PENERAPAN PROGRESSIVE MUSCLE RELAXATION UNTUK

MENURUNKAN SESAK PASIEN

EVIDENCE-BASED NURSING PRACTICE

Disusun oleh:
Fransiska Nova 30190122018
Kalistus Hernando 30190122023
Ruth Yohana 30190122029
Winda Agresella 30190122041
Anastasia Yovi 30190122049

PROGRAM STUDI PROFESI NERS KMB

SEKOLAH TINGGI ILMU KESEHATAN SANTO BORROMEUS
PADALARANG
2022
 KATA PENGANTAR

Puji syukur penyusun ucapkan kepada Tuhan atas karunia-Nya sehingga

literature review yang berjudul “Penerapan Progressive Muscle Relaxation Untuk
Menurunkan Sesak Pasien” ini dapat diselesaikan dengan baik.
Literature review ini dibuat untuk melengkapi tugas mata kuliah
Keperawatan Medikal Bedah, kami ucapkan terima kasih kepada semua pihak
yang telah membantu dalam penyusunan literature review ini. Kami juga
menyadari pentingnya akan sumber bacaan dan referensi internet yang telah
membantu dalam memberikan informasi yang akan menjadi bahan makalah.
Kami juga mengucapkan terima kasih kepada semua pihak yang telah
memberikan arahan serta bimbingannya selama ini sehingga penyusunan
literature review dapat dibuat dengan sebaik-baiknya. Kami menyadari masih
banyak kekurangan dalam penulisan literature review ini sehingga kami
mengharapkan kritik dan saran yang bersifat membangun demi penyempurnaan
literature review ini.
Kami mohon maaf jika di dalam literature review ini terdapat banyak
kesalahan dan kekurangan. Semoga makalah ini dapat bermanfaat bagi kita
semua.

Bandung, November 2022

Penulis

i
 DAFTAR ISI
KATA PENGANTAR..............................................................................................i
BAB I PENDAHULUAN........................................................................................1
A. Latar Belakang.......................................................................................................1
B. Tujuan Penelitian...................................................................................................2
C. Metode Penulisan...................................................................................................2
D. Sistematika Penulisan.............................................................................................2
BAB II TINJAUAN TEORITIS..............................................................................3
A. Rancangan Evidence-Based Nursing Practice........................................................3
B. Strategi Pencarian (PICO)......................................................................................3
C. Kriteria Inklusi dan Eksklusi..................................................................................4
D. Flow Diagram PRISMA.........................................................................................5
E. Tabel Ekstraksi Data..............................................................................................6
F. Pembahasan..........................................................................................................12
BAB III PENUTUP...............................................................................................16
A. Kesimpulan..........................................................................................................16
B. Saran....................................................................................................................16
DAFTAR PUSTAKA............................................................................................17
LAMPIRAN...........................................................................................................18

ii
 BAB I

PENDAHULUAN

A. Latar Belakang
Oksigenasi merupakan kebutuhan dasar manusia yang pertama.
Keberadaan oksigen berfungsi dalam proses metabolisme untuk
mempertahankan kelangsungan hidup sel-sel (Andarmoyo, 2012).
Kekurangan atau hilangnya jumlah oksigen yang beredar di aliran darah,
akan menyebabkan seseorang mati dalam hitungan menit (Rosdahl dan
Kowalski, 2012).

Dispnea adalah sensasi subjektif dari ketidaknyamanan atau sesak

bernapas. Kondisi dipsnea juga sering dialami oleh pasien yang
membutuhkan perawatan paliatif antara lain pada kanker stadium lanjut,
gagal jantung dan penyakit paru-paru kronis Lebih dari 50% kematian di
Amerika Serikat disebabkan oleh ketiga kategori penyakit ini
(World Health Organization, 2020). Gejala dipsnea memiliki efek negatif
terhadap kesehatan fisik, emosional dan psikologis pasien (Mendoza et al.,
2020).

Penatalaksanaan dispnea dilakukan secara efektif dengan mengatasi

penyebab dasar dispnea menggunakan berbagai kombinasi terapi
farmakologis dan pendekatan nonfarmakologi. Perawat berperan penting
dalam pengelolaan dispnea dengan pendekatan nonfarmakologis. PMR
adalah salah satu dari teknik relaksasi yang paling mudah dan sederhana
yang sudah digunakan secara luas. Menurut Richmond (2007), PMR
merupakan suatu prosedur untuk mendapatkan relaksasi pada otot melalui
dua langkah. Langkah pertama adalah dengan memberikan tegangan pada
suatu kelompok otot, dan kedua dengan menghentikan tegangan tersebut
kemudian memusatkan perhatian terhadap bagaimana otot tersebut
 menjadi relaks, merasakan sensasi relaks secara fisik dan tegangannya
menghilang.

Berdasarkan paparan diatas, penulis tertarik untuk melakukan

pembahasan literature review tentang penerapan progressive muscle
relaxation untuk menurunkan sesak pasien di ruang maria 3 Rumah Sakit
Santo Borromeus.

B. Tujuan Penelitian
1. Tujuan Umum
Literature review ini bertujuan untuk mengetahui efektifitas
progressive muscle relaxation untuk menurunkan sesak pasien.
2. Tujuan Khusus

a. Mengetahui manfaat penerapan progressive muscle relaxation

untuk menurunkan sesak pasien.
b. Menganalisis penerapan progressive muscle relaxation untuk
menurunkan sesak pasien.
C. Metode Penulisan
Metode penulisan digunakan adalah Literature Review dari
beberapa jurnal/artikel menggunakan metode Quasi Eksperiment yang
diterbitkan dari tahun 2017 sampai tahun 2022 tentang pengaruh
progressive muscle relaxation untuk menurunkan sesak pasien. Dalam
menguji kualitas studi menggunakan PICO framework yang berfokus pada
populasi, intervensi, pembanding intervensi, hasil yang diharapkan dan
waktu/tahun jurnal.

D. Sistematika Penulisan
BAB I berisi latar belakang, tujuan penelitian, metode penulisan, dan
sistematika penulisan.

BAB II berisi rancangan evidence-based nursing practice, strategi

pencarian (pico), kriteria inklusi dan eksklusi, flow diagram prisma, tabel
ekstraksi data, dan pembahasan.

2
BAB III berisi simpulan dan saran.

3
 BAB II

TINJAUAN TEORITIS
A. Rancangan Evidence-Based Nursing Practice
Dalam penyusunan literature review ini penulis melakukan
penelusuran fenomena yang terkait dengan terkait intervensi yang dapat
dilakukan untuk mengurangi sesak pasien. Penulis memilih topik
“Literature Review Penerapan Progressive Muscle Relaxation Untuk
Menurunkan Sesak Pasien”.

B. Strategi Pencarian (PICO)

Dalam penyusunan telaah jurnal ini penulis melakukan
penelusuran yang terkait dengan “Penerapan Progressive Muscle
Relaxation Untuk Menurunkan Sesak Pasien”. Artikel yang dicari harus
relevan sehingga membantu untuk mendapatkan gambaran dari tujuan
penyusunan EBN ini, mulai dari strategi pencarian literatur berlanjut
dengan menentukan kriteria inklusi dan eksklusi.

Strategi pencarian literatur dilakukan dengan menggunakan model

PICO. Model PICO adalah sebuah metode pencarian jurnal berdasarkan
topik pencarian. PICO merupakan singkatan dari P (Patient, Population,
Problem; kata-kata yang mewakili pasien, populasi, dan masalah yang
diangkat dalam karya ilmiah yang ditulis), I (Intervention, Prognostic
Factor, atau Exposure; kata ini mewakili intervensi, faktor prognostic atau
paparan yang diangkat dalam karya ilmiah), C (Comparison; kata ini
mewakili perbandingan atau intervensi yang ingin dibandingkan dengan
intervensi yang lain), dan O (Outcome atau hasil yang mewakili target apa
yang ingin dicapai dari suatu penelitian) (Nasution, 2019).

P (population / Problem) Patients with dyspnea

I (Intervention) Progressive Muscle Relaxation
C (Comparison) -
O (outcome) Reduced dyspnea
 Pencarian literature review dilakukan melalui menggunakan search
google scholar dan pubmed dengan kata kunci yang digunakan untuk
mencari jurnal international adalah progressive muscle relaxation and
dyspnea sedangkan untuk mencari jurnal nasionalnya menggunakan kata
kunci progressive muscle relaxation dan sesak. Pencarian dilakukan pada
mesin pencari setelah dipilih berdasarkan kriteria inklusi dan ekslusi
didapatkan 5 artikel.

C. Kriteria Inklusi dan Eksklusi

1. Kriteria inklusi:
a. Jurnal internasional dan nasional yang membahas topik mengenai
progressive muscle relaxation.
b. Jurnal nasional dan internasional memiliki ISSN/DOI.
c. Jurnal update 10 tahun terakhir (2012-2022).
2. Kriteria Eksklusi
Jurnal dalam bentuk Full text (dapat diakses secara penuh).

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D. Flow Diagram PRISMA

Identification
Jurnal yang di identifikasi mulai dari tahun
2012-2022:
Pubmed = 5
Google Scholar = 9.550
(N = 9.555)

Setelah dikurangi duplikasi

Pubmed: 1
Google scholar: 102
(N = 103)

Screening

Jurnal yang masuk berdasarkan judul, abstrak, dan Hasil screening yang tidak sesuai
kata kunci dengan judul dan abstrak dikeluarkan
Pubmed: 1 Google scholar: 30 Pubmed: 4
(N = 31) Google scholar=9.448
(N=9.452)

Eligibility

Jurnal yang masuk berdasarkan

Hasil screening yang tidak
screening full text
full text
Pubmed: 1, Google Scholar: 4
Google schoolar: 98 (N=98)
(N = 5)

Inclusion
Jurnal yang relevan dengan penelitian ini
Pubmed:1Google Schoolar: 4
(N = 5)

5
 E. Tabel Ekstraksi Data
Judul, Peneliti,
No Tujuan Sampel Intervensi Durasi Instrumen Metodologi Hasil
Tahun
1 Decreasing degrees Untuk melihat 40 responden Pursed Lip Selama tujuh The quasi- Hasil penelitian
of dyspnea in efektifitas terdiagnosis Breathing dan hari, Modified experimental menunjukkan
chronic obstructive kombinasi PPOK derajat Progressive kelompok I Medical study perbedaan derajat
pulmonary disease Pursed Lip I-II Muscle diberikan Research sesak yang
patients through Breathing dan Relaxation kombinasi Council signifikan setelah
combination of Progressive PLB dan (mMRC) pemberian
breathing exercises Muscle PMR selama Dyspnea kombinasi PLB
and relaxation Relaxation sepuluh Scale dan PMR (p <
terhadap derajat menit dua 0,05). Kombinasi
Juliana GEP Massie, dispnea kali sehari. PLB dan PMR
Muhamad Adam, membantu
Tuti Herawati, I mengurangi
Made Kariasa keparahan
dispnea.
2022
2 Effectiveness Of untuk menilai 40 pasien Progressive Waktu yang Instrumen kontrol pretest- Hasil penelitian

6
 Progressive Muscle efektivitas (kelompok Muscle dihabiskan termasuk posttest menunjukkan ada
Relaxation on relaksasi otot studi-20, Relaxation untuk oksimetri eksperimental perbedaan yang
Psycho- progresif pada kelompok prosedur nadi untuk signifikan dalam
Physiological parameter kontrol-20) pengumpulan mengukur psikoparameter
Parameters Among psikofisiologis yang data adalah saturasi fisiologis antara
Patients with COPD antara pasien didiagnosis 20-30 menit. oksigen, pasien yang
At University dengan PPOK, dengan PPOK PMR spigmanom melakukan PMR
Teaching Hospital dan untuk diacak. dilakukan eter dibandingkan
mengaitkan dua kali mereka yang
Naveen Jebakumar parameter sehari dan tidak. Relaksasi
M, Porkodi A, Akila psiko-fisiologis dilanjutkan mengurangi
P dengan variabel selama lima kecemasan di sana
latar belakang hari dengan tekanan
2014 yang dipilih di darah, detak
antara pasien jantung, dan
dengan PPOK dispnea
3 The Effect of Untuk 68 pasien yang The progressive Durasi setiap Descriptive randomized Penurunan rata-
Progressive menyelidiki datang ke muscle relaxation pelaksanaan Information controlled rata dispnea,
Relaxation pengaruh Rumah Sakit exercise PMRT adalah Form, experimental kelelahan, dan

7
 Exercises on latihan Negara technique 30 menit. COPD and skor tidur pada
Fatigue and Sleep relaksasi otot Aksaray (PMRT) PMRT Asthma kelompok
Quality in progresif pada MustafaYazıcı dilaksanakan Fatigue intervensi secara
Individuals With dispnea, Klinik Rawat dengan Scale, statistik lebih
COPD kelelahan, dan Jalan Penyakit penyidik 2 COPD and nyata secara
kualitas tidur Dada antara hari Asthma signifikan
Cemile Kutmec pada individu Juni 2015 dan seminggu dan Sleep dibandingkan
Yilmaz, Sevgisun dengan Januari 2016, oleh pasien Impact pasien pada
Kapucu penyakit paru didiagnosis sendiri. Scale, MRC kelompok kontrol
obstruktif dengan Dyspnea (P <0,05). Latihan
2017 kronik PPOK sedang Scale relaksasi progresif
atau lanjut dapat diterapkan
untuk mengurangi
dispnea.
4 Pengaruh Kombinasi Untuk Ibu hamil Breathing Intervensi Numeric quasi- Terdapat
Breathing exercise mengetahui trisemester III exercise & akan rating scale eksperimental pengaruh
& Progressive pengaruh yang Progressive diberikan (NRS) kombinasi
Muscle Relaxation kombinasi melakukan Muscle selama 8 untuk breathing exercise
Dalam Menurunkan breathing pemeriksaanrut Relaxation minggu. mengukur dan progressive

8
 Nyeri Punggung exercise dan in di Klinik nyeri muscle relaxation
&Sesak Napas Ibu progressive Bidan Rina punggung technique
Hamil Trimester III muscle Kota bawah dan (PMRT) terhadap
relaxation Malang nafas yang nyeri punggung
Nurul Aini technique dialami bawah dan tingkat
Rahmawati, Siti (PMRT) menggunak sesak nafas pada
Ainun Ma’rufa, terhadap nyeri an skala ibu hamil
Safun Rahmanto, punggung borg trisemester III
Dinda Lutfiah Mei bawah dan termodifika (p=0,000)
Handiny, Mita sesak nafas si
Andini Ayu Lestari pada ibu hamil
trisemester III
2021
5 Penatalaksanaan mendeskripsika 3 responden Progressive Rencana Instrumen Metode Pursed lip
Relaksasi Otot n yang Muscle tindakan penelitian kualitatif breathing
Progresif: Pursed penatalaksanaa mengalami Relaxation keperawatan yang dengan exercise dan
Lip Breathing dan n relaksasi otot hipertensi Management yang digunakan pendekatan respiratory
Respiratory Muscles rogresif: dengan kriteria dilakukan adalah studi kasus muscles stretch
Stretch Gymnastics pursed lip inklusi berusia selama 1 format gymnastics efektif

9
dengan breathing 20-60 tahun, minggu 3 kali asuhan untuk mengatasi
Ketidakefektifan exercise dan sesak napas kunjungan keperawata masalah
Pola Napas Pasien respiratory derajat 2 dilakukan n, lembar ketidakefektifan
PPOK di Desa muscles stretch (sesak saat Prosedur observasi, pola napas pada
Mojolaban gymnastics melakukan Pursed Lip Standart pasien PPOK.
Kabupaten dengan masalah aktivitas), Breathing Operational
Sukoharjo keperawatan respirasi > 16- Dan Prosedur
ketidakefektifa 20 kali/menit, Respiratory pursed lip
Novita Siti Fatimah, n pola napas hemodinamik Muscles breathing
Deden Dermawan pada pasien stabil (tekanan Stretch dan
PPOK. darah sistolik Gymnastics respiratory
2022 90-130 mmHg, muscles
nadi 60-100 stretch
kali/menit), gymnastics.,
suhu normal format
36,5 ºC -37,5 asuhan
ºC. keperawata
n, buku
catatan atau

10
 buku tulis,
panduan
untuk
wawancara,
dan alat-alat
pemeriksaa
n fisik:
(Stetoskop,
sphignoman
ometer, dan
termometer)
.

11
F. Pembahasan
Artikel penelitian dalam literature review ini berjumlah 5 artikel. 5
artikel tersebut didapatkan hasil terdapat hubungan progressive muscle
relaxation pada sesak pasien. Hasil pembahasan sebagai berikut:
1. Karakteristik Responden
Dari kelima artikel, dua artikel memiliki rentang umur
responden yang sama yaitu 20-60 tahun, satu artikel memiliki
responden mayoritas usia ≥ 65 tahun. Sebagian besar responden adalah
laki-laki.
Pada derajat sesak pasien, tiga artikel menggunakan pengukuran
skala nyeri mMRC dan satu artikel menggunakan skala borg. Dari
kelima artikel terdapat dua artikel yang memiliki responden sesak
derajat 2 dan satu artikel memilki responden dengan sesak derajat
ringan.
Dari kelima artikel, empat artikel memiliki responden dengan
PPOK atau COPD. Satu artikel memiliki responden pada ibu hamil
trimester 3.

2. Hasil Penelitiaan
········Terjadi penurunan elastisitas parenkim paru, hiperplasi dan
hipertrofi kelenjar mukosa bronkus yang meningkatkan tahanan pada
saluran nafas akan meningkatkan kerja pernafasan (Mulyono, 2018).
Hal ini ditandai dengan peningkatan frekuensi pernafasan, pemakaian
otot bantu pernafasan, sesak dan pola nafas yang tidak terkoordinasi.
Keadaan ini menyebabkan ketegangan atau konstriksi kronik pada
otototot pernafasan yang akan meningkatkan Kebutuhan metabolisme
energi, menurunkan aliran darah yang membawa suplai makanan dan
oksigen, serta aktivitas neuromuskular (Guyton dan Hall dalam Tintin
dkk 2019).
Hal ini akan makin memperburuk sesak nafas yang ada. Bila ini
terus berlanjut maka bisa terjadi hipoksia, lebih berat lagi menyebabkan

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vasokonstriksi pembuluh darah paru, polisitemia dan hipertensi
pulmonal yang bisa jatuh pada korpulmonal (Suyono et al., 2017).
Pemberian latihan progressive muscle relaxation bertujuan untuk
menurunkan tegangan atau konstriksi kronik pada otot-otot pernafasan,
terutama otot bantu pernafasan (Mulyono, 2018). Selain itu latihan ini
juga mampu menurunkan rasa cemas karena sesak nafas serta
memberikan sense of well-being yang diharapkan dengan pemberian
latihan ini akan mampu meningkatkan kualitas hidup (Patel dalam
Mulyono 2018).
Dari ke 5 artikel yang diektraksi 5 artikel menunjukkan terapi
PMR mampu mengurang sesak. Secara teori relaksasi otot progresif
merupakan Teknik yang memfokuskan relaksasi dan peregangan pada
sekelompok otot dalam suatu keadaan rileks. Teknik yang digunakan
berdasarkan suatu rangsangan pemikiran untuk mengurangi kecemasan
dengan menegangkan otot dan kemudian rileks (Putri, 2017). Menfaat
relaksasi yaitu untuk menrangsang adaptasi atau melati pergerakan otot
pernapasan secara optimal dalam memperbaiki saluran nafas, selain itu
juga perlu diperhatikan pengontrolan terhadap penyebab sesak nafas
dan mampu meningkatkan tingkat kontrol pada penderita sendiri
(Novarin et al., 2015).
Saat melakukan relaksasi otot progresif maka akan terjadi
peningkatan tekanan pada orngga mulut. Tekanan ini akan diteruskan
melalui cabang-cabang bronkus sehingga akan meningkatkan
intrabronkial agar seimbang atau sama dengan tekanan intraalveolar
mempermudah pengosongan udara dari rongga thoraks dan
mempermudah pengeluaran karbondioksida sehingga dapat mencegah
air trapping dan kolaps bronkiolus pada waktu ekspirasi. Aktivitas
ringan yang dilakukan secara rutin dalam durasi yang sama 15 menit
akan dapat menstimulasi saraf simpatis pada medulla adrenal yang
merangsang kelendar endokrin untuk mengeluarkan epinefrin dan
nonepinefrin. Nonepinefrin akan berkaitan dengan reseptor α dan β2 di

13
jantung dan otot rangka memperkuat mekanisme vasodilator local di
jaringan-jaringan paru, sehingga akan terjadi bronkodilatasi dan udara
yang keluar masuk akan lebih lancar (Novarin et al., 2015).
Progressive muscle relaxation merupakan kombinasi latihan
pernafasan terkontrol (diafragma breathing) dengan rangkaian
kontraksi relaksasi sekelompok otot tubuh. Pada diafragma breathing
dapat terjadi pursed lips breathing. Diafragma breathing
merelaksasikan otot-otot pernafasan, menyimpan energi dan
memperbaiki ventilasi sampai ke basal paru (Casabury and Petty dalam
Novita dkk 2022). Kontraksi dan relaksasi sekelompok otot tubuh
secara progresif membantu seseorang mengatasi ketegangan otot kronik
yang terjadi, sehingga menurunkan kebutuhan metabolisme energi dan
oksigen yang membuat nafas menjadi lebih pelan, dalam dan tidak
cepat lelah. Penggunaan metode progressive muscle relaxation mampu
memperbaiki sesak nafas pada penderita PPOK yang ditandai dengan
peningkatan PEFR (Peak Expiratory Flow Rate) penderita PPOK
(Mulyono, 2018).
Dari kelima artikel, 2 artikel menunjukkan waktu yang efektif
dalam pemberian terapi progressive muscle relaxation adalah 20-30
menit perhari. Dalam artikel Naveen et al (2022) pada hasil observasi
ke 5 mulai terjadi peningkatan dengan hasil yang signifikan. Yaitu
didapatkan responden mampu meningkatkan kekuatan otot pernapasan
dan tekanan pada saat ekspirasi sampai sekitar 37%. Progressive
muscle relaxation dapat menurunkan konstriksi otot polos pernapasan,
menyimpan energi dan memperbaiki ventilasi sampai basal paru
sehingga terjadi peningkatan volume tidal, penurunan kapasitas residu
fungsional dan peningkatan ambilan oksigen menjadi optimal . Hal ini
mungkin disebabkan proses adaptasi mulai mencapai titik optimal,
dimana responden sudah mampu melakukan Progressive muscle
relaxation dengan benar serta meningkatnya motivasi setelah benar-
benar memahami manfaat daripada Progressive muscle relaxation.

