Studi dokumentasi kelengkapan pengkajian nyeri post sectio caesarea oleh perawat di satu rumah sakit swasta Indonesia barat = documentation study completeness pain assessment of post sectio caesarea post by nurses in private hospital in west Indonesia.

Pelambi, Gratia Oktaviananda Putri and Sihombing, Resti Elva (2018) Studi dokumentasi kelengkapan pengkajian nyeri post sectio caesarea oleh perawat di satu rumah sakit swasta Indonesia barat = documentation study completeness pain assessment of post sectio caesarea post by nurses in private hospital in west Indonesia. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Latar Belakang: sectio caesarea (SC) merupakan tindakan bedah untuk melahirkan bayi yang berukuran lebih dari 1000 gram atau dengan umur kehamilan lebih dari 28 minggu. Tindakan dilakukan dengan insisi pada dinding abdomen ibu, yang dapat mengakibatkan nyeri di area pembedahan karena adanya robekan lapisan kulit. Pendokumentasi pengkajian nyeri merupakan hal yang penting karena pelayanan keperawatan yang diberikan pada klien membutuhkan catatan dan pelaporan sehingga perawat dapat mengetahui intervensi yang akan diberikan pada pasien. Tujuan penelitian: untuk mengetahui kelengkapan dokumen pengkajian skala nyeri dan skala nyeri pasien post sectio caesarea oleh perawat. Metode:penelitian kuantitatif deskriptif. Populasi penelitian:semua dokumen pasien di ruang rawat inap, sampel penelitian ini menggunakan teknik total sampling semua dokumen pasien yang ada di ruang rawat inap dengan kriteria inklusi:semua dokumen pasien dengan post sectio caesarea di bulan Juni 2018 yaitu 19 dokumen. Instrumen penelitian adalah lembar catatan observasi dan lembar catatan perkembangan terintegrasi yang ditulis oleh perawat. Hasil penelitian:terdapat 11 dokumen (57,9 %) pengkajian nyeri yang tidak terisi lengkap dan sebanyak 15 dokumen (78,94 %) pengkajian nyeri menggunakan Numeric Rating Scale dengan nyeri sedang. Peneliti mengharapkan perawat dapat meningkatkan kelengkapan dokumen serta untuk peneliti selanjutnya agar mencari faktor–faktor yang mempengaruhi ketidaklengkapan pendokumentasian oleh perawat = Background: Sectio caesarea (SC) is a surgical procedure to give birth baby of more than 1000 grams or with a gestational age of more than 28 weeks, by incision in the mother's abdominal wall, can cause pain in the surgery area because of ripped skin. Pain assessment documentation is important because nursing services provided to clients require records and reporting so that nurses can know the intervention that will be given to patients. The aims:to determine completeness the pain assessment document and pain scale of the patient with post sectio caesarea by nurse. Method:this research is descriptive quantitative. Research population:all patient documents in the inpatient room. The sample :total sampling technique is all patient documents in the inpatient room with inclusion criteria:all documents of patients with post sectio caesarea in Juny 2018 there are 19 documents.The instrument:an observation note sheet and an integrated progress note sheet, written by nurses. The results of the study were 11 documents (57.9%) incomplete pain assessment and 15 documents (78.94%) pain assessment using the Numeric Rating Scale with moderate pain. Researchers expect nurse can improve the completeness of the document and for the next researcher to find the factors that influence the incomplete documentation by the nurse.

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