YAYASAN ELISABETH RM B. 8.

3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

*Barcode identitas Pasien

Nama :
ASESMEN AWAL DAN ASESMEN ULANG NYERI No RM :
(MONITORING) Tanggal lahir :

 
A. ASESMEN AWAL NYERI.
 

Keluhan Verbal/ Ekspresi Nyeri: ......................................................................................................................................................................................................................................................................................................................

Cidera Agen Fisiologis: Inflamasi/ Iskemia/ Neoplasma/ Colic/....................................................................................................................................... )*

Provocatif/
Cidera Agen Kimiawi: Terbakar/ Bahan Kimia Iritan/...................................................................................................................................................................... )*
Pencetus
Cidera Agen Fisik: Abces/ Amputasi/ Terpotong/ Jatuh/ Terbentur/ Operasi/ Angkat Beban Berat/
Trauma Fisik lainnya ........................................................................................................................................................................................................................................................................... )*
Inpartu :Involuntio/ Kontraksi/................................................................................................................................................................................................................................................ )*

Quality/ Nyeri Tajam/ Teriris Nyeri Tumpul Mencengkeram/seperti diremas Rasa Terbakar
Kualitas Tertindih beban Melilit ....................................................................................................................................................................................................
Regio/Radiation Lokasi : .....................................................................................................................................................................................................................................................................................................................
Lokasi Penjalaran: Tidak ada Ada, ke ....................................................................................................................................................................................................................................

Severity/Scale Skala : ........................................., berdasar: Numerik Wong-Baker Fungsional .................................................................................................

Skala Khusus Post Operasi, Score Sedasi: 3 2 1 0 S
Time Akut Kronis Nyeri Konstan Nyeri hilang timbul ............................................................................................................................
Mulai kapan: ...................................................................................................................................................................................................................................................................................................................

Intervensi Awal Non Farmakologi : Panas Dingin Posisi Massage Relaksasi TENS Musik/ ..............................................
Farmakologi :  Analgetik : ...............................................................................................................................................................................................................................................
TT dan Nama Perawat

.......................................
B. MONITORING NYERI (ASESMEN ULANG NYERI).

Keluhan Intervensi
Tanggal/ Quality/ Regio/Radiasi Scale/ TT
Nyeri Pencetus Time Farmakologi/
Jam Kualitas Lokasi/Penjalaran Skala Nama
(+/ -) Non Farmakologi

Keluhan Intervensi
Tanggal/ Quality/ Regio/Radiasi Scale/ TT
Nyeri Pencetus Time Farmakologi/
Jam Kualitas Lokasi/Penjalaran Skala Nama
(+/ -) Non Farmakologi
 YAYASAN ELISABETH RM B. 8.
3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

Katagori Nyeri Skor Sedasi Intervensi Waktu Asesmen Ulang

Non Farmakologis
0 : Tidak Nyeri 3 : Sedasi berat, somnolent, 1. Panas. 1. Nyeri Kardiak: Tiap 5 menit setelah
1-3 : Nyeri Ringan sukar dibangunkan 2. Dingin. pemberian nitrat sublingual/ intravena
4-6 : Nyeri Sedang 2 : Sedasi Sedang, bicara 3. Posisi. 2. Tiap 30 menit, setelah intervensi
7-10 : Nyeri Berat Konstan, mengantuk. 4. Pijat/ Massage. analgetika injeksi rute lainnya
1 : Sedasi Ringan, kadang 5. TENS. 3. Tiap 60 menit setelah pemberian
mengantuk, mudah 6. Rileksasi analgetika oral atau Skala Nyeri 7-10.
dibangunkan 7. Musik 4. Tiap 3 Jam, pada Skala Nyeri 4-6.
0 : Sadar Penuh 8. Murotal 5. Tiap akhir shift, pada Skala Nyeri 1-3.
S : Tidur Normal 9. Dan lainnya 6. Dihentikan jika Skala 0/ Tidak Nyeri.