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 Dalam artikel Massie et al (2022) terapi Progressive muscle
relaxation menunjukkan hasil yang signifikan pada ke 15 responden
yang mengalami derejat dispnea berat setelah diberikan intervensi
Progressive muscle relaxation dalam waktu 10 menit dua kali sehari
selama seminggu. Responden yang mengalami derajat dispnea berat
mampu berkurang atau menurun ke derajat dispne sedang. Hal ini
sejalan dengan hasil penelitian Randomized Clinical Trial (RCT) yang
dilakukan oleh Seyedi Chegeni et al. menunjukkan bahwa delapan
minggu PMR berbasis rumah memiliki potensi untuk meningkatkan
fungsi jantung dan paru-paru, serta membuat orang merasa lebih baik
dan kurang cemas.

15
 BAB III

PENUTUP
A. Kesimpulan
······Ke 5 artikel tersebut memiliki kesamaan dengan hasil penelitian
bahwa latihan progressive mussle relaxtion dapat menurunkan sesak nafas
dan menurunkan rasa cemas karena sesak nafas serta memberikan sense of
well-being yang diharapkan dengan pemberian latihan ini akan mampu
meningkatkan kualitas hidup. Kontraksi dan relaksasi sekelompok otot
tubuh secara progresif membantu seseorang mengatasi ketegangan otot
kronik yang terjadi, sehingga menurunkan kebutuhan metabolisme energi
dan oksigen yang membuat nafas menjadi lebih pelan, dalam dan tidak
cepat lelah selain itu progressive mussle relaxtion yang dilakukan secara
kontinyu akan meningkatkan Peak Expiratory Flow Rate karena mampu
menurunkan resistensi pada saluran nafas.
B. Saran
Berdasarkan hasil penelitian peneliti menyarankan agar latihan nafas
progressive mussle relaxtion (PMR) hendaknya dilakukan secara kontinyu
untuk mengurangi gangguan pernafasan dan meningkatnya kualitas hidup
pasien. Dengan demikian hasil penelitian dapat menjadi dasar penetapan
standar operasional (SOP) (PMR) di Ruangan Maria 3, Rumah Sakit
Borromeus.
 DAFTAR PUSTAKA

Fatimah, N. S., & Dermawan, D. (2022). Progressive Muscle Relaxation

Management: Pursed Lip Breathing And Respiratory Muscles Stretch
Gymnastics With Ineffective breathing pattern of COPD patients in
Mojolaban Village, Sukoharjo Regency. Indonesian Journal on Medical
Science, 9(1).
Jebakumar, N et al. 2014. Effectiveness of Progressive Muscle Relaxation on
Psycho-Physiological Parameters among Patients with COPD at University
Teaching Hospital. Journal of Science Vol 4 Issue 1/2014/23- 26.
Massie, J. G., Adam, M., Herawati, T., & Kariasa, I. M. Decreasing degrees of
dyspnea in chronic obstructive pulmonary disease patients through
combination of breathing exercises and relaxation. Journal of Community
Empowerment for Health, 5(2), 85-93.
Rahmawati, N. A., Marufa, S. A., Rahmanto, S., Handiny, D. L. M., & Lestari, M.
A. A. (2021). Pengaruh Kombinasi Breathing exercise & Progressive
Muscle Relaxation Dalam Menurunkan Nyeri Punggung & Sesak Napas Ibu
Hamil Trimester III. Physiotherapy Health Science (PhysioHS), 3(2), 95-
100.
Yilmaz, C. K., & Kapucu, S. (2017). The effect of progressive relaxation
exercises on fatigue and sleep quality in individuals with COPD. Holistic
nursing practice, 31(6), 369-377.

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 SUBMITTED:

Lampiran
Decreasing degrees of dyspnea in
chronic obstructive pulmonary
disease patients through
combination of breathing exercises
and relaxation
Juliana GEP Massie,¹,³,* Muhamad Adam,²,³ Tuti Herawati,²,³ I
Made Kariasa²,³

¹ Postgraduate Program, Faculty of

KEYWORD Nursing, Universitas Indonesia, Depok,
S COPD Indonesia Program, Faculty of Nursing,
Universitas Indonesia, Depok, Indonesia
Dyspnea
² Department of Medical Surgical Nursing, Faculty of Nursing, Universitas
Indonesia, Depok, Indonesia
Progressive
Muscle ³ Department of Nursing, Universitas Indonesia Hospital
Relaxation 10 June 2021 REVISED: 29 June 2022 ACCEPTED:
Pursed Lip 20 August 2022
Breathing
ABSTRACT Shortness of breath (dyspnea) is a common symptom
that accompanies patients with Chronic Obstructive Pulmonary
Disease (COPD). Management of dyspnea in patients with COPD
is not only using pharmacological therapy but also non-
pharmacological therapy. Non-pharmacological therapy for patients
with COPD covers three main aspects: breath, mind, and functional
processing. Along with the development of complementary therapy
in nursing science, nursing interventions that can be done at home
begin to be in great demand because of their low cost and time
effectiveness. One of the interventions is providing breathing
exercises and relaxation for patients with COPD to reduce the
dyspnea complaints, increase the strength of breathing muscles and
prevent the hospital re-admission due to acute exacerbation. This
study aimed to see the effectiveness of the combination of Pursed
Lip Breathing (PLB) and Progressive Muscle Relaxation (PMR) on the
degree of dyspnea. This quasi-experimental study was conducted
with a pre and post-test design approach with 20 respondents in
each group. The results showed significant differences in the degree
of dyspnea after the combination of PLB and PMR (p < 0.05). The
results from this study recommend improving the development of
complementary therapy programs in nursing education and services
by modifying nursing care standards with the combinations of PLB
and PMR for patients with COPD.

© The Journal 2022. This article is distributed under a Creative Commons Attribution-ShareAlike 4.0
International license

18
1. Introduction
Chronic Obstructive Pulmonary
Disease (COPD) contributes
significantly to high morbidity and
mortality rates. It represents about 6%
of all causes of death worldwide,
leading to the deaths of 3 million
people every year.1 In 2015, there
were an estimated
3.17 million patients worldwide, with
COPD making up 5% of them. This
trend made COPD the fifth most
prevalent disease in the world by
2020.2,3
Almost 90% of COPD deaths occur
in Lower- Middle-Income Countries
(LMICs), with Indonesia
*Correspondence: juliana.gep71@ui.ac.id
Department of Medical Surgical Nursing,
Faculty of Nursing, Universitas Indonesia, Jl.
Prof. Dr. Sudjono D. Pusponegoro, Pondok
Cina, Kecamatan Beji, Depok, West Java 16424,
Indonesia.
being one of the countries included
in the category of high risk.4-6 Socio-
economic conditions are the main
determinants in determining health
status. Thus, there is a strong
relationship between socio-
economic conditions and the
prevalence of COPD, with high rates
of morbidity and mortality in LMICs.7
COPD has bio-psycho-social-
spiritual impacts on sufferers. The
main problem that patients with
COPD always complain about is
shortness of breath or dyspnea,
which is commonly encountered in
patients with lung disease.8 Dyspnea
was reported by nearly all (98%) of
833 patients with COPD in a web-
based survey conducted in 17
countries. The degree of dyspnea in
patients with COPD has a significant
correlation with survival rates over
the next 5 years.9 The severity of
dyspnea also deteriorates as COPD
19
worsens, which contributes to the patient's quality Jakarta was given, and the procedure in the Bandung
of life.10
Managing dyspnea in patients with COPD uses
not only pharmacological therapy, but also non-
pharmacological therapy. There are three main
aspects of non-pharmacological therapy for patients
with COPD: breath, mind, and functional treatment.
These three factors are beneficial in enhancing
COPD patients’ quality of life.11,12 Pursed Lip
Breathing (PLB) is one type of breathing exercise
that can be used to reduce the symptoms of
shortness of breath in patients with COPD.
Relaxation techniques are another non-
pharmacological treatment option for patients
with COPD. Mind-body therapy is used in this
technique, which targets the sympathetic and
parasympathetic nervous systems. Progressive
Muscle Relaxation (PMR), diaphragmatic breathing,
attention-focusing exercises, and behavioral
relaxation training are the four major types of
relaxation.13
Along with the development of complementary
therapy in nursing science, nursing interventions
that can be done at home begin to be in great
demand because of the low cost and time
effectiveness. One of the interventions is providing
breathing exercises and relaxation for patients with
COPD to reduce the dyspnea complaints, increase
the strength of breathing muscles and prevent the
hospital re- admission due to acute exacerbation.
This study aimed to see the effectiveness of the
combination of PLB and PMR on the degree of
dyspnea.2

2.Method
2.1 Design and participants
This quasi-experimental study was conducted in
two major public hospitals in Jakarta and Bandung,
from July 2019 to November 2019. A total of 40
respondents diagnosed with COPD grades I-II were
chosen using consecutive sampling techniques
and assigned into two intervention groups. The
researchers included respondents from Bandung
in the first group, and respondents from Jakarta in
the second group. The approach split up the groups
based on the situation and conditions in the field
where the research approval from the hospital in
20
hospital was done on more than half of the and their families were given educational leaflets
target respondents. and explanation sheets of the self- report exercises
Before beginning the study, all by the researcher. The researchers demonstrated
participants were given a thorough the exercises to the respondents using a video tool.
explanation of the technical implementation Furthermore, the researchers assessed
of the research, as well as the potential
benefits and drawbacks they might
encounter. Participants who agreed to
participate in the study signed an informed
consent form following the explanation. The
Faculty of Nursing Universitas Indonesia and
both hospitals provided ethical approval for
the study.

2.2. Measures
The Modified Medical Research Council
(mMRC) Dyspnea Scale was used in this
study to assess pre- and post-intervention
dyspnea. The mMRC Dyspnea Scale is a 5-
point (0 – 4) scale based on the severity of
dyspnea. For seven days, the group I was
given a combination of PLB and PMR for ten
minutes twice a day. Similarly, for seven
days, group II received PLB for ten minutes
twice a day. The severity of dyspnea was
assessed before and after the intervention.

2.3. Data collection

Medical records were used to collect the
patient's gender, age, length of suffering
COPD, smoking habits, previous history of
exposure to substance irritant, lung
infection, and using pulmonary drugs,
nutritional, and socio-economic status.
Before beginning the study, the researchers
explained the objectives and methods. All
participants were fully included in the study
with personal consent, were free to leave at
any time, and the data collected were kept
confidential, so the participants' names were
not listed in the results.

2.4. Intervention
The researchers assessed the
respondent's degree of dyspnea at the
first meeting using the mMRC instrument
Questionnaire Dyspnea Scale. Respondents
21
Table 1. Correlation between respondents’ characteristics and degree of dyspnea

Variable Group 1 Group 2

Degree of Tota Degree of Total

l
dyspnea p-value dyspnea p-value
Severe Mild n Total Severe Mild n Total
1 Sex
Male 2 16 18 90 8 8 16 80
Female 0 2 2 10 1.000 1 3 4 20 0.91
Total 2 8 20 100 9 11 20 100
2 Smoking habits
Smoking 2 16 18 90 7 9 16 80
Never 0 2 2 10 1.000 2 2 4 20 1.000
Total 2 18 20 100 9 11 20 100
3 History of exposure to
substance irritants/pollutants
Ever 2 15 17 85 8 2 10 50
Never 0 3 3 15 1.000 1 9 10 50 0.005
Total 2 18 20 100 9 11 20 100
4 History of lung infection
Ever 2 11 13 65 7 9 16 80
Never 0 7 7 35 0.521 2 2 4 20 1.000
Total 2 18 20 100 9 11 20 100
5 Comorbidities
Yes 1 11 12 60 3 3 6 30
None 1 7 8 40 1.000 6 8 14 70 1.000
Total 2 18 20 100 9 11 20 100
6 Use of pharmacological therapy
Use 1 10 11 55 7 3 10 50
Not use 1 8 9 45 1.000 2 8 10 50 0.70
Total 2 18 20 100 9 11 20 100
7 Nutritional status
Poor 2 10 12 60 6 3 9 45
Good 0 8 8 40 0.495 3 8 11 55 0.175
Total 2 18 20 100 9 11 20 100
8 Socio-economic status
Low 2 16 18 90 9 9 18 90
High 0 2 2 10 1.000 0 2 2 10 0.479
Total 2 18 20 100 9 11 20 100
Fisher’s Exact Test, significant p > 0.05.

the respondent's psychomotor abilities by having ensure that there were no other interventions involving the
the respondent independently perform the respondents.
exercises. As a guide for the respondents when
doing the exercise, the researchers/research
assistants distributed a soft copy of the video of the
stages of the exercise to the respondent and the
accompanying family. During the study period, the
researchers/research assistants attempted to
 For seven days, the exercises were
performed for 10 minutes, twice a day
(morning and evening) before the
participants ate. From the second to the
seventh meeting, the respondents were
accompanied by the researchers and a
family member or caregiver while
performing the exercise procedure.
Following the exercise procedure, the
respondents completed a self-reporting
form as evaluation material. On the last day
of the study, this self-reporting form was
returned to the researchers.
Table 2. Degree of dyspnea before and after intervention

Group 1 Group 2

Degree of dyspnea
Before After Before After
p-value p-value
n % n % n % n %
Severe 15 75 2 10 10 50 9 45
Mild 5 25 18 90 0.000 10 50 11 55 1.000
Total 20 100 20 100 20 100 20 100

Mc Nemar Test, significant p > 0.05.

Table 3. Difference in degree of dyspnea after intervention

Group 1 Group 2
Degree of dyspnea p-value
n % n %
Severe 2 10 9 45
Mild 18 90 11 55 0.034
Total 20 100 20 100

Chi-square test, significant p > 0.05.

If the respondent was allowed to leave the As many as 85% of the respondents in this study were
hospital before completing the 7-day intervention, male; 85% of respondents are active smokers and ex-
one of the researchers made a home visit in the smokers; 82.5% of respondents are
morning or evening, as agreed upon with the
respondent, to aid and evaluate the
implementation. If the researcher made a home
visit in the morning, the researcher performed
follow-up care in the afternoon by contacting the
respondent or family via telephone or video call to
ensure that the respondent had independently
performed the exercises. After seven days of
exercise, the researcher used the mMRC Dyspnea
Scale to assess the degree of dyspnea.

2.5. Statistical analysis

The data were analyzed using SPSS version
22.0 software (IBM Corp., Armonk, NY), as well as
descriptive and inferential statistical methods. The
association between confounding variables and
degree of dyspnea were confirmed by the Fisher’s
exact test and independent t-test. Furthermore, the
statistical significance level was set at p < 0.05.

3. Result
frequently exposed to irritants/pollutants;
57.5% of COPD respondents had a lung
infection; 55% of COPD respondents had no
comorbid disease; 52.5% of COPD
respondents used pharmacological therapy
to treat complaints of shortness of breath;
52.5% of respondents fall into the category
of poor nutrition, and 90% of respondents
have low income. The overall mean age of
the patients was 55.55 ± 14.254 years and
the mean length of suffering COPD was
2.53 ± 2.195 years.
Tables 1-3 show the bivariate analysis
between the respondents’ characteristic and
the degree of dyspnea. Further analysis
showed that most of the respondents’
characteristics did not have a significant
relationship with the degree of dyspnea (p >
0.05); except history of exposure to
irritants/pollutants in the group II (p < 0.05).
The differences in dyspnea severity
between the two intervention groups are
shown in Tables 2–3. Further investigation
revealed a significant difference in the
degree of dyspnea in patients with COPD
before and after a combination of PLB and
PMR (p < 0.05; Table 2). In this study,
however, there was no significant difference
in the degree of dyspnea before and after
PLB (p < 0.05; Table 2). The degree of
dyspnea after exercise differed significantly
between the two groups, according to the results of
the analysis (p < 0.05; Table 3).
4. Discussion
The combination of physical exercises in the form
of breathing and relaxation significantly improves
the patient's ability to regulate breathing patterns,
which helps to reduce the severity of dyspnea.
There was a significant difference in dyspnea
severity between the group that received only PLB
training and the group that received both PLB and
PMR. The results of this study support the
hypothesis that the combination of PLB and PMR
has a differential effect on the severity of dyspnea
in patients with COPD. In addition, the combination
of PLB and PMR administered to COPD patients
significantly altered their dyspnea levels.
Men and women have different phenotypes in
response to cigarette smoke exposure. Males are
more resistant to the emphysematous phenotype,
whereas females are more vulnerable to the airway
phenotype. The differences in sexual responses
to disease are thought to be caused by the body's
immune response based on sexual dimorphism.
As a result, it is recognizable why men and women
respond differently to illness.14 Patients with COPD
in this study included not only elderly people but
also young adults. The youngest respondent who
was diagnosed with COPD in this study was 20 years
old and had a history of smoking since the age of
seven. Smoking at a young age has caused a shift in
this phenomenon.
This study did not find a significant relationship
between duration of COPD and degree of dyspnea.
The patients have not felt the severity of respiratory
symptoms due to decreased lung function in COPD
degree I. The clinical diagnosis of chronic bronchitis,
which is one of the clinical features of COPD, is
established if the patient has had a cough for at
least 3 months in 2 consecutive years. 8 However, in
the elderly who experience symptoms of chronic
cough and often come for treatment at health
facilities, it is often not detected that they have
COPD.15 This causes differences in the length of time
experiencing COPD in published studies.
As many as 42% of patients reported having
COPD for 2-5 years or more. The length of time a
patient suffers from COPD is directly proportional
to the degree of obstruction suffered; thus, the
longer the patient suffers from COPD, the worse
the patient's quality of life will be.16 Exacerbations
of COPD, on the other hand, have the potential to
worsen the patient's quality of life regardless of
how long the patient has had COPD.17
Most previous studies have found a link
between smoking and COPD. As many as 90% of
patients with COPD are current or former
smokers.18 The high rate of cigarette consumption in
Indonesia is closely related to the ease with which
tobacco products can be obtained in public places.
In addition to having easy access to cigarettes, the
low selling price of cigarettes allows people with
low-income to purchase them.19
Statistically, there was no significant
relationship between the history of lung infection
and the degree of dyspnea in this study. In 2019,
GOLD reported that bacterial infections cause more
than half of all COPD exacerbations.8 The lack of a
significant relationship between a history of
pulmonary infection and the degree of dyspnea in
this study could be related to how the study criteria
were determined. Patients with COPD with degrees
of obstruction I-II, indicating early-stage COPD, were
one of the inclusion criteria in this study. As a result,
the impact of lung damage has been minimal.
Metabolic disease is a significant comorbidity in
COPD. This high metabolic comorbidity is due to all
respondents having the same cardiometabolic risk
factor, namely smoking. COPD alone can increase
the risk of vascular damage by two times in patients
with coronary heart disease, 3.9 times in patients
with heart failure, 2.4 times in patients with
arrhythmia, and 1.5 times in stroke patients.20
Comorbidities can predict mortality in patients with
COPD using the COPD Specific Comorbidity Test
index, but their role as predictors of acute
exacerbations in COPD is still being debated.21 In
this study, 45% of the subjects had no comorbid
disease. But since 40% of respondents in this study
had been diagnosed with COPD for less than a year,
they did not have systemic COPD side effects.
 Hanania and O'Donnell found that using mortality in COPD patients with low incomes is 2.5 times
bronchodilators in combination with long-term- higher
agonist receptors significantly increased dyspnea
symptoms as measured by the St. George
Respiratory Questionnaire (SGRQ).22 The Food and
Drug Administration (FDA) does not recommend
dual bronchodilators as a therapy to reduce
dyspnea complaints based on this assessment. 22-26
This study is not in line with the research of Lee et
al. on 102 patients with stable COPD taking
pharmacotherapy to reduce dyspnea symptoms.
Treatment response was evaluated after three
months of drug use. Based on the mMRC Dyspnea
Scale and COPD Assessment Test assessment (CAT),
it was found that there was a decrease in the
degree of dyspnea after three months of using
pharmacotherapy.
Mete et al. discovered a link between high
dyspnea scores and low body mass index (BMI)
scores. Their study included 105 COPD inpatients
using a nutritional assessment instrument with a
24-hour recall for three consecutive days.27
Furthermore, Baig et al. discovered a significant
relationship between BMI and upper arm
circumference on the degree of dyspnea and
severity of COPD in 138 hospitalized patients with
COPD. The findings of this study did not show a
relation between nutritional status and the degree
of dyspnea in patients with COPD.28 The researchers
analyzed this based on the respondents' smoking
habits. Patients have a tendency to continue
smoking in order to control their body weight.29 As
a result, the respondent's nutritional status has no
significant bearing on his or her decision to smoke.
Borné at al. conducted a study on 118,134
subjects with COPD ranging in age from 40 to 89
years in Sweden. Borné stated that there was
no statistically significant relationship between
socioeconomic status and the incidence of COPD
in nonsmokers. Borné argued that a smoker's
socioeconomic status is closely related to the risk of
COPD.30 Kanervisto et al., who also discovered a link
between respiratory tract obstruction disease with
low socioeconomic status, as defined by low levels
of education and income.31 Patients with COPD with
low income are 2.1 times more likely to have acute
COPD exacerbations.32 Furthermore, the rate of
than in COPD patients with high incomes. 33 better control during periods of dyspnea by
People with low socioeconomic status are increasing resistance during expiration and thereby
more likely to engage in unhealthy behaviors decreasing the respiratory rate. Pursed lips facilitate
such as smoking, lack of physical activity, breathing with a longer expiration duration and
and poor dietary intake.34 reduced lung volume at the end of exhalation. 35,36 In
People with lower socioeconomic status addition, PLB increases vagal modulation, which
are more vulnerable to disease. A person may
with high socioeconomic status can live a
healthier lifestyle by receiving regular
medical treatment and check- ups, living in a
clean environment with low pollution levels,
purchasing healthy and nutritious food,
participating in sports groups such as Zumba
or yoga, and being able to pay for smoking
cessation therapy. The findings of this
study revealed that there was no
significant relationship between socio-
economic status and the degree of dyspnea.
The researchers analyzed this in terms of the
respondents' smoking habits, with 85% of
the respondents in this study being smokers
or ex-smokers. Tobacco use has evolved into
a physiological, psychological, and social
dependency trait. Dependence on nicotine
in cigarettes is a behavioral disorder.29
PLB exercises are designed to improve
oxygen transport, train expiratory muscle
strength, increase airway pressure during
expiration, decrease airway obstruction, and
prevent lung collapse. Other studies have
demonstrated that PLB can temporarily
reduce the sensation of dyspnea,
allowing individuals to control their
breathing independently and in
accordance with their body's tolerance. The
process of pursed lips will lengthen the
duration of expiration, thus decreasing the
dead space in the airway. The manipulation
of breathing patterns can be advantageous
for cardiovascular and respiratory control in
physiological and pathological conditions.
Increased venous return, for instance, can
aid in maintaining stable blood pressure
during rest periods in critical illness.35
The pursed-lip maneuver is utilized
frequently in respiratory rehabilitation
programs. The purpose of pursed lips is to
increase respiratory efficiency and provide
be associated with a reduction in respiratory rate. 37 a comprehensive Standard Operating Procedure that
PLB can decrease respiratory rate and raise SpO2
levels. This breathing exercise is also recommended
to reduce dyspnea symptoms, boost self-esteem,
and alleviate night-time anxiety. Due to the
mechanism of increased airflow during the
expiration process, PLB results in a decrease in
respiratory frequency.38 While the use of accessory
muscles during respiration results in an increase in
tidal volume, an improvement in the exchange
process, and adequate breathing, the use of
accessory muscles does not affect tidal volume.36
The Randomized Clinical Trial (RCT) research
conducted by Seyedi Chegeni et al. demonstrated
that eight weeks of home-based PMR successfully
reduced fatigue and improved certain components
of sleep quality in COPD patients with obstructive
degrees III to IV at Shohada Teaching Hospital,
Iran.39 Similarly, Volpato, Banfi, Nicolini, and Pagnini
conducted an RCT study on patients with COPD at
the Don Gnocchi Hospital in Milan. The research
indicated that relaxation exercises have the
potential to improve the functioning of the heart
and lungs, as well as make people feel better and
less anxious.40
In this study, the researchers did not conduct
an inter-rater reliability test on the research
assistants in the second group. Therefore,
researchers cannot be certain of the perceptions
held in common by the researchers and research
assistants regarding PLB training. However, the
research assistants recruited for this study already
possess research experience, having worked in the
respiratory field for more than five years and
possess a Bachelor of Science in Nursing degree.
Consequently, the research assistants have been
generally considered acceptable enough to provide
PLB training in terms of competence.
This study's findings can be used to improve
COPD patients' ability to self-manage their disease
and reduce the frequency of acute exacerbations.
For therapy to be effective, nursing personnel who
are competent in providing this combination of
breathing exercises and relaxation techniques are
required. This combination of exercises is applicable
for both inpatient and outpatient COPD patients.
The findings of this study can also be used to create
 enables nurses to independently care for cycle of breathing technique terhadap
patients using a combination of PLB and peningkatan nilai VEP1, jumlah sputum, dan
PMR. mobilisasi sangkar thoraks pasien PPOK.
Indonesian Journal of Nursing Practices.
5. Conclusion 2017;1(2):44-54.
3. World Health Organization. Chronic Respiratory
This study's findings show that there is a Diseases. Jenewa: World Health Organization;
significant difference in the degree of
dyspnea after performing a combination of
PLB and PMR. Thus, combining PLB and PMR
has an indirect effect on improving lung
function, as evidenced by a reduction in
dyspnea after seven days of intervention.
Except for the degree of dyspnea,
improvements in lung function and
functional capacity in patients with COPD
can also be assessed using sputum
production, spirometry values, and the
number of exacerbations. As a result, this
study can serve as a reference and provide
preliminary data for future research for
patients with COPD by investigating the
relationship between the combination of
PLB and PMR and other indicators of disease
severity.

