A. Pain 1.

Definition of Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissues damage or describe in terms of such damage. Pain is an universal sensation that have plagued mankind since the beginning of time. Pain refers to the mechanism by which noxious stimuli are detected. Pain, however is more than just detection of noxious stimuli. Noxious stimuli may initiate the pain process, but the experience of pain depends on many factors, such as experience with the stimuli, the stress or anxiety at the time, and the affective state. Pain is unique, universal and individual sensation. Pain is individual because there are various of pain sensation in each individual response and it is different each other. 2. The Causes of Pain There are physique and psychological causes of pain. In the physique factors, there are trauma (mechanic, thermal, chemical, and electric) neoplasm, inflammation and blood circulation disorders. a. Trauma Mechanic trauma occurred when collision/friction that causes neuron disorder. Thermal trauma occurred when there is outside stimuli such as hot and cool to the receptors. Chemical trauma occurred when there is contact with strong acid and base substance. Electric trauma occurred when there is electrical current in the pain receptor. b. Neoplasm Neoplasm can cause pain when there is pressure or tissue disorder that include pain receptor and also because pinching or metastase. c. Inflammation Pain in inflammation occurred because of neuron receptor disorder related to inflammation or pinch with edema. 3. Classification of pain a. Pain based on place

1) Peripheral pain : pain in the surface area of body such as skin and mucosa 2) Deep pain : pain in the deeper surface area such as visceral organ 3) Refered pain : pain that caused by transmission of disease in organ or structure to the other part of body 4) Central pain : pain that caused by stimuli of central nervous system ,spinal cord,brain , thalamus b. Pain based on characteristics 1) Incidental pain : pain that occur incidentally 2) Steady pain : constant and long term pain 3) Paroxymal pain : pain in the high intencity ,occur in 10-15 minutes , disappear and occur again c. Pain based on intensity 1) Low pain 2) Medium pain 3) High pain d. Pain based on time 1) Acute pain: a complex constellation of unpleasant sensory, perceptual, and emotional experiences and certain associated, autonomic, psychological and emotional and behavioral responses. 2) Chronic pain: pain that persist beyond the time when the acute disease course or reasonable time for healing has passed. B. Perception The sensation is the process of receiving information from the outside environment. The perception is the process of interpreting information and forming the image of the environment. We can expand the view of perception as a mechanism through environmental stimulation, until the reached the conclusion that the perception of paramount importance for understanding the formation and behavior. An individual does not react or behave in a certain way, because there

are circumstances around it, but because of what she saw, or what is believed by him about the situation. Perception can be categorized in several sections, namely: 1. Visual perception: the sense of sight is obtained of the eye. 2. Auditory perception: the sense of hearing is obtained from the ear. 3. Perception of palpability: obtained from the tactile senses of the skin. 4. The perception of smell: obtained from the sense of smell is the nose. 5. The perception of taste or flavor: obtained from the sense of taste is the tongue. Principles of Perception: Most of the principles of perception is an organizing principle based on Gestalt theory. Gestalt theory believe that perception is not the sum of the parts are sensed someone, but more than that is the whole. Raw visual sensation is like the parts that have not been assembled; they should be brought together in an organized way before they are useful to us. Principles of perceptual organization is worthy of our consideration. Here are five principles of Gestalt Perception: 1. Figure - ground (images and background) 2. Continuity (continuity)

3. Proximity (closeness) 4. Similarity (similarity) 5. Closure (closure) PERCEPTION firmness (ILLUSION) We see the world as a place that is constant and unchanging. Light and the people have not changed in size, shape, or color from moment to moment. But the sensation that tells us about the further changes from moment to moment. There are several types of constancy perception, namely: 1. Brightness Constancy

2. Color Constancy 3. Size Determination 4. Determination Form Depth Perception Depth perception is the ability to sense the space sense of sight. Sensing chamber is a thorough appreciation, not a visual sensing only. Some of the benchmark used in depth perception, namely: 1. The quality of surface / texture gradient (sharpness reduced texture quality due to the further distance) 2. Linear perspective (the farther, the stripes will increasingly converge into one point) 3. Superposition (distant objects will be covered or the quality is declining because of the shadow of the object is closer, but it's closer objects will be located in front of more distant objects in our visual field) 4. Light and shadow (the surface farther from the light source will be darker than the close) 5. Movement speed (Object far appear to move in the field of vision more slowly than nearby objects. 6. Aerial perspective (the farther the object increasingly blurred) 7. Accommodation / standards that are well known (which we are familiar objects will be smaller in size distant)

