Universitas Muhammadiyah Surakarta

Program Profesi NERS 2018

RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLAN)

KENYAMANAN : Nyeri Akut (00132)
Domain : 12 (kenyamanan) Kelas : 1 (kenyamanan fisik)

Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain
related to anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature,
functional organ damage, functional damage to body tissue )

Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

Pain Management ( 1400) Pain Control (1605 )

Observasi 1. Menggunakan non analgesics untuk bantuan ( uses non

1. Lakukan pengkajian komprehensif meliputi lokasi, karakteristik, analgesic relief measure )
durasi, frekuensi, kualitas,intensitas/beratnya nyeri dan factor
pencetus ( perform a comprehensive assessment of pain to include 2. Menggunakan analgesik seperti yang dianjurkan( uses
location,characteristics, onset, frequency, quality,intensity or severity analgesic as recommended )
of pain and precipitating factors) 3. Laporan gejala tidak terkontrol kepada profesi
2. Observasi tanda ketidaknyamanan nonverbal terutama dengan
kesehatan( report uncontrolled symptoms to health
ketidakmampuan komunikasi efektif ( observe for non verbal of
professional )
discomport, especially in unable to communicate effectively)
Treatment 4. Laporan nyeri terkontrol( reports pain controlled )
3. Pastikan pasien mendapatkan perawatan analgesic ( assure patient
attentive analgesic care)

Tanggal/ Jam :

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Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain related to
anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature, functional
organ damage, functional damage to body tissue )

Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

4. Control factor lingkungan yang dapat meningkatkan respon Measurement Scale ( Skala pengukuran )
ketidaknyamanan pasien ,contoh temperature ruangan, cahaya dan
1= never demonstrated ( Tidak pernah menunjukan )
keributan ( control environmental factor that may influence the
patient response to discomport ,e.g room temperature, lighting, 2= rarely demonstrated ( Jarang menunjukan )
noise)
5. Posisi sejajar tubuh yang tepat untuk mengurangi tekanan pada saraf 3= sometimes demonstrated ( kadang Menunjukan )
dan jaringan( Position the body aligned the right to reduce the pressure on
4= often demonstrated ( Sering menunjukan )
the nerves and tissues )
6. Melakukan tindakan PCA ( implement the use patient controlled 5= consistently demonstrated ( Konsisten menunjukan )
analgecia)
Education
7. Memberikan informasi tentang penyebab nyeri,berapa lama
terjadinya dan antisipasi ketidaknyamanan dari prosedur ( provide
information about the pain, causes of the pain, how long it and
anticipated discomports from procedure)
8. Ajarkan prinsip dari manajemen nyeri ( teach principles of pain
management)

Nursing Diagnosis Nyeri akut berhubungan dengan cemas, takut akan prosedur dan alat medis,kesedihan,trauma jaringan,zat
kimia,perubahan suhu, kerusakan fungsional organ tubuh ,kerusan fungsional jaringan tubuh ( Acute pain
related to anxiety, fear of medical procedures and tools, sadness, tissue trauma, chemicals, changes of body temperature,
functional organ damage, functional damage to body tissue )

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Patient Goal Nyeri hilang/ berkurang ( no pain/reduce )

Intervention ( NIC ) Outcome ( NOC )

9. Ajarkan penggunaan teknik non pharmakologi ( hypnosis,relaksasi

music terapi ,distraksi, terapi bermain,terapi aktivitas,kompres
panas /dingin, pijatan ) selama,sesudah,sebelum ,pada saat
peningkatan nyeri )( teach the use nonpharmacological techniques
( hypnosis,relaxation, music therapy,distraction, play therapy, activity
therapy, cold/hot application, massage) during , after, before, or
increases pain )
10. Ajarkan tentang metode farmakologi dari gambaran nyeri ( teach
about pharmacological method of pain relief )
Collaboration
11. Kolaborasi dengan pasien dan tenaga kesehatan lainnya untuk
memilih dan meimplementasikan terapi nonfarmakologi ( Collaborate
with the patient and other health propessionals to select and
implement non pharmacological .
12. Kolaborasi dengan dokter jika pengobatan tidak berhasil dan
mengalami keluhan ulangan dari pengalaman nyeri pasien .( Notify
psysician if measure are unsuccessfull and current complaints from
past experience of pain)
*NANDA 2015-2017 edisi 10

Perawat primer Kepala Ruang

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