Acknowledgements
The authors are grateful to the Dean of the
Faculty of Nursing, Universitas Indonesia;
Director of Universitas Indonesia Hospital,
and Manager of Nursing Universitas
Indonesia Hospital for supporting this
research. Special thanks are extended for
the support that was given by all the
Intensive Care Nurses from Universitas
Indonesia Hospital and all the enumerators.

Conflict of interests
The authors declared no conflict of interest.

References
1. Bourdet SV, Williams DM. Chapter
27: Chronic Obstructive Pulmonary
Disease Pharmacotherapy: A
Pathophysiologic Approach. 10th ed.
New York: McGraw-Hill Education /
Medical; 2015. p. 537-54.
2. Huriah T, Ningtias DW. Pengaruh Active
 2019 [updated 2019 Dec 27; cited 2020 Jan 12]. Available from: https://www.who.int/ respiratory/copd/en/.
4. World Health Organization. Chronic Obstructive Pulmonary Disease (COPD) . Jenewa: World Health
Organization; 2017 [updated 2017 Dec 1; cited 2019 Feb 20]. Available from: https:// www.who.int/news-
room/fact-sheets/detail/ chronic-obstructive-pulmonary-disease-(copd).
5. Irianti EC, Arsin AA, Abdullah MT. Quality of life in patients with chronic obstructive pulmonary disease at
Pulmonary Community Health Centre Makassar. International Journal of Community Medicine and Public
Health. 2018;5(9):3753-9.
6. Quaderi SA, Hurst JR. The unmet global burden of COPD. Glob Health Epidemiol Genom. 2018;3:e4-e.
7. Grigsby M, Siddharthan T, Chowdhury MA, Siddiquee A, Rubinstein A, Sobrino E, et al. Socioeconomic status
and COPD among low- and middle-income countries. Int J Chron Obstruct Pulmon Dis. 2016;11:2497-507.
8. Global Initiative for Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention
of chronic obstructive pulmonary disease 2019 report USA: GOLD; 2021 [updated 24 March 2021; cited 2021
June 10]. Available from: https://goldcopd.org/wp-content/ uploads/2019/12/GOLD-2020-FINAL-ver1.2-
03Dec19_WMV.pdf.
9. Singh VP, Rao V, Prem V, Sahoo RC, Keshav Pai
K. Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD: a
randomized controlled pilot study. Chron Respir Dis. 2009;6(4):209-16.
10. Marciniuk DD, Goodridge D, Hernandez P, Rocker G, Balter M, Bailey P, et al. Managing dyspnea in patients
with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline.
Can Respir J. 2011;18(2):69-78.
11. Danvers L. Managing breathlessness and chest clearance 2017 [cited 2019 January 21]. Available from:
https://www.educationforhealth. org/wp-content/uploads/Day-2-Managing- Breathlessness-and-Chest-
Clearance-Laura- Danvers.pdf.
12. Ramadhani R, Sitorus R, Yona S. Peningkatan
 self efficacy dalam mengelola kesulitan bernafas melalui edukasi manajemen dispnea pada pasien
PPOK. Jurnal Aisyah : Jurnal Ilmu Kesehatan. 2018;3(2):125-33.
13. Ramdhani N, Putra AA. Pengembangan multimedia relaksasi 2008 [Available from:
http://neila.staff.ugm.ac.id/wordpress/wp- content/uploads/2008/05/relaksasi-otot.pdf.
14. Rini IS, Sitorus R, Sabri L. Hubungan antara efikasi diri dengan kualitas hidup pasien Penyakit Paru
Obstruktif Kronis dalam konteks asuhan keperawatan di RS Paru Batu dan RSU Dr. Saiful Anwar Malang
Jawa Timur [Tesis]. Depok: Universitas Indonesia; 2011.
15. Broekhuizen BD, Sachs AP, Hoes AW, Moons KG, van den Berg JW, Dalinghaus WH, et al. Undetected
chronic obstructive pulmonary disease and asthma in people over 50 years with persistent cough.
Br J Gen Pract. 2010;60(576):489-94.
16. Tsiligianni I, Kocks J, Tzanakis N, Siafakas N, van der Molen T. Factors that influence disease- specific
quality of life or health status in patients with COPD: a review and meta-analysis of Pearson
correlations. Prim Care Respir J. 2011;20(3):257-68.
17. Jones PW, Brusselle G, Dal Negro RW, Ferrer M, Kardos P, Levy ML, et al. Health-related quality of life in
patients by COPD severity within primary care in Europe. Respir Med. 2011;105(1):57-66.
18. Persatuan Dokter Paru Indonesia. Pedoman diagnosis dan penatalaksanaan Penyakit Paru Obstruktif
Kronis (PPOK) di Indonesia Jakarta: PDPI; 2016 [cited 2019 March 14]. Available from:
https://www.klikpdpi.com.
19. Achadi A. Regulasi pengendalian masalah rokok di Indonesia. Jurnal Kesehatan Masyarakat Nasional.
2008;2(4):161-5.
20. Finkelstein J, Cha E, Scharf SM. Chronic obstructive pulmonary disease as an independent risk factor for
cardiovascular morbidity. Int J Chron Obstruct Pulmon Dis. 2009;4:337-49.
21. Divo M, Cote C, de Torres JP, Casanova C, Marin JM, Pinto-Plata V, et al. Comorbidities and risk of
mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med.
2012;186(2):155-61.
22. Hanania NA, O'Donnell DE. Activity-relate

dyspnea in chronic obstructive pulmonary
disease: physical and psychological
consequences, unmet needs, and future
directions. Int J Chron Obstruct Pulmon Dis.
2019;14:1127-38.
23. Donohue JF, Maleki-Yazdi MR, Kilbride S, Mehta
R, Kalberg C, Church A. Efficacy and safety of
once-daily umeclidinium/vilanterol 62.5/25
mcg in COPD. Respir Med. 2013;107(10):1538-
46.
24. Bateman ED, Ferguson GT, Barnes N, Gallagher
N, Green Y, Henley M, et al. Dual
bronchodilation with QVA149 versus single
bronchodilator therapy: the SHINE study. Eur
Respir J. 2013;42(6):1484-94.
25. Buhl R, Maltais F, Abrahams R, Bjermer L,
Derom E, Ferguson G, et al. Tiotropium and
olodaterol fixed-dose combination versus
mono- components in COPD (GOLD 2-4). Eur
Respir J. 2015;45(4):969-79.
26. Martinez FJ, Rabe KF, Ferguson GT, Fabbri LM,
Rennard S, Feldman GJ, et al. Efficacy and Safety of
glycopyrrolate/formoterol metered dose inhaler
formulated using co-suspension delivery technology in
patients with COPD. Chest. 2017;151(2):340-57.
27. Mete B, Pehlivan E, Gulbas G, Gunen H. Prevalence of
malnutrition in COPD and its relationship with the
parameters related to disease severity. Int J Chron
Obstruct Pulmon Dis. 2018;13:3307-12.
28. Baig MMA, Hashmat N, Adnan M, Rahat
T. The relationship of dyspnea and disease severity
with anthropometric indicators of malnutrition among
patients with chronic obstructive pulmonary disease.
Pak J Med Sci. 2018;34(6):1408-11.
29. Artana IB, Rai IN. Tingkat ketergantungan nikotin dan
faktor-faktor yan gberhubungan pada perokok di Desa
Penglipuran 2009. Jurnal Penyakit Dalam.
2010;11(1):1-9.
30. Borné Y, Ashraf W, Zaigham S, Frantz S. Socioeconomic
circumstances and incidence of chronic obstructive
pulmonary disease (COPD) in an urban population in
Sweden. COPD: Journal of Chronic Obstructive
Pulmonary Disease. 2019;16(1):51-7. 31. Kanervisto M, Vasankari T, Laitinen T,
Heliovaara M, Jousilahti P, Saarelainen S. Low
socioeconomic status is associated with chronic
obstructive airway diseases. Respir Med.
2011;105(8):1140- 6.
32. Eisner MD, Blanc PD, Omachi TA, Yelin EH,
Sidney S, Katz PP, et al. Socioeconomic status,
race and COPD health outcomes. Journal of
Epidemiology and Community Health.
2011;65(1):26.
33. Gershon AS, Dolmage TE, Stephenson A, Jackson
B. Chronic obstructive pulmonary disease and
socioeconomic status: a systematic review.
Copd. 2012;9(3):216-26.
34. Pampel FC, Krueger PM, Denney JT.
Socioeconomic disparities in health behaviors.
Annu Rev Sociol. 2010;36:349-70.
35. Sakhaei S, Sadagheyani HE, Zinalpoor S,
Markani AK, Motaarefi H. The Impact of
pursed-lips breathing maneuver on cardiac,
respiratory, and oxygenation parameters in
COPD patients. Open Access Maced J Med Sci.
2018;6(10):1851-6.
36. Garzon-Perez LV. Reactivation of the
parasympathetic system with pursed lips after
physical exercise [Thesis]. France: Université de
Franche-Comté; 2017.
37. Rossi RC, Pastre CM, Ramos EMC, Vanderlei
LCM. Pursed-lip breathing in chronic
obstructive pulmonary disease: a literature
review. Fisioterapia e Pesquisa. 2012;19(3):282-
9.
38. Roberts SE, Schreuder FM, Watson T, Stern M.
Do COPD patients taught pursed lips breathing
(PLB) for dyspnoea management continue to
use the technique long-term? A mixed
methodological study. Physiotherapy.
2017;103(4):465-70.
39. Seyedi Chegeni P, Gholami M, Azargoon A,
Hossein Pour AH, Birjandi M, Norollahi H. The
effect of progressive muscle relaxation on the
management of fatigue and quality of sleep in
patients with chronic obstructive pulmonary
disease: a randomized controlled clinical trial.
Complement Ther Clin Pract. 2018;31:64-70.
40. Volpato E, Banfi P, Nicolini A, Pagnini F. A quick
relaxation exercise for people with chronic
obstructive pulmonary disease: explorative
randomized controlled trial. Multidiscip Respir
Med. 2018;13:13
 The Effect of Progressive Relaxation Exercises
on Fatigue and Sleep Quality in Individuals
With COPD
■ Cemile Kutmec Yilmaz, PhD ■ Sevgisun Kapucu, PhD

This randomized controlled experimental study was conducted to investigate the effect of
progressive muscle relaxation exercises on dyspnea, fatigue, and sleep quality in individuals
with chronic obstructive pulmonary disease. A Descriptive Questionnaire and the Chronic
Obstructive Pulmonary Disease and Asthma Fatigue Scale, Chronic Obstructive Pulmonary
Disease and Asthma Sleep Scale and Medical Research Council Dyspnea Scale were used for
data collection. The decrease in the mean dyspnea, fatigue, and sleep scores in the intervention
group was statistically significantly more pronounced than the patients in the control group (P
< .05). Progressive relaxation exercises can be implemented to decrease the dyspnea, fatigue,
and sleep problems seen in patients with moderate and advanced chronic obstructive
pulmonary disease by nurses working in the clinic. KEY WORDS: chronic obstructive
pulmonary disease, dyspnea, fatigue, progressive muscle relaxation exercises, sleep

Holist Nurs Pract 2017;31(6):369–377

Chronic obstructive pulmonary disease have a negative effect on each other.6-8

(COPD) is a chronic disease, with gradually
increasing incidence worldwide. It leads to
mortality and morbidity and creates a social
and economic burden.1 COPD may have
many symptoms such as dyspnea,
coughing, fatigue, sleep problems, anxiety,
and depression because of the permanent
and progressive airflow limitation occurring
as a result of the chronic inflammatory
C¸ ınar
Author Affiliations: Health High School, Nursing
Department, Ak- saray University, Turkey (Dr Yilmaz);
and Faculty of Nursing, Hacettepe University, Ankara,
Turkey (Dr Kapucu).
The authors have disclosed that they have no significant
relationships with, or financial interest in, any
commercial companies pertaining to this article.

response in the lungs.1,2 The symptom most Correspondence: Cemile Kutmec Yilmaz, PhD, Health
High School, Nursing Department, Aksaray University,
commonly reported by the patients is Aksaray, Turkey (cemilekutmec @yahoo.com).
dyspnea.
DOI: 10.1097/HNP.0000000000000234
Dyspnea is a subjective symptom
characterized by difficulty in breathing,
and causes discomfort, activity
restriction, and decreased quality of
life.3,4 Increased fatigue and sleep
problems can occur with dyspnea.5
Fatigue and sleep problems are
reported to be common in patients with
COPD and according to the literature

and Olgun9 reported that 98% of
patients with COPD experienced sleep
problems, with a daily sleep duration of
5 hours on average. The fatigue further
increased the sleep problems while
similarly the sleep disorders led to an
increase in the fatigue symptoms. All
the patients with COPD (n 90)
were found to experience fatigue. The
sleep quality was poor in 78.9% and the
level of fatigue increased as the sleep
quality worsened in a study by
Dog˘an.10
The increased dyspnea, fatigue, and
sleep problems affect the physical,
social, and mental functions of the
patients negatively and limit activities
related to tasks at home and self-care
such as bathing and getting dressed.11
They also cause problems such as a
methods used for symptom management
in patients with COPD include respiratory
exercises,14 reflexology,15 aerobic and
strength exercises, physical exercise,16
home-based nursing care programs,17
and relaxation exercises.18,19 The
progressive muscle relaxation exercise
technique (PMRT) has been reported to
be effective on patient dyspnea, fatigue,
and sleep problems.18,20
PMRT was developed by Jacobson in
1920 and consists of voluntarily
stretching and relaxing the large muscle
groups gradually from the hands to the
feet to ensure a relative decrease in
anxiety by the elimination of tension in
the muscles.21,22 There are studies
evaluating the effect of PMRT on
symptoms such as dyspnea,18 pain, sleep
problems and fatigue,23 anxiety and
depression,24,25 and nausea and vomiting
because of chemotherapy.26 Singh et al18
have found music and PMRT to be
effective in decreasing dyspnea in
patients with COPD. S¸ ahin and
decrease in productivity at work,
impairment of concentration,
indifference to the environment,
inability to participate in social
activities, and decreased
performance.3,12 Pharmacological and
nonpharmacological methods are used
to treat the dyspnea, fatigue, and sleep
problems that significantly limit the
daily self-care activities of the patients.
Despite intensive medical treatment
=
used for patients with COPD, it may
not be sufficient to ease patient
symptoms in the advanced stages of
the disorders.
This has increased the interest in
nonpharmacological approaches to be
added to drug treatment in advanced
stage patients.13 Common
nonpharmacological
Dayapog˘lu19 found PMRT to alleviate
fatigue and sleep problems. PMRT was
found to decrease the level of fatigue and
increase the sleep quality in studies
conducted in various patient groups with
non-COPD.18,27,28
Most of the rehabilitation interventions
toward the control of disease symptoms
in patients with COPD may need to be
continued at the hospital because of
individual difficulties and limited health
care services.29 However, providing care
through home visits is reported to be
effective in symptom management,
decreasing the number of presentations
to the hospital while increasing
motivation, and also increasing
compliance with disease process and
recommended exercise programs.30-32 O¨
zkaptan and Kapucu17 reported that
providing nursing care according to the
self-care model through home visits was
effective in the symptom management of
patients with COPD. These results show
that more home
visit-based applications are required for
the relief of COPD symptoms and
increased active participation of the
patients. We therefore conducted PMRT
by making home visits to patients with
COPD in our study. We aimed to
increase the compliance and increase
the motivation of our patients regarding
such compliance with a PMRT program.
METHODS
Sample group
The study was conducted with 68
patients who presented to the Aksaray
State Hospital Mustafa
Yazıcı Chest Diseases Outpatient Clinic
between June 2015 and January 2016,
were diagnosed with moderate or
advanced COPD by the physician
according to Global Initiative for
Chronic Obstructive
Lung Disease (GOLD) criteria, accepted
to participate after receiving
information on the study, and provided
written consent.
Study inclusion criteria were as
follows: (a) patients diagnosed with
moderate or severe COPD on the basis
of GOLD criteria by the physician, (b) no
diagnosis of neurologic or psychiatric
disease, (c) no disease causing
insomnia and not using sleeping pills,
(d) no vision, speech, or hearing
problem that would prevent
understanding the information and
PMRT applications, (e) no additional
disorders such as pneumonia,
tuberculosis, or lung cancer, (f) no acute
exacerbation episodes within the last
month, (g) living at the province center,
(h) not receiving PMRT, and (i)
volunteering to participate in the study.
The patients who experienced an acute
exacerbation episode, were hospitalized
at the application stage of the study,
who could not implement the
relaxation exercises regularly, or who
wanted to leave the study were
excluded.
Power analysis was used to calculate
the sample size for the study. This
showed that the sample size would
need to be 32 for each group assuming
5% type 1 error and 80% power, and we
therefore included 34 patients in each
group taking into account possible
losses,
for a total of 68 patients with COPD.
Between June 22, 2015, and November
15, 2015, 160 patients with COPD
presented to the chest diseases
outpatient clinic because of COPD. A
total of 94 patients who met
the study inclusion criteria were
interviewed, and 80 patients who
accepted to participate were
included in the sample. Twelve
patients were excluded for various
reasons (requesting to quit the study,
deteriorating health, and inability to
contact the patient). Block
randomization was conducted
according to the age, gender and,
disease stage characteristics to
determine the patients to be
included in the intervention and
control groups. Accordingly, the
randomization of the patients to be
assigned to the intervention and
control groups was performed by
using the http://www.e-picos.
com/randomizer_rpg.php link.
Sleep Impact Scale (CASIS), and Medical Research
Council (MRC) Dyspnea Scale that was developed by the
investigator on the basis of the literature and included
the sociodemographic and medical characteristics of
patients with COPD were used.
Descriptive Information Form
score is calculated with the formula below. A high
score indicates poor sleep quality and a low score
indicates good sleep quality.34,35 The validity and
reliability study of the CASIS in our country was
conducted by Ayhan35 and the Cronbach α coefficient
of the scale was identified as 0.87. The results
obtained from this

This form consisted of a total of 26 questions, with

16 close-ended and 10 open-ended questions. The
Descriptive Information Form contained questions
for identifying the medical and sociodemographic
characteristics, fatigue, and sleep problems of the
patients.