*Barcode identitas Pasien

Nama :
ASESMEN AWAL NYERI DAN MONITORING NYERI No RM :
Tanggal lahir :

 
A. ASESMEN AWAL NYERI.
 

Keluhan Verbal/ Ekspresi Nyeri: ......................................................................................................................................................................................................................................................................................................................

Cidera Agen Fisiologis: Inflamasi/ Iskemia/ Neoplasma/ Colic/....................................................................................................................................... )*

Provocatif/
Cidera Agen Kimiawi: Terbakar/ Bahan Kimia Iritan/...................................................................................................................................................................... )*
Pencetus
Cidera Agen Fisik: Abces/ Amputasi/ Terpotong/ Jatuh/ Terbentur/ Operasi/ Angkat Beban Berat/
Trauma Fisik lainnya ........................................................................................................................................................................................................................................................................... )*
Inpartu :Involuntio/ Kontraksi/................................................................................................................................................................................................................................................ )*
 YAYASAN ELISABETH RM B. 8.
3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

Quality/ Nyeri Tajam/ Teriris Nyeri Tumpul Mencengkeram/seperti diremas Rasa Terbakar
Kualitas Tertindih beban Melilit ....................................................................................................................................................................................................
Regio/Radiation Lokasi : .....................................................................................................................................................................................................................................................................................................................
Lokasi Penjalaran: Tidak ada Ada, ke ....................................................................................................................................................................................................................................

Severity/Scale Skala : ........................................., berdasar: Numerik Wong-Baker Fungsional .................................................................................................

Skala Khusus Post Operasi, Score Sedasi: 3 2 1 0 S
Time Akut Kronis Nyeri Konstan Nyeri hilang timbul ............................................................................................................................
Mulai kapan: ...................................................................................................................................................................................................................................................................................................................

Intervensi Awal Non Farmakologi : Panas Dingin Posisi Massage Relaksasi TENS Musik/ ..............................................
Farmakologi :  Analgetik : ...............................................................................................................................................................................................................................................
TT dan Nama Perawat

.......................................
B. MONITORING NYERI (ASESMEN ULANG NYERI).

Tanggal/ Keluhan Nyeri Intervensi Farmakologi/ TT

Quality Region/ Radiasi Scale/ Skala Time
Jam (+/ -)** Non Farmakologi Nama

Tanggal/ Keluhan Nyeri Intervensi Farmakologi/ TT

Quality Region/ Radiasi Scale/ Skala Time
Jam (+/ -)** Non Farmakologi Nama
 YAYASAN ELISABETH RM B. 8.
3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

Katagori Nyeri Skor Sedasi Intervensi Waktu Asesmen Ulang

Non Farmakologis
0 : Tidak Nyeri 3 : Sedasi berat, somnolent, 1. Panas. 1. Nyeri Kardiak: Tiap 5 menit setelah
1-3 : Nyeri Ringan sukar dibangunkan 2. Dingin. pemberian nitrat sublingual/ intravena
4-6 : Nyeri Sedang 2 : Sedasi Sedang, bicara 3. Posisi. 2. Tiap 30 menit, setelah intervensi
7-10 : Nyeri Berat Konstan, mengantuk. 4. Pijat/ Massage. analgetika injeksi rute lainnya
1 : Sedasi Ringan, kadang 5. TENS. 3. Tiap 60 menit setelah pemberian
mengantuk, mudah 6. Rileksasi analgetika oral atau Skala Nyeri 7-10.
dibangunkan 7. Musik 4. Tiap 3 Jam, pada Skala Nyeri 4-6.
0 : Sadar Penuh 8. Murotal 5. Tiap akhir shift, pada Skala Nyeri 1-3.
S : Tidur Normal 9. Dan lainnya 6. Dihentikan jika Skala 0/ Tidak Nyeri.

