REPORT INTRODUCTION NURSING CARE

DISORDER IN PATIENTS WITH COMFORT

OLEH:
A6-c
1.
2.
3.
4.
5.

Ni Kadek Nilam Cahyani

Ni Komang Opik Septiari
Ni Luh Gede Puspayanti
Dewa Ayu Putri Ari Laksmi
Ni Kadek Suka Sari

(12.321.1603)
(12.321.1606)
(12.321.1607)
(12.321.1610)
(12.321.1615)

PROGRAM STUDI ILMU KEPERAWATAN

STIKES WIRA MEDIKA PPNI BALI
2013

A. Basic consepts of comfort

1. Definition
Changes comfort is a condition in which individuals experience unpleasant
sensations in respond to a harmful stimulus.
Pain is an unpleasant feeling in the form of the condition is very subjective
because of the feeling of pain is different for each person in terms of scale or grade,
and only one is exactly who can explain or evaluate
Here is the opinion of some experts about the definition of pain:
a. Mc Coffery (1979) defines pain as a condition that affects a person whose
existence is known only if the person is experiencing.
b. Wolf welfsel (1974) says that the pain is a feeling of physical and mental
suffering or feeling that can lead to tension.
2. Epidemiology
According to Bennett (1997) and Tollison (1998) in the United States there are
approximately 75-80 million chronic pain sufferers, 25 million of whom are arthtritis.
Number of patients with neuropathic pain approximately 1% of the total population,
lower back pain is approximately 15% of the total population (Fordyce, 1995).
Results of a multicentre study in outpatient units in 14 teaching hospitals across
Indonesia in the study group pain Neurologist Indonesian Doctors Association (Pokdi
Pain Perdossi) in May 2002, in 4,456 cases get pain which is 25% of total visits in
that month. The number of male patients as much as 2,200 people, 2,256 men and
women. Headache cases numbered 1,598 persons (35.86%), back pain (waist)
18.37%, which is a combination of neuropathic pain deabetika neuropathic pain, postherpetic pain, and trigeminal neuralgia as many as 422 people (9.5%), and other pains
such as shoulder pain, neck, joints, myofascial, and so many as 1,617 people
(36.27%).
3. Etiology
Cause of the pain can be classified into two groups, namely related causes related to
physical and psychic. Physically such cause is trauma (mechanical, thermal, chemical,
and electrical), neoplasm, inflammation, blood circulation disorders and others.
a. Mechanical trauma causes pain because the free nerve endings were damaged in a
collision, friction, or injury.
b. Thermal trauma causes pain because the nerve endings got receptor stimulation by
heat or cold.
c. Trauma occurs because the chemical substances touched a strong acid or base

d.

Electrical trauma can cause pain due to the strong influence of electricity on the

pain receptors.
e. Neoplasms causing pressure or pain due to tissue damage-containing receptors are
also due to strain and pain, pinching or metaphase.
Pain in the inflammation occurs due to damage to nerve endings receptor due to
inflammation or pinched by swelling.
Pain caused by psychological factors is pain that is felt but not for organic causes of
psychological trauma and its effects on physical

4. Predisposing factors
a. Fever
b. Improper position
c. Excessive activity
5. Characteristics
Pain can be classified into several categories based on the place, nature, severity of
pain and the time duration of the attack.
a. Pain based on place
1) Pheriperal pain is pain felt on the surface of the body such as the skin.
2) Deep pain is pain felt on the surface of the deeper body.
3) Refered pain is pain caused by the disease in the organ or structure in the body
that gets transmitted in different areas of the body, not the origin of pain.
4) Central pain is pain that occurs due to stimulation of the central nervous
system, spinal cord, brain stem, thalamus, and others.
b. Pain by its nature
1) incidental pain is pain that arises from time to time or lost.
2) Steady pain is pain that arises and settle down and be felt in a long time.
3) Paroxysmal pain is pain that is felt high intensity and strong. Pain usually
settle around 10-15 minutes, then disappear and then reappear.
c. Based on the severity of pain
1) Low Pain is pain with low intensity.
2) Moderate pain is pain that cause reaction.
3) Severe pain is pain with high intensity.
d. Pain by the time duration of the attack

1) Acute pain is pain that is felt in a short time and ended less than 6 months, and
the source of pain is clearly known areas such as surgical wound.
2) Chronic pain is pain that is felt more than 6 months and the pattern varied.
e. Clinical Symptoms
1)

The individual shows or reported discomfort.