C. Sensation 1. Sympathetic Nervous System

2. Psychological Response

3. Parasympathetic Nervous System

D. Factors influencing pain Many factors can affect a persons perception of reaction to pain. Such as : 1. Ethnic and culture values Ethnic background and culture recognize as factors that influenced both a persons reaction to pain and the expression of the pain, individuals from the another culture may have learn to keep those feeling to them self. The level of pain that an individual is willing to tolerate affected by their culture background. 2. Developmental stage The age and developmental stage is an important thing that will influence both the reactions and the expression of pain. a. Infant : respond to pain increase sensitivity, perceived pain. b. Toddler and pre school : do has ability to describe the pain, its intensity, and location c. School age-child : tries to be brave when facing pain, rationalizes in an attemp to explain the pain, can identify the location and describe the pain. d. Adolescent : slow to acknowladge pain , wants to appear brave in front of peers and not repair the pain. e. Adult : behaviors exhibited when experiencing pain may be genderbased behaviors learned as a child. Ignore pain because to admit it is perceived as a sign of weakness of failure. Fear of what pain means may prevent some adults from taking action. f. Olther adult : perceive pain as part of the aging process. Decreased sensations or perceptions of the pain. Have multiple conditions vague symptoms. Not to be brave to admit or show the pain because of fear the treatment. 3. Environment and support people A strange environment can affecting the pain. The lonely person perceive pain as severe ,whereas the person that give many support may perceive less pain. In some situation women may be permitted to express the pain

openly then the man. Their activity may affect the perceive pain, because the people who has many activity or job will ignore the pain, because they have to stay on job. 4. Previous Pain Experience Previous pain experience may affect the variation of sensitivity in patient. The people who has experienced the pain will be anticipated pain than they who did not ever experience the pain. 5. Meaning of Pain Many clients may perceive the pain more widely than others,depending on their intrepetation of their-self. The patient who has positive outcome may withstand the pain well. For example, a woman giving birth to a child or an athlete undergoing knee surgery to prolong his career may tolerate pain better.

E. Characteristic of Pain Depend on location , quality , intensity. 1. Location : Area of the body Difuse or localized Radiates and area involved 2. Quality : Stabbing, knife-like Throbbing Cramping Vise-like , suffocating Searing, burning Superficial, deep 3. Intensity Rate on scale : 0-10 ( 0 = no pain , 10 = most pain ever experienced )

F. The body function which disturb affected by pain in child 1. Skin disturbance. Pain affects skin function because pain in the skin can occurred hypersensitivity of stimuli G. PQRST assessment 1. Provoking Incident factors of :whether there are something that can be the reduced when rest, whether the

pain, whether pain is

pain grows worse when do the activity. Factors that can relieve pain (e.g. too much movement,exertion, rest, medications, etc.) and the clients believed to help decreasing of pain. 2. Quality and Quantity of Pain : How are the feeling of pain from

the client such as burn ,beat ,sharp, and puncture . 3. Region: Radiation :Relief : where is the location of pain must

be acurately shown by client , whether the pain can be relief , and whether the pain spread to the others part of body.Pressure in the neuron give the sign and symptom of pain that called radiating pain. The others pain called reffered pain which is pain insome place caused by abnormality in the others place . 4. Severity (Scale )of Pain : how severe the pain ? it can be based on scale of descriptive pain (no pain , low pain, moderate , severe , unbearable) and client can explain how the pain affect the ability function of daily activity (such as sleep, appetite ,concentration , interaction with others , phisic movement , work , and enjoyed activity). Acute pain related with anxiety and chronic pain with depression . 5. Time : how long pain occur ? (acute and chronic) ,when it occur?

berapa lama nyeri berlangsung ( bersifat akut atau kronis ) ,when,whether is there time to increase pain ? For younger students (aged about 3 years and older), those who are less comfortable with numbers, and those who lack the cognitive skills to think about pain in relative terms, the Wong-Baker FACES Scale may be useful.

