Makalah Manajemen Nyeri Pada Luka

MAKALAH KEPERAWATAN
“ MANAJEMEN NYERI PADA LUKA “

KEPERAWATAN GAWAT DARURAT
DOSEN FASILITATOR :
Ns. MERRY JANUAR FIRSTIANA. S. Kep., M.Kep
Diajukan Sebagai Salah Satu Tugas Kelompok 4 Mata Kuliah Keperawatan Gawat
Darurat
DI SUSUN OLEH:
1 FADLI NP 204070306 7 ROSNAWATI NP 204070308

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2 NURHAYATI NP 204070307 8 MEGAWATI. L NP 204070307
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3 HADIJAH NP 204070306 9 HASMIDAH NP 204070306
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4 FARASIAN.M.S. NP 204070306 1 MARIAM. S NP 204070307
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5 M. SAHRIR NP 204070307 1 SAMPE.J.RAJA. NP 204070308
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6 PURNAMA. B NP 204070308 1 MARWAH NP 204070307
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FAKULTAS ILMU KESEHATAN

PROGRAM STUDI S1 KEPERAWATAN KELAS KERJASAMA
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UNIVERSITAS BORNEO
TARAKAN
2021
KATA PENGANTAR
Puji syukur khadirat allah SWT karna atas berkat rahat dan hidayahnya lah
kami dapat menyelesaikan makalah yang berjudul “ MANAJEMEN NYERI PADA
LUKA “ ini dapat kami selesaikan tepat pada waktunya.
Dalam penyelesaian makalah ini selain dari hasil kerja kelompok IV, kami juga
mendapatkan dukungan dari beberapa pihak, dan pada kesempatan kali ini kami
ingin mengucapkan banyak terimaksih kepada :
1. Dosen pembimbing kami Ns.Merry Januar Firstiana.S.Kep.M.Kep yang telah
meluangkan Ilmu,waktu,kritik & sarannya dalam pembuatan makalah ini sehingga
makalah ini dapat selesai pada waktunya.
2. Keluarga kami yang membantu dalam doa dan dukungan semangat sehingga
makalah ini dapat selesai dengan baik dan tepat waktu.
Pemilihan judul tersebut merupakan salah satu tugas mata muliah keperawatan
gawat darurat, Kami menyadari bahwa makalah ini masih banyak kesalahan dalam
penyususnan, baik dari segi EYD, kosa kata, tata Bahasa,etika maupun isi. Oleh
karnanya kami sangat mengharapkan kritik dan saran yang membangun dari pembaca
sekalian untuk kami jadikan sbagai bahan evaluasi.
Demikian makalah ini dapat di terima sebagai ide / gagasan yang menambah
kekayaan intelektual bangsa. Terima kasih & Assalamualaikum Wr.Wb
Tarakan, 18 Mei 2021
Kelompok IV
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DAFTAR ISI
HALAMAN JUDUL......................................................................................i
KATA PENGANTAR..................................................................................ii
BAB I : PENDAHULUAN
A. Latar Belakang......................................................................................1
B. Tujuan ...................................................................................................2
C. Rumusan Masalah.................................................................................2
D. Manfaat .................................................................................................3
BAB II : TINJAUAN PUSTAKA
A. Definisi Nyeri........................................................................................4
B. Sifat-Sifat Nyeri....................................................................................4
C. Mekanisme Nyeri..................................................................................5
D. Katagori nyeri........................................................................................5
E. Jenis – Jenis Nyeri...............................................................................11
F. Cara Menghitung Nyeri.......................................................................12
G. Pathway Nyeri.....................................................................................18
H. Fisiologi Nyeri.....................................................................................19
I. Respon Tingkah Laku Terhadap Nyeri...............................................21
J. Klasifikasi Nyeri.................................................................................23
K. Factor Yang Mempengaruhi Nyeri.....................................................26
L. Penatalaksanaan Nyeri Pada Luka......................................................31
BAB III : PENUTUP
A. Kesimpulan..........................................................................................31
B. Saran....................................................................................................31
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DAFTAR PUSTAKA..................................................................................34
LAMPIRAN JURNAL...............................................................................35
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BAB 1
PENDAHULUAN
A. LATAR BELAKANG
Nyeri merupakan alasan yang paling umum seseorang mencari bantuan
perawatan kesehatan. Nyeri terjadi bersama proses penyakit, pemeriksaan
diagnostik dan proses pengobatan. Nyeri sangat mengganggu dan menyulitkan
banyak orang. Perawat, bidan dan tenaga kesehatan lain tidak bisa melihat dan
merasakan nyeri yang dialami oleh klien, karena nyeri bersifat subyektif (antara
satu individu dengan individu lainnya berbeda dalam menyikapi nyeri). perawat
memberi asuhan keperawatan kepada klien di berbagai situasi dan keadaan,
yang memberikan intervensi untuk meningkatkan kenyamanan. Menurut
beberapa teori keperawatan kenyamanan adalah kebutuhan dasar klien yang
merupakan tujuan pemberian asuhan keperawatan. Pernyataan tersebut
didukung oleh Kolcaba yang mengatakan bahwa kenyamanan adalah suatu
keadaan telah terpenuhinya kebutuhan dasar manusia.(Iskandar, n.d.)
Nyeri sering kali merupakan aspek perawatan luka yang terabaikan, dan
nyeri yang tidak terselesaikan dapat berdampak negatif pada penyembuhan
luka. Etiologi dan penyakit penyerta yang terkait dengan luka kronis juga dapat
mempersulit penilaian kuantitas dan kualitas nyeri yang dirasakan oleh pasien.
Sangat penting untuk menilai nyeri secara memadai saat membuat rencana
perawatan yang komprehensif.
Nyeri adalah faktor yang sering dialami, namun seringkali diabaikan
dalam perawatan luka dan penyembuhan luka. Tidak dapat disangkal bahwa
nyeri memengaruhi praktik perawatan luka, dan nyeri yang tidak terselesaikan
berdampak negatif pada penyembuhan luka dan kualitas hidup pasien.
Meskipun pengetahuan kita tentang nyeri meningkat, masih terdapat
kesenjangan yang besar antara pengetahuan dan penerapan manajemen nyeri.
Nyeri adalah multidimensi; melibatkan komponen fisiologis dan
psikologis.
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Komponen fisik meliputi penyebab luka dan nyeri dari intervensi klinis.
Pengaruh yang dimainkan faktor psikososial dalam persepsi pasien tentang
nyeri juga tidak dapat diremehkan.
Faktor tersebut termasuk pikiran negatif tentang nyeri, tekanan
emosional, nyeri antisipatif, dan kecemasan. Banyak dokter tidak nyaman
menilai nyeri dan tidak yakin strategi apa yang diterapkan untuk mengatasi
masalah nyeri secara efektif.
Ketidakmampuan untuk membedakan antara faktor penyebab nyeri luka
membuat sulit untuk menetapkan etiologinya dan pada gilirannya,
mengembangkan rencana perawatan yang efektif.
B. TUJUAN
1. Tujuan Umum
Agar mahasiswa dapat mengetahui tentang keterampilan dasarkebidanan
serta tentang gambaran nyeri, jenis serta manajemen nyeri.
2. Tujuan Khusus
a) Untuk mengetahui definisi nyeri
b) Untuk mengetahui tentang sifat jenis nyeri
c) Untuk mengetahui tentang fisiologi nyeri
d) Untuk mengetahui tentang klasifikasi nyeri
e) Untuk mengetahui tentang apa saja faktor nyeri
f) Untuk mengetahui tentang metode menghilangkan nyeri
C. RUMUSAN MASALAH
1. Apakah definisi nyeri ?
2. Apakah sifat jenis nyeri ?
3. Bagaimana fisiologi nyeri ?
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4. Bagaimana klasifikasi nyeri ?
5. Apa saja faktor nyeri ?
6. Apa saja metode menghilangkan nyeri ?
D. MANFAAT
Penyusunan makalah ini diharapkan dapat bermanfaat baik secara teoritis
maupun praktis. Secara teoritis makalah ini berguna sebagai
1. pengembangan pengetahuan mengenai keterampilan dasar keperawatan serta
tentang gambaran nyeri, jenis serta manajemen nyeri
2. Penulis, sebagai wahana penambah pengetahuan dan keilmuan di bidang
keperawatan
3. Pembaca sebagai media informasi dalam pembuatan makalah.
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BAB II
TINJUAN PUSTAKA
A. DEFINISI NYERI
Menurut International Association for Study of Pain (IASP), Nyeri adalah
sensori subyektif dan emosional yang tidak menyenangkan yang didapat terkait
dengan kerusakan jaringan aktual maupun potensial, atau menggambarkan
kondisi terjadinya kerusakan.
Teori Specificity “suggest” menyatakan bahwa Nyeri
adalah sensori spesifik yang muncul karena adanya injury, dan informasi ini
didapat melalui sistem saraf perifer dan sentral melalui reseptor nyeri di saraf
nyeri perifer dan spesifik di spinal cord.
B. SIFAT – SIFAT NYERI

1. Nyeri melelahkan dan membutuhkan banyak energi
2. Nyeri bersifat subyektif dan individual.
3. Nyeri tak dapat dinilai secara objektif seperti sinar X atau lab
4. perawat hanya dapat mengkaji nyeri pasien dengan melihat perubahan
fisiologis tingkah laku dan dari pernyataan klien.
5. Hanya klien yang mengetahui kapan nyeri timbul dan seperti apa rasanya.
6. Nyeri merupakan mekanisme pertahanan fisiologis.
7. Nyeri merupakan tanda peringatan adanya kerusakan jaringan.
8. Nyeri mengawali ketidakmampuan.
9. Persepsi yang salah tentang nyeri menyebabkan manajemen nyeri
tidak optimal.
10. Nyeri tidak menyenangkan
11. Nyeri Merupakan suatu kekuatan yg mendominasi.
12. Nyeri bersifat tidak berkesudahan.
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C. MEKANISME NYERI
Mekanisme nyeri secara sederhana dimulai dari transduksi stimuli akibat
kerusakan jaringan dalam saraf sensorik menjadi aktivitas listrik, kemudian
ditransmisikan melalui serabut saraf bermielin A delta dan saraf
tidak bermielin C ke kornu dorsalis medula spinalis, talamus,
dan korteks serebri. Impuls listrik tersebut dipersepsikan dan didiskriminasikan
sebagai kualitas dan kuantitas nyeri setelah mengalami modulasi sepanjang
saraf perifer dan disusun saraf pusat. Rangsangan yang dapat membangkitkan
nyeri dapat berupa rangsangan mekanik, suhu (panas atau dingin) dan
agen kimiawi yang dilepaskan karena trauma / inflamasi
D. KATAGORI NYERI
Nyeri umumnya dikategorikan menjadi empat kategori:
1. Nyeri Latar Belakang (Nyeri Basal atau Baseline)
Nyeri latar belakang terkait dengan penyebab luka, faktor luka lokal, dan
patologi terkait lainnya. Latar belakang nyeri dirasakan saat istirahat, bila
tidak ada manipulasi jaringan atau pergerakan pasien atau perubahan kondisi
fisik pasien secara tiba-tiba. Nyeri latar belakang berhubungan langsung
dengan penyebab luka pasien. Nama lain untuk nyeri latar belakang adalah
nyeri Basal atau Baseline. Jenis nyeri ini mungkin terus menerus atau
intermiten
Mengelola Nyeri Latar Belakang
a. Obati penyebab yang mendasari: atasi etiologi luka dan patologi terkait.
b. Obati faktor lokal yang menyebabkan nyeri luka: Gunakan protokol
manajemen luka lokal. Beberapa faktor luka lokal termasuk: iskemia,
infeksi, kekeringan berlebihan atau eksudat berlebihan, edema, masalah
dermatologis dan maserasi kulit di sekitarnya.
Organisasi Kesehatan Dunia (WHO) mengembangkan pendekatan tiga
langkah untuk menghilangkan rasa sakit pada pasien kanker, dan ini dapat
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dimodifikasi untuk perawatan luka. Sifat inflamasi dari luka kronis dan ulkus
tekanan adalah dasar untuk manajemen nyeri farmakologis.
Langkah 1:
Analgesik non-opiod (NSAID) dengan atau tanpa adjuvan analgesik.
Adjuvan termasuk antidepresan trisiklik, antikonvulsan, antihistamin,
benzodiazepin, steroid, dan fenotiazin. Adjuvan diberikan untuk manfaat
tidak langsungnya dalam manajemen nyeri
Langkah 2:
Jika nyeri tidak terkontrol: Lanjutkan pengobatan awal dan tambahkan
opioid, seperti kodein atau tramedol, dan adjuvan.
Langkah 3:
Ketika pasien tidak merespon obat langkah kedua, ini harus dihentikan dan
narkotika oral yang lebih kuat dimulai.
Manfaat pendekatan farmakologis untuk nyeri luka harus dipertimbangkan

terhadap risikonya sebelum rencana ini dimulai. '' Analgesia dapat
memfasilitasi ambulasi, yang mendorong penyembuhan luka dan
mengurangi risiko komplikasi seperti trombosis vena dalam, komplikasi paru
dan ulkus tekanan. Namun, efek samping analgesik harus dipertimbangkan,
efek seperti depresi pernapasan, mual, sembelit dan sedasi. Analgesia juga
dapat menutupi gejala dan komplikasi lebih lanjut.
2. Nyeri Terobosan (Incident Pain)