2)

Diaphoresis (sweating).

3)

Position careful.

4)

Facial expression of pain (crying / moaning).

5)

Feel tightness in abdomen

6. Physical examination
Physical examination performed in patients with impaired comfort nursing care found
in the format set out in the assessment GORDON.
7. Diagnostic tests
Regular checks carried out to determine the nutritional changes are as follows:
a. Laboratory examination.
b. Radiology.
8. Management
a. Reduce the lack of knowledge: explaining the causes of the changes to individual
comfort.
b. Provide accurate information to reduce the sense of comfort.
c. Give people a chance to rest.
B. Basic Concepts of Nursing
1. Assessment
P: Provocate
a. What makes the pain worse?
b. What reduces pain?
Q: Quality
a. What kind of pain is felt?
b. Does the pain is felt sharp, blunt, pressed with a heavy, throbbing just as
sliced, or choke?
R : Region
a. Where's the pain?
b. Does the pain spread or settle in one place?

S: Scale
Mild or moderate pain experienced patients can be known through the pain scale of
0 to 10
a. Is the pain mild moderate or severe?
b. How severe the pain?
T: Time
a. How long will the pain be felt?
b. Is the pain constant or occasional?
2. Assessment of subjective data and objective data
a. Subjective data
1) The patient complains of pain
2) Patients showing the location of pain
b. Objective data
1) The patient complains of pain seen
2) Patients who looks protects the pain
3) Patients are seen focusing on yourself
4) Scale pain more than 4
3. Nursing Diagnosis
a. Acute pain
Associated with:
1) Injury agents (biological, psychological, physical chemistry)
Characterized by:
1)
2)
3)
4)
5)
6)

Reported pain verbally or non-verbally

Showing the damage
Position to reduce pain
The movement to protect
The behavior to be-careful
Sleep disturbance (eyes glazed, looking tired, difficult or chaotic movement

and grins)
7) Focus on yourself
4. Action Plan
No
1

Objectives and criteria of

the results
After the act of nursing for 1.
comfort 3 x 24 hours

Intervention
Give a comfortable
position

Rational
1. Corresponding
position helps in

expected

disturbances

eliminating and

resolved with the expected

lowering muscle

outcomes:
Patients dont complain

weakness and

of pain
2.
The patient does not
show the location of

pain
Patients dont look that

protects the pain

Patients are not seen to

focus on yourself
The scale of pain 0

discomfort.
2. Distraction is a

Teach distraction

method of

and relaxation

relieving pain and

techniques

how to turn
attention to the
patient, on the
other things the
patient will forget
the pain they
experienced
3. To determine
whether or not the
3.

Observational pain
scale

pain
4. To determine the
body's response to

4.

Observation of vital
signs

5. Collaboration

providing
medicine
5. Evaluation
No

Diagnosis

Evaluation

pain is felt
5. Analgesics relieve
pain

in
analgesic

Acute pain associated with S:

injury clients

Patients dont complain of pain

The patient does not show the location of
pain

O:
Patients dontt look that protects the pain
Patients arent seen to focus on yourself
The scale of pain 0
A: problem solved
P: Stop the intervention

DAFTAR PUSTAKA

Lynda Juall, Carpenito 2000. Diagnosa Keperawatan. Jakarta

Doengus. Rencana Keperawatan. Jakarta