih 15-30 menit”
6. Menanyakan kesediaan, dan mempersilahkan bertanya “
baik ibu dari penjelasan saya tadi apakah ibu bersedia? Jika
iya sebelumnya ada yang ingin ibu tanyakan?”
7. Menjaga privasi klien “ permisi yaa ibu saya tutup tirainya
dahulu”.

TAHAP KERJA 1. Melakukan pengkajian nyeri dengan “OPQRSTUV”

a. O: kapan nyeri itu timbul, seberapa lama nyeri
timbul, seberapa sering nyeri itu timbul
b. P: penyebab nyeri itu dapat timbul, hal-hal yang
membuat nyeri itu semakin bertambah atau dapat
berkurang ?
c. Q: rasa nyeri yang dirasakan seperti apa ? tertusuk,
terhantam benda keras, dipukul?
d. R : daerah nyeri? Menyebar atau tidak ?
e. S : nyeri teringan yang pernah dirasakan, seberapa
menganggu dari nyeri yang dirasakan terhadap
aktifitas yang dilakukan ?
f. T : terapi yang digunakan untuk mengurangi nyeri
oleh pasien, waktunya kapan muncul nyeri tersebut?
 g. U: dampak dari nyeri yang dirasakan pada dirinya ?
h. V: target hasil yang diharapkan pasien setelah
mendapatkan treatement atau terapi pereda nyeri ?
2. Melakukan teknik pereda nyeri :
1) Mengatur posisi klien : bertujuan untuk memperlancar
sirkulasi dari darah pada bagian tubuh tertentu sehingga
suplai oksigen akan meningkat dan dapat mengurangi
nyeri yang dirasakan
a) Mengarahkan pasien untuk miring kiri atau kanan
b) Menaikkan bed pasien 45o
c) Menaikkan bed pasien 90o
2) Mengajarkan teknik nafas dalam : bertujuan untuk
membuka (vasodilatasi) pembuluh darah sehingga aliran
darah lancar dan dapat mengurangi nyeri serta dapat
menarik jumlah oksigen untuk disalurkan pada otak
sehingga dapat membuat otak mengeluarkan hormon
untuk mengurangi nyeri
a) Menginstruksikan klien untuk menarik nafas lewat hidung
dan mengeluarkan lewat mulut dan tahan selama 3 detik
saat sebelum dikeluarkan ( teknik nafas dalam yang benar:
saat menarik nafas terlihat adanya tarikan otot dinding
dada sehingga membuat dada terlihat mengembang.
b) Ulangi prosedur tersebut sampai 3 kali
c) Menginstruksikan keklien untuk melakukan nafas dalam
saat nyeri yang dirasakan timbul
3) Mengajarkan teknik distraksi : bertujuan untuk
mengalihkan pikiran dari pasien agar tidak terfokus pada
nyeri yang dirasakan.
a) Menanyakan ke klien tentang hal-hal yang suka dilakukan
, misal membaca koran, mendengarkan musik, bercerita
dsb
b) Menginstruksikan klien untuk melakukan teknik distraksi
saat nyeri timbul
4) Mengajarkan teknik guided imagery : bertujuan untuk
membuka kembali memori jangka pendek ataupun
panjang yang menyenangkan sehingga otak dengan
sendirinya akan mengeluarkan hormon pereda nyeri.
a) Menanyakan hal-hal yang membuat klien merasa senang
dan nyaman, misal : memori bertamasya bersama
keluarga, kegiatan kumpul dan bermain bersama anak.
b) Menginstruksikan klien untuk nafas dalam dan
mengrilekskan semua badan dan tidak memperdulikan
lingkungan dan suara sekitar kecuali suara
praktikan/instruktor
 c) Memberikan sugesti postif, menginstruksikan klien untuk
membayangan sesuatu yang indah (ulangi sampe klien
benar-benar bisa memasuki suasana tersebut)

3. Mengevaluasi hasil dari pengkajian dan managemen

nyeri non farmakologi

TAHAP TERMINASI 1. Mengeksplorasi perasaan dan evaluasi tindakan

managemen nyeri non farmakologi “ klien mengatakan
merasa lebih lega bisa menghilangkan nyeri yang dia
rasakan tanpa menggunakan obat”
2. Melakukan kontrak waktu selanjutnya “ baik ibu, nanti jam
13 saya akan menemui ibu lagi untuk memberikan obat
oral ya bu?”
3. Mengucap salam “ kalau begitu saya permisi ibu,
assalamualaikum, syafakillah bu”.
4. Mencuci tangan