Nyeri terobosan kadang-kadang disebut nyeri Insiden.Nyeri terobosan
umumnya onset cepat, intensitas parah dan durasi singkat. Flare yang
berhubungan dengan nyeri latar umumnya ringan, jarang, onset lambat dan
ditoleransi serta ditangani dengan lebih mudah.Nyeri terobosan dapat terjadi
selama aktivitas sehari-hari seperti mobilisasi pasien selama pemindahan
atau setelah selip pembalut di mana luka trauma oleh luka. gerakan balutan
di atas permukaan kulit. Pada tahun 1990, Portenoy dan Hogan, bekerja
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dengan pasien kanker, mendefinisikan nyeri breakthrough sebagai
peningkatan nyeri sementara pada pasien yang mengalami nyeri yang stabil,
diobati, dan persisten.Nyeri breakthrough sering kali dipicu oleh gerakan
atau aktivitas pasien. Kegagalan '' End of Dose '' bukanlah rasa sakit yang
luar biasa. Nyeri akhir dosis terjadi ketika analgesik yang diresepkan secara
teratur tidak memadai dalam dosis atau ketika interval antara pemberian
dosis yang memadai terlalu lama. Penting juga untuk dicatat bahwa nyeri
breakthrough tidak dapat terjadi kecuali nyeri latar belakang terkontrol
secara memadai. Jika tidak, situasinya adalah nyeri latar belakang yang
benar-benar tidak terkendali daripada rasa sakit yang melonjak. Nyeri latar
belakang bukan hanya fluktuasi nyeri dasar karena terapi farmakologis yang
tidak adekuat. Obat-obatan yang digunakan untuk mengobati nyeri
breakthrough biasanya bersifat jangka pendek. Ini kadang-kadang disebut
'pengobatan penyelamatan'. Harus jelas bahwa mengelola nyeri latar
belakang sangat berbeda dari manajemen nyeri breakthrough.
Mengelola Rasa Sakit Terobosan
Pengobatan untuk nyeri breakthrough mungkin bersifat farmakologis dan
non-farmakologis. Perubahan posisi tubuh, gerakan, dan pengelolaan gejala
sistemik komorbiditas seperti batuk, sembelit, atau nyeri sendi, dapat
membantu meringankan nyeri breakthrough.Ketika nyeri break-through
dapat diprediksi, seperti nyeri terkait gerakan, pasien dapat diberikan obat
pereda nyeri tambahan sebagai pencegahan. Ini biasanya dilakukan 30 menit
sebelum aktivitas yang memicu rasa sakit
Strategi pengobatan farmakologis untuk nyeri breakthrough termasuk

meningkatkan dosis opioid, menambahkan obat nyeri kerja pendek yang
lebih kuat atau mengurangi interval waktu antar dosis. Jumlah yang tepat
dari dosis supelemental haruslah dosis yang akan meredakan nyeri tanpa
efek samping. Jika memungkinkan, agen farmakologis yang digunakan
untuk pengobatan nyeri breakthrough harus dihentikan setelah episode nyeri
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breakthrough tertentu diatasi dan nyeri latar belakang dinilai sebagai
penatalaksanaan. Jika agen farmakologis dihentikan, itu harus tersedia untuk
pasien jika rasa sakit yang menembus ini diantisipasi untuk terulang
kembali. Saat memilih dosis tambahan obat opioid, umumnya dianjurkan
untuk memilih salah satu yang diberikan dengan rute yang sama dengan obat
yang digunakan untuk analgesik basal.
Intervensi non-farmakologis untuk Nyeri

Meskipun hanya ada sedikit penelitian yang mendukungnya, cara
nonfarmakologis untuk manajemen nyeri tidak boleh dikesampingkan.
Kekuatan berbicara dengan pasien sebelum mengganti pembalut tidak dapat
diremehkan serta menjelaskan prosedur yang akan dilakukan dan tindakan
yang akan diambil untuk meminimalkan rasa sakit. Komunikasi sebelum
tindakan akan mengurangi perasaan takut dan cemas.16 Telah dinyatakan
bahwa waktu yang dihabiskan sebelum mengganti pakaian adalah waktu
yang dihabiskan dengan baik.Cara non-farmakologis yang dapat membantu
dalam mengatasi rasa sakit termasuk terapi musik, strategi relaksasi,
meditasi, citra, aktivitas fisik, istirahat, reposisi dan modalitas fisik seperti
Stimulasi Saraf Listrik Transkutan (TENS). 1,8 TENS sering dihipotesiskan
untuk mengontrol rasa sakit melalui teori yang dikenal sebagai '' Teori
Kontrol Gerbang. '' TENS mengaktifkan besar -diameter serat sensorik
myelinated dan blok transmisi input nosiseptif yang dibawa oleh serat nyeri
kecil myelinated dan non-myelinated. Stimulasi listrik yang disediakan oleh
unit TENS pada dasarnya menutup pintu transmisi rangsangan nyeri
3. Nyeri Prosedural
Hasil nyeri prosedural dari intervensi rutin seperti pelepasan balutan,
pembersihan atau aplikasi pembalut
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Pemilihan balutan
Banyak pekerjaan yang berhubungan dengan nyeri telah dilakukan selama
penggantian balutan Dalam studi multinasional
Selengkapnya tentang teks sumber iniDiperlukan teks sumber untuk
mendapatkan informasi terjemahan tambahan dilakukan oleh European
Wound Management Associa- tion (EWMA), dokter menilai perubahan
dressing sebagai waktu nyeri terbesar bagi pasien mereka.Selain itu, dressing
kering dan perekat agresif kemungkinan besar menyebabkan nyeri selama
pelepasan dressing. telah dibuktikan bahwa pasien melaporkan lebih banyak
rasa sakit dengan pembalut kasa dibandingkan dengan pembalut perawatan
luka tingkat lanjut lainnya.Luka mengandung jaringan yang rapuh dan
pengangkatan pembalut agresif dapat menyebabkan trauma tidak hanya pada
luka, tetapi juga jaringan di sekitarnya. . Salah satu cara untuk membatasi
rasa sakit saat melepas balutan adalah dengan menggunakan pembalut yang
mendorong pengangkatan atraumatik untuk mencegah terjadinya trauma.
Pembalut tersebut termasuk pembalut silikon lembut, hidrogel, hidrofiber,
dan alginat.
Beralih ke balutan atraumatik dapat secara efektif mengurangi rasa sakit
yang terkait dengan penggantian balutan. Dalam sebuah penelitian terhadap
5.850 pasien (dilaporkan oleh 656 dokter perawatan primer), beralih ke
balutan yang tidak patuh mengurangi nyeri luka pada 95% pasien dengan
luka akut dan 88% pasien dengan luka kronis. Penulis penelitian
menyimpulkan bahwa memilih balutan yang sesuai dan tidak patuh
meningkatkan penerimaan pasien terhadap penggantian balutan
Sudah menjadi pengetahuan umum bahwa luka sembuh lebih cepat di
lingkungan yang lembab. Ada banyak faktor yang berkontribusi terhadap hal
ini; kelembaban meningkatkan proses epitelisasi ulang, memfasilitasi aksi
faktor pertumbuhan dan keratinosit dan proliferasi fibroblast serta
meningkatkan sintesis kolagen, angiogenesis dan kontraksi luka awal.Salah
satu kesalahpahaman yang umum adalah bahwa dressing harus diganti
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sesering mungkin. Panduan terbaru menyarankan bahwa penggantian
balutan harus dilakukan tergantung pada karakteristik luka, tetapi sesering
mungkin, untuk mengurangi kemungkinan infeksi oleh kontaminan
eksternal.Ovington menyebutkan bahwa penggantian balutan yang lebih
sering menyebabkan penurunan suhu luka, yang mana menyebabkan
vasokonstriksi dan penurunan perfusi darah ke area tersebut.Penurunan
perfusi darah telah terbukti secara drastis mengganggu kemampuan oksigen
untuk membersihkan bakteri dari luka yang menyebabkan peningkatan
infeksi jaringan.29 Pembalut kain kasa yang dipasang di luka tidak banyak
membantu untuk menghalangi penguapan cairan
dan suhu jaringan mengukur 25◦C hingga 27◦C (77.0- 80.6◦F) —di bawah
suhu jaringan normal. Busa dan lapisan tipis mempertahankan dasar luka
pada suhu 91-95 derajat.
Secara regional, pembalut kain kasa perlu diganti lebih sering untuk
mencegah kekeringan
Memilih balutan yang tepat bisa menjadi proses yang menakutkan.
Seseorang harus menjaga keseimbangan kelembaban, memberikan
kelembaban yang cukup tanpa menyebabkan maserasi atau desikasi, yang
keduanya menghambat penyembuhan. Jika balutan mengering pada luka,
perendaman mungkin diperlukan untuk mempromosikan pengangkatan
tanpa rasa sakit. yang secara tidak perlu mengekspos luka ke elemen
eksternal seperti bakteri dan menurunkan suhu permukaan luka.Dessication
mengganggu migrasi epidermis yang diperlukan untuk penutupan
luka.Perban alternatif harus dipilih yang dapat mengatur kebutuhan cairan
luka dengan lebih baik.
Sebaliknya, cairan yang berlebihan dapat menyebabkan maserasi jaringan
jika pembalut tidak dapat menangani kebutuhan cairan yang tinggi pada
luka. Cairan kaya enzim, jika dibiarkan menempel di kulit, dapat
menyebabkan nyeri, maserasi, dan erosi jaringan.4 Sekali lagi,
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direkomendasikan untuk memilih pembalut yang lebih tepat untuk mengatasi
kebutuhan luka.
Balutan menghilangkan pengingat yang terlihat bagi pasien tentang luka
yang mereka miliki. Mereka memungkinkan pasien untuk melanjutkan
aktivitas normal sehari-hari dan memberikan penghalang untuk rangsangan
fisik.16 Pilihan ukuran dan jenis balutan dapat mempengaruhi tingkat
kecemasan pasien selama penggantian balutan dan mempengaruhi kualitas
hidup mereka secara keseluruhan.
4. Nyeri Operasi
Nyeri operatif dikaitkan dengan intervensi apa pun yang biasanya dilakukan
oleh spesialis dan membutuhkan anestesi (lokal atau umum) untuk mengatasi
nyeri.Dokter juga harus mempertimbangkan peran faktor Psikososial dan
Lingkungan dalam penyebab nyeri luka. Faktor psikososial seperti usia,
lingkungan dan riwayat nyeri sebelumnya semua dapat mempengaruhi
pengalaman pasien tentang nyeri dan kemampuan untuk
mengkomunikasikan nyeri mereka. Faktor lingkungan mungkin menjadi
salah satu yang paling penting untuk dikenali oleh dokter karena hal ini
seringkali mudah untuk diperbaiki dan diatasi untuk pasien. Contohnya
adalah waktu prosedur, suhu ruangan, tingkat kebisingan dan posisi pasien
D. Jenis-Jenis Skala Nyeri

Secara umum, skala ini digambarkan dalam bentuk nilai angka, yakni 1-10.
Berikut adalah jenis skala nyeri berdasarkan nilai angka yang perlu Anda
ketahui.
1. Skala 0, tidak nyeri
2. Skala 1, nyeri sangat ringan
3. Skala 2, nyeri ringan. Ada sensasi seperti dicubit, namun tidak begitu sakit
4. Skala 3, nyeri sudah mulai terasa, namun masih bisa ditoleransi
5. Skala 4, nyeri cukup mengganggu (contoh: nyeri sakit gigi)
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6. Skala 5, nyeri benar-benar mengganggu dan tidak bisa didiamkan dalam
waktu lama
7. Skala 6, nyeri sudah sampai tahap mengganggu indera, terutama indera
penglihatan
8. Skala 7, nyeri sudah membuat Anda tidak bisa melakukan aktivitas
9. Skala 8, nyeri mengakibatkan Anda tidak bisa berpikir jernih, bahkan terjadi
perubahan perilaku
10. Skala 9, nyeri mengakibatkan Anda menjerit-jerit dan menginginkan cara
apapun untuk menyembuhkan nyeri
11. Skala 10, nyeri berada di tahap yang paling parah dan bisa menyebabkan
Anda tak sadarkan diri
E. Cara Menghitung Skala Nyeri

Metode ini membantu para tenaga medis untuk mendiagnosis penyakit,
menentukan metode pengobatan, hingga menganalisis efektivitas dari
pengobatan tersebut. Dalam dunia medis, ada banyak metode penghitungannya.
Berikut ini beberapa cara menghitung skala nyeri yang paling populer dan
sering digunakan.
1. Visual Analog Scale (VAS)
Visual Analog Scale (VAS) adalah cara menghitung skala nyeri yang
paling banyak digunakan oleh praktisi medis. VAS merupakan skala linier
yang akan memvisualisasikan gradasi tingkatan nyeri yang diderita oleh
pasien.
Pada metode VAS, visualisasinya berupa rentang garis sepanjang kurang
lebih 10 cm, di mana pada ujung garis kiri tidak mengindikasikan nyeri,
sementara ujung satunya lagi mengindikasikan rasa atau intensitas nyeri
terparah yang mungkin terjadi.
Selain dua indicator tersebut, VAS bisa diisi dengan indikator redanya
rasa nyeri. VAS adalah prosedur penghitungan yang mudah untuk
digunakan. Namun, VAS tidak disarankan untuk menganalisis efek nyeri
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pada pasien yang baru mengalami pembedahan. Ini karena VAS
membutuhkan koordinasi visual, motorik, dan konsentrasi. Berikut adalah
visualisasi VAS:
sumber: unud.ac.id
2. Verbal Rating Scale (VRS)

Verbal Scale (VRS) hampir sama dengan VAS, hanya, pernyataan verbal
dari rasa nyeri yang dialami oleh pasien ini jadi lebih spesifik. VRS lebih
sesuai jika digunakan pada pasien pasca operasi bedah karena prosedurnya
yang tidak begitu bergantung pada koordinasi motorik dan visual. Skala
nyeri versi VRS:
sumber: unud.ac.id
3. Numeric Rating Scale (NRS)

Metode Numeric Rating Scale (NRS) didasari pada skala angka 1-10 untuk
menggambarkan kualitas nyeri yang dirasakan pasien. NRS diklaim lebih
mudah dipahami, lebih sensitif terhadap jenis kelamin, etnis, hingga dosis.
NRS juga lebih efektif untuk mendeteksi penyebab nyeri akut ketimbang
VAS dan VRS. Skala nyeri dengan menggunakan NRS:
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sumber: unud.ac.id
NRS di satu sisi juga memiliki kekurangan, yakni tidak adanya pernyataan
spesifik terkait tingkatan nyeri sehingga seberapa parah nyeri yang dirasakan
tidak dapat diidentifikasi dengan jelas.
4. Wong-Baker Pain Rating Scale
Wong-Baker Pain Rating Scale adalah metode penghitungan skala nyeri
yang diciptakan dan dikembangkan oleh Donna Wong dan Connie Baker.
Cara mendeteksi skala nyeri dengan metode ini yaitu dengan melihat
ekspresi wajah yang sudah dikelompokkan ke dalam beberapa tingkatan rasa
nyeri.
sumber: wongbakerfaces.org
Saat menjalankan prosedur ini, dokter akan meminta pasien untuk memilih
wajah yang kiranya paling menggambarkan rasa nyeri yang sedang mereka
alami. Seperti terlihat pada gambar, skala nyeri dibagi menjadi:
1. Raut wajah 1, tidak ada nyeri yang dirasakan
2. Raut wajah 2, sedikit nyeri
3. Raut wajah 3, nyeri
4. Raut wajah 4, nyeri lumayan parah
5. Raut wajah 5, nyeri parah
6. Raut wajah 6, nyeri sangat parah
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5. McGill Pain Questinonnaire (MPQ)
Metode penghitungan skala nyeri selanjutnya adalah McGill Pain
Questinnaire (MPQ). MPQ adalah cara mengetahui skala nyeri yang
diperkenalkan oleh Torgerson dan Melzack dari Universitas Mcgill pada
tahun 1971. Sesuai dengan namanya, prosedur MPQ berupa pemberian
kuesioner kepada pasien.
Kuesioner tersebut berisikan kategori atau kelompok rasa tidak nyaman yang
diderita. Terdapat 20 kelompok yang masing-masing terdiri dari sejumlah
kata sifat (adjektiva). Pasien diminta untuk memilih kata-kata yang kiranya
paling menggambarkan kondisi mereka saat ini.
a. Kelompok 1-10
Menggambarkan kualitas sensorik dari nyeri. Gejala yang termasuk
dalam kelompok ini di antaranya:
1) Berdenyut
2) Menusuk
3) Panas
4) Kesemutan
5) Gatal
6) Perih
7) Kram
8) Koyak
b. Kelompok 11-15
Kelompok 11-15 menggambarkan efektivitas nyeri, seperti:
1) Melelahkan
2) Memuakkan
3) Menakutkan
4) Celaka
5) Kejam
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6) Membunuh
c. Kelompok 16
Sementara itu, adjektiva pada kelompok 16 lebih ke dimensi evaluasi,
terdiri atas:
1) Menjengkelkan
2) Menyusahkan
3) Sengsara
4) Tak tertahankan
d. Kelompok 17-20
Terakhir, kelompok 1-20 berisi kata-kata yang sifatnya spesifik, seperti:
1) Menyiksa
2) Mengerikan
3) Dingin
4) Memancarkan
5) Menembus
Lazimnya, dokter akan meminta pasien memilih tiga kata dari kelompok 1-
10, dua kata dari kelompok 11-15, satu katan dari kelompok 16, dan satu
kata dari kelompok 17-20. Setelah itu, dokter menjumlahkan kata-kata yang
dipilih oleh pasien sehingga menghasilkan angka total yang digunakan untuk
menentukan skala nyeri.
6. Oswetry Disability Index (ODI)