COPD and Asthma Fatigue Scale

This scale has been developed by Revicki et al33
to identify the effect of COPD and asthma on
fatigue. The internal consistency value was found to
be
0.95 for both groups; the test-retest result was 0.82
for patients with COPD and 0.84 for patients with
asthma. The original scale consisted of 12 items. It is
a 5-point Likert-type scale, with a minimum score of
12 and
a total maximum score of 60. The total scale score is
converted to a value between 0 and 100 with the
help of the formula below: Increased scale score
indicates higher fatigue level.5,33 The validity and
reliability study of the scale in our country was
conducted by Arslan and O¨ ztunc¸ 5 and the
Cronbach α value for the reliability coefficient of the
scale was identified as 0.92.

Scale score calculation : Total raw score

— minimum value to be obtained (12)/(48) ×
100

COPD and Asthma Sleep Impact

Scale
The scale was developed by Pokrzywinski et al34 to
identify the effect of COPD and asthma on sleep and
the Cronbach α coefficient was found to be 0.90 in
the analyses conducted. The items of the 7 Likert-
type questions are answered in the form of never,
rarely, sometimes, often, and very frequently. The
initial
5 questions are coded regularly, whereas the other
2 questions are reverse coded. The total raw score is
obtained by adding all item scores, and the scale
 advanced stage COPD by the physician were
study show that the scale is valid and reliable for interviewed,
use in Turkey.35 and the patients who accepted to
participate after information on the study
Scale score calculation= (Total raw score−7)/28×100 was provided
were included in the study. The patients were
MRC Dyspnea Scale included in the intervention and control groups
simultaneously. Patients were included in the
The MRC Dyspnea Scale is based on various physical interventio
activities that cause a sensation of dyspnea and
intensify shortness of breath perceptions.36 When
the MRC Dyspnea Scale is administered, the patients
are asked to state the activity level that causes
dyspnea.
The patient reads the options in the scale and
chooses the most appropriate level identifying the
respiratory distress. The scoring of the options are
between
0 and 4 and scored as 0 no dyspnea; 1 mild dyspnea
(presence of shortness of breath while moving
quickly on level ground and while walking slightly
uphill);
2 moderate dyspnea (walking slower than the
peers on level ground and stopping to breathe); 3
severe dyspnea (stopping to breathe after walking
about
100 m); and 4 very severe dyspnea (having shortness
of breath while doing daily work at home, while
getting dressed, removing clothes, or using the
bathroom).37

Relaxation Exercise Information Guide

The Relaxation Exercise Information Guide was
prepared to allow patients to perform muscle
stretching-relaxation exercises correctly. The guide
includes the benefits of relaxation exercises for the
body and how each exercise is performed. Each
muscle stretching-relaxation movement to be
performed during the exercise was photographed,
and information was provided together with these
photographs in the guide so that the patients could
perform the exercise correctly. The guide was given
to the patients who constituted the intervention
group at the initial interview. The necessary consent
was obtained to use the pictures in the guide.

Interventions
The patients who presented to Aksaray State
Hospital Mustafa Yazıcı Chest Diseases
outpatient
clinic and were diagnosed with moderate or
control groups according to the randomization codes
using the http://www.e-picos.com/randomizer
rpg.php link, whereas the Descriptive Information
Form, CAFS, CASIS, and MRC Dyspnea Scale were
administered at the initial interview at the hospital.
The Relaxation Exercise Information Guide and
“Relaxation Exercises CD Sound Records” prepared
by the Turkish Psychologists Association38 were used
during patient training. Each patient was given an
MP3 player, headphones, and the “Relaxation
Exercise Information Guide” by the investigator.
Training on PMRT and implementation and MP3
where relaxation exercises were loaded were given
to the experimental group patients at the initial
home visit. The investigator provided practical
training for the patient so that the relaxation
exercises could be performed correctly. First, the
patient was taken to a comfortable couch in a quiet
environment and the relaxation exercises were
explained. The implementation of the exercises was
shown by the investigator while the patient listened
to the MP3 player. The muscles in both hands and
arms, shoulders, chest, abdomen, hips, legs, feet,
and face regions were contracted after a deep
breath and then relaxed while exhaling after
counting to 5 in sequence with the patient. This
preliminary training lasted
90 minutes on average for each patient. The
duration of each PMRT implementation was 30
minutes.
PMRT was implemented with the investigator 2 days
a week and by the patients themselves on the other
days. The exercise days and hours of the patients
were queried during the exercise program and
recorded in the PMRT monitoring schedule. The
sessions continued for 8 weeks and the CAFS, CASIS,
and MRC Dyspnea Scale were administered again at
the end of the fourth and eighth weeks. Home visits
2 days a week were scheduled in the study, and we
also conducted an average of 4 phone interviews
with each patient. In addition, the patients were
provided the phone number of the investigator to
use if required during the relaxation exercise
program stage.
The Descriptive Information Form, CAFS, CASIS,
and MRC Dyspnea Scale were administered to the
control group at the first interview in hospital. We
then administered the CAFS, CASIS, and MRC
Dyspnea Scale again at the patient’s home at the end
of the fourth and eighth weeks. The CAFS, CASIS, and
MRC Dyspnea Scale were administered again later at
the end of the fourth and eighth weeks. No
intervention was used for the control group (Figure
1).
Statistical analysis
The statistical analyses were conducted with the
IBM SPSS for Windows 22.0 software program. The
numerical variables were presented with mean ±
 The Effect of Progressive Relaxation Exercises on Fatigue and Sleep Quality in Individuals With COPD 373

standard deviation or median (range) values and the Committee (2015/16) and Aksaray Province General
categorical variables with numbers and percentages. Secretariat of the Union of Public Hospitals
The χ 2 test or Fisher exact test was used to (33527579-773/3372). The necessary permissions
investigate whether there was a difference between were obtained to use the CAFS and CASIS scales and
the independent groups in terms of categorical the PMRT sound records of the Turkish Psychologists
variables. Before the comparison, the compliance of Association. We also secured written consent from
the numerical variables with the normal distribution the individuals who accepted to participate in the
was determined with the Shapiro-Wilk test and the study.
homogeneity of the variances with the Levene test. The limitations of the study
We used the variance analysis with repetitive
measurements to evaluate whether there were The limitations include being a single-center study
differences within time and between groups for the that was mainly conducted during the summer,
intervention and control groups in terms of and evaluation of the level of fatigue and sleep
numerical variables when parametric assumptions quality according to the patients’ self-reports.
were met. The difference between groups was
RESULTS
evaluated with the Mann-Whitney U test, and the
change in time was determined with the Friedman The demographic and medical characteristics of
test when the parametric test assumptions were not the patients in the intervention and control
met. The significance level was accepted as P < .05. groups in our study are presented in Table 1.
We found that the difference between the mean
CAFS, CASIS, and MRC Dyspnea Scale total scores of
the patients in the intervention and control gro

TABLE 1. Descriptive Characteristics of the Patients

Experimental Group Control Group Pretest Comparison
Variable n (%) n (%) Test/P Valuea

Age, mean ± SD 65.1 ± 6.7 66.8 ± 9.4

40-64 y 15 (44.1) 13 (38.2) χ 2 = 0.061
≥65 y 19 (55.9) 21 (61.8) Pa = .805
Gender
Female 4 (11.8) 4 (11.8) χ2 = 0.061
Male 30 (88.2) 30 (88.2) Pa = .805
Education level
Illiterate 6 (17.6) 8 (23.5) Pb = .437
Primary school 27 (79.4) 23 (67.7)
High school or more 1 (3.0) 3 (8.8)
Disease stage
χ2 = 0.000
Moderate 13 (38.2) 14 (41.2)
Pa = 1.000
Severe 21 (61.8) 20 (58.8)
Duration of disease, y
χ 2 = 0.000
1-9 18 (52.9) 19 (55.9)
Pa = 1.000
≥10 16 (47.1) 15 (44.1)
Smoking
χ 2 = 1.158
Yes 8 (23.5) 5 (14.7) Pa = .560
Former smoker 21 (61.8) 25 (73.5)
No 5 (14.7) 4 (11.8)
Using oxygen at home P = .628
Yes 16 (47.1) 19 (55.9)
No 18 (52.9) 15 (44.1)

Abbreviation: SD, standard deviation.

a
P < .05.
b
Fisher exact test values given to χ2 value could not be given.
374 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2017

was not statistically significant before PMRT was
implemented (P > .05). The CAFS total score of the
patients in the intervention group (42.76 14.37) was
± 16.22),
lower than those in the control group (70.77
± was
and the decrease in the CAFS score after PMRT
implemented for 8 weeks was statistically significant
(P .001). The decrease in the total CAFS score
=
shows that the fatigue levels of the patients
decreased (Table 2). Similarly, the mean CASIS scores
of the patients in the intervention group± (35.29
13.8) were found to decrease statistically
significantly compared with the patients±in the
control group (64.91 16.1) (P <
.001; Table 2).
The difference between the degree of dyspnea of
the patients in the intervention and control groups
was found to be statistically significant in the
evaluation conducted according to the MRC Dyspnea
Scale results (P < .05). The oxygen saturation (SpO2)
measurements showed an increase in oxygen
saturation in the intervention group at the end of
PMRT, but this increase was not statistically
significant in the comparison of the 2 groups (P >
.05).
DISCUSSION
The permanent and progressive airflow limitation
occurring in the lungs and airways in COPD leads to
the development of dyspnea. Fatigue and sleep
problems are also commonly seen with dyspnea in
these patients and limit their daily activities. The
control of dyspnea, fatigue, and sleeplessness with
proper and efficient interventions is therefore
essential for these patients. We investigated the
effects of PMRT on fatigue and the sleep quality in
patients with COPD in this study.The effect of
progressive relaxation exercises on fatigue
Patients with COPD who used PMRT were seen to
experience less fatigue in our study (Table 2). Our
results are similar to those of other studies that
investigated the same issue.7,19,27,39,40 PMRT was
found to decrease fatigue in a study conducted on
dialysis patients by Kaplan41 and similarly in patients
with multiple sclerosis in a study by Dayapog˘lu and
Tan.7 It also decreased fatigue in patients with cancer
after surgery in a study conducted by Dimeo et al. 39
Moriya and Ikeda42 found PMRT to be an effective
method for coping with fatigue. Home visits
performed by the investigators 2 days a week helped
regular use of PMRT. The decrease in fatigue in our
patients can be explained with regular PMRT
increasing respiratory function,19 increasing oxygen
saturation, improving sleep quality,43 decreasing
dyspnea severity, anxiety, and depression, 44
decreasing stress levels,45 and decreasing physical
and mental stress by ensuring the relaxation of
skeletal

TABLE 2. Comparison of the Mean CAFS, CASIS, and MRC Dyspnea Scale Scores of the Patients in the Intervention
and Control Groups
Experimental Group Control
(n = 34) Group (n =
Variable Mean ± SD 34) t Value P Valuea,b
Mean ± SD
CAFS
Pretest 63.97 ± 15.3 66.85 ± 18.9 F = 98.962 P < .001
Posttest 42.76 ± 14.4 70.77 ± 16.2
CASIS
Pretest 57.14 ± 15.4 60.08 ± 20.1 F = 80.348 P < .001
Posttest 35.29 ± 13.8 64.91 ± 16.1
SpO2
Pretest 88.85 ± 5.3 89.21 ± 4.4 F = 26.921 P < .001
Posttest 92.23 ± 4.0 88.93 ± 4.2
Median (Range) Median (Range)
MRC Dyspnea Scale
Pretest 2 (1-4) 2.5 (0-4) Z = −0.340 P = .734
Posttest 2 (0-4) 3 (1-4) Z = −3.138 P < .05

Abbreviations: CAFS, COPD and Asthma Fatigue Scale; CASIS, COPD and Asthma Sleep Impact Scale; SpO2, oxygen saturation; SD, standard deviation.
a
P variance analysis in repeating measurements was used.
b
P < .05.
 The Effect of Progressive Relaxation Exercises on Fatigue and Sleep Quality in Individuals With COPD 375

results of
muscles with its sympathetic nervous
system inhibiting effect.44
The effect of progressive relaxation
exercises on sleep quality
Patients with COPD who used PMRT were seen to
experience fewer sleep problems in our study
(Table 2). S¸ ahin and Dayapog˘lu19 reported that
8 weeks of PMRT increased sleep quality in
patients with COPD, whereas Saeedi et al46 and
Demiralp
et al27 similarly reported an increase in sleep quality
in patients following PMRT. Relaxation exercises
were found to be effective for sleep duration,
efficiency, quality, and daytime dysfunction in a
study conducted on patients with cancer
experiencing sleeplessness problems.43 A positive
correlation was reported between the number of
PMRT implementations and sleep quality in a study
conducted by Erdem.28 Dayapog˘lu and Tan7 found 6-
week PMRT use to increase the sleep quality of
patients with multiple sclerosis. These results were
similar to those of our study. The changes occurring
during the rapid eye movement period of sleep
impair sleep quality by leading to disrupted gas
exchange, decreased oxygen saturation, severe
hypoxemia, and hypercapnia in patients with COPD.47
In addition, various symptoms such as dyspnea,
fatigue, and cough seen in patients with COPD have a
negative effect on the sleep process. Increase in
dyspnea severity decreases the total sleep duration,
sleep quality, deep sleep, and rapid eye movement
sleep of the patient while increasing the number of
times he/she wakes up during the night.24,25,27,45
PMRT is thought to affect the sleep process
positively by decreasing the dyspnea severity, anxiety
level, sensitivity to pain, and fatigue.
The effect of progressive relaxation exercises on
dyspnea

Patients with COPD who used PMRT were seen to

experience less dyspnea in our study (Table 2).
Respiration exercises accompanied by a device and
music were found to have a positive effect on the
dyspnea and type of respiration of patients with
COPD by Borge et al.48 Singh et al18 reported that
PMRT applied in patients with COPD decreased
dyspnea. An exercise and dyspnea self-management
program directed by a nurse was found to decrease
the emotional dimension (dyspnea anxiety and
stress) of dyspnea.49 Our results were similar to the
other studies. PMRT is a relaxation technique
where deep respiration exercises are performed
simultaneously with muscle stretching-relaxation
exercises. The respiration exercises performed
regularly and efficiently during the 8-week exercise
program in our study are thought to have been
effective in decreasing the severity of dyspnea.
Besides, PMRT is reported to contribute to the
development of positive emotions such as being
energetic, cheerful, peaceful, freshened, and
relieved mentally and physically.24,50 It is believed
that the effects of PMRT increase the psychological
well-being of the patients and thus decrease
their perception of the severity of dyspnea.
CONCLUSION

Progressive relaxation exercises were found to be

effective in decreasing dyspnea, fatigue, and sleep
problems in our study. On the basis of these
results, PMRT use can provide an additional benefit
to home visit-based pulmonary rehabilitation
programs for patients with COPD. We recommend
conducting similar studies using larger samples.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an active role from the identification to

the management of the dyspnea, fatigue, and
sleeplessness symptoms commonly seen in patients
with COPD. PMRT was found to decrease dyspnea,
fatigue, and sleep problems in patients with
moderate and advanced stage COPD in our study.
PMRT can be implemented by clinical nurses in
patients with moderate and advanced stage COPD.

REFERENCES
1. Global Initiative for Chronic Obstructive Lung Disease. Global
Strategy for Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease.
http://www.msc.es/organizacion/sns/ planCalidadSNS/pdf/GOLD
Report 2015 Apr2.pdf. Updated 2015. Accessed September 7, 2017.
2. Borge CR, Wahl AK, Moum T. Association of breathlessness with
multiple symptoms in chronic obstructive pulmonary disease. J Adv
Nurs. 2010;66(12):2688-700.
3. Akıncı AC¸ , Pınar R. Dyspnea rehabilitation in patients with chronic
obstructive pulmonary disease. J Cumhuriyet Univ School Nurs. 2012;
1:24-29.
4. Peters JB, Heijdra YF, Daudey L, et al. Course of normal and ab-
normal fatigue in patients with chronic obstructive pulmonary
disease and its relationship with domains of health status. Patient
Educ Couns. 2011;85:281-285.
376 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2017
5. Arslan S, O¨ ztunc¸ G. Validity and reliability of chronic
obstructive pulmonary disease and Asthma Fatigue Scale.
Hems¸irelikte Aras¸tırma Gelis¸tirme Dergisi. 2013;15(1):48-60.
6. Wong CJ, Goodridge D, Marciniuk DD, Rennie D. Fatigue in patients
with COPD participating in a pulmonary rehabilitation program. Int J
Chron Obstruct Pulmon Dis. 2010;5(5):319-326.
7. Dayapoglu N, Tan M. Evaluation of the effect of progressive
relaxation exercises on fatigue and sleep quality in patients with
multiple sclerosis. J Altern Complement Med. 2012;18(10):983-987.
8. McDonnell LM, Hogg L, McDonnell L, White P. Pulmonary rehabili-
tation and sleep quality: a before and after controlled study of
patients with chronic obstructive pulmonary disease. NPJ Prim Care
Respir Med. 2014;10;24:14028.
9. C¸ inar S, Olgun N. Determining of fatigue and sleep disturbance
in patients with chronic obstructive pulmonary disease. J Nurs Sci.
2012; 2(1).
10. Dog˘an B. Determination Sleep Quality and Fatigue in Patients With
COPD. Nicosia, Cyprus: Near East University; 2013.
11. Akıncı C¸ , Pınar R. The dependency status of the patients with
chronic obstructive pulmonary disease while performing activities of
daily liv- ing and factors affecting. J New World Sci Acad. 2011;6(1).
12. Karakurt P, U¨ nsal A. Fatigue, anxiety and depression levels, activities
of daily living of patients with chronic obstructive pulmonary disease.
IntJ Nurs Pract. 2013;19:221-231.
13. Clini EM, Ambrosino N. Nonpharmacological treatment and relief of
symptoms in COPD. Eur Respir J. 2008;32:218-228.
14. C¸ ic¸ek HS, Akbayrak N. The effects of breathing exercises on
pulmonary functions tests and arterial blood gas for the patients with
chronic ob- structive pulmonary disease (COPD). Gu¨lhane Med J.
2004;46(1):1-9.
15. Polat H, Ergu¨ney S. The effect of reflexology applied to patients
with chronic obstructive pulmonary disease on dyspnea and fatigue
[published online ahead of print March 9, 2016]. Rehabil Nurs.
doi:10.1002/mj.266.
16. Arslan S, O¨ ztunc¸ G. The effects of a walking exercise program
on
fatigue in the person with COPD [published online ahead of print
March 9, 2016]. Rehabil Nurs. doi:10.1002/rnj.206.
17. O¨ zkaptan BB, Kapucu S. Home nursing care with the self-care model
improves self-efficacy of patients with chronic obstructive pulmonary
disease. Jpn J Nurs Sci. 2016;13(3):365-377.
18. Singh VP, Rao V, Prem V, Sahoo RC, Keshav PK. Comparison of the
effectiveness of music and progressive muscle relaxation for anxiety
in COPD—a randomized controlled pilot study. Chron Respir Dis.
2009;6(4):209-216. doi:10.1177/1479972309346754.
19. S¸ ahin ZA, Dayapog˘lu N. Effect of progressive relaxation exercises
on fatigue and sleep quality in patients with COPD. Complement Ther
Clin Pract. 2015;21(4):277-281.
20. Gift AG, Moore T, Soeken K. Relaxation to reduce dyspnea and anxiety in
COPD patients. Nurs Res. 1992;41(4):242-246.
21. Kwekkeboom KL, Hau H, Wanta B, Bumpus M. Patients’ perceptions
of the effectiveness of guided imagery and progressive muscle relax-
ation interventions used for cancer pain. Complement Ther Clin
Pract. 2008;14(3):185-194.
22. Zargarzadeh M, Shirazi M. The Effect of progressive muscle relaxation
method on test anxiety in nursing students. Iranian J Nurs Midwifery
Res. 2014;19(6):607-612.
23. Nazik E, O¨ ztunc¸ G, S¸ ahin B. Effects of progressive relaxation
training
on sleep quality and pain in patients with breast cancer undergoing
chemotherapy. J Anatolia Nurs Health Sci. 2014;17:3.
24. Klainin-Yobas P, Oo WN, Suzanne Yew PY, Lau Y. Effects of relax- ation
interventions on depression and anxiety among older adults: a systematic
review. Aging Mental Health. 2015;19(12):1043-1055.
25. Zhou K, Li X, Li J, et al. A clinical randomized controlled trial of music therapy
and progressive muscle relaxation training in female breast cancer
patients after radical mastectomy: results on depression, anxiety and
length of hospital stay. Eur J Oncol Nurs. 2015;19(1):54-59.
26. Molassiotis A, Yung HP, Yam BM, Chan FY, Mok TS. The effectiveness of
progressive muscle relaxation training in managing chemotherapy-
induced nausea and vomiting in Chinese breast cancer patients: a ran-
domised controlled trial. Support Care Cancer. 2002;10(3):237-246.
27. Demiralp M, Oflaz F, Komurcu S. Effects of relaxation training on sleep
quality and fatigue in patients with breast cancer undergoing
adjuvant chemotherapy. J Clin Nurs. 2010;19(7-8):1073-1083.
28. Erdem N. The Investigation of the Effectiveness of Progressive Relax-
ation Exercise on the Sleep and Life Quality in Dialysis Patients [PhD
thesis]. Erzurum, Turkey: Atatu¨rk University; 2005.
29. Carrie-Kolhman V, Donesky-Cuenco D, Neuhaus J. Impact of brief or
extended exercise training on the benefit of a dyspnea self-
management program in COPD. J Cardiopulm Rehabil. 2005;25:275-
284.
30. Hermiz O, Comino E, Marks G, Daffurn K, Wilson S, Harris M.
Randomized controlled trial of home based care of patients with
chronic obstructive pulmonary disease. Br Med J. 2002;325(7370):
938-940.
31. Bal O¨ zkaptan B, Kapucu S. The Importance of home care to improve
self-efficacy of people with chronic obstructive pulmonary disease.
Cumhuriyet Nurs J. 2015;4(2):74-80.
32. Taylor SJC, Candy B, Bryar RM, et al. Effectiveness of innovations in
nurse led chronic disease management for patients with chronic
obstructive pulmonary disease, systematic review of evidence. Br
Med J. 2005;331(485):1-7.
33. Revicki DA, Meads DM, McKenna SP, Gale R, Glendenning GA,
Pokrzywinski MHA. COPD and Asthma Fatigue Scale (CAFS): de-
velopment and psychometric assessment. Health Outcomes Res
Med. 2010;1(1):5-16.
34. Pokrzywinski RF, Meads DM, McKenna SP, Glendenning GA, Re- vicki
DA. Development and psychometric assessment of the COPD and
asthma sleep ımpact scale (CASIS). Health Qual Life Outcomes.
2009;7;1-98.
35. Ayhan E. The Validity and Reliability Study of Chronic Obstructive
Pulmonary Disease and Asthma Sleep Impact Scale in the patients
With Chronic Obstructive Pulmonary Disease [master’s thesis].
Erzurum, Turkey: Atatu¨rk University; 2011.
36. Kara D, Yıldız H. Effectıveness and frequencıes of dyspnea scales in
evaluating symptom of dyspnea. Gu¨mu¨s¸hane Universitesi Sag˘lık
Bilim- leri Dergisi. 2013;2(1).
37. Ulas¸lı SS, U¨ nlu¨ M. New concept in the classification of chronic ob-
structive pulmonary disease severity. Gu¨ncel Go¨gu¨s Hastalıkları
Serisi. 2013;1(1):13-19.
38. Boyaciog˘lu G, Kabakcı E. Gevs¸eme Egzersizleri Kaseti. Ankara,
Turkey: Tu¨rk Psikologlar Derneg˘i Yayınlari. www.psikolog.org.tr.
Accessed March 25, 2016.
39. Dimeo FC, Thomas F, Raabe-Menssen C, Pro¨pper F, Mathias M. Ef-
fect of aerobic exercise and relaxation training on fatigue and
physical performance of cancer patients after surgery. A randomised
controlled trial. Support Care Cancer. 2004;12(11):774-779.
40. Zhang PJ, Guo YF, Zhang LY, Zhang X, Bao CY, McCorkle R. Effects of
progressive muscle relaxation training among lung cancer patients
receiving chemotherapy. J Nurs Health Sci. 2015;1(4):40-48.
41. Kaplan E. The Effect of Progressive Relaxation Exercises on Pain, Fa-
tigue and Quality of Life in Dialysis Patient [master’s thesis]. Gaziantep,
Turkey: Gaziantep University; 2012.
42. Moriya R, Ikeda N. A pilot study of the effects of progressive
muscle relaxation on fatigue specific to multiple sclerosis. Br J
Neurosci Nurs. 2013;9(1).
43. Simeit R, Deck R, Conta-Marx B. Sleep management training for
cancer patients with insomnia. Support Care Cancer.
2004;12(3):176-183.
44. Safi SZ. A fresh look at the potential mechanisms of progressive
mus- cle relaxation therapy on depression in female patients
with multiple sclerosis. Iranian J Psychiatry Behav Sci.
2015;9(1):e340.
45. Lolak S, Connors GL, Sheridan MJ, Wise TN. Effects of
progres- sive muscle relaxation training on anxiety and
depression in patients