TAHAP DOKUMENTASI S: Klien mengatakan sebelum diterapi nyeri yang dirasakan

disebabkan saat dia menarik nafas dahak yang ada didalam
dadanya tidak mampu keluar, dia merasakan nyeri setiap
kali menarik nafas dengan rasa nyeri seperti dipukul
dibagian dada dengan skala 8, yang bisa klien lakukan
untuk mengurangi nyeri adalah beristigfar tetapi terkadang
tidak mampu fokus sehingga nyeri tetap dapat dia rasakan,
klien merasa cemas dan gelisah serta merasa sangat
kesakitan saat ingin menarik nafas, dia berharap nyeri yang
dia rasakan dapat berkurang menjadi 5. Setelah diterapi
nyeri yang dirasakan disebabkan saat dia menarik nafas
dahak yang ada didalam dadanya tidak mampu keluar, dia
merasakan nyeri setiap kali menarik nafas dengan rasa
nyeri seperti dipukul dibagian dada dengan skala 5, klien
sudah mulai berkurang untuk perasaan cemas dan gelisah.
O: klien tampak tidak nyaman, sesak nafas, cemas, dan
gelisah
A; nyeri teratasi sebagian
P : kolaborasikan dengan terapi managemen nyeri
farmakologi.
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null
"Business"
[End Time]>[Start Time]
0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
0

"Good"
0

"Good"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
[End Time]>[Start Time]
Today()

"Good"

0
0

No
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
[Subtotal]+[Tax]

0
0

No
[End Date]>[Start Date]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
=Today()
[Delivery Date]>=Today()

No

"Not Started"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null
"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Full-time"
[Unit Price]*[Quantity]*(1-[Discount])

0
"None"
=Today()

0
[End Time]>[Start Time]
[End Date]>=[Start Date]

"Not Submitted"
=Today()

No
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
[Subtotal]+[Tax]+[Shipping]

0
[Original Contract Sum]+[Change Orders]

[Completed Previously]+[Completed This Period]

([Completed Previously]+[Completed This Period])*0.05

([Completed Previously]+[Completed This Period])-
(([Completed Previously]+[Completed This Period])*0.05)+
[Tax]

(([Completed Previously]+[Completed This Period])-

(([Completed Previously]+[Completed This Period])*0.05)+
[Tax])-[Previous Payments]

0
0

0
Today()
"1 - New"

"1 - Critical"

=Today()
Make sure the Status and Resolution fields are in sync

[Status]="3 - Resolved"

[Resolution] Is Null

If the Status is Resolved but the Resolution is

not specified, raise an error to prevent the data
from being saved

You must select a resolution.

[Status]="4 - Closed"
[Resolution] Is Null

If the Status is Closed but the Resolution is not

specified, raise an error to prevent the data from
being saved

An issue must be resolved before it can be

closed.

[Resolution] Is Not Null

If the Status is not Resolved and not Closed but

a Resolution is specified, clear the resolution
 Resolution

Null

Make sure the Status and Resolution fields are in sync

[Status]="3 - Resolved"

[Resolution] Is Null
If the Status is Resolved but the Resolution is
not specified, raise an error to prevent the data
from being saved

You must select a resolution.

[Status]="4 - Closed"

[Resolution] Is Null

If the Status is Closed but the Resolution is not

specified, raise an error to prevent the data from
being saved

An issue must be resolved before it can be

closed.
[Resolution] Is Not Null

If the Status is not Resolved and not Closed but

a Resolution is specified, clear the resolution

Resolution

Null
0
"Good"
0

0
IIf([Returned Date] Is Null,"Checked Out","Returned")

Today()
IIf([Returned Date] Is Null,"Checked Out","Returned")

Today()
IIf([Returned Date] Is Null,"Loaned","Returned")

Today()
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
0
0

No
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
[Unit Price]*[Quantity]*(1-[Discount])
0

"None"
IIf([Status]="Completed",No,Yes)
=Today()