Diperkenalkan pertama kali pada tahun 1980 oleh Jeremy Fairbank, Oswetry
Disability Index (ODI) adalah metode deteksi skala nyeri yang bertujuan
untuk mengukut derajat kecacatan, pun indeks kualitas hidup dari pasien
penderita nyeri, khususnya nyeri pinggang.
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Pada penerapannya, pasien akan diminta melakukan serangkaian tes guna
mengidentifikasi intensitas nyeri, kemampuan gerak motorik, kemampuan
berjalan, duduk, fungsi seksual, kualitas tidur, hingga kehidupan pribadinya.
Dari sini, dokter dapat mengetahui skala nyeri dan memastikan apa
penyebab utama dari nyeri yang dirasakan tersebut.
7. Brief Pain Inventory (BPI) Awalnya, metode ini digunakan untuk

menghitung skala nyeri yang dirasakan oleh penderita kanker. Namun. Saat
ini BPI juga digunakan untuk menilai derajat nyeri pada penderita nyeri
kronik.
8. Memorial Pain Assessment Card

Cara mengukur skala nyeri dengan metode Memorial Pain Assessment Card
ini dinilai cukup efektif, terutama untuk pasien penderita nyeri kronik.
Dalam penerapannya, MPAC akan berfokus pada empat indicator, yakni
intensitas nyeri, deskripsi nyeri, pengurangan nyeri, dan mood.
Skala nyeri sifatnya subjektif. Anda bisa saja berpendapat bahwa nyeri yang
sedang dirasakan masuk ke dalam kelompok nyeri berat. Jangan
berspekulasi. Segera periksakan diri ke dokter untuk mendapatkan informasi
jelas perihal tingkat keparahan nyeri yang sebenarnya Anda alami.
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D. PATHWAY NYERI
Trauma jaringan infeksi cidera
Kerusakan sel
Pelepasan mediator nyeri

( histamin,bradykinin, prostaglandin,, serotonin, ionkalium, dll
Merangsang nosiseptor
( reseptor nyeri )
Dihantarkan serabut tipe A dan serabut tipe C
Medulla spinaslis
System aktivasi retikuler area grisea

Peraikueduktus Retikuler
Thalamus hipotalamus dan system limbik thalamus
otak
(korteks somatosensoarik)
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Persepsi nyeri
Nyeri akut/nyeri kronis
E. FISIOLOGI NYERI
Banyak teori berusaha untuk menjelaskan dasar neurologis dari nyeri,
meskipun tidak ada satu teori yang menjelaskan secara sempurna bagaimana
nyeri ditransmisikan atau diserap.
Untuk memudahkan memahami fisiologi nyeri, maka perlu mempelajari 3
(tiga) komponen fisiologis berikut ini:
1. Resepsi (proses perjalanan nyeri)

Adanya stimulus yang mengenai tubuh (mekanik, termal, kimia) akan
menyebabkan pelepasan substansi kimia seperti histamin,
bradikinin, kalium. Substansi tersebut menyebabkan nosiseptor
bereaksi, apabila nosiseptor mencapai ambang nyeri, maka akan
timbul impuls syaraf yang akan dibawa oleh serabut saraf perifer. Serabut
syaraf perifer yang akan membawa impuls syaraf ada dua jenis, yaitu
serabut A-delta dan serabut C. impuls syaraf akan di bawa sepanjang serabut
syaraf sampai ke kornu dorsalis medulla spinalis. Impuls syaraf tersebut
akan
menyebabkan kornu dorsalis melepaskan neurotrasmiter (substansi P). Subs
tansi P ini menyebabkan transmisi sinapis dari saraf perifer ke
saraf traktus spinotalamus. Hal ini memungkinkan impuls syaraf
ditransmisikan lebih jauh ke dalam system saraf pusat. Setelah impuls syaraf
sampai di otak, otak mengolah impuls syaraf kemudian akan timbul
respon reflek protekti.
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Contoh : Apabila tangan terkena setrika, maka akan merasakan sensasi
terbakar, tangan juga melakukan reflek dengan menarik tangan dari
permukaan setrika. Proses ini akan berjalan jika system saraf
perifer dan medulla spinalis utuh atau berfungsi normal.
2. Persepsi ( kesadaran seseorang terhadap nyeri )

Fase ini merupakan titik kesadaran seseorang terhadap nyeri, pada saat
individu menjadi sadar akan nyeri, maka akan terjadi reaksi yang
komplek. Persepsi menyadarkan individu dan mengartikan nyeri itu
sehingga kemudian individu dapat bereaksi.
Proses persepsi secara ringkas adalah sebagai berikut:

Stimulus Nyeri Medula Spinalis Talamus Otak (area limbik) Reaksi
emosi Pusat otak, Persepsi Stimulus nyeri ditransmisikan ke medula spinalis,
naik ke talamus, selanjutnya serabut mentrasmisikan nyeri ke seluruh bagian
otak, termasuk area limbik. Area ini mengandung sel-sel yang yang bisa
mengontrol emosi (khususnya ansietas). Area limbik yang akan berperan
dalam memproses reaksi emosi terhadap nyeri. Setelah transmisi syaraf
berakhir di pusat otak, maka individu akan mempersepsikan nyeri.
3. Reaksi ( respon fisiologis & perilaku setelah mempersepsikan nyeri )

Reaksi terhadap nyeri merupakan respon fisioligis dan perilaku yang terjadi
setelah mempersepsikan nyeri. Nyeri dengan intensitas ringan hingga sedang
dan nyeri yang superfisial menimbulkan reaksi ”flight atau fight”, yang
merupakan sindrom adaptasi umum. Stimulasi pada cabang simpatis pada
saraf otonom menghasilkan respon fisiologis, apabila nyeri berlangsung
terus menerus, maka sistem parasimpatis akan bereaksi.
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Secara ringkas proses reaksi adalah sebagai berikut:
Impuls nyeri medula spinalis batang otak & talamus Sistem
syaraf otonom Respon fisiologis&perilaku Impuls nyeri ditransmisikan ke
medula spinalis menutju ke batang otak dan talamus. Sistem saraf otonom
menjadi terstimulasi, saraf simpatis dan parasimpatis bereaksi, maka akan
timbul respon fisiologis dan akan muncul perilaku.
F. RESPON TINGKAH LAKU TERHADAP NYERI

Respon perilaku terhadap nyeri dapat mencakup:
1. Pernyataan verbal seperti Mengaduh, Menangis, Sesak Nafas, Mendengkur.
2. Ekspresi wajah seperti Meringis, Menggeletukkan gigi, Menggigit bibir.
3. Gerakan tubuh (Gelisah, Imobilisasi, Ketegangan otot, peningkatan
gerakan jari & tangan).
4. Kontak dengan orang lain/interaksi sosial (Menghindari percakapan,
Menghindari kontak sosial, Penurunan rentang perhatian, Fokus pada
aktivitas menghilangkan nyeri) Individu yang mengalami nyeri mendadak
dapat bereaksi sangat berbeda terhadap nyeri yang berlangsung selama
beberapa menit atau menjadi kronis.
Nyeri dapat menyebabkan keletihan dan membuat individu terlalu letih untuk
merintih atau menangis. Pasien dapat tidur, bahkan dengan nyeri hebat. Pasien
dapat tampak rileks dan terlibat dalam aktivitas karena menjadi mahir dalam
mengalihkan perhatian terhadap nyeri.
Meinhart & McCaffery Mendiskripsikan 3 Fase Pengalaman Nyeri:
1. Fase Antisipasi Terjadi Sebelum Nyeri Diterima.
Fase ini mungkin bukan merupakan fase yg paling penting, karena fase
ini bisa mempengaruhi dua fase lain. Pada fase ini memungkingkan
seseorang belajar tentang nyeri dan upaya untuk menghilangkan nyeri
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tersebut. Peran bidan dalam fase ini sangat penting, terutama dalam
memberikan informasi pada klien.
Contoh: Sebelum dilakukan tindakan bedah, bidan menjelaskan tentang
nyeri yang nantinya akan dialami oleh klien pasca pembedahan, dengan
begitu klien akan menjadi lebih siap dengan nyeri yang nanti akan dihadapi.
2. Fase sensasi terjadi saat nyeri terasa.
Fase ini terjadi ketika klien merasakan nyeri. karena nyeri itu
bersifat subyektif, maka tiap orang dalam menyikapi nyeri juga berbeda-
beda. Toleraransi terhadap nyeri juga akan berbeda antara satu orang dengan
orang lain. orang yang mempunyai tingkat toleransi tinggi terhadap nyeri
tidak akan mengeluh nyeri dengan stimulus kecil, sebaliknya orang yang
toleransi terhadap nyerinya rendah akan mudah merasa nyeri
dengan stimulus nyeri kecil.
Klien dengan tingkat toleransi tinggi terhadap nyeri mampu menahan
nyeri tanpa bantuan, sebaliknya orang yang toleransi terhadap nyerinya
rendah sudah mencari upaya pencegah nyeri, sebelum nyeri datang.
Keberadaan enkefalin dan endorfin membantu menjelaskan bagaimana
orang yang berbeda merasakan tingkat nyeri dari stimulus yang sama. Kadar
endorfin berbeda tiap individu, individu dengan endorfin tinggi sedikit
merasakan nyeri dan individu dengan sedikit endorfin merasakan nyeri lebih
besar.
Klien bisa mengungkapkan nyerinya dengan berbagai jalan, mulai dari
ekspresi wajah, vokalisasi dan gerakan tubuh. Ekspresi yang ditunjukan
klien itulah yang digunakan bidan untuk mengenali pola perilaku yang
menunjukkan nyeri. Bidan harus melakukan pengkajian secara teliti apabila
klien sedikit mengekspresikan nyerinya, karena belum tentu orang yang
tidak mengekspresikan nyeri itu tidak mengalami nyeri. Kasus-kasus seperti
itu tentunya membutuhkan bantuan bidan untuk membantu klien
mengkomunikasikan nyeri secara efektif.
3. Fase akibat (aftermath) terjadi ketika nyeri berkurang atau berhenti
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Fase ini terjadi saat nyeri sudah berkurang atau hilang. Pada fase ini
klien masih membutuhkan kontrol dari perawat, karena nyeri bersifat krisis,
sehingga dimungkinkan klien mengalami gejala sisa pasca nyeri. Apabila
klien mengalami episode nyeri berulang, maka respon akibat (aftermath)
dapat menjadi masalah kesehatan yang berat. perawat berperan dalam
membantu memperoleh kontrol diri untuk meminimalkan rasa takut akan
kemungkinan nyeri berulang.
G. KLASIFIKASI NYERI
1. Berdasarkan sumbernya:
a. Cutaneus/superfisial, yaitu nyeri yang mengenai kulit/
jaringan subkutan. Biasanya bersifat burning (seperti terbakar).
Contoh : terkena ujung pisau atau gunting.
b. Deep somatic/ nyeri dalam, yaitu nyeri yang muncul dari ligament,
pembuluh darah, tendondan syaraf, nyeri menyebar & lebih lama dari
pada cutaneus.
Contoh : sprain sendi.
c. Visceral (pada organ dalam), stimulasi reseptor nyeri dalam
rongga abdomen, cranium dan thorak.
Contoh : Biasanya terjadi karena spasme otot, iskemia, regangan
jaringan.
2. Berdasarkan penyebab
a. Fisik
Bisa terjadi karena stimulus fisik.
contoh: fraktur femur
b. Psycogenic
Terjadi karena sebab yang kurang jelas/susah diidentifikasi, bersumber
dari emosi/psikis dan biasanya tidak disadari.
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Contoh: Orang yang marah-marah, tiba-tiba merasa nyeri pada dadanya)
biasanya nyeri terjadi karena perpaduan 2 sebab tersebut.
3. Berdasarkan lama/durasinya
a. Nyeri Akut
Nyeri yang terjadi segera setelah tubuh terkena cidera,
atau intervensi bedah dan memiliki awitan yang cepat,
dengan intensitas bervariasi dari berat sampai ringan. Fungsi nyeri ini
adalah sebagai pemberi peringatan akan adanya cidera atau penyakit yang
akan datang. Nyeri ini terkadang bisa hilang sendiri tanpa
adanya intervensi medis, setelah keadaan pulih pada area yang rusak.
Apabila nyeri akut ini muncul, biasanya tenaga kesehatan
sangat agresif untuk segera menghilangkan nyeri. Nyeri akut secara
serius mengancam proses penyembuhan klien, untuk itu harus
menjadi prioritas bidan. Rehabilitasi bisa tertunda dan hospitalisasi bisa
memanjang dengan adanya nyeri akut yang tidak terkontrol.
b. Nyeri kronik
Nyeri kronik adalah nyeri konstan atau intermiten yang menetap
sepanjang suatu periode tertentu, berlangsung lama, intensitas bervariasi,
dan biasanya berlangsung lebih dari enam bulan. Nyeri ini disebabkan
oleh kanker yang tidak terkontrol, karena pengobatan kanker tersebut atau
karena gangguan progresif lain. Nyeri ini bisa berlangsung terus sampai
kematian. Pada nyeri kronik, tenaga kesehatan tidak seagresif pada nyeri
akut. Klien yang mengalami nyeri kronik akan mengalami
periode remisi (gejala hilang sebagian atau keseluruhan)
dan eksaserbasi (keparahan meningkat). Nyeri ini biasanya tidak
memberikan respon terhadap pengobatan yang diarahkan pada
penyebabnya.
Nyeri ini merupakan penyebab utama ketidakmampunan fisik
dan psikologis. Sifat nyeri kronik yang tidak dapat diprediksi membuat
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klien menjadi frustasi dan seringkali mengarah pada depresi psikologis.
Individu yang mengalami nyeri kronik akan timbul perasaan yang tidak
aman, karena ia tidak pernah tahu apa yang akan dirasakannya dari hari
ke hari.
Perbedaan karakteristik nyeri akut dan kronik