The scale allows a student to point to a cartoon face with an expression that reflects the students pain experience. Pain may be assessed in infants and those with developmental impairment or other impediments to verbal communication by observing behavioral cues, such as facial grimace, and physiologic parameters, such as heart rate. WONG- BAKER FACES PAIN RATING SCALE

H. Pain affected by IV complication Babies cannot communicate through verbal as a whole, although the behavior they display facial expressions of pain such as crying, facial grimacing, eyes narrowed, his chin quivering. Babies are perfectly dependent on medical staff to assess pain and interpret their pain (Marie, 2002). According to Wong & Whaley's (1996) many methods we can use to assess pain in children, one in common: QUESTT 1. Question the children (ask the kids) 2. Use pain rating scale (using a pain scale) 3. Evaluate behavior (behavioral evaluation) 4. Secure the parent's involvement (includes parents) 5. Take into account cause of pain (look for the cause of pain) 6. Take action (take action)

Installation of complications IV: 1. Inflammation (swelling, pain, fever) and infections at the infusion site 2. Hematoma (blood collects in the tissue due to rupture of arteries, veins / capillaries. This occurs due to the lack of proper emphasis when inserting a needle or repeated punctures in blood vessels

3. Infiltration: the entry of fluids into the surrounding tissue (not blood vessels). This happens due to the IV needle tip through the blood vessels 4. Thrombophlebitis or swelling (inflammation) in the veins. This occurs due to the infusion set is not strictly and properly monitored 5. Air embolism. : The entry of air into the blood circulation. This occurs because the entry of air in the fluid infusion into a vein

I. Pathophysiology of Thypus The entry of the bacteria Salmonella typhi (S.typhi) and parathypi Salmonella (S. parathypi) into the human body occurs through contaminated food bacteria. The number of bacteria needed to cause infection is 105-109. Most of the germs were destroyed in the stomach by gastric acid, while others escaped into the intestine and subsequent breeding. When the humoral mucosal immune response (IgA) intestinal unfavorable, then the bacteria will penetrate cells - epithelial cells (M cells) and subsequently to the lamina propia in the small intestine. In lamina propia germs multiply and difagosit by phagocytic cells mainly by macrophages. Germs can live and multiply in the macrophages and subsequently taken to the distal ileum Peyeri plague through the microvilli and then to the mesenteric lymph nodes. Continue through the duct torasikus germs contained in this macrofag into the blood circulation (resulting in the first bacteremia [primary] is asymptomatic) and spread throughout the reticuloendothelial organs of the body especially the liver and spleen. In these organs the bacteria leave the phagocytic cells and then multiply outside cells or rooms sinusoil and then enter into the blood circulation resulting in bacteremia again the second time (secondary) with accompanying signs and symptoms of systemic infection. Bacteria into the gall bladder, along with breeding and intermittent bile secreted into the bowel lumen. Most of the bacteria through feces and partially released back into the circulation after penetrating the intestine. The same process is repeated, since macrophages have been activated and the current hyperactive phagocytosis of bacteria salmonella the release of

several inflammatory mediators that in turn will cause the symptoms of systemic inflammatory reactions such as fever, malaise, myalgia, headache, abdominal pain, vascular instability, mental disorders, and coagulation. In the plague Peyeri hyperactive macrophages cause tissue hyperplasia response (macrophages induces intra S.typhi slow type hypersensitivity reaction, necrotic tissue and organ hyperplasia). GI bleeding can occur due to erosion of blood vessels around the plague Peyeri undergoing necrosis and hyperplasia caused by accumulation of mononuclear cells in the intestinal wall. Pathological process of lymphoid tissue may develop up to the muscle layer, serosa and may lead to perforation of the intestinal endotoxin can be attached to the capillary endothelial cell receptor with the consequent onset of complications such as neuropsychiatric disorders, cardiovascular, respiratory, and other organ disorders. These bacteria affect endotoxin stimulate the formation of endogenous pyrogens. Endogenous pyrogens cause fever by producing prostaglandins, which increase the hypothalamic set point of