enrolled in an outpatient pulmonary rehabilitation program.

Psychother Psychosom. 2008;77(2):119-125.

46. Saeedi M, Ashktorab T, Saatchi K, Zayeri F, Akbari SAA. The

effect of progressive muscle relaxation on sleep quality of patients
undergoing hemodialysis. Iranian J Crit Care Nurs. 2012;5(1): 23-
28.
47. Bu¨lbu¨l Y. Sleep disturbances in chronic obstructive pulmonary
disease.
Gu¨ncel Go¨g˘u¨s Hastalıkları Serisi. 2013;1(1):80-85.

48. Borge CR, Mengshoel AM, Omenaas E, et al. Effects of guided

deep breathing on breathlessness and the breathing pattern in
chronic

obstructive pulmonary disease: a double-blind randomized control

study. Patient Educ Couns. 2015:98(2):182-190.

49. Donesky D, Nguyen HQ, Paul SM, Carrieri-Kohlman V. The affec-

tive dimension of dyspnea improves in a dyspnea self-
management program with exercise training. J Pain Symptom
Manage. 2014;47(4): 757-771.
50. Volpato E, Banfi P, Rogers SM, Pagnini F. Relaxation techniques for
people with chronic obstructive pulmonary disease: a systematic
re- view and a meta-analysis. Evid Based Complement Altern Med.
2015; 628365.
 Pengaruh Kombinasi Breathing exercise &
Progressive Muscle Relaxation Dalam
Menurunkan Nyeri Punggung &
Sesak Napas Ibu Hamil Trimester III
Nurul Aini Rahmawati*, Siti Ainun Ma’rufa, Safun Rahmanto, Dinda Lutfiah Mei
Handiny, Mita Andini Ayu Lestari

Departement Fisioterapi, Universitas Muhammadiyah Malang, Jalan Bandung No. 1Malang 65133
*Corresponding author: ainirahmawati@umm.ac.id

ABSTRAK
Selama masa kehamilan, akan terjadi berbagai perubahan pada tubuh yang menyebabkan ketidaknyamanan pada
tubuh ibu hamil. Ketidaknyamanan yang paling sering dikeluhkan ibu hamil saat memasuki kehamilan trisemester
III diantaranya nyeri punggung bawah dan sesak nafas. Salah satu intervensi yang dapat digunakan untuk
mengurangi nyeri punggung bawah dan sesak nafas pada wanita hamil yaitu breathing exercise dan progressive
muscle relaxation technique (PMRT). Penelitian ini bertujuan untuk mengetahui pengaruh kombinasi breathing
exercise dan progressive muscle relaxation technique (PMRT) terhadap nyeri punggung bawah dan sesak nafas
pada ibu hamil trisemester III. Penelitian ini menggunakan desain quasi-eksperimental dengan menggunakan alat
ukur Numeric rating scale (NRS) untuk mengukur nyeri punggung bawah dan nafas yang dialami menggunakan
skala borg termodifikasi .Masing-masing sampel diukur nyeri punggung bawah dan tingkat sesak nafas sebelum
dan sesudah diberikan intervensi kombinasi breathing exercise dan progressive muscle relaxation technique.
Berdasarkan hasil uji statistic dengan Independent T test dan Wilcoxon test didapatkan nilai signifikansi
0.000(p>0,005) Sehingga dapat disimpulkan bahwa terdapat pengaruh kombinasi breathing exercise dan
progressive muscle relaxation technique (PMRT) terhadap nyeri punggung bawah dan tingkat sesak nafas pada ibu
hamil trisemester III.

Keywords: Breathing Exercise, Progressive Muscle Relaxation Technique, Ibu Hamil, Nyeri Punggung
Bawah, Sesak Nafas
PENDAHULUAN
Kehamilan merupakan kondisi dimana seorang wanita sedang mengandung dan mengembangkan fetus
dalam rahimnya selama sembilan bulan atau selama fetus masih berada di dalam rahim ibu (Casagrande et al.,
2015). Pada masa kehamilan akan terjadi berbagai perubahan pada ibu hamil, baik secara fisiologis maupun
psikologis. Beberapa perubahan yang terjadi pada ibu hamil diantaranya pada system kardiovaskuler, system
respirasi, system renal, dan system musculoskeletal. Perubahan-perubahan tersebut menyebabkan ibu hamil
merasa tidak nyaman selama proses kehamilan, dan akan mencapai puncaknya saat memasuki trisemester III
(Sukarta &

Yuliana, 2018) .

Permasalahan yang paling sering dikeluhkan ibu hamil saat memasuki trisemester III diantaranya yaitu nyeri
punggung bawah dan sesak nafas. Kondisi janin yang semakin membesar menyebabkan center of gravity pada ibu
hamil tersebut berpindah ke arah depan. Kemudian ligamen sakroiliaka menjadi lemah sehingga pelvic akan
berotasi kedepan dan menambah ketegangan pada lumbal bagian bawah maupun pada pelvis. Hal tersebut akan
menyebabkan nyeri punggung bawah belakang pada ibu hamil (Casagrande et al., 2015). Selain itu kondisi janin
yang semakin membesar juga akan mendesak diafragma ke atas sehingga fungsi diafragma dalam proses
pernafasan akan terganggu, yang mengakibatkan turunnya oksigenasi maternal, sedangkan pada kehamilan akan
meningkatkan 20% konsumsi oksigen dan 15% laju metabolik, hal ini yang dapat membuat ketidakseimbangan
ventilasi-perfusi yang menyebabkan sesak nafas pada ibu hamil (Handayani & Rodiani, 2014).

Beberapa intervensi yang dapat digunakan untuk mengurangi nyeri punggung bawah dan sesak nafas pada
ibu hamil yaitu breathing exercise dan progressive muscle relaxation technique (PMRT). Penelitian-penelitian
sebelumnya menunjukkan bahwa baik pemberian breathing exercise maupuan pemberian PMRT terbukti efektif
dalam mengurangi nyeri punggung bawah dan sesak nafas pada ibu hamil (Akmeşe & Oran, 2014; Casagrande et
al., 2015; Fitriani et al., 2019; Ravanbakhsh & Nargesi, 2015; Sd & Pennick, 2015). Namun belum terdapat
penelitian yang menguji efektivitas dari kombinasi breathing exercise dan PMRT, sehingga peneliti tertarik untuk
menelaah pengaruh kombinasi Breathing exercise dan progressive muscle relaxation technique dalam menurunkan
nyeri punggung bawah dan sesak nafas pada ibu hamil trisemester III.

METODE
Populasi pada penelitian ini adalah ibu hamil trisemester III yang melakukan pemeriksaan rutin di Klinik
Bidan Rina Kota Malang. Peneliti menggunakan purposive sampling dengan kriteria inklusi yaitu ibu hamil
trisemester III, mengalami nyeri punggung bawah, terdapat keluhan sesak nafas, dan berusia 20-40 tahun. Kriteria
eksklusi pada penelitian ini yaitu ibu hamil memiliki riwayat penyakit kardiorespirasi, mengalami plasenta previa,
dan tidak bersedia menjadi responden penelitian. Kriteria dropout pada penelitian ini yaitu responden yang tidak
mengikuti latihan sebanyak >2kali, melahirkan ditengah pelaksanaan penelitian, mengalami masalah kehamilan
serius seperti perdarahan & keguguran ditengah penelitian, dan mengundurkan diri sebagai responden.

Sampel pada penelitian ini adalah populasi yang memenuhi kriteria inklusi yang telah ditetapkan dan dibagi
menjadi kelompok perlakuan yang mendapatkan intervensi kombinasi breathing exercise dan PMRT, serta
kelompok kontrol yang tidak diberikan perlakuan apapun. Intervensi akan diberikan selama 8 minggu. Sampel
nantinya akan diukur tingkat nyeri punggung bawah menggunakan NRS dan sesak nafas yang dialami
menggunakan skala borg termodifikasi. Analisa data dilakukan menggunakan SPSS uji Paired T test & Independent
T test serta Uji Wilcoxon dan Mannwhitney.
 HASIL DAN PEMBAHASAN

Tabel 1 Hasil Uji Paired T-Test & Independent T-Test Tingkat Nyeri Punggung
Bawah
Perlakuan Kontrol p
Mean Pre- 5,55 4,82
Test
Mean Post- 3,82 6,18
Test
P=0,000 P=0,002

Selisih mean 1,73 -1,36 0,000

pre-test dan
post-test

Berdasarkan tabel 1 didapatkan adanya penurunan rata-rata nilai nyeri punggung bawah pada kelompok
perlakuan antara sebelum dan sesudah pemberian intervensi kombinasi breathing exercise dan PMRT dengan
nilai 1,73, sedangkan pada kelompok kontrol didapatkan adanya peningkatan rata-rata nilai nyeri punggung bawah
antara sebelum dan sesudah pemberian intervensi kombinasi breathing exercise dan PMRT dengan nilai 1,36.
Berdasarkan hasil uji paired T test didapatkan hasil pada kelompok perlakuan nilai p=0,000, pada kelompok kontrol
nilai p=0,002. Kemudian perbedaan rerata antara kelompok perlakuan dan kelompok kontrol dianalisis
menggunakan uji Independent T test, yang didapatkan hasil nilai p=0,000.

Dari hasil data tersebut dapat diinpretasikan bahwa terdapat penurunan tingkat nyeri punggung bawah pada ibu
hamil di kelompok perlakuan dan terdapat pengaruh yang signifikan dari pemberian kombinasi breathing
exercise dan PMRT terhadap nyeri punggung bawah pada ibu hamil trisemester III.

Tabel 2 Hasil Analisis Uji Wilcoxon dan Mann Whitney Tingkat Sesak Nafas

Perlakuan Kontrol p
Mean Pre- 3,91 3,36
Test
Mean Post- 1,09 3,64
Test
0,003 0,180

Selisih mean -2,82 + 0,28 0,000

pre-test dan
post-test

Berdasarkan tabel 2 didapatkan adanya penurunan rata-rata nilai tingkat sesak nafas pada kelompok
perlakuan antara sebelum dan sesudah pemberian intervensi kombinasi breathing exercise dan PMRT dengan
nilai 2,82, sedangkan pada kelompok kontrol didapatkan adanya peningkatan rata-rata nilai tingkat sesak nafas
antara sebelum dan sesudah pemberian intervensi kombinasi breathing exercise dan PMRT dengan nilai 0,28.
Berdasarkan hasil uji Wilcoxon didapatkan hasil pada kelompok perlakuan nilai p=0,003, pada kelompok kontrol
nilai p=0,18. Kemudian perbedaan rerata antara kelompok perlakuan dan kelompok kontrol dianalisis
menggunakan uji Mann Whitney, yang didapatkan hasil nilai p=0,000. Dari hasil data tersebut dapat
diinpretasikan bahwa terdapat penurunan tingkat sesak nafas pada ibu hamil di kelompok perlakuan dan
terdapat pengaruh yang signifikan dari pemberian kombinasi breathing exercise dan PMRT terhadap tingkat
sesak nafas pada ibu hamil trisemester III.

Nyeri punggung bawah dalam proses kehamilan di gambarkan sebagai nyeri pada regio lumbal yang berada
di atas sacrum yang dapat menjalar sampai daerah kaki (Zakaria et al., 2019). Salah satu penyebab dari nyeri
punggung bawah di masa kehamilan sangat bervariasi dan juga saling berhubungan diantaranya adalah kenaikan
berat badan pada masa kehamilan, perubahan postur tubuh, peregangan yang terjadi pada otot rectus abdominis,
maupun tingkat stress emosional (Sukarta & Yuliana, 2018). Peregangan sendi yang meningkat di masa kehamilan
sebagai hasil dari peningkatan sejumlah hormon, diantaranya adalah hormon progresteron, relaksin, dan
estrogen. Hormon relaksin merupakan hormon yang di produksi oleh plasenta dan korpus luteum. Hormon –
hormon tersebut mulai meningkat pada awal masa kehamilan dan terus meningkat hingga trimester ke tiga di
akhir kehamilan (Khaerunnisa, 2018). Suatu penelitian menunjukkan bahwa wanita hamil dengan keluhan low
back pain memiliki jumlah hormon relaksin yang cenderung tinggi (Casagrande et al., 2015).

Pada masa kehamilan seiring dengan membesarnya uterus, maka pusat gravitasi akan berpindah kearah
depan sehingga ibu hamil harus menyesuaikan posisi berdirinya, dimana ibu hamil harus bergantung dengan
kekuatan otot, penambahan berat badan, sifat relaksasi sendi, kelelahan serta postur sebelum hamil. Postur tubuh
yang tidak tepat akan memaksa peregangan tambahan dan kelelahan pada tubuh, terutama pada bagian tulang
belakang sehingga akan menyebabkan terjadinya sakit atau nyeri pada bagian punggung ibu hamil

(Casagrande et al., 2015).

Perubahan postur dipengaruhi oleh keadaan perut yang semakin hari semakin membesar yang kemudian
menyebabkan pusat gravitasi pada ibu hamil akan berpindah ke depan. Hal demikian akan menyebbakan terjadi
hyperlordosis dan rotasi pelvis kedepan. Yang dapat menambah ketegangan pada daerah pelvis dan lumbal
bawah. pergerakan tersebut dapat memberikan tekanan pada intervertebral disk, untuk penekanan lebih parah
hingga mengeluarkan cairan diskus. Sehingga yang sering dikeluhkan ibu hamil adalah nyeri punggung bawah

(Casagrande et al., 2015).

Rahim yang mulai membesar akan mengerahkan posisi istirahat dari kepala diafragma, dan mengurangi
volume cadangan ekspirasi (pengurangan sekitar 10-20%), dan juga kapasitas residu fungsional (Lee et al., 2017).
Hiperventilasi pada masa kehamilan biasanya terdapat volume tidal yang lebih tinggi dibandingkan takipnea.
Terjadinya peningkatan hormone progesterone dan estrogen pada saat kehamilan merupakan faktor yang
membuat peningkatan kebutuhan fisik serta hiperventilasi. Progesteron merupakan sebagai pemicu pusat
pernapasan primer dengan menurunkan ambang batas serta meningkatkan sensitivitas pusat pernapasan
terhadap CO2, sementara estrogen digunakan dalam proses peningkatan jumlah serta sensitivitas reseptor
progesterone pada hipotalamus dan medula. Secara bersamaan progesterone dan estrogen dapat membuat
penigkatan dorongan terjaga serta meningkatkan sensitivitas kemoreseptor sentral dan perifer, dan dapat
menurunkan ambang batas pengerahan ventilator, dengan demikian menyebabkan hiperventilasi terhadap
kehamilan (Lee et al., 2017).

Deep breathing exercise didefinisikan sebagai salah satu latihan otot pernapasan dalam meningkatkan
kapasitas vital paru yang bisa mengoptimalkan proses disfusi.

Meningkatnya kapasitas vital paru dapat membuat semakin meningkatnya perbedaan tekanan parsial gas yaitu
antara tekanan parsial gas pada alveoli dengan tekanan parsial gas pada darah kapiler paru. Peningkatan yang
terjadi pada parsial gas oksigen pada alveoli membuat tidak mengganggu proses disfusi, dengan demikian akan
meningkatkan saturasi oksigen (Mertha et al., 2018). Deep breathing exercise telah terbukti berhasil dalam
mengurangi sesak napas pada ibu hamil. Dilakukan dengan cara melakukan inspirasi secara dalam melewati
hidung dengan demikin akan membuat gerakan kebawah dari diafragma dan ekspansi pada perut ke luar
disertakan dengan pernapasan yang pelan melewati mulut sehingga dapat membantu dalam menurunkan laju
pernapasan dan mengoptimalkan pertukaran gas darah (Mertha et al., 2018). Selain itu, Kolar et al., (2012),
menunjukkan bahwa orang – orang dengan keluhan nyeri punggung bawah memiliki posisi diafragma yang tidak
normal. Kolar juga menjelaskan adanya hubungan antara nyeri punggung, fungsi diafragma dan juga fungsi core.
Pada penelitian yang dilakukan oleh Chiuman (2020) menunjukkan bahwa latihan kehamilan dan diaphragm
breathing exercise dapat mengurangi keparahan nyeri puggung setelah intervensi minggu ketiga dan ke empat

Selain itu penambahan Teknik relaksasi otot progresif atau progressive muscular relaxation technique
(PMRT) dalam latihan ini juga membantu mengidentifikasi otot yang tegang kemudian menurunkan ketegangan
dengan melakukan teknik relaksasi untuk mendapatkan perasaan relaks. PMRT akan menstimulasi saraf simpatis
pada medulla adrenal yang merangsang kelenjar endokrin dalam mengeluarkan epinefrin dan nonepinefrin.
Nonepinefrin selalu berkaitan pada reseptor α dan β2. Selama proses aktivitas simpatis, epinefrin yang berikatan
sama β2 di jantung serta otot rangka meningkatkan mekanisme vasodilator local pada jaringan-jaringan paru.
Dengan demikian dapat terjadi bronkodilatasi yang membuat udara keluar masuk akan lebih lancar dan aliran
puncak respirasi dapat meningkat (Sadhegi et al.,

2018)

KESIMPULAN
Pemberian kombinasi Breathing exercise dan progressive muscle relaxation technique berpengaruh dalam
menurunkan nyeri punggung bawah dan sesak nafas pada ibu hamil trisemester III