Nyeri akut Nyeri kronik
1. Lamanya dalam hitungan 1. Lamanya sampai hitungan
menit. bulan, > 6 bulan.
2. Ditandai peningkatan BP, 2. Fungsi fisiologi bersifat normal.
nadi, dan respirasi.
3. Respon pasien Fokus pada 3. tidak ada keluhan nyeri.
nyeri, menyetakan nyeri
menangis dan mengerang.
4. Tingkah laku menggosok 4. Tidak ada aktifitas fisik sebagai
bagian yang nyeri. respon terhadap nyeri.
4. Berdasarkan lokasi/letak
a. Radiating pain
Nyeri menyebar dari sumber nyeri ke jaringan di dekatnya.
Contoh: cardiac pain.
b. Referred pain
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Nyeri dirasakan pada bagian tubuh tertentu yang diperkirakan berasal dari
jaringan penyebab nyeri.
c. Intractable pain
Nyeri yg sangat susah dihilangkan.
Contoh: nyeri kanker maligna.
d. Phantom pain
Sensasi nyeri dirasakan pada bagian.Tubuh yg hilang.
Contoh: Bagian tubuh yang diamputasi atau bagian tubuh yang lumpuh
karena injuri medulla spinalis
H. FAKTOR YANG MEMPENGARUHI NYERI

1. Usia
Anak belum bisa mengungkapkan nyeri, sehingga bidan harus mengkaji
respon nyeri pada anak. Pada orang dewasa kadang melaporkan nyeri jika
sudah patologis dan mengalami kerusakan fungsi. Pada lansia cenderung
memendam nyeri yang dialami, karena mereka menganggap nyeri adalah hal
alamiah yang harus dijalani dan mereka takut kalau mengalami penyakit
berat atau meninggal jika nyeri diperiksakan.
2. Jenis kelamin
Gill (1990) mengungkapkan laki-laki dan wnita tidak berbeda
secara signifikan dalam merespon nyeri, justru lebih dipengaruhi faktor
budaya.
Contoh: tidak pantas kalo laki-laki mengeluh nyeri, wanita boleh mengeluh
nyeri.
3. Kultur
Orang belajar dari budayanya, bagaimana seharusnya mereka berespon
terhadap nyeri.
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Contoh : suatu daerah menganut kepercayaan bahwa nyeri adalah akibat
yang harus diterima karena mereka melakukan kesalahan, jadi
mereka tidak mengeluh jika ada nyeri.
4. Makna nyeri
Berhubungan dengan bagaimana pengalaman seseorang terhadap nyeri dan
dan bagaimana mengatasinya.
5. Perhatian
Tingkat seorang klien memfokuskan perhatiannya pada nyeri dapat
mempengaruhi persepsi nyeri. Menurut Gill (1990), perhatian yang
meningkat dihubungkandengan nyeri yang meningkat, sedangkan upaya
distraksi dihubungkan dengan respon nyeri yang menurun. Tehnik relaksasi,
guided imagery merupakan tehnik untuk mengatasi nyeri.
6. Ansietas
Cemas meningkatkan persepsi terhadap nyeri dan nyeri juga bisa
menyebabkan seseorang cemas.
7. Pengalaman masa lalu
Seseorang yang pernah berhasil mengatasi nyeri dimasa lampau, dan saat ini
nyeri yang sama timbul, maka ia akan lebih mudah mengatasi nyerinya.
Mudah tidaknya seseorang mengatasi nyeri tergantung pengalaman di masa
lalu dalam mengatasi nyeri.
8. Pola koping
Pola koping adaptif akan mempermudah seseorang mengatasi nyeri dan
sebaliknya pola koping yang maladaptive akan menyulitkan seseorang
mengatasi nyeri.
9. Support keluarga dan social
Individu yang mengalami nyeri seringkali bergantung kepada anggota
keluarga atau teman dekat untuk memperoleh dukungan, bantuan dan
perlindungan.
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I. METODE YANG DIGUNAKAN UNTUK MENGHILANGKAN NYERI
1. Distraksi
Distraksi adalah metode pengalihan perhatian dari "persepsi" rasa
nyeri. Dengannmengalihkan perhatian, kita bisa mengurangi fokus terhadap
respon nyeri. Distraksi bisa diterapkan untuk rasa nyeri ringan dan sedang,
untuk rasa nyeri berat obat masih menjadi pilihan paling tepat.
Contoh dari metode distraksi dalam mengurangi rasa nyeri adalah
melakukan kegiatan ringan untuk mengalihkan "persepsi" rasa nyeri, bisa
dengan mengobrol, menonton tv, atau dengan menikmati pemandangan
alam.
Dengan menerapkan metode distraksi untuk mengurangi rasa nyeri
akan menghindari dampak negatif dari obat kimia, seperti yang dijelaskan di
atas, distraksi bisa diterapkan pada nyeri ringan dan sedang, untuk itu pada
kasus rasa nyeri berat harus ditangani dengan obat/tindakan medis.
2. Relaksasi
Teknik relaksasi dapat mengurangi ketegangan otot dan mengurangi
kecemasan Membantu klien dengan teknik relaksasi , bidan dapat mengenal
nyeri klien dan ekspresi kebutuhan dibantu dari klien untuk
mengurangi distress yang disebabkan oleh nyerinya. Teknik relaksasi lebih
efektif untuk klien dengan nyeri kronik.
Relaksasi memberikan efek positif untuk klien yang mengalami nyeri, yaitu:
a. Memperbaiki kualitas tidur
b. Memperbaiki kemampuan memecahkan masalah
c. Mengurangi keletihan / fatigue
d. Meningkatkan kepercayaan dan perasaan dapat mengontrol diri dalam
mengatasi nyeri
e. Mengurangi efek kerusakan fisiologi dari stress yang berlanjut atau
berulang karena nyeri
28
f. Pengalihan rasa nyeri/distraksi.
g. Meningkatkan keefektifan teknik – teknik pengurangan nyeri yang lain.
h. Memperbaiki kemampuan mentoleransi nyeri
i. Menurunkan distress atau ketakutan selama antisipasi terhadap nyeri.
Secara umum untuk melakukan teknik relaksasi membutuhkan 4 hal, yaitu:

a. Berikan posisi yang nyaman
b. Dilakukan dalam lingkungan yang tenang
c. Mengulang kata-kata, suara, phrase, doa-doa tertentu
d. Melakukan sikap yang pasif saat mendistraksi klien.
e. Metode yang lain untuk meningkatkan relaksasi dapat berupa music atau
suara alam sambil santai, memikirkan sesuatu yang merilekskan, atau
dengan teknik meditasi seperti yoga, dan lain-lain.
3. Imagery
Klien dapat menggunakan imagery / membayangkan untuk menurunkan
nyeri. Imagery sesuatu yang menyenangkan. Imagery dapat digunakan
lebih efektif pada klien dengan nyeri kronik dari pada nyeri akut, atau nyeri
berat. Bidan dapat mengajarkan klien untuk menggunakan teknik imagery
dengan melakukan guided imagery.
4. Stimulasi Kutan
Teknik dengan menstimulasi permukaan kulit untuk mengurangi
nyeri. Meintz (1995) menyatakan bahwa massage, salah satu
bentuk stimulasi kutan, dapat mengurangi kecemasan dan persepsi nyeri
pada klien dengan kanker.
Stimulasi kutan, meliputi :
a. Massage
b. Kompres hangat atau dingin, atau keduanya bergantian
c. Accupressure
d. Stimulasikon trilateral.
29
5. Anestesi
Anestesi secara umum berarti suatu tindakan menghilangkan rasa sakit
ketika melakukan pembedahan dan berbagai prosedur lainnya yang
menimbulkan rasa sakit pada tubuh. Istilah anestesi digunakan pertama kali
oleh Oliver Wendel Holmes Sr pada tahun 1846.
a. Pengelompokan Anestesi
Obat untuk menghilangkan nyeri terbagi ke dalam 2 kelompok,
yaitu analgetik dan anestesi. Analgetik adalah obat pereda nyeri tanpa
disertai hilangnya perasaan secara total. seseorang yang mengonsumsi
analgetik tetap berada dalam keadaan sadar.
Analgetik tidak selalu menghilangkan seluruh rasa nyeri, tetapi
selalu meringankan rasa nyeri. Beberapa jenis anestesi menyebabkan
hilangnya kesadaran, sedangkan jenis yang lainnya hanya
menghilangkan nyeri dari bagian tubuh tertentu dan pemakainya tetap
sadar.
b. Tipe Anestesi
1) Pembiusan total — hilangnya kesadaran total.
2) Pembiusan lokal — hilangnya rasa pada daerah tertentu yang
diinginkan (pada sebagian kecil daerah tubuh). Pembiusan lokal
atau anestesi lokal merupakan salah satu jenis anestesi yang hanya
melumpuhkan sebagian tubuh manusia dan tanpa menyebabkan
manusia kehilangan kesadaran. Obat bius jenis ini bila digunakan
dalam operasi pembedahan, maka setelah selesai operasi tidak
membuat lama waktu penyembuhan operasi.
3) Pembiusan regional — hilangnya rasa pada bagian yang lebih luas
dari tubuh oleh blokade selektif pada jaringan spinal atau saraf yang
berhubungan dengannya.
5. Terapi Musik
Terapi musik terdiri dari 2 kata, yaitu kata “terapi” dan “musik”.
Terapi (therapi) adalah penanganan penyakit (Brooker, 2001). Terapi juga
30
diartikan sebagai pengobatan (Laksman, 2000). Sedangkan musik adalah
suara atau nada yang mengandung irama. Terapi musik adalah keahlian
menggunakan musik atau elemen musik oleh seseorang terapis untuk
meningkatkan, mempertahankan dan mengembalikan kesehatan mental,
fisik, emosional dan spiritual.
Dalam kedokteran, terapi musik disebut sebagai terapi pelengkap
(Complementary Medicine), Potter juga mendefinisikan terapi musik
sebagai teknik yang digunakan untuk penyembuhan suatu penyakit dengan
menggunakan bunyi atau irama tertentu. Jenis musik yang digunakan
dalam terapi musik dapat disesuaikan dengan keinginan, seperti musik
klasik, instrumentalia, dan slow musik.
Menurut Willougnby (1996), musik adalah bunyi atau nada yang
menyenangkan untuk didengar. Musik dapat keras, ribut, dan lembut yang
membuat orang senang mendengarnya. Orang cenderung untuk
mengatakan indah terhadap musik yang disukainya. Musik ialah bunyi
yang diterima oleh individu dan berbeda bergantung kepada sejarah, lokasi,
budaya dan selera seseorang.
J. PENATALAKSANAAN NYERI PADA LUKA

Untuk merumuskan rencana manajemen nyeri, sifat nyeri pasien harus dinilai.
Apakah nyeri ini merupakan perubahan pada nyeri latar belakang, seperti
perubahan etiologi, memburuknya proses penyakit yang mendasari? Apakah
nyeri latar belakang telah ditangani dan oleh karena itu, apakah nyeri muncul
tiba-tiba terkait dengan gerakan pasien? Apakah nyeri terkait dengan prosedur,
seperti penggantian balutan atau pembersihan luka? Apakah nyeri ini
menunjukkan munculnya patologi baru atau berbeda? Apakah ini masalah
dengan penyakit penyerta yang tidak terkelola?
31
BAB III
PENUTUP
A. KESIMPULAN
Dari pembahasan makalah dapat disimpulkan :
1. Secara umum nyeri didefinisikan sebagai apapun yang menyakitkan tubuh,
yang dikatakan individu yang mengalaminya, dan yang ada kapanpun
individu mengatakannya.
2. Sifat nyeri yaitu: melelahkan dan membutuhkan banyak energi, bersifat
subyektif dan individual, tak dapat dinilai secara objektif, bidan hanya dapat
mengkaji nyeri pasien dengan melihat perubahan fisiologis tingkah laku
dan dari pernyataan klien.
3. Untuk memudahkan memahami fisiologi nyeri, maka perlu mempelajari 3
(tiga) komponen fisiologis yaitu: resepsi, persepsi, reaksi .
4. Klasifikasi nyeri dibedakan berdasarkan : sumber, penyebab, lama (durasi),
dan lokasi (letak).
32
5. Faktor yang mempengaruhi nyeri yaitu : usia, jenis kelamin, kultur, makna
nyeri, perhatian, ansietas, pengalaman masa lalu, pola koping, support
keluarga dan social
6. Metode yang digunakan untuk menghilangkan nyeri ialah distraksi,
relaksasi, imagery, stimulasi kutan, anestesi dan terapi musik.
Luka adalah sumber rasa sakit dan kecemasan yang hebat bagi pasien,
membuat banyak orang merasa putus asa dan tertekan serta sangat merusak
kualitas hidup mereka. Ada komponen fisiologis dan psikologis dari rasa
sakit; keduanya berdampak negatif pada penyembuhan. Dokter memiliki
kemampuan untuk mengurangi efek ini dengan memahami etiologi nyeri,
menilai laporan nyeri pasien secara tepat dan menetapkan rencana perawatan
individual. Sangat penting bahwa dokter menerima persepsi pasien tentang
nyeri sebagai valid. Manfaat pengurangan nyeri dapat meningkatkan tingkat
penyembuhan dan pada akhirnya meningkatkan kualitas hidup pasien. Ini
adalah tanggung jawab moral dan etika dokter untuk menjadi profesional yang
kompeten dalam pendekatan yang paling tepat untuk mengelola nyeri
B. SARAN
Penulis mengetahui bahwa dalam penyusunan makalah ini masih
banyak terdapat kekurangan baik dari segi penulisannya, bahasa dan lain
sebagainnya. Oleh sebab itu saran untuk teman-teman agar dapat
menambahkan referensi tentang keterampilan dasar kebidanan khususnya di
perpustakaan agar lebih dapat meningkatkan jumlah referensi-referensi terbaru.
33
DAFTAR PUSTAKA
Chester, S. J., Stockton, K., De Young, A., Kipping, B., Tyack, Z., Griffin, B.,
Chester, R. L., & Kimble, R. M. (2016). Effectiveness of medical hypnosis for
pain reduction and faster wound healing in pediatric acute burn injury: Study
protocol for a randomized controlled trial. Trials, 17(1), 1–11.
https://doi.org/10.1186/s13063-016-1346-9
Iskandar, M. (n.d.). Makalah Manajemen NYERI.
https://www.academia.edu/33592526/Makalah_Manajemen_Masjid_Konsep_Da
sar_Masjid
Sadati, L., Froozesh, R., Beyrami, A., Khaneghah, Z. N., Elahi, S. A., Asl, M. F., &
Salehi, T. (2019). A Comparison of Three Dressing Methods for Pilonidal Sinus
Surgery Wound Healing. Advances in Skin and Wound Care, 32(7), 1–5.
https://doi.org/10.1097/01.ASW.0000558268.59745.d2
34
13063_2016_Article_1
346.pdf
LAMPIRAN
DOI 10.1186/s13063-016-1346-9 1 (Chester et al., 2016)
STUDY PROTOCOL Open Access
Effectiveness of medical hypnosis for pain