"New"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
1

No
0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
"Open"
0

0
No

0
IIf([Status] In ("Completed","Deferred"),No,Yes)

[End Date]>=[Start Date]

"2 - Medium"

"Not Started"

Now()
Not Update([Changed Date])

Changed Date

Now()
0

0
0
=Today()

0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
[Quantity]*[Unit Price]

0
[Unit Price]*[Quantity]*(1-[Discount])
0

"None"
IIf([Status]="Completed",No,Yes)

=Today()

0
0

"New"
Concat([Budget Year]," - ",[Budget Quarter])
DateDiff(MONTH,[Start Date],[End Date])*[Rental Rate]

[End Date]>=[Start Date]

0
2
0
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
0

No
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
"On Track"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
IIf([Status] In ("Completed","Deferred"),No,Yes)

[Percent Complete] Between 0 And 1

"2 - Medium"

"Not Started"

This data macro makes sure the Status is set correctly if the
Percent Complete is updated or it makes sure the Percent
Complete is set correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

[Percent Complete]=0

Percent Complete is default - check Status

[Status]="Completed"

If Status is changed to Completed set Percent

Complete to 100%

Percent Complete

[Percent Complete]=1

If Percent Complete is 100% set Status to

Completed
[Status]

"Completed"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100%

and the Status is either Completed or Not
Started, set Status to In Progress

Status

"In Progress"
This data macro makes sure the Status is set correctly if the
Percent Complete is updated or it makes sure the Percent
Complete is set correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

Update([Percent Complete])

[Percent Complete]=1

If Percent Complete is changed to 100% and

Status is not set to Completed, set Status to
Completed
[Status]<>"Completed"

Status

"Completed"

[Percent Complete]=0

If Percent Complete is changed to 0% and Status

is Completed, set Status to Not Started
[Status]="Completed"

Status

"Not Started"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100%
and the Status is either Completed or Not
Started, set Status to In Progress

Status

"In Progress"

Update([Status])

[Status]="Completed"
If Status is changed to Completed and Percent
Complete is not 100%, set Percent Complete to
100%

[Percent Complete]<>1

Percent Complete

[Status]="Not Started"
If Status is changed to Not Started and Percent
Complete is not 0%, set Percent Complete to 0%

[Percent Complete]<>0

Percent Complete

[Percent Complete]=1
If Status is changed to something other than
Completed and the Percent Complete is 100%,
set Percent Complete to 0%

Percent Complete

0
IIf([Status] In ("Completed","Deferred"),No,Yes)

[Percent Complete] Between 0 And 1

"2 - Medium"

"Not Started"

This data macro makes sure the Status is set correctly if the
Percent Complete is updated or it makes sure the Percent
Complete is set correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

Update([Percent Complete])

[Percent Complete]=1
If Percent Complete is changed to 100% and
Status is not set to Completed, set Status to
Completed

[Status]<>"Completed"

Status

"Completed"

[Percent Complete]=0
If Percent Complete is changed to 0% and Status
is Completed, set Status to Not Started

[Status]="Completed"

Status

"Not Started"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100%
and the Status is either Completed or Not
Started, set Status to In Progress

Status

"In Progress"

Update([Status])
[Status]="Completed"

If Status is changed to Completed and Percent

Complete is not 100%, set Percent Complete to
100%

[Percent Complete]<>1

Percent Complete

1
[Status]="Not Started"

If Status is changed to Not Started and Percent

Complete is not 0%, set Percent Complete to 0%

[Percent Complete]<>0

Percent Complete

0
[Percent Complete]=1

If Status is changed to something other than

Completed and the Percent Complete is 100%,
set Percent Complete to 0%

Percent Complete

0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not

Null

"Business"
0

=Today()
[Sunday]+[Monday]+[Tuesday]+[Wednesday]+[Thursday]+
[Friday]+[Saturday]

([Sunday]+[Monday]+[Tuesday]+[Wednesday]+[Thursday]+
[Friday]+[Saturday])*[Pay Rate]

0
0

0
0
0
DateDiff(DAY,[Start Date],[End Date])
[End Date]>=[Start Date]

"Pleasure"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First
Name],[Email],[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First

Name],[Email],[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not
Null

"Business"
Today()

"Best Way"
0