REFERENCE Fitriani, Erika A.K, & Syahrul. (2019). Progressive

Akmeşe, Z. B., & Oran, N. T. (2014). Effects of
Progressive Muscle Relaxation Exercises
Accompanied by Music on Low Back Pain and
Quality of Life During Pregnancy.
Journal of Midwifery and Women’s
Health, 59(5), 503–509.
https://doi.org/10.1111/jmwh.12176
Casagrande, D., Gugala, Z., Clark, S. M., & Lindsey, R.
W. (2015). Low Back Pain and Pelvic Girdle
Pain in Pregnancy. Journal of the American
Academy of Orthopaedic Surgeons,
23(9), 539–549.
https://doi.org/10.5435/JAAOS-D-
14-00248
Chiuman, L. (2020). Comparison of pregnancy
Exercise and Depth Breath Relaxation For
Lower Back Pain in Pregnant Women. Prima
Medical Journal ( Primer ). 2019– 2021.
Muscle Relaxation dalam Menurunkan Nyeri.
Jurnal Keperawatan Muhammadiyah, 36–
40.
Handayani, D. W., & Rodiani. (2014). Multigravida
Hamil 35 Minggu dengan Asma pada
Kehamilan Multigravida 35 Minggu Kehamilan
dengan Asma. Jurnal Agromedicine
UNILA, 3(1), 1–6.
http://juke.kedokteran.unila.ac.id/ind
ex.php/agro/article/view/1174 Khaerunnisa,
H. (2018). Pengaruh Kombinasi Lumbar
Flexion Exercise Dan Diaphragm Breathing
Exercise
Terhadap Perubahan Nyeri Punggung Bawah
Pada Hurulaeni Khaerunnisa Program Studi
Fisioterapi. Skripsi.
Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O.,
Andel, R., Kumagai, K., & Kobesová, A. (2012).
Postural function of the diaphragm in persons
with and without chronic low back pain.
 Journal of Orthopaedic and Sports Physical Interventions for preventing and treating low-
Therapy, 42(4), 352–362. back and pelvic pain during pregnancy
(Review).
Lee, S. Y., Chien, D. K., Huang, C. H.,
https://doi.org/10.1002/14651858.C
Shih, S. C., Lee, W. C., & Chang, D001139.pub4.www.cochranelibrary
W. H. (2017). Dyspnea in pregnancy. .com
Taiwanese Journal of Obstetrics and
Gynecology, 56(4), 432–436. Sukarta, A., & Yuliana, Y. (2018).
Mertha, I. M., Putri, P. J. Y., & Suardana, I. ketut. Pengetahuan Ibu Hamil Tentang
(2018). Pengaruh Pemberian Deep Breathing
Exercise Terhadap Saturasi Oksigen Pada Perubahan Dan Adaptasi Psikologi Trimester
Pasien PPOK. Jurnal Gema Keperawatan, 1, 1– Iii. JIKI Jurnal Ilmiah Kesehatan IQRA, 6(2),
9. 104–111.
https://stikesmu-sidrap.ejournal.id/JIKI/article
Ravanbakhsh, M., & Nargesi, M. (2015). The Effect of /view/70
Breathing Exercises on Breathing Pattern of
Pregnant Women. November 2014.
Sadeghi, B., Sirati-Nir, M., Hajimini, Z., Ebadi, A., &
Ali-Asgari, M. (2018). Comparing the effects of
progressive muscle relaxation and physical
activity on pregnant women’s general health.
Iranian Journal of Nursing and Midwifery
Research, 23(4), 298–304.
Sd, L., & Pennick, V. (2015).
e ISSN 2277 - 3290

Print ISSN 2277 - 3282

Journal of Science Nursing

www.jo
urnalof
science.
net

EFFECTIVENESS OF PROGRESSIVE MUSCLE

RELAXATION ON
PSYCHO-PHYSIOLOGICAL PARAMETERS
AMONG PATIENTS WITH COPD AT
UNIVERSITY TEACHING HOSPITAL
*
Naveen Jebakumar M, 1Porkodi A, 2Akila P
*
M.Sc. II year, Faculty of Nursing, Sri Ramachandra University, Porur,
Chennai, Tamil Nadu, India.
1
Reader (Ph.D), Faculty of Nursing, Sri Ramachandra University, Porur,
Chennai, Tamil Nadu, India.
2
Lecturer (MSN), Faculty of Nursing, Sri Ramachandra University, Porur,
Chennai, Tamil Nadu, India.

ABSTRACT
Anxiety is common among COPD patients and considerably alters breathing pattern.
The aim of this study was to assess the effectiveness of progressive muscle relaxation on
psycho-physiological parameters among patients with COPD. A sample of 40 COPD
patients were randomly assigned to study and control groups and PMR was given.
Results showed that PMR significantly reduced anxiety and thereby peak expiratory flow
rate (PEFR), blood pressure and heart rate.

Keywords: Progressive Muscle Relaxation, COPD, Anxiety, Physiological Parameters.

INTRODUCTION Dyspnea is a common symptom of many

The prevalence of chronic disease is
showing an uphill trend in most of the
countries and about one-third of the
population is affected with chronic
diseases. Among the chronic diseases,
COPD is a serious contemporary health
issue. Psychological comorbidities such
as anxiety and depression are very
common among COPD patients.
lung disorders. The feeling of not being
able to get air, especially on a regular
basis, can be upsetting. This anxiety can
further deteriorate the shortness of
breath. There is a direct relationship
between dyspnea and anxiety and that
if one were reduced, the other also
might lessen. Relaxation exercises are
used to improve functional status of

119
.
patients with COPD by reducing the
respiratory rate and increasing alveolar
ventilation [1-6].
OBJECTIVES
The objectives of the study were
to assess the
effectiveness of progressive muscle
relaxation on psychophysiological
parameters among patients with COPD,
and to associate the psycho-
physiological parameters with selected
background variables among patients
with COPD.
MATERIALS AND
METHODS
The research design adopted by the
investigator
was an experimental pretest-posttest
control group design. A total of 40
patients (study group-20, control group-
20) who were diagnosed with COPD
were randomized. Participants were
randomly assigned by simple lottery
method to either the study or the
control group. Based on the inclusion
and exclusion criteria patients were
selected for the study. The investigator
conducted the pretest after one day of
admission to chest ward on background
variables, Blood pressure, Heart rate,
PEFR, Borg CR10 scale and SSAI using
standardized tool. The investigator then
demonstrated the PMR on one to one
basis at the bedside and return
demonstration was done by them after
Corresponding Author:- Naveen Jebakumar M Email:- naveenjebakumar@gmail.com
each session. PMR was done twice a day
and continued for five days under
guidance and a posttest was conducted
on the fifth day. The time spent for data
collection procedure was 20-30 minutes
for each study participant: whereas,
control group participants received only
the routine nursing care. After
completion of the procedure each
individual was provided with the
opportunity to clarify their doubts. After
posttest PMR was demonstrated to the
control group participants.
ETHICAL
CONSIDERATION
The study was conducted after
the approval from the Institutional
Ethics committee. Participants were
explained clearly about the study
purpose and a written informed consent
was obtained before conducting the
study. Confidentiality of the responses
were assured and maintained
throughout the study [7-11].
CONCEPTUAL
FRAMEWORK
The investigator has applied the
―Modified Ernestine Weidenbach’s
helping art of clinical Nursing theory‖
(1964) to be appropriate for the current
study. Weidenbach’s in her theory has
stated that nursing action has four
distinct kinds of actions that include
reflex, conditioned, impulsive, and
deliberate nursing practice. The
deliberate nursing practice further
comprises of three components. They
are as follows: 1. Identification of
patient’s need (assessment of
background variables) 2. Ministration of
the help needed (progressive muscle
.
relaxation) and 3.Validation of action
(assessment of psycho-physiological
parameters) [12-16].
RESULTS
Table 1 illustrates that in the pretest
14(70%) of the study group patients had
severe anxiety and in the control group
19(95%) patients had moderate anxiety.
Whereas in the posttest, 18(90%)
patients in the study group and 11(55%)
patients in the control group had
moderate anxiety.
Table 2 illustrates
that the physiological
parameters such as diastolic BP and
dyspnea were statistically significant
when compared to control group.
Whereas no significant improvement in
systolic BP, heart rate and PEFR.
There was no significant
association between anxiety and
demographic variables except residence
during the pretest in the study group
which was
statistically significant at p<0.05
NURSING IMPLICATIONS
With prevalence of COPD
showing an uphill trend in most
countries it is imperative that
implications drawn from the study are of
vital concern to the field of nursing
including nursing service, education,
administration and research.
Nursing practice
PMR can be implemented as a part of
the treatment and can be carried out by
caregivers in the day to day activities
while caring for COPD patients. The
nurse needs to motivate the patients to
practice PMR in their daily life. It is
nurse’s responsibility to carry out and
teach PMR as a part of pulmonary
rehabilitation in the community as well.
Nursing Education
On education perspective it is
important that nurses not only be aware
of the techniques but also master them.
Progressive muscle relaxation should be
emphasized in the nursing education so
that tomorrows nurses are better
equipped to handle and preserve the
physical, emotional and social
disabilities associated with COPD and
other diseases.
Nursing Administration
Nurse administrator should organize
programs on PMR and proper protocols
and resources should be arranged for
the nursing staff to implement PMR for
patients to preserve and promote their
wellbeing.
Nursing Research
A team response must be
generated among the nurses to perform
the research on application of PMR,
standards and protocols and to
implement it in practice [18,19].
RECOMMENDATIONS FOR
FUTURE STUDY
1. A similar study can be replicated
with a larger sample size
2. A multicenter study can be done
among patients with
COPD
3. A similar study can be done using
audio instructed aids
4. Home based practice of PMR can
also be studied
5. A similar study can be done for a
longer period and regular follow up.
.

Table 1. Frequency and percentage distribution of anxiety during pretest

and posttest among patients with COPD in the study group and the control
group (N=40)
Duration Anxiety Study group (n=20) Control group(n=20)
No. % No. %
Pretest Mild - - - -
Moderate 6 30 19 95
Severe 14 70 1 5
Posttest Mild 2 10 0 0
Moderate 18 90 11 55
Severe 0 0 9 45
Table 2. Mean, standard deviation, independent t value and p value of
physiological parameters among patients with COPD in the study group and
the control group during posttest (N=40)
Sl.N Physiological Study group (n=20) Control group (n=20) Independent ‘t
o parameters Mean SD Mean SD value and p val
-1.796
1. Systolic BP 127 10.8 135.5 18.2
0.081(NS)
-3.126
2. Diastolic BP 79.5 8.87 88.5 9.3
0.003**
-0.866
3. Heart rate 73.85 5.47 75.85 8.7
0.392(NS)
-0.101
4. PEFR 255.50 28.37 256.50 33.91
0.920(NS)
-9.603
5. Dyspnea 3.55 1.037 6.75 1.070
0.000***

Figure 1. Percentage distribution of age in years (N=40)

Most patients seven (35%) in the study group were between the age group of 51 and 60 years and in the control group
six (30%) of them were distributed between 41 and 50 years, 51-60 years and 61-70 years respectively.
.

Figure 2. Percentage distribution of gender (N=40)

With regard to gender 16(80%) in the study group and 15(75%) in the control group were male

Figure 3. Percentage distribution of GOLD classification of COPD (N=40)

As per GOLD classification of COPD 17(85%) and 14(70%) were in class II-moderate COPD in both the study group and in
the control group respectively.

CONCLUSION
There was a significant
difference in the psychophysiological
parameters among patients who
performed PMR than those who do not.
Relaxation reduces anxiety there by
blood pressure, heart rate and
dyspnea.

ACKNOWLEDGEMENT
It is my privilege to be a part of the Sri
Ramachandra University and I thank the
Managing

Trustee, for allowing me to utilize the

resources available

in the University. I express my feeling of

deep gratitude,
.
1. Anne MB. Advanced Practice
Nursing. (1st ed.). Sudbury. Jones
and barlett publishers, 2009.
2. Baraniak A & Sheffield D. The
efficacy of psychologically based
interventions to improve anxiety,
depression and quality of life in
COPD: A systematic review and
meta-analysis. Patient Education
and Counseling, 83(1), 2011, 29- 36.
3. Basavanthappa BT. Nursing
Research. (2 nd
ed). New Delhi:
Jaypee Publishers, 2007.
4. Brenes GA. Anxiety and chronic
obstructive pulmonary disease.
Prevalence, impact, and treatment,
65(6), 2003, 963-70.
5. Chan-Yeung M, Ait-Khaled N, White
N, Ip MS & Tan WC. The burden and
impact of COPD in Asia and Africa.
REFERENCES
indebtedness and reverence to my
esteemed teachers and eminent guides
Prof. P.V. Ramachandran, M.Sc.(N).,
Chairman Nursing Education, Dr. A.
Porkodi, M.Sc(N)., Ph.D., Reader, Dept
of Medical Surgical Nursing and Mrs.
Akila P, M.Sc.(N)., Lecturer, Dept. of
Medical
Surgical Nursing Sri Ramachandra
College of Nursing, Sri Ramachandra
University for their constant
encouragement, exemplary suggestions,
enduring guidance and all their blessings
for the successful completion of my
research.
Int J Tuberc Lung Dis, 8, 2004, 2-
14.
6. Davis JA. The effects of progressive
muscle relaxation upon breathing
and anxiety in patients with chronic
obstructive pulmonary disease,
1980.
7. Global Initiative for Chronic
Obstructive Lung Disease. Global
strategy for diagnosis, management
and prevention of COLD.
NHLMI/WHO Workshop Report.
Bethesda, National Heart, Lung and
Blood Institute. NIH Publication No.
2701, 2001, 1-100.
8. Jindal SK. COPD: The Unrecognized
Epidemic in India supplements.
JAPI, Vol. 60, 2012.
9. Julie Erskine-Milliss, Ba, M Psych,
Malcolm Schonell. Relaxation
Therapy in Asthma: A Critical
.

Review Psychosomatic Medicine, Heart & Lung : the Journal of

43(4), 1981. Critical Care, 17(4), 1988, 408-13.
10. Kaplan GM. Enhancing 16. Sermsak Lolak, Gerilynn L. Connors,
hypnotizability: Differential effects Michael J. Sheridan & Thomas N
of flotation restricted Wise. (2008) ―Effects of
environmental stimulation Progressive Muscle Relaxation
technique and progressive muscle Training on Anxiety and Depression
relaxation, 1986. in Patients Enrolled in an Outpatient
11. Lewis, Heitkemper, Dirksen, O’Brien Pulmonary Rehabilitation Program.‖
and Bucher. (7th ed.) Lewis’s medical Psychotherapy & Psychosomatics,
surgical nursing: assessment & 77, 2008, 119–125.
management of clinical problems. 17. Sheila S, Barbara I, Shyan HL & Lin
Elsevier, 2011. CM. Effects of progressive muscle
12. McCallie M, Blum C & Hood C. relaxation on blood pressure and
Progressive Muscle Relaxation. psychosocial status for clients with
Journal of Human Behavior in the essential hypertension in Taiwan.
Social Environment, 13 (3), 2006, HNP, 17(1), 2003.
51-66. 18. Singh VP. Comparison of the
13. Phipps. Medical Surgical Nursing. effectiveness of music and
(8th ed). Noida: Elsevier Publishers, progressive muscle relaxation for
2009. anxiety in COPD—A randomized
14. Polit DF and Hungler BP. Nursing controlled pilot study Chronic
research principles and methods. 6 th Respiratory Disease. 6(4), 2009,
edition Philadelphia: Lippincott 209-216.
Williams 19. Surinder K. Jindal. Emergence of
15. Renfroe KL. Effect of progressive chronic obstructive pulmonary
relaxation on dyspnea and state disease as an epidemic in India.
anxiety in patients with chronic Indian J Med Res, 124, 2006, 619-
obstructive pulmonary disease. 630.

Penatalaksanaan Relaksasi Otot Progresif : Pursed Lip Breathing dan

Respiratory Muscles
Stretch Gymnastics dengan Ketidakefektifan Pola Napas Pasien PPOK di Desa Mojolaban
Kabupaten Sukoharjo
Progressive Muscle Relaxation Management : Pursed Lip Breathing And
Respiratory Muscles Stretch Gymnastics With Ineffective breathing pattern of
COPD patients in Mojolaban Village,
Sukoharjo Regency
Novita Siti Fatimah1, Deden Dermawan2
1,2
Politeknik Kesehatan Bhakti Mulia
novitasf18@gmail.com,
deden_abm@yahoo.co.id
Https://doi.org/10.55181/ijms.v9i1.347

Abstract: Chronic Obstructive Pulmonary Disease (COPD) is a disease

characterized by airflow obstruction in the airways (lungs) that is not fully
.

reversible (PDPI, 2011). The prevalence of COPD in Indonesia according to

Riskesdas (2013) reaches 3.7% or around 9.2 million people. Measures to
overcome the ineffectiveness of non-pharmacological breathing patterns are by
practicing progressive muscle relaxation breathing techniques: pursed lip
breathing exercise and respiratory muscle stretch gymnastics. The purpose of
this action was to describe the management of progressive muscle relaxation:
pursed lip breathing exercise and respiratory muscles stretch gymnastics with
nursing problems of ineffective breathing patterns in COPD patients. The
researcher uses a qualitative method with a case study approach. The technique
of taking the research subject is non-probability sampling with a purposive
sampling approach. The study population was 3 subjects with COPD. The results
of the study. Subjects said that they felt less short of breath, were not use nostril
breathing, were not use mouth breathing, respiration was in the normal range
(16-20 times/minute). The conclusion was that the provision of progressive
muscle relaxation exercises: pursed lip breathing exercise and respiratory
muscles stretch gymnastics is effective for overcoming the problem of ineffective
breathing patterns in COPD patients
Keywords: Pursed Lip Breathing, Respiratory Muscles Stretch Gymnastics,
Chronic Obstructive Pulmonary Disease
Abstrak: Penyakit Paru Obstruktif Kronik (PPOK) adalah penyakit yang ditandai dengan
adanya hambatan aliran udara di saluran napas (paru-paru) yang tidak sepenuhnya
reversibel (PDPI, 2011). Prevalensi PPOK di Indonesia menurut Riskesdas (2013)
mencapai 3,7% atau sekitar 9,2 juta jiwa.Tindakan untuk mengatasi ketidakefektifan
pola napas secara non farmakologis yaitu dengan latihan teknik pernapasaan relaksasi
otot progresif: pursed lip breathing exercise dan respiratory muscles stretch
gymnastics. Tujuan dilakukan tindakan ini untuk mendeskripsikan penatalaksanaan
relaksasi otot rogresif: pursed lip breathing exercise dan respiratory muscles
stretch gymnastics dengan masalah keperawatan ketidakefektifan pola napas pada
pasien PPOK. Peneliti menggunakan metode kualitatif dengan pendekatan studi kasus.
Teknik pengambilan subjek peneliti yaitu non-probality sampling dengan pendekatan
puposive sampling. Populasi penelitian adalah 3 subjek penderita PPOK. Hasil
penelitian Subjek mengatakan sesak napas yang dirasakan berkurang, tidak
menggunakan pernapasan cuping hidung, tidak menggunakan pernapasan mulut,
respirasi dalam rentang normal (1620 kali/menit). Kesimpulan pemberian latihan
relaksasi otot rogresif: pursed lip breathing exercise dan respiratory muscles
stretch gymnastics efektif untuk mengatasi masalah ketidakefektifan pola napas pada
pasien PPOK.