reduction and faster wound healing in
pediatric acute burn injury: study protocol
for a randomized controlled trial
Stephen J. Chester1,2,3*, Kellie Stockton1, Alexandra De Young1, Belinda Kipping1, Zephanie
Tyack1,
Bronwyn Griffin1, Ralph L. Chester4 and Roy M. Kimble1
35
Abstract
Background: Burns and the associated wound care procedures can be extremely painful and
anxiety-provoking for children. Burn injured children and adolescents are therefore at greater risk of
experiencing a range of psychological reactions, in particular posttraumatic stress disorder, which
can persist for months to years after the injury. Non-pharmacological intervention is critical for
comprehensive pain and anxiety management and is used alongside pharmacological analgesia and
anxiolysis. However, effective non-pharmacological pain and anxiety management during pediatric
burn procedures is an area still needing improvement. Medical hypnosis has received support as a
technique for effectively decreasing pain and anxiety levels in adults undergoing burn wound care
and in children during a variety of painful medical procedures (e.g., bone marrow aspirations,
lumbar punctures, voiding cystourethrograms, and post-surgical pain). Pain reduction during burn
wound care procedures is linked with improved wound healing rates. To date, no randomized
controlled trials have investigated the use of medical hypnosis in pediatric burn populations.
Therefore this study aims to determine if medical hypnosis decreases pain, anxiety, and biological
stress markers during wound care procedures; improves wound healing times; and decreases rates
of traumatic stress reactions in pediatric burn patients.
Methods/Design: This is a single-center, superiority, parallel-group, prospective randomized
controlled trial. Children (4 to 16 years, inclusive) with acute burn injuries presenting for their first
dressing application or change are randomly assigned to either the (1) intervention group (medical
hypnosis) or (2) control group (standard care). A minimum of 33 participants are recruited for each
treatment group. Repeated measures of pain, anxiety, stress, and wound healing are taken at every
dressing change until ≥95 % wound re-epithelialization. Further data collection assesses impact on
posttraumatic stress symptomatology, speed of wound healing, and parent perception of how easy
the dressing change is for their child.
Discussion: Study results will elucidate whether the disease process can be changed by using
medical hypnosis with children to decrease pain, anxiety, and stress in the context of acute burn
wounds. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12615000419561
Keywords: Burns, Child, Hypnosis, Hypnotherapy, Pain, Stress, Anxiety, Posttraumatic stress
disorder, Salivary α-amylase,
Randomized controlled trial
* Correspondence: sjackchester@gmail.com
1
Centre for Children’s Burns and Trauma Research, Level 7, Centre for
Children’s Health Research, University of Queensland, 62 Graham Street,
South Brisbane QLD 4101, Australia
2
School of Medicine, Mayne Medical School, The University of Queensland,
288 Herston Road, Herston, Brisbane QLD 4006, Australia
Full list of author information is available at the end of the article
© 2016 Chester et al. Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons
license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
36
Background
Global pediatric burns burden
Worldwide numbers of annual pediatric hospital admissions for burn treatment vary
geographically from a rate of 4.4/100,000 total population in America (North, Central, and
South) to 10.8/100,000 total population in Africa [1]. Every day in the USA approximately
300 children aged 0 to 19 years receive treatment in emergency departments for burn
injuries and two children die from burns [2]. In Australia, approximately 40.1/100,000
children aged 0 to 14 years are hospitalized annually due to burns and scalds [3]. While
pediatric burn mortality rates are decreasing worldwide, the morbidity attributed to burns
due to factors such as pain, psychological distress, and physical impairment is increasing [4].
Thus, it is important to identify the most effective interventions to reduce the burden of
burns.
Pediatric burn pain

In modern medicine, pain has moved beyond concern as a mere disease symptom and is
now considered a basic human rights issue [5]. Burns and the associated wound care
procedures (e.g., wound cleaning, debridement, and dressing) can be painful for children
[6]. After the initial burn is sustained, procedural pain remains both the most intense and
undertreated type of pain despite continual advancements in burn wound care [6].
Furthermore, many patients indicate that wound care procedures are as painful as the
original burn insult (and occasionally more painful), provoking intense anticipatory anxiety
[7].
Psychological distress
In addition to being painful, burn injuries can result in severe psychological distress [8]. Burn
injury leads to an increased risk of children developing a range of major mental illnesses, in
particular posttraumatic stress disorder (PTSD) [9, 10]. Several clinical studies have identified
traumatic stress reactions in preschool children in the first year post-burn, ranging between
25 and 30 % in the acute phase to approximately 10 % one year after the burn [8]. Acute
stress is prevalent in approximately one third of school-aged children post-burn, and
qualitative, cross-sectional studies have identified current PTSD in 10–20 % of the children
and young adults many years post-burn [8]. A prospective observational study in our burns
center with 130 burn injured children found that 35 % were diagnosed with at least one
psychological disorder, with a high comorbidity rate of PTSD [11]. Furthermore, prior
research indicates that a clinically significant relationship may exist between symptoms of
psychological distress and burn pain, each of which can exacerbate the other [12].
Unaddressed fears and anxiety contribute to noncompliance and can complicate pain
management and healing [13]. Thus, treatment options that alleviate pain and distress must
be offered to patients for optimal care [14].
Physiologic effects of pain and stress on wound healing It is worth studying endogenous pain
mediators in children, not only for compassionate reasons of pain control, but also in the
context of their direct physiologic effects on wound healing [15]. Widgerow theorizes that
WWW.WOUNDCAREJOURNAL.COM 37 ADVANCES IN SKIN & WOUND CARE • JULY 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

greatly increased pain mediator release in the context of burns may result in nociceptors
becoming overly sensitized, increased inflammatory cellular and extracellular matrix
alterations, and possibly increased hypertrophic scarring risk [15]. Hypertrophic scarring, a
common thermal injury complication, is manifested by excessive collagen deposition in the
healing wound bed [16]. Therefore, aside from modulating a child’s subjective (i.e., central)
interpretation of pain, decreasing acute burn pain can potentially promote faster wound
healing and improve long-term scar outcomes by downregulating local pain mediator
release [15].
In humans the release of glucocorticoids (e.g., cortisol) and catecholamines (e.g.,
epinephrine and norepinephrine) elicits the classic “fight, flight, or freeze” response when
psychological stress is experienced [4]. Herndon et al. have demonstrated increased levels of
epinephrine and norepinephrine sustained for up to 35 weeks in children post-burn,
providing evidence of the magnitude and duration of the catecholamine surge encountered
in this population [17, 18]. These physiologic effects in response to stress are important, as a
number of studies and meta-analyses have implicated psychological stress in significantly
delaying cutaneous wound healing [19–21]. Attention to and relief of pain, anxiety, and
stress for burned children is therefore a high clinical priority [13].
Pharmacological and non-pharmacological pain and anxiety management
To prepare pediatric patients for burn wound care procedures, a pharmacological protocol is
usually employed for analgesia and anxiolysis [14]. A variety of nonpharmacological
techniques are also used adjunctively with pharmacological methods for pain and anxiety
control. Distraction and preparation techniques and devices have demonstrated benefit in
pediatric burn patients [6, 22–24]. Importantly, pain reduction during burn wound care
procedures has been linked with clinically significant improvement in wound healing (i.e.,
reepithelialization) rates [6, 25, 26].
Medical hypnosis
Medical hypnosis helps patients focus their attention to lessen pain and anxiety and
enhances patients’ acceptance of clinicians’ positive suggestions to change or reframe their
perceptions, sensations, thoughts, and behaviors [27].
Hypnotherapeutic techniques have decreased pain and anxiety in the short term and
decreased psychological distress over the long term, thereby optimizing patient outcomes
and complementing existing treatment modalities [28]. Medical hypnosis can also empower
pediatric patients to assist themselves at will beyond the presence of the therapist by
teaching them self-hypnosis, which engenders self-mastery and active participation in their
own treatment [29].
In children, clinical hypnotherapy techniques including hypnoanalgesia and
hypnoanesthesia (hypnotically induced analgesia and anesthesia, respectively) have
alleviated acute pain associated with a number of painful pediatric medical procedures [30].
There is a growing body of evidence supporting medical hypnosis’ ability to reduce pain and
anxiety associated with venipuncture, bone marrow aspiration, and lumbar puncture in
children [31]. A recent review of studies on the effectiveness of medical hypnosis for

reducing procedure-related pain in children and adolescents less than 19 years old
consistently found that hypnosis was more effective than control conditions in alleviating
discomfort associated with bone marrow aspirations, lumbar punctures, voiding
cystourethrograms, the Nuss procedure (surgery to correct congenital deformities of pectus
excavatum), and post-surgical pain [32]. Furthermore, all controlled studies included in the
review found the effectiveness of hypnosis to be either equal or superior to that of
distraction [32].
In adults, medical hypnosis during burn wound debridement has resulted in clinically
significant pain and anxiety reduction [7, 33–35]. Additionally, adult hypnotherapy has
repeatedly demonstrated effectiveness in treating pain and psychological distress incurred
by a number of classically uncomfortable procedures including tooth extraction [36], bone
marrow aspiration [37], and colonoscopy [38].
Prior research has shown that children over the age of three respond to medical hypnosis
[30, 39] and that hypnotic responsivity (historically known as “hypnotizability”) is generally
greater in children than in adults [29, 39]. It has been proposed that hypnotherapy may be
the preferred non-pharmacological intervention for young children, given how easily and
fluidly they enter trance-like states (e.g., playing with imaginary “friends”) [29, 40]. The
hypnotic induction of an altered state of consciousness in children is characterized by
narrowed attention, absorption in trance phenomena, and some degree of detachment from
the surrounding external environment. Hypnotic intervention provides a context in which
children can exercise their curiosity while producing a novel experience which increases
their mastery over physical and mental response patterns. In the younger child, play is a
natural form of expression and problem-solving which uses altered levels of consciousness
to vivify the child’s experience. Thus, the normally developing child has a naturally large
repertoire of imaginative experience to draw on when provided with a hypnotherapeutic
intervention [41]. Despite children’s generally greater responsivity to hypnotherapy
compared to that of adults, to our knowledge no randomized controlled trial (RCT) has
examined the effectiveness of medical hypnosis for decreasing pain intensity, healing times,
procedural anxiety, and rates of traumatic stress reactions in pediatric burn patients.
Together these findings, in addition to the ease of application, lack of adverse side effects,
and cost-effectiveness of medical hypnosis with children [42], provide a strong rationale for
implementing this study.
Objectives
The primary aims of this study are to investigate whether medical hypnosis affects pain
intensity and the rate of burn wound healing (i.e., re-epithelialization) in acutely burned
children. The secondary aims are to investigate if medical hypnosis affects procedural
anxiety, biological stress markers (salivary cortisol and salivary α-amylase), and the rate of
PTSD symptom development. We hypothesize that use of medical hypnosis for pediatric
patients with acute burns will decrease pain intensity, procedural anxiety, and biological
stress markers during wound care procedures; improve wound healing times; and decrease
rates of traumatic stress reactions compared to a standard care control group.

Methods/Design
Protocol and registration
This study has received ethical approval from the Queensland Children’s Health Services
(Lady Cilento
Children’s Hospital) Human Research Ethics Committee (approval number:
HREC/15/QRCH/32) and the University of Queensland Ethics Committee (approval number:
2015000456). The study methodology was documented in a protocol and registered prior to
starting recruitment (Australian New Zealand Clinical Trials Registry, ID:
ACTRN12615000419561). This is version 1 of the study protocol completed on 10 September
2015. Methods have been documented in accordance with the Consolidated Standards of
Reporting Trials (CONSORT 2010) [43] and Standard Protocol Items: Recommendations for
Interventional Trials (SPIRIT 2013) [44] statements. The intervention has been described
using the Template for Intervention Description and Replication (TIDieR 2014) guidelines
[45].
Design and setting

This study is a single-center, superiority, parallel-group, prospective randomized controlled
trial (see Fig. 1). Eligible participants are randomized to receive either (1)
medical hypnosis (intervention group) or (2) standard care (control group).

Participants are recruited from the Pegg Leditschke Paediatric Burns Centre (PLPBC) at
Lady Cilento Children’s Hospital (LCCH), Brisbane, Australia (AUS). The PLPBC is the major
specialist tertiary burns center for Queensland and Northern New South Wales, Australia.
The center’s clinical multidisciplinary team treats approximately 800 new burn patients per
year.
Eligibility criteria for participants
Eligible participants are children aged between 4 and 16 years (inclusive) who meet the
inclusion criteria of (1) an acute burn of any depth (excluding erythema only) and (2)
presentation to the PLPBC for treatment (inpatient or outpatient). Children are excluded
from the study if they are non-English speaking; cognitively impaired; under the care or
investigation of the Department of Communities, Child Safety, and Disability Services; on
ventilator support; or if they have initial burn wound care procedures carried out in the
operating room under general anesthesia.
Patients of the PLPBC are identified by the center’s research manager, and participants’
eligibility is assessed by the nursing staff. All eligible patients presenting to the PLPBC are
approached and invited to participate in this RCT by a clinical research team member not
involved in their primary care. Parent (the term parent includes legal guardian) informed
consent is obtained and recorded. Child consent is obtained for all children able to read and
write. Verbal assent is obtained for all other eligible children.
Interventions
Recruited participants are randomized into either (1) the intervention group: medical
hypnosis or (2) the control group: standard care immediately prior to their first wound care
procedure (i.e., dressing change or application, which may involve cleaning the wound) at
the PLPBC:
1. Intervention group Medical hypnosis

Medical hypnotherapy is used with this group after gathering baseline data.
Hypnotic induction (i.e., the method for guiding the participant into a hypnotic
trance) starts before nursing staff begin the burn wound care procedure and is
maintained throughout the procedure. The hypnotic induction is adjusted for the
participant’s age, understanding, and communicative capacity as per the clinician’s
judgment. After the first hypnotherapy session (concurrent with the participant’s
first wound care procedure), a maximum of four additional hypnotherapy sessions
are provided during subsequent visits to the PLPBC for wound care procedures. The
clinical judgment of the treating hypnotherapist in consultation with the burns
nurses and pediatric surgeons is used to determine the total number of hypnotherapy
sessions. Aside from the hypnotherapy, all other treatment is administered according
to established standard care. Standard care at PLPBC includes administering
oxycodone, with the dosage determined by body weight, 0.1 mg/kg orally
(Mundipharma Pty. Ltd.,
Sydney, NSW 2000, Australia); and paracetamol, 150 mg/kg orally (Sanofi-Aventis
AUS Pty. Ltd., Macquarie Park, NSW 2113, Australia).

