Pendokumentasian skala nyeri cries oleh perawat di ruang neonatal intensive care unit siloam hospitals kebon jeruk = documenting the scale of pain cries by the nurse in the neonatal intensive care unit of siloam hospitals kebon jeruk.

Sitompul, Ruminta Novita Sari (2018) Pendokumentasian skala nyeri cries oleh perawat di ruang neonatal intensive care unit siloam hospitals kebon jeruk = documenting the scale of pain cries by the nurse in the neonatal intensive care unit of siloam hospitals kebon jeruk. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Dokumentasi keperawatan khususnya pengkajian nyeri, merupakan salah satu bukti atas tindakan perawat selama menjalankan tugas pelayanan kesehatan. Nyeri mempunyai sensasi subjektif dan setiap individu berbeda respon nyeri nya, begitu juga neonatus, neonatus bisa merasakan nyeri tetapi neonatus tidak dapat menunjukkan respon nyeri itu. CRIES adalah pengkajian nyeri untuk neonatus dengan lima variabel fisiologis dan perilaku. C: Menangis, R: Membutuhkan Administrasi Oksigen Yang Meningkat, I: Tanda-Tanda Vital Yang Meningkat, E: Ekspresi, S: Susah Tidur. Tujuan penelitian untuk mengidentifikasi pendokumentasian skala nyeri CRIES oleh perawat di ruang Neonatal Intensive Care Unit. Metode penelitian yang digunakan adalah deskriptif kuantitatif dengan studi dokumentasi. Populasi dan sampling sebanyak 55 dokumen medical record pasien yang di rawat di NICU. Instrumen yang digunakan adalah lembar observasi pendokumentasian yang diadopsi dari pengkajian CRIES di Siloam Hospitals Kebon Jeruk. Hasil penelitian didapatkan pendokumentasian yang belum dilakukan, dari 55 file pasien didapatkan menangis (89,1%), kebutuhan oksigen (69,1%), peningkatan tekanan darah (47,3%), ekspresi (54,5%) dan susah tidur (65,5%). Rekomendasi untuk peneliti selanjutnya yaitu untuk membandingkan dengan skala nyeri yang lain / Nursing documentation particularly in the pain assesment, is one of evidence of the actions by the nurse during health care service. Pain is a subjective sensation and each individual have the different response of pain, as well as neonates, neonates can feel the pain but neonates cannot indicate the pain itself. CRIES is pain assessment for neonates with five variables of physiological and behavioral. C: crying, R: need oxygen administration increases, I: vital signs are increasing, E: expression S: sleeping difficulty. The purpose of the research to identify and documenting the scale of pain cries by the nurse in The Neonatal Intensive Care Unit. The research method ued descriptive quantitative with the study documentation. Population and sampling as much as 55 medical record documents of patients treated in the NICU. The Instruments Used In This Study Are The Observation Sheets Documentation That Adopted From Studies Of Cries In Siloam Hospitals Kebon Jeruk. The research result, obtained by the documentation that has not been done, from the 55 patient’s files shows; crying (89, 1%), expression (54, 5%), oxygen needen (69, 1%), increased blood pressure (47, 3%), and insomnia (65, 5%). Recommendation for the next researcher are comparing this study with other pain scale.

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