thermoregulation. If the source is removed pyrogens (eg, having successfully overcome the immune system the microorganisms), then levels off. This will return to the normal set point. The mechanism of fever arise in response to the formation of certain cytokines, including interleukin-1, interleukin-6 and tumor necrosis factor. Interleukin-1 stimulates the activation of locally produced vagus nerve which then relay the information to the central nervous system. Once the signal reaches the central nervous system, the formation of brain prostaglandins and increase the hypothalamic set point of

thermoregulation. Coated tongue is a layer of white, yellow, or brown on the upper surface of the tongue, caused by the accumulation of bacteria, food debris, leukocytes from periodontal pockets, and desquamation of epithelial cells (Danser et al, 2003). Coated tongue cause a buildup of bacteria, bad breath

and the sensation of the tongue is less sensitive (Quirynen et al, 2004). Microscopically the formation of coated tongue closely related to the level multipikasi epithelial cells, the quantity of desmosomes and the lining membrane of the granules (Danser et al, 2003). Here there are some predisposing coated tongue (Scully, 2001): 1. Edentulous 2. Diet soft foods 3. Poor oral hygiene 4. Fasting 5. Fever 6. Xerostomia 7. Consumption of various drugs Basically, the top surface of the tongue is the affluent that are vulnerable irritation. This irritation often caused by hot drinks or food that is too harsh. This causes the surface of the tongue to form a protective layer of keratin that has died. Under normal circumstances the same amount of keratin produced by the peeling keratin (dead). In the normal state of equilibrium is disturbed, causing coated tongue. Coated tongue can also be caused by a diet of soft food that causes the keratin is stimulated to peel (AOMP, 2005). Clinical picture of a tongue coated membranes (plaque lesions) that cover the upper surface of the tongue. These membranes can be white to yellowish brown. Membrane consists of an accumulation of bacteria, food debris, leukocytes from periodontal pockets, and desquamation of epithelial cells. These membranes can be lost without leaving the erythematous area. Coated tongue can appear and disappear in a short time (Danser et al 2003; Laskaris, 2006; Scully, 2001). Salmonella into the stomach causes an increase in stomach acid. This increase in gastric acid cause nausea. An enlarged liver and spleen can also occurred nausea due to suppression that occurs in the stomach. Liver and spleen enlargement occurs due to attacks from bacteria that breed. Excessive stretching of hollow organs and cause pain in the epigastrium.

Nodes located in the left upper abdomen between the gastric and diapraghm, which lies along the long axis of the left X costa. While the liver, is at the top of the abdominal cavity. In the cavity abdominis and pelvic cavity, there is a thin serous membrane that lines the wall called the peritoneum. Innervation found in the peritoneum there are two, namely peritoneum and peritoneum viscerale parietale. Peritoneum parietale sensitive to pain, temperature, touch and press.

REFERENCES Hickey,Joanne V.1997.The Clinical Practice of Neurological and Neurosurgical Nursing.Philadelphia:Lippincott Asmadi.2008.Teknik Prosedural Keperawatan : Konsep dan Aplikasi Kebutuhan Dasar Klien.Jakarta : Salemba Medika Ganong,William F.2008.Buku Ajar Fisiologi Kedokteran. Ed.22.Jakarta:EGC Berman,Andrey.,Sherlee Snyder.2012.Fundamental of Nursing : Concepts, Process and Practice.New Jersey:Pearson Smith Sandra F, Duell Donna J, Martin Barbara C. 2000. Clinical Nursing Skill Basic To Advanced Skills.Fifth Edition. New Jersey : Prentice Hall, Inc.

PAPER Submitted for the Fulfillment of Perception Sensory Assignment Instructor : Elsa Naviati,

By L.S. Lintang Kinanti Lidia Ruliastiniwa Barus Diah Tika Anggraeni Isnan Nur Khoirunnisa 22020110120006 22020110120019 22020110120045 22020110141014

SCHOOL OF NURSING FACULTY OF MEDICINE DIPONEGORO UNIVERSITY 2012