Essential elements of medical hypnosis The medical hypnosis intervention follows five
stages: establishing rapport and creating a setting of positive expectancy; slowing
breathing and enhancing relaxation; providing suggestions for deepening relaxation
and absorption in the hypnotic state; direct hypnotic suggestions for hypnotically
induced analgesia, anesthesia, anxiolysis, and rapid healing; and alerting (i.e.,
bringing the participant out of the hypnotic trance) [46].
Materials
The medical hypnosis intervention designed for the treatment purposes of this trial
has been documented in a manual and can be obtained from the study’s principal
investigator on request.
Procedures
This study uses two hypnotic inductions: the Favorite Stories induction [47] (for
children less than 7 years old) and the Favorite Place induction [29] (for children 7
years old and older). Once trance is achieved, suggestions for hypnoanalgesia or
hypnoanesthesia are given using the Switches method [29, 48] or the Glove
Anesthesia method [29] (sometimes referred to as the Magic Glove in the relevant
literature). Suggestions for rapid wound healing are also given, and self-hypnosis is
taught to the child [29].
Provider
The medical hypnosis provider in this study is a medical student and Research
Higher Degree candidate who received group training by the American Society of
Clinical Hypnosis (ASCH) and individual face-to-face training with Dr. Dabney M.
Ewin, M.D., FACS, ABMH, Professor of Surgery and Psychiatry at Tulane
University, New Orleans, USA and former president of both the ASCH and the
American Board of Medical
Hypnosis.
All medical hypnosis is delivered face to face in a clinical consulting room within the
PLPBC, LCCH. A minimum of one session and maximum of five sessions of
medical hypnosis are provided for each participant in the intervention group,
concurrent with their scheduled wound care procedures. Each session lasts for the
duration of the participant’s wound care procedure.
Although the medical hypnosis manual is adhered to as closely as possible, the
intervention is tailored to the participant based on their developmental and
chronological age, capacity to focus, distress related to the total burn area and
depth, acuity and nature of the burn event, and location of the burn. This adherence
allows replication of hypnotherapy procedures used to the extent permitted given
that the children and adolescents who participate have varied developmental and
chronological ages, presentations, and levels of capacity for focus, as well as
distress related to total burn area and depth, acuity and nature of the burn event, and
different specific anatomy involved.
2. Control group Standard care
Standard procedural distraction is available to this group, including music, toys, the
Ditto™ (Diversionary Therapy Technologies, QLD,
Australia) [6] and other electronic devices (e.g., TV, hand-held games, portable
DVD players), books, and parental presence. The consulting hypnotherapist is
positioned in the procedure room with the participant but does not provide

hypnosis to ensure that the only difference is the use of medical hypnosis. The
hypnotherapist does not interact with participants in the control group to avoid
potentially using hypnotic techniques and is only present to help record outcome
measures associated with wound care procedures.
Outcomes
Previously validated scientific measures are used for all outcomes. The duration of each
wound care procedure is timed. Prior to the application of new dressings at the first dressing
change, the burn depth is calculated by measuring blood perfusion at the burn site using a
Moor LDI2-BI2 Laser Doppler Imager (Moor Instruments Limited, Devon, UK). Data is
collected at every dressing change until ≥95 % re-epithelialization occurs, and the total
number of dressing changes is recorded.
Primary outcome measures
The two primary outcome measures are pain intensity and wound healing (i.e., re-
epithelialization time). Pain measurements are taken several times for each participant. The
first time point (baseline) is immediately before premedication prior to removal of the
wound dressing in clinic. The second time point is immediately after the new dressing is in
place; the worst pain is assessed reflecting the maximal pain intensity experienced by the
participant during the procedure (retrospective). For the third time point, a final pain
assessment occurs to gauge pain intensity immediately after the new dressings are in place
and hypnotherapy has ceased. No pain measurements are taken during hypnosis. Assessing
pain intensity in this manner effectively gives three time points relative to the procedure:
before, during, and after. These measurements take place at each subsequent dressing
change until ≥95 % wound re-epithelialization.
Pain
A range of pain scales are utilized to measure pain intensity (assessed by child, nurse, or
parent). The Faces Pain ScaleRevised (FPS-R) [49] is used to assess the child’s self-report of
pain and will be the primary outcome measure. Convergent validity of the FPS-R is
supported by a strong positive correlation (r = 0.93, p < 0.001, N = 76) with a visual analog
scale (VAS) pain intensity measure in children aged 5–12 years and by strong positive
correlations with the VAS (r = 0.92, p < 0.001, N = 45) and the color analog scale (r = 0.84, p <
0.001, N = 45) in a clinical sample of pediatric inpatients aged 4–12 years [49]. Even among
the youngest patients sampled (four-year-olds), there is evidence of usage of the FPS-R and
analog scales in a consistent and reliable manner [49]. Nurses report a
behavioral/observational rating on the Face, Legs, Arms, Cry, Consolability (FLACC) scale [50,
51]. The FLACC scale has been validated for use in settings such as postoperative pain [50].
Despite a recent systematic review rescinding recommendation of the FLACC scale for
procedural pain assessment [51], we have chosen this scale in the absence of an acceptable
alternative due to its extensive use in prior clinical trials examining procedural pain. Parents
also rate their child’s pain using an 11-point (0 to 10) numeric rating scale (NRS) [52]. Pain
scores reported verbally by the parent (NRS) and child (FPS-R) are documented by the
primary investigator. Nurses document the FLACC pain scores.

Wound healing
Re-epithelialization is defined as ≥95 % wound healing and no further wound dressings
required. Scabs or crusts are defined as unhealed areas [53]. For the purpose of the main
analysis, this outcome measure will be assessed using the percentage re-epithelialization
assessed from 3D digital photography by an independent surgeon and nurse blinded to
study treatment group. The percentage reepithelialization reported by the independent
surgeon will be used in the main analysis if appropriate. The outcome will also be measured
from 3D digital photography by the investigator (SJC), and the time to wound healing
recorded in the medical records will also be used for comparative purposes. Wound
photographs are taken at each dressing change using 3D LifeViz System™ (Quantificare,
Sophia Antipolis, France) [54]. The independent blinded surgeon and nurse will mark out the
wound edges after the photographs are taken, along with any unhealed areas. Surface area
computer mapping will then be used to determine percentage re-epithelialization [53, 54].
Secondary outcome measures

Secondary outcome measures collected at baseline include a self-reported procedural
anxiety measure, a saliva sample (for measurement of stress biomarkers: salivary cortisol
and salivary α-amylase), and heart rate (HR). Baseline measurements are taken before
nurses administer pharmacological analgesia according to PLPBC standard practice.
Procedural anxiety
The visual analog scale for anxiety (VAS-A) [55, 56] will be used to measure procedural
anxiety in children. Selfreported anxiety measures will only be administered to children 8
years old and above. For participants younger than 8 years, the parent will be asked to
assess their child’s anxiety using the same scale. The anxiety measurement is obtained prior
to premedication and immediately after new dressing application.
PTSD
PTSD severity three months following injury will be assessed using the Child PTSD Symptom
Scale (CPSS) [57] for children aged 7 years or older. The CPSS is designed to assess PTSD
diagnosis and symptom severity in children ages 8 to 18 who have experienced a
singleincident traumatic event [57]. Total symptom score and the three symptom clusters of
the CPSS demonstrate high internal consistency (α = 0.89 for total score) [57]. The
percentage agreement between PTSD diagnoses at two separate time points was 84 %,
indicative of moderately high reliability [57]. Test-retest reliability of the total CPSS score is
acceptable (κ = 0.84) [57]. Convergent validity of the CPSS has been supported (Pearson’s r =
0.80, p < 0.001) when measured against the Child PTSD Reaction Index (CPTSD-RI) [57].
The Young Child PTSD Checklist (YCPC) [58] will be used for children younger than seven
years old. Face validity of the YCPC items is excellent based on a series of studies by
Scheeringa et al. that used these items in an interview format and formed the basis for the
new DSM-5 disorder titled “Posttraumatic stress disorder for children six years and younger”
[59–62]. The test-retest reliability (intraclass correlation coefficient = 0.87) [63] was

acceptable, and the predictive validity [64] of PTSD symptoms using an interview format has
been supported.
Parent satisfaction
Ease of the child’s wound care procedure as assessed by the parent is a secondary outcome
measure. At the conclusion of every dressing change, a parent rates how easy they believe
the wound care procedure was for their child on a 5-point Likert scale (from “not at all easy”
to “extremely easy”) with higher values indicating greater satisfaction.
Biochemical stress markers
Salivary cortisol, representing hypothalamic-pituitaryadrenal axis activity, and salivary α-
amylase (a proxy for norepinephrine indicative of sympathetic adrenomedullary system
activity) are measured as biomarkers of stress associated with wound care procedures [65].
The participant places a Salivette™ (Sarstedt Australia Pty., Ltd. Mawson Lakes, SA, Australia)
under their tongue for 2 minutes for saliva collection at these times: (1) immediately before
premedication prior to removal of wound dressing in clinic, (2) immediately after the new
dressings are in place, and (3) three months post-injury to obtain a baseline. The parent
completes a saliva collection survey which records variables pertinent to salivary analysis:
collection time, time participant last woke up, time participant last brushed teeth, any
medication given, any food/drink/gum during the previous hour, time participant last had
any caffeine, and pertinent smoking or tobacco history.
The date, time, and volume of saliva collection are recorded in the laboratory and samples
are refrigerated at 4 °C and processed within 7 days. Samples are spun in a centrifuge at
1400 × g at room temperature for 10 minutes and the saliva frozen at −80 °C until analysis.
Salivary cortisol and α-amylase will be quantified using ELISA kits (Stratech Scientific, Avalon,
NSW, Australia) with saliva samples analyzed in triplicate. Heart rate will also be recorded as
a physiologic measure of pain and distress at time points (1) and (2) for each dressing
change.
Hypnotic responsivity
The Stanford Hypnotic Clinical Scale for Children (SHCS-C) [66] will be used to assess and
record hypnotic responsivity for participants in the intervention group as recommended by
prior methodological reviewers of relevant literature [32]. This assessment will only be
conducted within the intervention group to ensure that control participants remain naïve to
hypnotherapy. Normative data for hypnotic responsivity are available for children aged 3–16
years. The SHCS-C correlated 0.67 with a slightly modified version of the Stanford Hypnotic
Susceptibility Scale, Form A for pediatric use [66], supporting concurrent validity.
Demographic and clinical information Participant demographics and medical history are recorded
from the caregiver and hospital chart: mechanism and site of injury, estimated percentage
total body surface area (TBSA) of burn, burn depth, any first aid treatment applied, and
medication given. TBSA is determined by a consultant surgeon using the Lund and Browder
method [67].
Participant timeline

Participants are enrolled after presenting to the PLPBC and after their study eligibility has
been assessed (Fig. 1). Regardless of which trial arm they are randomized into, all
participants receive treatment during their scheduled appointment times for burn wound
care at the PLPBC. Primary outcome data is collected concurrently with participants’
scheduled wound care procedures until the burn wound is ≥95 % re-epithelialized. The
endpoint for secondary outcome data collection is 3 months post-burn.
No extra participant visits to the PLPBC are required for the sole purpose of data collection.
Sample size
A sample size estimate was derived from the primary outcomes: days to re-epithelialization
and pain. Based on reepithelialization within 15 (SD = 4) days and a minimum clinically
important difference (MCID) of 3 days [26], the sample size required was estimated as 29
per group, using 80 % power and an α of 0.05. Allowing for 10 % loss to follow-up, a total of
66 participants will be required. Additionally, this sample size is adequate to show an MCID
of 2 (SD 2.5) in the pain outcome measures [26]. Recruitment will continue until at least 33
participants in each arm have been obtained with complete data for the primary outcomes.
Randomization
A computerized random number generator is used to randomize study participants. Simple
randomization is overseen by staff not involved with the study. Thirdparty concealment of
group allocation occurs by using a numbered series of opaque, sealed envelopes prepared in
advance. The primary researcher is then told to which group the participant is allocated.
Blinding
Medical hypnosis provided throughout a procedure cannot be masked. This study’s nature
prevents full blinding, but certain outcome measures are blinded. The re-epithelialization
assessors are blinded, as these measurements take place using 3D digital photographs. Trial
group allocation remains unknown to this assessor. If discrepancy arises between the two
re-epithelialization assessors, the assessment of the blinded assessor is taken as definitive to
reduce potential performance bias. Burn depth and salivary analysis are also blinded
measures, as data for these variables are provided to the investigators in a non-identifiable
format and as the assessor of these variables is blinded to trial group allocation.
Discontinuation
Study participants can withdraw from the trial at any time. The number of adverse events
will be documented, and any adverse event will be described in detail for both treatment
groups. Current relevant literature has not reported any serious harmful effects associated
with indicated pediatric medical hypnosis or hypnotherapy.
Data analysis
Data will be analyzed using SPSS 23 (IBM Corporation, Armonk, NY, USA). Descriptive
statistics such as the mean and standard deviation, median and interquartile range, and
confidence intervals will be used to report the sample demographics (i.e., age, gender, and
mechanism of injury) and to summarize outcome measures, as appropriate. Between-group
comparisons will be conducted for potential confounding variables for the primary

outcomes. Potential confounding variables affecting wound healing that will be examined
include burn depth, days taken to present to the PLPBC, ethnicity, mechanism of injury,
percent TBSA, age, and gender [25]. Potential confounding variables affecting pain intensity
that will be examined include age, the presence/absence of skin grafting, state anxiety
(determined by VAS-A), pharmacologic analgesia given immediately before or during wound
care procedures, percent TBSA, and days to re-epithelialization [26, 68]. If significant
between-group differences are present for potential confounding variables, those variables
will be controlled for in the primary analyses. Between-group differences will be
investigated using univariate parametric or non-parametric analyses as applicable (e.g.,
linear regression, Student’s t test, or MannWhitney U test for continuous data and the chi-
squared test or Fisher’s exact test for categorical data). All data will be analyzed on the
intention-to-treat (ITT) principle as the primary approach. However, a sensitivity analysis will
be conducted for data collected as per protocol. A repeated measures analysis will be
undertaken using generalized estimating equations (GEEs) [69] including the main effect of
treatment group and time on the primary pain and healing outcomes, as well as on the
secondary outcomes of procedural anxiety, PTSD, parent satisfaction, and biochemical stress
markers.
Analyses will be conducted with data stratified for burn depth (superficial partial-
thickness/deep partial-thickness/ full-thickness) and participant age (e.g., <8 years/≥8 years,
with age strata based on age-group validity of the VAS-A) [69]. Differences in hypnotic
responsivity between the intervention group and a normative comparison group will be
analyzed using z-scores or using equivalent nonparametric tests such as the Mann-Whitney
U test where applicable. Differences in re-epithelialization by the independent blinded raters
(surgeon and nurse) and the investigator (SJC) will be examined using reliability coefficients
and measures of agreement (e.g., percentages of exact agreement). Differences between
measures of pain (e.g., observer report by parents versus child selfreport) will be examined
using correlational analyses where appropriate.
The influence of demographic and clinical factors, and primary and secondary outcomes
not included as dependent variables, on primary and secondary outcomes will be examined
using regression models and GEE models. Post hoc adjustment for multiple comparisons will
be conducted using the Šidák correction [70] where appropriate. Statistical significance will
be set at p < 0.05.
Data storage
Data are protected in locked filing cabinets within the secure area of the Centre for
Children’s Health Research, University of Queensland. Data are entered into a spreadsheet
using Excel. Any incomplete data are coded as unknown, missing, or not applicable. The data
set will be cleaned, checked, and then locked for analysis. Upon trial completion, data will
be stored for 15 years as stipulated by the Queensland Children’s Health Services (LCCH)
Human Research Ethics Committee.
Dissemination
Outcomes will be published in a peer-reviewed medical journal (publication target Burns)
and will also be reported at relevant conferences.