Kata Kunci: Pursed Lip Breathing, Respiratory Muscles Stretch Gymnastics,

Penyakit Paru Obstruktif
Kronik
I. PENDAHULUAN terusmenerus dengan peningkatan
Penyakit Paru Obstruktif Kronik respon inflamasi kronis di jalan
(PPOK) merupakan penyakit yang napas ke partikel berbahaya
dapat dicegah dan dapat diobati,
(Roisin, 2016). PPOK merupakan
yang ditandai dengan keterbatasan
penyakit yang dikarakteristikan
aliran udara progresif dan
dengan adanya sumbatan jalan
.
napas secara progresive dan hanya
sebagian yang bisa kembali normal,
terjadinya inflamasi pada jalan
napas, dan berpengaruh kepada
siskemik (Decramer, dkk, 2012).
PPOK menduduki peringkat ke-4
diantara penyakit tidak menular
dengan mortalitas tertinggi setelah
penyakit kardiovaskuler,
keganasaan, dan diabetes melitus.
The Global Burden of Disease
Study melaporkan prevalensi secara
global COPD sebanyak 251 juta kasus
pada tahun 2016, pada tahun 2015
kematian yang disebabkan oleh
penyakit PPOK mencapai 3,17 juta
yaitu 5% dari semua kematian di
seluruh dunia pada tahun itu (WHO,
2017).
Prevalensi Penyakit Paru
Obstruktif Kronik (PPOK) di
Indonesia menurut Riskesdas (2013)
mencapai 3,7% atau sekitar 9,2 juta
jiwa. PPOK lebih banyak pada laki-
laki (4,2%) dari pada perempuan
(3,3%). PPOK menjadi urutan
pertama pada kelompok penyakit
paru di Indonesia yang memiliki
angka kesakitan 35%, diikuti asma
bronchial 33%, kanker paru 30%, dan
lainnya 12% (Sugiharti, dkk, 2015).
Dinkes Jateng (2018) melaporkan
bahwa Penyakit Paru Obstruktif
Kronik (PPOK) di Jawa Tengah
menunjukan prevalensi 2,24%
dengan jumlah 54.110 jiwa. Dinkes
Jateng (2018) juga melaporkan
bahwa penderita PPOK di Kabupaten
Sukoharjo menurut data terakhir
pada tahun 2018 sebanyak 599 jiwa
dan asma bronkial sebanyak 3.291
jiwa.
Penatalaksanaan PPOK secara
farmakologi yaitu dengan cara
pemberian bronkodilator,
antikolinergik inhalasi,
simpatomimetik, mukolitik,
kortikosteroid sistemik, dan lain-lain
(Kristiningrum, 2019).
Penatalaksanaan non farmakologi
yaitu dengan cara edukasi, olahraga,
dan latihan pernapasan seperti
Pursed Lip Breathing Exercise,
Active Cycle Of Breathing
Technique (ACBT), Respiratory
Muscle Stretch Gymnastics
(RMSG) dan lain- lain.
Pursed lip breathing merupakan
salah satu terapi intervensi
keperawatan non farmakologi dan
non invasive yang dapat mengurangi
sesak napas (menurunkan frekuensi
pernapasan), meningkatkan saturasi
oksigen dan meningkatkan arus
puncak respirasi (Sitorus, 2015).
Tahapan mengerutkan bibir pada
pursed lip breathing dapat
memperpanjang ekshalasi, hal ini
akan mengurangi udara yang
terjebak di jalan napas, serta
meningkatkan pengeluaran CO2 dan
menurunkan kadar CO2 dalam darah
arteri serta meningkatkan O2,
sehingga akan terjadi perbaikan
homeostatis yaitu kadar CO2 dalam
darah arteri normal, pH darah juga
akan menjadi normal (Mutaqqin,
2012).
Respiratory Muscle Stretch
Gymnastics (RMSG) merupakan
teknik yang dikembangkan untuk
meringankan gangguan pernapasan
pada pasien PPOK. Dalam teknik ini,
aktivitas aferen dari serabut otot
interkostalis diperpanjang untuk
.
meringankan sesak napas, untuk
meminimalkan atrofi otot
pernapasan, dan menfasilitasi
kontraksi otot pernapasan yang
terkoordinasi (Rekha dkk,2016).
Penelitian terkait Pursed lip
breathing exercise yang dilakukan
oleh Silalahi dan Siregar (2018)
dalam penelitiannya didapatkan
hasil bahwa Pursed lip breathing
exercise efektif untuk menurunkan
sesak napas pada pasien PPOK, dan
penelitian yang dilakukan oleh
Vitaloka (2015) hasil penelitian
menjelaskan ada pengaruh
Respiratory muscle exercise
terhadap penurunan sesak napas
(dyspnea) pada penderita PPOK.
Berhubungan dengan adanya
pandemi Coronary Virus Disease
(Covid-19) serta peraturan yang
telah ditetapkan oleh pemerintah
dan institusi untuk memutus rantai
penyebaran Coronary Virus
Disease (Covid-19) maka penelitian
akan dilakukan di lingkungan sekitar
penelitiyaitu di Wilayah Kecamatan
Mojolaban Kabupaten Sukoharjo.
Berdasarkan uraian diatas peneliti
tertarik untuk melakukan study
kasus tentang Penatalaksanaan
Relaksasi Otot Progresif: pursed lip
breathing exercisedan respiratory
muscle stretch gymnastics dengan
masalah ketidakefektifan pola napas
pada pasien ppok di wilayah
kecamatan Mojolaban kabupaten
Sukoharjo.
METODOLOGI PENELITIAN
II.
Desain penelitian adalah
penelitian kualitatif, menggunakan
studi kasus dengan pendekatan
proses keperawatan. Penelitian
dilaksanakan pada bulam Juni – Juli
2020 di Wilayah Kecamatan
Mojolaban Kabupaten Sukoharjo.
Populasi penelitian adalah pasien
yang mempunyai Penyakit Paru
Obstruktif Kronik (PPOK) di Wilayah
Kecamatan Mojolaban Kabupaten
Sukoharjo. Penentuan sampel
dilakukan saat memasuki lapangan
dan selama penelitian berlangsung
(Emergent Sampling Design),
dengan cara memilih orang tertentu
yang dipertimbangkan akan
memberikan data yang diperlukan.
Teknik pengambilan subjek yaitu
non-probability sampling dengan
pendekatan purposive sampling.
Subjek penelitian sebanyak 3
responden yang mengalami
hipertensi dengan kriteria inklusi
berusia 20-60 tahun, sesak napas
derajat 2 (sesak saat melakukan
aktivitas), respirasi > 1620
kali/menit, hemodinamik stabil
(tekanan darah sistolik 90-130
mmHg, nadi 60-100 kali/menit),
suhu normal 36,5 ºC -37,5 ºC.
Pengumpulan data didapatkan
dari hasil wawancara, observasi,
pemeriksaan fisik, dan studi
dokumentasi. Instrumen penelitian
yang digunakan adalah format
asuhan keperawatan, lembar
observasi, Standart Operational
Prosedur pursed lip breathing dan
respiratory muscles stretch
gymnastics., format asuhan
keperawatan, buku catatan atau
buku tulis, panduan untuk
wawancara, dan alat-alat
pemeriksaan fisik: (Stetoskop,
.