*Barcode identitas Pasien

Nama :
ASESMEN AWAL NYERI DAN MONITORING NYERI No RM :
Tanggal lahir :

 
A. ASESMEN AWAL NYERI.
 

Keluhan Verbal/ Ekspresi Nyeri: ......................................................................................................................................................................................................................................................................................................................

P Cidera Agen Fisiologis: Inflamasi/ Iskemia/ Neoplasma/ Colic/....................................................................................................................................... )*

Provocatif Cidera Agen Kimiawi: Terbakar/ Bahan Kimia Iritan/...................................................................................................................................................................... )*
(Pencetus/ Cidera Agen Fisik: Abces/ Amputasi/ Terpotong/ Jatuh/ Terbentur/ Operasi/ Angkat Beban Berat/
Penyebab) Trauma Fisik lainnya .......................................................................................................................................................................................................................................................................... )*
Inpartu :Involuntio/ Kontraksi/................................................................................................................................................................................................................................................ )*

Q Nyeri Tajam/ Teriris Nyeri Tumpul Mencengkeram/seperti diremas Rasa Terbakar

Quality/Kualitas Tertindih beban Melilit ..................................................................................................................................................................................................
R
Regio/Radiation Lokasi : .....................................................................................................................................................................................................................................................................................................................
Penjalaran: Tidak ada Ada, ke ....................................................................................................................................................................................................................................

S
Severity/Scale Skala : ........................................., berdasar: Numerik Wong-Baker Fungsional .................................................................................................
Khusus Post Operasi, Score Sedasi: 3 2 1 0 S
T Akut Kronis Nyeri Konstan Nyeri hilang timbul ...........................................................................................................
Time Mulai kapan: ...................................................................................................................................................................................................................................................................................................................
Intervensi Awal Non Farmakologi : Panas Dingin Posisi Massage Relaksasi TENS Musik/ ..............................................
Farmakologi :  Analgetik : ...............................................................................................................................................................................................................................................
TT dan Nama Perawat
 YAYASAN ELISABETH RM B. 8.
3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

(.......................................................)

B. MONITORING NYERI (ASESMEN ULANG NYERI).

Tanggal/ Keluhan Nyeri Katagori Intervensi Farmakologi/ Keterangan TT

Scale/ Skala
Jam (+/ -)** Nyeri Non Farmakologi Nama

Tanggal/ Keluhan Nyeri Katagori Intervensi Farmakologi/ Keterangan TT

Scale/ Skala
Jam (+/ -)** Nyeri Non Farmakologi Nama

Intervensi
Katagori Nyeri Skor Sedasi Waktu Asesmen Ulang
Non Farmakologis
0 : Tidak Nyeri 3 : Sedasi berat, somnolent, 1. Panas. 1. Tiap 30 menit, setelah intervensi
1-3 : Nyeri Ringan sukar dibangunkan 2. Dingin. analgetika injeksi.
4-6 : Nyeri Sedang 2 : Sedasi Sedang, bicara 3. Posisi. 2. Tiap 60 menit setelah pemberian
7-10 : Nyeri Berat Konstan, mengantuk. 4. Pijat/ Massage. analgetika oral atau Skala Nyeri 7-10.
1 : Sedasi Ringan, kadang 5. TENS. 3. Tiap 3 Jam, pada Skala Nyeri 4-6.
 YAYASAN ELISABETH RM B. 8.
3..........
RUMAH SAKIT ST. ELISABETH SEMARANG
Jl. Kawi No.1 Telp: 8310035, 8310076, 8448566 Fax : 8413373
Semarang-50231

mengantuk, mudah 6. Rileksasi 4. Tiap akhir shift, pada Skala Nyeri 1-3.
dibangunkan 7. Musik 5. Dihentikan jika Skala 0/ Tidak Nyeri.
0 : Sadar Penuh 8. Murotal 6. Khusus Nyeri Kardiak: Tiap 5 menit
S : Tidur Normal 9. Dan lainnya setelah pemberian nitrat Sublingual/IV