Discussion
To our knowledge, this is the first RCT in the field of pediatric burn care investigating the
impact of medical hypnosis on pain intensity, wound healing, procedural anxiety, biological
stress markers, and PTSD development associated with wound care procedures. The neural
mechanisms responsible for the antinociceptive effects of hypnosis have been rigorously
studied by Rainville et al. [71, 72] and Faymonville et al. [73–78] by measuring regional
cerebral blood flow (rCBF) using positron emission tomography. They independently
reached the same conclusions: (1) Both the intensity (sensory component) and
unpleasantness (affective component) of noxious stimuli are reduced during the hypnotic
state, and (2) hypnotic pain modulation is chiefly facilitated by the anterior cingulate cortex
[73]. Functional brain imaging studies like these not only help prove the existence of a
hypnotic state but also validate the therapeutic effects of hypnotherapy in the medical
setting [78].
As noted by early nineteenth-century physicians and surgeons going at least as far back as
Dr. James Braid (1795–1860), children and adolescents are especially “sensitive” to hypnotic
techniques and responsive to hypnotherapeutic strategies for patient care [29]. In terms of
clinical benefits, hypnotherapy can aid in decreasing at least two facets of the complex,
multidimensional phenomenon of pain: the sensory component (tied to pain intensity) and
the affective component (tied to the emotional experience of pain) [79]. In addition to
hypnotic suggestions for analgesia and anxiolysis, the hypnotherapist is uniquely able to give
posthypnotic suggestions prior to ending the pediatric patient’s trance.
Barber explains that posthypnotic suggestions are capable of causing dissociation of
noxious perceptions, aiding in reducing the sensory and affective components of pain [80].
Successive hypnotherapy sessions have a cumulative effect, resulting in neuroplastic
changes. Neural reorganization is thought to occur, such that pain responses are replaced by
non-painful responses devoid of suffering that develop in response to originally noxious
stimuli [80]. Barber also identifies the hypnotic effect as being enhanced by the clinical
relationship and the establishment of good rapport [80].
Since one classic element of the therapeutic hypnotic state is a feeling of relaxation (i.e.,
increased parasympathetic tone), anxiety reduction goes hand in hand with clinical hypnosis.
A randomized trial (n = 50, age 2–11 years) conducted by Calipel et al. compared the efficacy
of hypnosis to reduce anxiety and perioperative behavioral disorders versus midazolam
premedication in children [81]. The number of anxious children was significantly less during
anesthetic induction in the hypnosis group (39 % versus 68 %, p < 0.05) [81]. Hypnosis
reduced the frequency of postoperative behavioral disorders by about half on day 1 and day
7 relative to midazolam [81]. These findings suggest that hypnosis is more efficient at
reducing preoperative anxiety in children compared to midazolam, with the added benefit of
reducing behavioral disorders in the first two postoperative weeks.
Given the ease with which even preschool-aged children [48] use and learn simple self-
hypnosis techniques for pain and anxiety management, and considering that a child’s
successful use of self-hypnosis facilitates a sense of selfmastery and empowerment, this RCT
seeks to validate medical hypnosis as a useful tool and opportunity to help manage or

prevent the pain, distress, and negative psychological sequelae commonly associated with
pediatric burns and wound care procedures.
Significance of the study

Pediatric burn pain, anxiety, and the need for adjunct treatment used synergistically to
complement pharmacological management are well established in the scientific literature.
The effectiveness of medical hypnosis for reducing the pain and anxiety associated with
numerous painful and distressful procedures in adults, including burn wound treatment
procedures, is also well documented [7, 33–38, 82]. If our study’s hypothesis holds true,
hypnotherapeutic techniques could find a prominent, evidence-based place in the “toolkit”
at the pediatric burn care staff’s disposal. They may use this enhanced, sophisticated form of
communication to decrease suffering and complement existing pharmacological
management of burned children worldwide.
If the intervention is shown to be effective, possible next steps for wider clinical
implementation could include training burn care staff to use hypnotic techniques or
developing a short film that could be viewed by children in the waiting room prior to
scheduled wound care procedures. Creating such a film that could induce (or facilitate)
hypnosis for children and invite dissociation from noxious and anxious perceptions is a
potential future research direction that could build on this study’s results.
Continuing to identify connections between pain, anxiety, stress, and healing time in acute
burn wound treatment is crucial for patients and health care providers and has medical
applications and implications beyond the field of burns.
Trial status
This trial has commenced and recruitment is expected to be completed by the end of 2015.
Abbreviations
ABMH: American Board of Medical Hypnosis; ASCH: American Society of
Clinical Hypnosis; AUS: Australia; CCBTR: Centre for Children’s Burns and
Trauma Research; CONSORT: Consolidated Standards of Reporting Trials;
CPSS: Child Posttraumatic Stress Disorder Symptom Scale; CPTSD-RI: Child
Posttraumatic Stress Disorder Reaction Index; DSM-5: Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition; FLACC: Face, Legs, Activity, Cry, Consolability pain scale; FPS-R: Faces Pain Scale -
Revised; g: gravitational force; GEE: generalized estimating equation; HR: heart rate; HREC: Human Research Ethics Committee; ITT:
intention-to-treat; LCCH: Lady Cilento Children’s Hospital; LDI: laser Doppler imager; MCID: minimum clinically important difference;
NRS: numeric rating scale; PLPBC: Pegg Leditschke Paediatric Burns Centre; PTSD: Posttraumatic stress disorder; rCBF: regional cerebral
blood flow; RCT: randomized controlled trial; SD: standard deviation; SHCS-C: Stanford Hypnotic Clinical Scale for Children;
SPIRIT: Standard Protocol Items: Recommendations for Interventional Trials; SPSS: Statistical Package for the Social Sciences; TBSA:
total body surface area; TIDieR: Template for Intervention Description and Replication; VAS: visual analog scale; VAS-A: visual analog
scale for anxiety; YCPC: Young Child Posttraumatic Stress Disorder Checklist.
Competing interests
All authors declare that they have no competing interests.
Authors’ contributions
SJC and RLC conceived the idea for the study. All authors participated in the study design. The manuscript was drafted by SJC with input
from ADY, ZT, and BK for specific sections and was edited by all authors. SJC, KS, BG, and RMK contributed to participant recruitment.
SJC provided the study intervention (i.e., medical hypnosis). SJC, BG, and RMK are the study leaders and have overall responsibility for
the conduct of the study. All authors have read and approved the final version of the manuscript.
Authors’ information
Stephen J. Chester B.A. is a medical student in the University of Queensland

- Ochsner Clinical School Program. He is also a Clinical Researcher at the Centre for Children’s Burns and Trauma Research, Brisbane,
Australia. This study forms part of a Research Higher Degree.
Kellie Stockton Ph.D., B.App.Sc. (Physio), Post Grad. Dip. Physio (Cardiothoracic) is Head of Physiotherapy at Wesley and St. Andrew’s
War Memorial Hospitals,
Brisbane, Australia.
Alexandra De Young Ph.D., B.Psych. (Hons) is a University of Queensland Postdoctoral Research Fellow at the CCBTR, Brisbane,
Australia.
Belinda Kipping M.Phil., B.Occ.Thy. is a Senior Occupational Therapist (Burns and Vascular) at the Lady Cilento Children’s Hospital,
Brisbane, Australia. Zephanie Tyack Ph.D., B.Occ.Thy. (Hons) is a University of Queensland
Research Fellow at the CCBTR. She is also a Senior Research Fellow at the Centre for Health and Functioning, Metro South Health,
Brisbane, Australia. Bronwyn Griffin Ph.D., B.Nurs., Post Grad. Dip. ACNE is Clinical Research Manager of the CCBTR, Brisbane, Australia.
Ralph L. Chester M.D. is the Medical Director of Child and Adolescent Psychiatry at Horizon Behavioral Health, VA, USA. He is Board
Certified in General Psychiatry and Child and Adolescent Psychiatry, and is a Medical Psychoanalyst. Roy M. Kimble M.D., FRCS, FRACS is
Professor of Pediatric Surgery with Children’s Health Services Queensland. He is also a pediatric burn surgeon at the PLPBC and Director
of the CCBTR, Brisbane, Australia.
Acknowledgements
We acknowledge all the PLPBC staff for their unending support and thank the children and families who participate in this study.
Without you, this study would not be possible. This study is funded by a Queensland Children’s Medical Research Institute Program
Grant received by the CCBTR. This research is also supported by a University of Queensland International Scholarship.
Author details
1
Centre for Children’s Burns and Trauma Research, Level 7, Centre for
Children’s Health Research, University of Queensland, 62 Graham Street,
South Brisbane QLD 4101, Australia. 2School of Medicine, Mayne Medical
School, The University of Queensland, 288 Herston Road, Herston, Brisbane QLD 4006, Australia. 3Ochsner Clinical School, Ochsner
Hospital, 1514 Jefferson Highway, New Orleans, LA 70121, USA. 4Horizon Behavioral Health, 2241 Langhorne Road, Lynchburg, VA
24501, USA.
Received: 2 October 2015 Accepted: 15 April 2016
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A_Comparison_of_Thr
ee_Dressing_Methods_for.9.pdf
LAMPIRAN 2 (Sadati et al., 2019)
A Comparison of Three Dressing Methods for

Pilonidal Sinus Surgery Wound Healing
Leila Sadati, MScN, BScN; Robab Froozesh, MScN, BScN; Alireza Beyrami, MSc; Zahra Nouri
Khaneghah, MSc;
Seyed Ahmad Elahi, MD; Mohammad Faryab Asl, MSc; and Tannaz Salehi, MSc

D
dedfromhttp://journals.lww.com/aswcjournal
by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI=
ABSTRACT
OBJECTIVE: To evaluate the effect of different dressing methods on the wound healing process after pilonidal
sinus surgery. METHODS: In this clinical trial, 60 patients undergoing pilonidal sinus surgery were randomly
assigned to one of three groups. In the first group, hydrogel or alginate and hydrocolloid compounds were
used as a standard occlusive dressing method. A modified dressing method was used for the second group, in
which transparent hydrocolloid films were replaced by Vaseline gauze. The third group was treated using
gauze swabs soaked in normal saline. The length and depth of the studied wounds were recorded once a
week for a month. During dressing changes, patient pain was recorded using an 11-point numeric rating scale.
The collected data were analyzed by descriptive and inferential statistical methods.
RESULTS: There was a significant reduction in wound length after 2 weeks in all three groups (P < .05), and the
pain experienced by the first and second groups was significantly lower than the third group. However, the
modified method used for the second group was associated with a lower cost.
CONCLUSIONS: Considering the beneficial results of using modern dressings for wound healing and reducing
the severity of associated pain, providers may want to consider using modified wound dressings after
pilonidal sinus surgery. Study authors recommend that providers receive training on how to use these
products. KEYWORDS: alginate, dressing, hydrocolloid, hydrogel, pilonidal sinus, pilonidal sinus surgery,
wound healing ADV SKIN WOUND CARE 2019;32:1–5.
on05/16/2021
INTRODUCTION
Pilonidal sinus is a painful inflammatory disease of the skin characterized by the appearance
of a cyst in the skin with pus discharge. The cause of this disease is said to be the deep
penetration of hair in the skin, infecting the area. Although this disease mostly occurs in the
sacrum, it can also appear in other parts of the body such as the umbilicus, the axilla, or the
pubic area.1 Annually, 70,000 people in the US are afflicted with pilonidal disease, and the
incidence has been reported to be 26 per 100,000 people. The condition mostly affects
younger adults, and men are twice as likely as women to develop it. 2
Depending on the disease’s progression, various treatments are available; these can be
divided into invasive and noninvasive procedures. Among the noninvasive or nonsurgical
procedures are shaving the inflamed and infected area, injecting phenol into the sinus, and
antibiotic therapy.3 In cases where the treatment of the disease is not possible through
noninvasive or pharmaceutical methods, various surgical procedures are used, from
creating a simple incision to drain the wound to more complex procedures such as using
skin and muscle flaps to fill the space caused by the excision. 4 Because one of the risk factors
for recurrence is a closed surgical technique, open surgery is recommended. 5 In an open
surgical procedure, the surgical area is not sutured or covered with a flap, and wound
healing can occur gradually with proper wound dressings. Therefore, wound care and using
the right dressing are among the most important postoperative measures. 6
Considering the importance of wound dressing in open surgeries, an appropriate type of
dressing is required. An ideal dressing should match the shape and size of the wound, be
able to absorb excessive wound discharge while maintaining the wound’s temperature and
humidity, prevent bacteria from entering the wound, create proper pressure to maintain
homeostasis, reduce pain during the healing process and while changing the dressing,
alleviate pain, promote autolytic debridement, accelerate wound epithelialization, and not
require frequent replacement/be cost effective. 7

Today, modern wound dressings with many of these features have replaced conventional
dressings that lacked them. Alginate, hydrocolloid, foam, and hydrogel dressings and
transparent films are among the most practical options that have been used widely for
dressing various types of ulcers in recent decades. 8–10
At the Alborz University of Medical Sciences, in Karaj, Iran, Leila Sadati, MScN, BScN, is a faculty member, Paramedic School; Robab Froozesh, MScN, BScN, is a Neonatal Intensive Care Nurse,
Paramedic School; Zahra Nouri Khaneghah, MSc, is a faculty member, Paramedic School; and Seyed Ahmad Elahi, MD, is faculty member, Department of General Surgery, School of Medicine. At the
Iran University of Medical Sciences in Tehran, Iran, Alireza Beyrami, MSc, and Mohammad Faryab Asl, MSc, are Operating Room Technologists, Faculty of Allied Medicine. Tannaz Salehi, MSc, is a
Master’s Student of Medical Physiology, Faculty of Medicine, Tehran University of Medical Sciences. Acknowledgments: The authors thank the patients who participated in this study as well as the
Shahid Bahonar and Shahid Madani Hospitals for their cooperation and financial support of this research. This article was funded by the Alborz University of Medical Sciences in Karaj, Iran. The authors
have disclosed no other financial relationships related to this article. Submitted July 22, 2018; accepted in revised form September 13, 2018.
At present, awide varietyof hydrocolloid dressings are available that are produced by
different companies. These dressings are mainly used to treat superficial wounds with low
or intermediate
exudate to accelerate the formation of granulation tissue on the wound surface. 11 Alginate
dressings derived from marine algae compounds have been used to shorten the wound
healing process for a wide range of chronic and acute ulcers for years. 12 Hydrogel dressings
have achieved popularity over the last three decades as effective products tomaintain a
moist wound bed, promote autolytic debridement, and reduce pain. 5
Withthesemoderndressings,depending onthespecificproduct, stage of the wound healing
process, and type of wound, the frequency of dressing changes may be significantly
reduced,13 which reduces the patient’s time traveling between home and treatment centers
considerably.As a result, patients will also feel less pain during dressing changes, and the
wound healing process will be accelerated. 14 The mean duration of wound healing after
open surgery is about 40 to 50 days, depending on the physical condition and nutrition
status of the patient.15 However, studies show that applying modern dressings can reduce
this period by 5 to 7 days.16
Another criterion for choosing the right type of dressing is cost. Typically, after open
pilonidal sinus excision, daily dressing of the surgical site involves cleaning the wound with a
normal saline solution and filling it with moist sterile gauze. 17 In many developed countries,
this traditional or conventional wound dressing is an acceptable choice because of easy
access to nursing care centers, the presence of experienced nurses at the patient’s bedside,
and the possibility of receiving wound care at home with effective insurance coverage. 12 In
Iran, conventional dressings are cheaper than modern dressings, but the frequent daily trips
between home and healthcare facilities to change the dressing and repeated fees increase
long-term expenses. As a result, patients tend to continue their wound care at home,
although this increases the risk of wound infections and disease relapse.
Ontheotherhand,somemoderndressings,despitebeingeffectivein the wound healing process,

are not favored by patients and physicians
becauseofthecostsperdressingchange.Therefore,itseemsthatthedevelopment of methods
that do not impose additional costs on patients while maintaining the effectiveness of the
modern types of dressings should be a priority for the medical community.