sphignomanometer, dan Jumlah 3 100

termometer).
Pada penelitian ini jumlah total
III. HASIL PENELITIAN 1.
subjek yang diambil oleh peneliti
Gambaran lokasi penelitian
sebanyak 3 subjek. Hasil
Penelitian dilakukan di desa
pengambilan data didapatkan 3
Klumprit dan desa Joho pada tahun
subjek penelitian dengan umur 20-
2020. Desa Klumprit dan desa Joho
60 tahun menderita PPOK di
merupakan desa yang berada di
kecamatan Mojolaban. Karakteristik
kecamatan Mojolaban kabupaten
subjek sebagian besar dalam rentang
Sukoharjo. Desa Klumprit dengan
usia 20-60 tahun (100%), berjenis
luas wilayah 335,37 ha, terdiri dari 3
kelamin laki-laki (100%), latar
Rukun Warga (RW) dan 6 Rukun
belakang pendidikan subjek antara
Tetangga (RT), dimana setiap rukun
SD dan SMP mempunyai proporsi
tetangga terdiri dari 30-40 Kepala
yang sama sebanyak 3 orang (100%),
Keluarga (KK). Jumlah penduduk
dan sebagian besar subjek
desa Klumprit 5.258 jiwa, dengan
mempunyai pekerjaan buruh yaitu 3
jumlah penduduk laki-laki sebanyak
orang (100%).
2.587 jiwa dan jumlah penduduk
perempuan sebanyak
3.Pengkajian
2.671 jiwa
Hasil pengkajian dari ketiga
subjek didapatkan data subjektif:
2. Karakteristik subjek penelitian mengatakan sesak napas, batuk
Tabel 1 : Karakteristik Subjek dengan dahak yang sulit keluar. Data
Penelitian objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
No Frekuensi Presentase
cuping hidung, tampak bernapas
Karakteristik (ƒ) (%)
dengan mulut, frekuensi pernapasan
1 Usia
24-28 kali/menit, irama pernapasan
20-40 tahun 1 33
tidak teratur, upaya bernapas tidak
40-50 tahun 2 67
maksimal, menggunakan otot bantu
Jumlah 3 100
pernapasan, pengembangan paru
2 Jenis kelamin tidak maksimal, suara napas ronchi,
Laki-laki 3 100 0 ujung eksremitas teraba dingin.
Perempuan 0 100
Jumlah 3
3 Pendidikan 4. Diagnosis keperawatan
SD 1 33 Data dari pengkajian, digunakan
SMP 2 67 sebagai rumusan diagnosis
Jumlah 3 100 keperawatan yaitu: ketidakefektifan
4 Pekerjaan pola napas berhubungan dengan
Petani 1 33 kekurangan suplai O2.
Buruh 2 67
.
5. Perencanaan keperawatan
Rencana tindakan keperawatan
yang dilakukan selama 1 minggu 3
kali kunjungan dilakukan Prosedur
Pursed Lip Breathing Dan
Respiratory Muscles Stretch
Gymnastics dengan kriteria hasil:
sesak napas berkurang, frekuensi
pernapasan 16-20 kali/menit, upaya
bernapas maksimal, pengembangan
paru maksimal, tidak menggunakan
otot bantu pernapasan, suara napas
vesikuler.
6. Pelaksanaan keperawatan
a. Subjek 1
Pertemuan ke-1 peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: subjek mengatakan
sesak napas apabila melakukan
aktivitas yang berlebih dan data
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
26 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan masih
merasakan sesak napas, respon
objektif: tampak sesak napas, napas
subjek belum terkontrol, masih
menggunakan otot bantu
pernapasan. Tindakan selanjutnya
melatih subjek dengan tindakan
relaksasi respiratory muscles
gymnastics. Setelah dilakukan
tindakan respon subjektif: subjek
mengatakan masih merasakan sesak
napas. Respon objektif: keadaan
umum lemah, terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, frekuensi
pernapasan 26 kali/menit, irama
pernapasan tidak teratur, upaya
bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-2 tanggal 30 Juni 2020
pukul
09.00 WIB peneliti melakukan
observasi status pernapasan subjek
dan didapatkan respon subjektif:
mengatakan sesak napas apabila
melakukan aktivitas berlebih, data
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
24 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan masih
merasakan sesak napas, respon
objektif: terlihat sesak napas, napas
subjek belum terkontrol. Tindakan
selanjutnya melatih subjek dengan
.
tindakan relaksasi respiratory
muscles stretch gymnastics.
Setelah dilakukan tindakan respon
subjektif: subjek mengatakan masih
merasakan sesak napas. Respon
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
22 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-3 tanggal 01 juli
2020 pukul 09.10 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan masih
merasakan sesak napas, keadaan
umum lemah, terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, frekuensi
pernapasan 22 kali/menit, irama
pernapasan tidak teratur, upaya
bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan sesak
napas berkurang, respon objektif:
sesak napas berkurang, napas subjek
belum terkontrol, masih
menggunakan otot bantu
pernapasan. Tindakan selanjutnya
melatih subjek dengan tindakan
relaksasi respiratory muscles
stretch gymnastics. Setelah
dilakukan tindakan respon subjektif:
subjek mengatakan lebih relaks dan
sesak napas berkurang. Respon
objektif: tidak terlihat sesak napas,
tidak pernapasan cuping hidung,
tidak tampak bernapas mulut,
frekuensi pernapasan 20 kali/menit,
irama pernapasan teratur, upaya
bernapas maksimal, tidak
menggunakan otot bantu
pernapasan, pengembangan paru
maksimal, suara napas vesikuler.
b. Subjek 2
Pertemuan ke-1 tanggal 29 Juni
2020 pukul 15.20 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan sesak
napas, data objektif: keadaan umum
lemah, terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, frekuensi
pernapasan 26 kali/menit, irama
pernapasan tidak teratur, upaya
bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan
napasnya lebih relaks dan terkontrol,
respon objektif: tampak sesak napas
berkurang, napas sudah mulai
terkontrol, masih menggunakan otot
bantu pernapasan. Tindakan
selanjutnya melatih subjek dengan
.
tindakan relaksasi respiratory
muscles stretch gymnastics.
Setelah dilakukan tindakan respon
subjektif: subjek mengatakan masih
merasakan sesak napas dan masih
merasakan batuk. Respon objektif:
keadaan umum lemah, terlihat sesak
napas, pernapasan cuping hidung,
tampak bernapas dengan mulut,
frekuensi pernapasan 24 kali/menit,
irama pernapasan tidak teratur,
upaya bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-2 tanggal 30 Juni
2020 pukul 15.00 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan sesak
napas, respon objektif: keadaan
umum lemah, terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, frekuensi
pernapasan 26 kali/menit, irama
pernapasan tidak teratur, upaya
bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek
mengatakannapasnya lebih
terkontrol, respon objektif: tampak
lebih relaks, napas subjek mulai
terkontrol. Tindakan selanjutnya
melatih subjek dengan tindakan
relaksasi respiratory muscles
stretch gymnastics. Setelah
dilakukan tindakan respon subjektif:
subjek mengatakan masih
merasakan sesak napas. Respon
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
22 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-3 tanggal 01 juli
2020 pukul 15.00 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan masih
merasakan sesak napas, respon
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
24 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan sesak
napas berkurang dan napas lebih
terkontrol, respon objektif: sesak
napas berkurang, napas subjek mulai
terkontrol, masih menggunakan otot
bantu pernapasan. Tindakan
selanjutnya melatih subjek dengan
.
tindakan relaksasi respiratory
muscles stretch gymnastics.
Setelah dilakukan tindakan respon
subjektif: subjek mengatakan lebih
relaks dan masih merasakan sesak
napas. Respon objektif: tidak terlihat
sesak napas, tidak ada pernapasan
cuping hidung, tidak tampak
bernapas dengan mulut, frekuensi
pernapasan 20 kali/menit, irama
pernapasan teratur, upaya bernapas
maksimal, tidak menggunakan otot
bantu pernapasan, pengembangan
paru maksimal, suara napas
vesikuler, ujung eksremitas teraba
dingin. c. Subjek 3
Pertemuan ke-1 tanggal 29 Juni
2020 pukul 10.20 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan sesak
napas, Respon objektif: keadaan
umum lemah, terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, frekuensi
pernapasan 26 kali/menit, irama
pernapasan tidak teratur, upaya
bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan
napasnya lebih relaks dan terkontrol,
respon objektif: tampak sesak napas
berkurang, napas sudah mulai
terkontrol. Tindakan selanjutnya
melatih subjek dengan tindakan
relaksasi respiratory muscles
stretch gymnastics. Setelah
dilakukan tindakan respon subjektif:
subjek mengatakan masih
merasakan sesak napas. Respon
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
24 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-2 tanggal 30 Juni
2020 pukul 10.00 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan sesak
napas, respon Respon objektif:
keadaan umum lemah, terlihat sesak
napas, pernapasan cuping hidung,
tampak bernapas dengan mulut,
frekuensi pernapasan 24 kali/menit,
irama pernapasan tidak teratur,
upaya bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan lebih
nyaman saat bernapas, respon
objektif: tampak lebih relaks, napas
subjek mulai terkontrol. Tindakan
selanjutnya melatih subjek dengan
tindakan relaksasi respiratory
muscles stretch gymnastics.
.
Setelah dilakukan tindakan respon
subjektif: subjek mengatakan sesak
napas berkurang. Respon objektif:
keadaan umum lemah, terlihat sesak
napas, pernapasan cuping hidung,
tampak bernapas dengan mulut,
frekuensi pernapasan 22 kali/menit,
irama pernapasan tidak teratur,
upaya bernapas tidak maksimal,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Pertemuan ke-3 tanggal 01 juli
2020 pukul 10.10 WIB peneliti
melakukan observasi status
pernapasan subjek dan didapatkan
respon subjektif: mengatakan masih
merasakan sesak napas, respon
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
24 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin.
Tindakan kedua adalah melatih
subjek dengan latihan teknik
pernapasan pursed lip breathing
setelah dilakukan tindakan respon
subjektif: subjek mengatakan sesak
napas berkurang dan napasnya lebih
terkontrol, respon objektif: sesak
napas berkurang, napas subjek mulai
terkontrol. Tindakan selanjutnya
melatih subjek dengan tindakan
relaksasi respiratory muscles
stretch gymnastics. Setelah
dilakukan tindakan respon subjektif:
subjek mengatakan lebih relaks dan
sesak napas berkurang. Tidak
terlihat sesak napas, tidak ada
pernapasan cuping hidung, tidak
bernapas dengan mulut, frekuensi
pernapasan 20 kali/menit, irama
pernapasan teratur, upaya bernapas
maksimal, tidak menggunakan otot
bantu pernapasan, pengembangan
paru maksimal, suara napas
vesikuler.
7. Evaluasi keperawatan
a. Subjek 1
Setelah dilakukan tindakan
keperawatan selama 3x kunjungan
didapatkan hasil: data subjektif:
subjek mengatakan lebih relaks dan
sesak napas berkurang. Data
objektif: subjek tampak relaks, tidak
terlihat sesak napas, tidak
pernapasan cuping hidung, tidak
tampak bernapas mulut, frekuensi
pernapasan 20 kali/menit, irama
pernapasan teratur, upaya bernapas
maksimal, tidak menggunakan otot
bantu pernapasan, pengembangan
paru maksimal, suara napas
vesikuler. Evaluasi: ketidakefektifan
pola napas berhubungan dengan
suplai O2 teratasi. b. Subjek 2
Setelah dilakukan tindakan
keperawatan selama 3x kunjungan
didapatkan hasil:data subjektif:
subjek mengatakan lebih relaks dan
sesak napas berkurang. Data
objektif: subjek tampak relaks, tidak
terlihat sesak napas, tidak ada
pernapasan cuping hidung, tidak
tampak bernapas dengan mulut,
frekuensi pernapasan 20 kali/menit,
irama pernapasan teratur, upaya
.
bernapas maksimal, tidak
menggunakan otot bantu
pernapasan,
pengembangan paru
maksimal, suara napas vesikuler.
evaluasi: ketidakefektifan
pola napas
berhubungan dengan suplai O2
teratasi. c. Subjek 3
Setelah dilakukan tindakan
keperawatan selama 3x kunjungan
didapatkan: data subjektif: subjek
mengatakan lebih relaks dan sesak
napas berkurang. Data objektif:
subjek tampak relaks, tidak sesak
napas, tidak ada pernapasan cuping
hidung, tidak tampak bernapas
dengan mulut, frekuensi pernapasan
20 kali/menit, irama pernapasan
teratur, upaya bernapas maksimal,
tidak menggunakan otot bantu
pernapasan, pengembangan paru
maksimal, suara napas vesikuler.
Evaluasi: ketidakefektifan pola
napas berhubungan dengan suplai
O2 teratasi.
IV. PEMBAHASAN
1. Pengkajian
Pengkajian adalah proses
pengumpulan data relevan yang
continuetentang respon manusia,
status kesehatan, kekuatan dan
masalah klien. Kemampuan berfikir
kritis digunakan untuk membedakan
informasi esensial dan relevan dari
data yang tidak relevan. Pengkajian
memvalidasi data penting dan
mengkategorikan serta
mengorganisasi informasi dengan
cara yang bermakna (Dermawan,
2012).
Peneliti melakukan pengkajian
terhadap subjek dengan Penyakit
Paru Obstruktif Kronik (PPOK)
sejumlah 3 subjek penelitian
menggunakan pengkajian format
asuhan keperawatan dengan
mengajukan pertanyaan berupa
nama, umur, alamat, jenis kelamin,
kebiasaan merokok, pekerjaan,
keluhan yang dirasakan oleh subjek.
Penelitian, dan melakukan
pemeriksaan fisik berupa mengukur
tanda – tanda vital dan melakukan
pemeriksaan dada.
Hasil pengkajian karakteristik
dari 3 subjek terlihat sesak napas,
pernapasan cuping hidung, tampak
bernapas dengan mulut, upaya
bernapas tidak maksimal, irama
pernapasan tidak teratur,
menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi.
RR subjek 24-28 kali/menit, ujung
eksremitas teraba dingin. Hal ini
sejalan dengan teori Menurut
Vogelmeirer et al (2017).
Manifestasi klinis beberapa pasien
yang menderita PPOK yaitu: sesak
napas, kecemasan, batuk, produksi
sputum, mengi, kelelahan,
penurunan berat badan, anoreksia
dan sulit bernafas saat beraktivitas.
Wawancara, observasi langsung
dan pengukuran yang digunakan
untuk memperoleh data subjektif
dan objektif. Data otomatis dicatat
dan berfungsi sebagai dasar semua
komponen dalam proses
keperawatan. Pengumpulan data
.
otomatis dicatat dan berfungsi
sebagai dasar semua komponen
dalam proses keperawatan.
Pengumpulan data bersifat
keseimbangan selama melakukan
proses keperawatan, karena data
baru mungkin mengubah komponen
lain, maka data dokumentasi secara
tepat
(Dermawan, 2012).
Hasil pengkajian karakteristik
subjek berdasarkan usia, rata-rata
subjek berusia di rentang 20-50
tahun. Usia dalam proses penuaan
dapat menyebabkan terjadinya
penurunan fungsi paru. Hasil
penelitian ini sesuai dengan Darmojo
(2011) yang mengatakan bahwa usia
berkaitan dengan proses penuaan
dimana semakin bertambahnya usia
maka semakin besar kemungkinan
terjadinya penurunan kapasitas
fungsi paru. Perubahan struktur dan
anatomis karena penuaan antara
lain gangguan dan hilangnya serabut
elastin, pengecilan diameter
bronkiolus, pembesaran airspace
terminal, penambahan jumlah pori-
pori kohn, pengurangan total area
permukaan alveolar, dan
pengurangan jumlah kapiler per
alveolus, karena terjadinya
penurunan kapasitas fungsi paru,
sehingga pada usia 20-50 tahun lebih
rentan terkena polutan.
Hasil pengkajian karakteristik
subjek berdasarkan jenis kelamin
didapatkan data semua subjek
berjenis kelamin laki-laki. Mayoritas
penderita PPOK adalah laki-laki. Hal
ini sesuai dengan Irawan (2010) yang
menyatakan PPOK menyerang laki-
laki dua kali lebih banyak dari wanita
karena diperkirakan laki-laki adalah
perokok berat. Hal ini serupa dengan
penelitian Lestari, Herawati &
Rosella (2015) yang menyebutkan
bahwa mayoritas penderita PPOK
92% adalah laki-laki.
Hasil pengkajian karakteristik
subjek berdasarkan tingkat
pendidikan diketahui bahwa
proporsi tingkat pendidikan rendah
yaitu SD dan SMP, hal tersebut
sesuai dengan Irawan (2010) yang
menyatakan pendidikan
berpengaruh terhadap kesehatan,
hal ini sejalan dengan Mappadang
(2016) yang menyatakan bahwa
seseorang berpendidikan rendah
berpengaruh pada tingkat
pengetahuan mengenai penyakit,
faktor risiko penyakit dan cara
pencegahannya. Karena seseorang
dengan pendidikan rendah akan
cenderung tidak menerapkan pola
hidup bersih dan sehat, bagaimana
menghindari penyakit dan apa yang
harus dilakukan sebagai upaya
penanggulangan masalah penyakit.
Hasil pengkajian berdasarkan
karakteristik status pekerjaan
didapatkan data semua subjek
dengan status pekerjaan buruh,
salah satu faktor resiko Penyakit
Paru Obstruktif Kronik (PPOK) adalah
status pekerjaanya. Hal ini sesuai
dengan Helmi (2013) yang
menyatakan bahwa status pekerjaan
buruh (bangunan, pembuatan batu
bata, buruh pabrik, petani, dan lain -
lain), pertambangan (emas,
batubara), tukang las, serta supir
berisiko menderita PPOK, karena
.
seseorang dengan status pekerjaan
buruh akan cenderung sering
terpapar dengan polutan di tempat
kerja seperti bahan kimia, debu atau
zat yang mengiritasi, dan gas
beracun.
Hasil pengkajian didapatkan hasil
3 subjek merupakan perokok aktif
dan memiliki riwayat merokok dalam
jangka waktu lama 5 sampai 20
tahun. Kebiasaan merokok dalam
jangka waktu tertentu mampu
menjadi penyebab terjadinya
berbagai penyakit paru. Hasil
penelitian ini sesuai dengan
Sepdianto (2015) yang menyatakan
bahwa kebiasaan merokok
merupakan salah satu penyebab
meningkatnya prevalensi PPOK. Hal
ini sesuai dengan Somantri (2012),
bahwa merokok menjadi penyebab
utama kanker paru, emfisema dan
bronkhitis kronis, semua kejadian
tersebut sangat jarang terjadi pada
nonperokok. Hal tersebut banyak
dipengaruhi usia mulainya kebiasaan
merokok dan rata-rata jumlah rokok
yang dihisap per hari. Chang (2010)
juga menyebutkan PPOK bersifat
progresif pada individu yang tetap
merokok. Mekanisme merokok
tembakau yang menyebabkan PPOK
sangat kompleks, karena setiap
batang rokok mengandung ribuan
bahan kimia tersendiri yang
merangsang peradangan dan
kerusakan jaringan alveolar. Produk
tembakau merusak pertahanan
sistem pernapasan normal yang
menyebabkan sempitnya jalan
napas.
Berdasarkan pengkajian yang
dilakukan peneliti terhadap 3 subjek
didapatkan data bahwa semua
subjek merasakan sesak napas dan
batuk disertai dahak yang sulit
keluar dan suara nafas ronchi.
Menurut Khasanah (2014) sesak
napas atau dyspnea merupakan
gejala yang umum dijumpai pada
penderita PPOK. Penyebab sesak
napas tersebut bukan hanya karena
obstruksi pada bronkus tetapi lebih
disebabkan karena adanya
hiperinflasi. Menurut Handoko
(2012) Sesak napas disebabkan oleh
aliran udara dalam saluran
pernapasan karena penyempitan.
Penyempitan dapat terjadi karena
saluran pernapasan menguncup,
oedema atau timbulnya sekret yang
menghalangi saluran pernapasan.
Sesak napas dapat ditentukan
dengan menghitung pernapasan
dalam satu menit.
2. Diagnosis keperawatan
Diagnosis keperawatan adalah
keputusan klinik tentang respon
individu, keluarga, dan masyarakat
tentang masalah kesehatan aktual
atau potensial, berdasarkan
pendidikan dan pengalamannya,
perawat secara akuntabilitas dapat
mengidentifikasi dan memberikan
intervensi secara pasti untuk
menjaga, menurunkan, membatasi,
mencegah, dan merubah status
kesehatan (Dermawan, 2012).
Berdasarkan data-data yang
diperoleh peneliti dari hasil
pengkajian penelitian pada 3 subjek
didapatkan data subjektif: subjek
.
mengatakan sesak napas. Data
objektif: keadaan umum lemah,
terlihat sesak napas, pernapasan
cuping hidung, tampak bernapas
dengan mulut, frekuensi pernapasan
24-28 kali/menit, irama pernapasan
tidak teratur, upaya bernapas tidak
maksimal, menggunakan otot bantu
pernapasan, pengembangan paru
tidak maksimal, suara napas ronchi,
ujung eksremitas teraba dingin. Data
tersebut sesuai dengan karakteristik
Herdman (2018) yaitu: dyspnea,
irama pernapasan tidak teratur,
menggunakan otot bantu
pernapasan, pernapasan cuping
hidung, pernapasan bibir.
Berdasarkan data tersebut muncul
masalah keperawatan dengan
problem ketidakefektifan pola
napas. Berdasarkan hasil pengkajian
yang dilakukan peneliti terhadap ke-
3 subjek dapat dirumuskan diagnosis
keperawatan yaitu ketidakefektifan
pola napas berhubungan dengan
kekurangan suplai O2.
Ketidakefektifan pola napas adalah
inspirasi dan/atau ekspirasi yang
tidak memberi ventilasi inadekuat
(Herdman, 2018).
3. Perencanaan keperawatan
Perencanaan keperawatan
adalah fase proses keperawatan
yang penuh pertimbangan dan
sistematis mencakup pembuatan
keputusan dan penyelesaian
masalah. Dalam perencanaan,
perawat merujuk pada data
pengkajian subjek dan pernyataan
yang diperlukan untuk mencegah,
mengurangi, atau menghilangkan
masalah kesehatan subjek.
Intervensi keperawatan adalah
setiap tindakan berdasarkan
penilaian klinis dan pengetahuan,
yang perawat lakukan untuk
meningkatkan hasil pada subjek
(Kozier, 2010).
Tahap perencanan merupakan
tahap lanjutan dari diagnosis
keperawatan, dimana tahapan ini
akan menentukan keberhasilan
suatu tindakan dengan menetapkan
penulisan tujuan dan hasil
berdasarkan “SMART” yaitu
Specific dimana tujuan ini harus
spesifik dan tidak menimbulkan arti
ganda. Measureble dimana tujuan
keperawatan ini harus dapat diukur
dalam arti dapat dilihat
didengarkan, dirasakan, dan diraba.
Achievable dimana tujuan ini
harus dicapai. Reasonable/realitic
dimana tujuan harus dapat
dipertanggungjawabkan secara
ilmiah. Time dimana tujuan harus
mempunyai batasan waktu yang
jelas.
(Dermawan, 2012).
Peneliti menetapkan rencana
tindakan keperawatan untuk
mengatasi masalah keperawatan
ketidakefektifan pola napas pada
Penyakit Paru Obstruktif Kronik
(PPOK). SMART, S: specific dalam
penelitian ini tujuan pursed lip
breathing dan respiratory
muscles stretch gymnasticsyaitu
untuk mengurangi sesak napas
(menurunkan frekuensi
pernapasan), M: measurable,
setelah diberikan pursed lip
breathing dan respiratory
muscles stretch gymnastics
.
respirasi dalam rentang normal
yaitu 16-20 kali/menit. A:
achievable, pemberian pursed lip
breathing dan respiratory
muscles stretch
gymnasticstercapai apabila subjek
mengatakan sesak berkurang,
subjek bernapas tidak
menggunakan otot bantu
pernapasan, pengembangan paru
maksimal, kedalaman bernapas
maksimal, irama napas teratur,
suara napas vesikuler. R:
reasonable pemberian pursed lip
breathing dan respiratory
muscles stretch gymnastics
sudah terbukti efektif menurut
penelitian Silalahi dan Siregar
(2018) dan Vistaloka (2015). T: time
waktu dilakukan tindakan pursed
lip breathing dan respiratory
muscles stretch gymnastics
dengan durasi 10-
15 menit dalam 3 kali kunjungan
dalam 1minggu.
Perencanaan keperawatan yang
peneliti tetapkan sudah sesuai
dengan (Bulechek, 2013), yang
meliputi: observasi tanda-tanda
vital, kaji status pernapasan, berikan
posisi semi fowler, stabilisasi dan
membuka jalan napas, fisioterapi
dada, resusitasi, ajarkan teknik
pernapasan dan teknik relaksasi otot
progresif (misalnya pursed lip
breathing dan respiratory muscles
stretch gymnastics), dan berikan
terapi O2 sesuai anjuran dokter.
Peneliti merencanakan tindakan
keperawatan yang dilakukan berupa
pursed lip breathing dan
respiratory muscles stretch
gymnasticsuntuk mengatasi
masalah keperawatan
ketidakefektifan pola napas. Latihan
pernapasan pursed lip breathing
dan respiratory muscles stretch
gymnasticsmerupakan salah satu
latihan pernapasan untuk
mengontrol pernapasan agar
menghasilkan pola pernapasan yang
tenang dan ritmis sehingga menjaga
kinerja otot-otot pernapasan
(Edward, 2012). Alasan peneliti
memilih tindakan keperawatan
pursed lip breathing dan
respiratory muscles stretch
gymnastics karena efektif dan
dapat digunakan sebagai salah satu
alternatif intervensi keperawatan
mandiri dalam memberikan asuhan
keperawatan pada subjek PPOK.
Menurut (Yunani, et al, 2017)
latihan pernapasan pursed lip
breathing dan respiratory muscles
stretch gymnastics merupakan
salah satu latihan pernapasan yang
selain berfungsi untuk mengurangi
dyspnea dengan meningkatkan pola
pernapasan, meningkatkan ventilasi
dan oksigenasi, meregangkan dan
mengurangi kekakuan dinding dada
khususnya otot-otot pernapasan,
mempertahankan fungsi paru.
PPOK dapat menimbulkan
dampak pada penurunan elastisitas
dan compliance paru dan dapat
meningkatkan kerja otot pernapasan
serta kemampuan ekspirasi
maksimum (Guyton & Hall, 2010).
Salah satu tanda dan gejala yang
sering terjadi pada subjek yang
mengalami PPOK adalah dyspnea,
dan manfaat latihan pernapasan
.
pursed lip breathing dan
respiratory muscles stretch
gymnastics adalah dapat
mengurangi dyspnea (Edward,
2012). Hal ini sejalan dengan
penelitian Kritina L Silalahi dan
Tobus Hasiholah Siregar (2018) dan
Astika Galuh Vistaloka (2015). Bahwa
pursed lip breathing dan
respiratory muscles stretch
gymnastics dapat mengurangi
dyspnea.
Penelitian dilakukan selama 3
hari berturutturut, waktu 3 hari ini
relatif cukup untuk latihan yang
dilakukan sehingga mendapatkan
hasil yang maksimal. Hal tersebut
sesuai dengan Kritina L Silalahi dan
Tobus Hasiholah Siregar (2018) yang
menyebutkan bahwa hasil penelitian
dilakukan 3 hari berturut-turut
karena frekuensi atau durasi waktu
latihan yang semakin lama akan
semakin besar penurunan frekuensi
napas dan semakin terlatihnya
otototot pernapasan. Secara
fisiologis latihan pursed lip
breathing dan respiratory muscles
stretch gymnastics mampu
mengkoordinasi pengembangan
(compliance) dan pengempisan
(deflection) paru secara optimal,
serta pengaliran udara dari dalam
paru.
4. Pelaksanaan keperawatan
Penatalaksanaan terdiri atas
melakukan dan
mendokumentasikan tindakan
yang merupakan tindakan
keperawatan khusus yang
diperlukan untuk melaksanakan
intervensi (program keperawatan).
Perawat melaksanakan atau
mendelegasikan tindakan
keperawatan untuk intervensi yang
disusun dalam tahap perencanaan
dan kemudian mengakhiri tahap
implementasi dengan mencatat
tindakan keperawatan dan respon
subjek terhadap tindakan
keperawatan tersebut (Kozier,
2010).
Berdasarkan rencana tindakan
yang telah disusun, untuk mengatasi
ketidakefektifan pola napas
berhubungan dengan kekurangan
suplai O dengan teknik relaksasi
otot progresif pursed lip breathing
dan respiratory muscles stretch
gymnastics yang dilakukan pada
tiga subjek selama 3 kali pertemuan
adalah melakukan latihan relaksasi
otot progresif pursed lip breathing
dan respiratory muscles stretch
gymnastics, yang dilakukan selama
10-15 menit, setelah melakukan
relaksasi, sesak napas dapat
berkurang dari 24-28 kali/menit
menjadi 16-20 kali/menit.
Peneliti menerapkan
implementasi pemberian teknik
relaksasi otot progresif pursed lip
breathing dan respiratory muscles
stretch gymnastics. Sebelum
dilakukan tindakan relaksasi otot
progresif pursed lip breathing dan
respiratory muscles stretch
gymnastics dikaji terlebih dahulu
tentang status pernapasannya,
kemudian dilakukan tindakan teknik
relaksasi otot progresif pursed lip
breathing dan respiratory muscles
stretch gymnastics, setelah
.
dilakukan tindakan tersebut dikaji
kembali tentang status
pernapasannya. Hal tersebut sesuai
dengan Silalahi dan Siregar (2018)
yang menyatakan bahwa pursed lip
breathing dan respiratory muscles
stretch gymnastics bermanfaat
untuk menurunkan derajat sesak
napas serta mampu menjaga
manajemen pernapasan dan kontrol
pernapasan yang lebih baik.
Menurut Potter & Perry (2010)
teknik fisik seperti pembaharuan
kardiopulmonal (misalnya olahraga,
teknik pernapasan dan pengontrolan
batuk) membantu mengurangi
dyspnea. Latihan pernapasan
adalah Teknik untuk meningkatkan
ventilasi dan oksigenasi. Pursed lip
breathing adalah pernapasan dalam
mengerutkan bibir dan pernapasan
diafragma. Latihan ini mampu
meningkatkan efisiensi pernapasan
dengan menurunkan jumlah udara
yang terperangkap. Hal ini sesuai
dengan teori Sepdianto (2015) yang
menyebutkan dengan latihan
pernapasan dapat menurunkan
gejala dyspnea.
5. Evaluasi keperawatan
Evaluasi adalah fase kelima dan
fase terakhir proses keperawatan.
Evaluasi adalah aspek penting proses
keperawatan karena kesimpulan
yang ditarik dari evaluasi
menentukan apakah intervensi
keperawatan harus diakhiri,
dilanjutkan atau diubah. Evaluasi
berlanjut sampai subjek mencapai
tujuan kesehatan atau selesai
mendapatkan asuhan keperawatan
sesuai kebutuhan (Kozier, 2010).
Peneliti melakukan evaluasi
dengan membandingkan data
subjektif dan data objektif dengan
kriteria hasil yang sudah ditetapkan
pada perencanaan. Menurut Potter
& Perry (2010) eveluasi keperawatan
dilakukan dengan membandingkan
kemajuan subjek dengan tujuan dan
hasil yang diharapkan dari rencana
asuhan keperawatan. Hasil dari
implementasi 3 subjek penelitian
didapatkan hasil bahwa pada hari
pertama dilakukan pursed lip
breathing dan respiratory muscles
stretch gymnastics terdapat tanda
dan gejala ketidakefektifan pola
napas. Setelah dilakukan latihan
pursed lip breathing dan
respiratory muscles stretch
gymnasticsselama 3 hari berturut-
turut selama 10-15 menit setiap
tindakan, masalah keperawatan
ketidakefektifan pola napas
teratasi
Subjek mengatakan sesak napas
yang dirasakan berkurang, tidak
menggunakan pernapasan cuping
hidung, tidak menggunakan
pernapasan mulut, respirasi dalam
rentang normal (16-20 kali/menit).
Menurut Pyor & Webber (2010)
pursed lip breathing dan
respiratory muscles stretch
gymnastics merupakan salah satu
latihan pernapasan yang berfungsi
untuk mengurangi dyspnea. Hal ini
sesuai dengan penelitian yang
dilakukan oleh Astika Galuh
Vistaloka (2015) yang menyatakan
bahwa subjek dengan sesak napas
.
setelah diberikan pursed lip
breathing dan respiratory muscles
stretch gymnastics menunjukan
adanya penurunan sesak napas atau
dyspnea pada penderita PPOK.
Hasil implementasi terhadap 3
subjek penelitian sebelum dan
sesudah melakukan tindakan
pursed lip breathing dan
respiratory muscles stretch
gymnastics didapatkan data
meningkatnya status pernapasan,
mengurangi sesak napas dan
menurunkan frekuensi pernapasan
dalam rentang normal (16-20
kali/menit) masing-masing subjek
mengalami peningkatan yang
berbeda-beda yang disebabkan
antara lain karena terapi yang
diperoleh, tingkat kekuatan efisiensi
otot pernapasan dan keseriusan
subjek dalam melakukan latihan
pernapasan. Hal tersebut sesuai
dengan Vitaloka (2015) yang
menyatakan bahwa besar kecilnya
perubahan respirasi dipengaruhi
oleh kekuatan dan efisiensi dari otot-
otot pernapasan.
DAFTAR PUSTAKA
Chang, E. 2010.Patofisiologi: Aplikasi
pada Praktik Keperawatan
Edisi Bahasa Indonesia.
Jakarta: EGC.
Darmojo, R. 2011. Buku Ajar Geriatric
(Ilmu Kesehatan Lanjut Usia).
Jakarta: Balai
Penerbit FKUI
Decramer, Marc, Janssens, and
Marc
Miravitlles. 2012. Chronic
Obstructive
6. Keterbatasan penelitian
Berdasarkan penelitian yang
dilakukan peneliti di wilayah
Kecamatan Mojolaban Kabupaten
Sukoharjo yaitu mengalami
keterbatasan berupa subjek yang
berlatar belakang berbeda, tingkat
pengetahuan yang berbeda, serta
peneliti tidak dapat mengontrol
terapi yang diberikan dari rumah
apakah subjek menjaga pola
aktivitasnya atau tidak, selain itu
peneliti juga kurang lengkap dalam
melakukan pengkajian terkait
lamanya riwayat penyakit PPOK
yang dialami oleh masing-masing
subjek.
V. SIMPULAN
Penatalaksanaan pursed lip
breathing dan respiratory
muscles stretch gymnastics
efektif diberikan pada pasien
PPOK dengan masalah
keperawatan ketidakefektifan pola
napas di Kecamatan Mojolaban
Kabupaten Sukoharjo.
Pulmonary Disease.
Seminar
379(9823):1341-51
Dermawan, D. 2012. Proses
Keperawatan Penerapan
Konsep & Kerangka Konsep.
Yogyakarta: Gosyen Publishing.
Edward, 2012.Buku Saku Hitam
Kedokteran Paru. Jakarta:
Indeks.
.
Guyton dan Hall, 2010.Buku Ajar
Fisiologi Kedokteran Edisi 11.
Jakarta: EGC.
Handoko, 2012.Asuhan Keperawatan
Pada Subjek Dengan
Gangguan Sistem
Helmi, N. 2013. Gambaran Faktor-
faktor Yang
Mempengaruhi Terjadinya
PPOK.
http://respiratory.unri.ac.id.
Jurnal.pdf. Diakses tanggal 15
Juli 2020
Herdman, T. Heather, Kamitsuru,
Shigemi. 2018. NANDA-1
Diagnosis Keperawatan
Definisi dan Klasifikasi
2018-2020.
Jakarta: EGC.
Khasanah S, dan Maryoto M. 2014.
Efektifitas Posisi Condong Ke
Depan (CKD) Dan Pursed Lips
Breathing (PLB) Terhadap
Peningkatan Saturasi Oksigen
Subjek Penyakit Paru
Obstruktif Kronik (PPOK).
http://id.portalgaruda.org/.
Diakses 07 September 2020.
Kozier, B. 2010.Buku Ajar
Fundamental Keperawatan
Konsep Proses Dan Praktik.
Jakarta: EGC.
Kristiningrum, Esther. 2019.
Farmakoterapi
Penyakit Paru Obstruktif Kronik
(PPOK).
Departement Medical. PT
Kalbe
Farma.Tbk. 266-269.2019
Lestari, R.I and , Herawati,I, &, Rosella K,
(2015) Manfaat Active Cycle Of
Breathing Technique (ACBT)
Bagi Penderita Penyakit Paru
Obstruktif Kronik (PPOK).
Skripsi thesis, Universitas
Muhammadiyah Surakarta.
Mappadang R,V, Sekeon S, A, S. 2016.
Hubungan Antara Kebiasaan
Merokok,Tingkat Pendidikan
Dan Pendapatan Dengan
Kejadian Tuberculosis Paru Di
Puskesmas.
http://medkesfkm.unsrat.ac.id/2
018/08.
diakses tanggal 18 juli 2020
Mutaqqin, Arif. 2012. Buku Ajar
Asuhan Keperawatan Klien Dengan
Gangguan Sistem Pernapasan.
Jakarta: Salemba
Medika
PDPI. 2011. PPOK (Penyakit Paru
Obstruktif Kronik) Diagnosis dan
Penatalaksanaan.
Jakarta: PDPI.
Potter P. A, dan Perry A. G.
2010.Fundamental Nursing
Edition. Jakarta:
Salemba Medika.
Pyor Dan Webber. 2010.
Physiotherapy For Respiratory
And Cardiac
Problems.London: Churchill
Livingstone.
Rekha, K., Rai, S., Anandh, V., & D, S. S.
D.
.
2016. Effect of Stretching
Respiratory Accessory Muscles in
Cronic Obstruktive Pulmonary
Disease, 9, 1-4.
Roisin RR. 2016. Chronic Obstructive
Pulmonary Disease Update 2010
Global Initiative for Chronic
Obstructive Lung Disease.
Global Initiative for Chronic
Obstructive Lung
Disease, Inc,
194.https://doi.org/10.1097/000
08483-
200207000-00004
Sepdianto T.C, Tyas, M.D C, dan
Anjaswarni. 2013. Peningkatan
Saturasi Oksigen Melalui
Latihan Deep Diapraghmatic
Breathing Pada Subjek
Gagal
Jantung.
Silalahi, Kritiana L & Siregar, Tobus
Hasiholan. 2018. Pengaruh
Pulsed Lip Breathing
Exercise terhadap Penurunan
Sesak Napas pada Pasien
Penyakit Paru Obstruktif Kronik
(PPOK) Di RSU Royal Prima
Medan 2018.Jurnal
keperawatan priority, Volume
2, No. 1, Januari 2019 ISSN
2614-4719.
Somantri, I. 2012. Asuhan
Keperawatan Pada Klien
Dengan Gangguan
Sistem
Pernapasan. Jakarta: Salemba
Medika.
Vitaloka, Astika Galuh. 2015. Pengaruh
Respiratory Muscle Exercise
Terhadap Penurunan Sesak
Napas (Dyspnea) pada
Penderita Penyakit Paru
Obstruktif Kronik (PPOK) Di
Balai Besar Kesehatan Paru
Masyarakat (BBKPM)
Surakarta PdH Thesis.
Universitas Muhammadiyah
Surakarta.http://
scholar.googleuserconte
nt.com/scholar?
q=cache:yHd0E4yuaTsJ:
scholar.google.com/+astika+galu
h+vitalo
ka&hl=id&as_sdt=0,5.Diakses
tanggal 18 Februari 2020.
Yunani & Widiati 2017. Respiratory
Muscle Stretching Toward
Pulmonary Vital Capacity For
Asthma Patient.Institute Of
Health Scince Karya Husada
Semarang:
Indonesia.
WHO. 2017. Chronic Respiratory
Diseasis: Chronic Obstruktive
Pulmonary Disiase (COPD).
http://www.who.int/respiratory/
copd/en/.
Diakses tanggal 28 Februari 2020.