For example, hydrocolloid dressings usually serve as secondary dressings to maintain wound
moisture, but their use can increase the cost of treatment considerably. One traditional
dressing is a product called Vaseline gauze (Kaveh BGC Co, Saveh, Iran), which is mainly
used for burn wounds or skin grafts. This product is a continuous nonfraying nonadherent
occlusive dressing impregnated with Vaseline. This absorbent gauze has a fine mesh fabric
that does not stick to the wound and is easily applied to all body parts. Its mesh fabric lets
the wound breathe appropriately while maintaining a moist wound healing environment. 18
Therefore, it is possible that by using Vaseline gauze instead of hydrocolloid dressings as a
secondary wound dressing, treatment costs could be reduced for patients and families
while providing optimum conditions.
Toascertainthis,thepresentstudywasdesignedandconductedto assess the effect of three

methods of dressing wounds (conventional, modern, and modified) on the healing process
of pilonidal sinus wounds. Outcome measures included wound size reduction, the amount
of pain experienced by patients during dressing changes, treatment costs, and the length of
patients’ leave from work.
METHODS
This clinical trial (registration no. IRCT2014072118553N1, reviewed and registered by the
Iranian Registry of Clinical Trials) was conducted on 60 patients who were candidates for
pilonidal sinusectomy. A convenience sample of patients was included in the research based
on the following criteria:
1. no skin disease or immunocompromise
2. no history of immunosuppressive drugs
3. planned operations by surgeons with similar experience usinga similar procedure
4. no diabetes
5. no signs of organ paralysis or immobilization
6. a body mass index between 19 and 35 kg/m2
7. a surgical wound depth and length of 4 to 7 cm
Written informed consent was obtained from all participants, and they were provided with
complete study information, including the right to withdraw at any stage of the study and
data confidentiality.
After the surgery but before the wound cavity was filled with moist sterile gauze, the depth
and length of the surgical wound was measured and recorded using a standard millimeter
ruler. Then the patients were randomly assigned one of three 20member groups.
In the first (modern standard) group, the wounds were dressed through the standard
method recommended for alginate, hydrocolloid, and hydrogel compounds. In the first
week and after the surgeon’s first visit to the ward, the wound cavity was filled with
hydrogel (Comfeel; Coloplast, Humlebaek, Denmark), and a hydrocolloid dressing (Comfeel
Plus; Coloplast) was used as a secondary dressing to cover the wound. This procedure was
repeated three times in the first week. In the second week, the hydrogel was replaced by
alginate (Biatain Alginate; Coloplast), and the dressings were changed every 2 days. The

same method was used every 3 days during the third week. Finally, in the fourth week, only
the hydrocolloid dressing was replaced every 4 days.
In the second group, a modified dressing was used. In this method, Vaseline gauze was
applied instead of the transparent hydrocolloid dressing.
ADVANCES IN SKIN & WOUND CARE • VOL. 32 NO. 7 WWW.WOUNDCAREJOURNAL.COM
In the third (traditional) group, the dressing change was performed through daily cleaning
and filling the cavity with sterile gauze.
TableMEAN
1. WOUND LENGTH AND DEPTH REDUCTION (MEAN ± SD) 4 WEEKS POSTSURGERY
First week Second week Third week Fourth week
Group Length Depth Length Depth Length Depth Length Depth
5.77 ± 0.59 3.35 ± 0.46 4.5 ± 0.47 2.67 ± 0.46 2.7 ± 0.37 1.60 ± 0.30 1.4 ± 0.34 0.85 ± 0.28
5.70 ± 0.61 3.35 ± 0.40 4.1 ± 0.41 2.45 ± 0.45 2.75 ± 0.47 1.52 ± 0.37 1.47 ± 0.52 0.72 ± 0.25 5.70 ± 0.61 3.20 ± 0.41 4.45 ± 0.48 2.65 ±
Standard
0.46 3.02 ± 0.37 2.02 ± 0.34 2 ± 0.45 1.20 ± 0.34
Modified
.904 .441 .016 .24 .034 <.001 <.001 <.001
Traditional
P
Based on the arrangements made with patients, the depth and the length of thewounds
were measured once a week for 1 month. In addition, patients’ pain levels were measured
and recorded when changing the dressing,using the 11-pointnumericrating scale. In this
scale, zero represents no pain; 1 to 3, mild pain; 4 to 6, moderate pain; and scores higher
than 7 represent severe pain.
During the 1-month evaluation, the number of dressing changes, the wound healing
process, the amount of pain experienced by patients, the total costs associated with each
method, and the length of leave from work were entered into the SPSS 19 software
program (IBM, Armonk, New York). Then the data were analyzed using descriptive and
inferential statistical methods (χ2 test, 1-way analysis of variance, Student t test, and Wilks Λ
test).
RESULTS
Based on the results of this study, there were no significant differences among groups based
on demographic information (age, gender, and body mass index). The results associated
with the wound healing process based on the wound size reduction (length and depth) are
shown in Table 1; the modified method led to the highest reductions in wound size (P < .
001). The findings on pain experienced and reported by patients within 4 weeks of surgery
are shown in Table 2; the standard method had the lowest self-reported pain scores (P < .
001).
The comparison of the average total dressing costs among the three groups is shown in
Figure 1. Although the total dressing cost of the modified method is comparable with that of
the traditional method and 50% less than the standard method (Figure 1), it reduced the
average number of days for sick leave (taken in the first 4 weeks after treatment) in
comparison with both traditional and standard methods (Figure 2).

DISCUSSION
For this study, researchers examined the consequences of using three dressings (traditional,
standard, and modified methods) on the healing process of wounds caused by pilonidal
sinus surgery including the wound healing process and period, the pain experienced by the
patients during dressing changes, the treatment costs, and the duration of patient leave
from work.
Based on the results of this study, after 2 weeks, there was a significant difference in mean
wound length among the three groups (P < .05), indicating shorter wound healing time in
the modified and standard groups over the traditional group. This is consistent with the
findings of Xakellis and Chrischilles. 19
The results concerning the wound healing process in the first and second weeks indicate the
similar effectiveness of all three dressing methods, which is consistent with the findings of
Dumville et al,20 O’Meara et al,21 and Viciano et al.22
Another outcome measurewas the amount of pain experienced by the patients during
dressing changes, the means of which were measured and compared in the three groups
every week. During the first dressing changes, patients reported pain scores ranging from
4.5 to 5.4, which is consistent with the findings of the study conducted by Stewart et al 23
(average pain scores, 5 out of 10). There was a significant decrease in pain levels
experienced by the patients during dressing changes over all 4 weeks. However, the pain
scores in the standard and modified groups were lower than those in the conventional
group, which was consistent with the results of the study of Viciano et al. 22 Dinah and
Adhikari13 also confirmed that pain experienced during alginate and foam dressing changes
is less than the pain caused by packing sterile gauze (consistent with the results of the
current study).
In addition, in another study comparing permanganate, Betadine gauze, and alginate

dressing in hemorrhoidectomy patients, it became clear that patients in the alginate group
experienced less pain during dressing changes, and their wound healing took less time; 24
again, this is in agreement with the results of the present study.
Table
MEAN 2. PAIN REDUCTION 4 WEEKS POSTSURGERY,
MEAN ± SD
Group
Standar Week 1 Week 2 Week 3 Week 4
d
Modifie
4.5± 0.82 2.5 ± 1.05 0.15 ± 0.36 0±0
d
Traditio 4.4 ± 1.60 1.25 ± 0.78 0.40 ± 0.50 0.15 ± 0.36
nal 5.4 ± 0.94 2 ± 1.33 1.55 ± 1.09 0.95 ± 0.88
P .014 .02 <.001 <.001
Figure 1.
COMPARING THETOTAL COST OF DRESSINGS NORMALIZED BY THE TOTAL COST OF THETRADITIONAL METHOD AFTER 4 WEEKS

The treatment cost over the 4-week study period was also assessed; a significant difference
was observed among the three groups. The modified dressing method cost the least of all
studied methods. Although the traditional method and using ordinary gauze in each
dressing change cost less per dressing change, that does not include the cost of the nurse
performing the dressing change.
Therefore, it seems that, because of the decrease in the number of dressing changes, the
total cost of applying modified dressings is not significantly different from that of traditional
methods.
Figure 2.
COMPARING THE AVERAGE LEAVE AT WORK (IN DAYS) AFTER 4 WEEKS
ADVANCES IN SKIN & WOUND CARE • VOL. 32 NO. 7 WWW.WOUNDCAREJOURNAL.COM
In accordance with this finding, Payne et al 25 showed that because of the lower number of
dressing changes, using foam dressings to treat stage 2 pressure ulcers is cheaper than

using moist gauze alone. In a comparative study on the cost of wound healing with a
hydrocolloid dressing and moist gauze, Xakellis and Chrischilles 19 found that the cost of
hydrocolloid wound dressings is 3.3 times higher per dressing change; however, in treating
stage 2 pressure ulcers, a moist gauze dressing took eight times longer than hydrocolloid
dressings. Their findings also indicated that with a gauze dressing wound healing is slower,
the infection rate is higher, and the long-term cost of treatment is 3.45 times higher than
the hydrocolloid method, which is consistent with the results of the present study. 19
The amount of participant leave from work was the last outcome measure evaluated in this
study; this is one of the most important patient concerns in postoperative care after open
surgical procedures. In a study on the parameters for the management of pilonidal disease,
Steele et al4 stated that the surgical treatment of chronic pilonidal disease through excision
of diseased tissue with primary closure is usually associated with a more rapid return to
work. A significant difference was observed in the amount of leave taken from work when
comparing the three groups (P < .001). Participants in the traditional dressing group took
the most leave (reported to be more than 10 days), whereas in the standard and modified
dressing groups this number averaged 6 to 7 days.
Limitations
Because of financial constraints (the high cost of purchasing needed dressings and visiting
the patients at home for wound changes), it was not possible to continue this study for
longer than 4 weeks. Therefore, the wound healing process is reported up to the end of the
fourth week. Because the wounds were not healed entirely in some patients, there is a
possibility that extending the study period would have altered the results. Moreover, the
small sample size examined in this study, along with a narrow distribution of the samples
from the demographic point of view, limits the generalization of the results outside the
Iranian population.
CONCLUSIONS
Considering the positive results seen with the use of modern wound dressings that contain
alginate and hydrocolloid compounds, the use of these products in wound dressings is
recommended. Because nursing care centers are becoming more common in Iran, future
studies might involve performing a more accurate financial analysis in comparing the
effectiveness of these dressing methods across facilities. In addition, the authors suggest
that the surgeons and nurses responsible for performing dressing changes be trained in
using modified methods that are more cost effective than standard procedures. •
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Makalah Manajemen Nyeri Pada Luka

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MAKALAH KEPERAWATAN

“ MANAJEMEN NYERI PADA LUKA “

1 FADLI NP 204070306 7 ROSNAWATI NP 204070308

FAKULTAS ILMU KESEHATAN

Tarakan, 18 Mei 2021

B. SIFAT – SIFAT NYERI

Manfaat pendekatan farmakologis untuk nyeri luka harus dipertimbangkan

2. Nyeri Terobosan (Incident Pain)

Strategi pengobatan farmakologis untuk nyeri breakthrough termasuk

Intervensi non-farmakologis untuk Nyeri

D. Jenis-Jenis Skala Nyeri

E. Cara Menghitung Skala Nyeri

2. Verbal Rating Scale (VRS)

3. Numeric Rating Scale (NRS)

6. Oswetry Disability Index (ODI)

7. Brief Pain Inventory (BPI) Awalnya, metode ini digunakan untuk

8. Memorial Pain Assessment Card

Pelepasan mediator nyeri

Dihantarkan serabut tipe A dan serabut tipe C

System aktivasi retikuler area grisea

Thalamus hipotalamus dan system limbik thalamus

Nyeri akut/nyeri kronis

1. Resepsi (proses perjalanan nyeri)

2. Persepsi ( kesadaran seseorang terhadap nyeri )

Proses persepsi secara ringkas adalah sebagai berikut:

3. Reaksi ( respon fisiologis & perilaku setelah mempersepsikan nyeri )

F. RESPON TINGKAH LAKU TERHADAP NYERI

Perbedaan karakteristik nyeri akut dan kronik

H. FAKTOR YANG MEMPENGARUHI NYERI

Secara umum untuk melakukan teknik relaksasi membutuhkan 4 hal, yaitu:

J. PENATALAKSANAAN NYERI PADA LUKA

STUDY PROTOCOL Open Access

Effectiveness of medical hypnosis for pain

Pediatric burn pain

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Design and setting

medical hypnosis (intervention group) or (2) standard care (control group).

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1. Intervention group Medical hypnosis

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Secondary outcome measures

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Significance of the study