Key skils demonstration

1. Pengkajian dari aspek dasar bio-psiko-sosial pada pasien dengan nyeri kronis
There are several factors that can contribute to a patient’s chronic pain, which are
biological, psychosocial, and social factors. Biological factors such as nociception,
neuropathic, inflammation, nociplastic, and neuroplasticity (changes in the central
nervous system  more sensitive) would cause physical changes in the patient (for
example: weaker muscle, joint stiffness, less fit, weight gain, dsb). Aside from that,
many treatments to chronic pain may cause a variation of side effects (digestion
problems, lethargy, constipation, etc) that would make the patient uncomfortable.
Psychological factors that contribute to the patient’s pain are the patient’s mood
(depression, anxiety/worry, anger, frustration), coping strategies (that can be assessed
from cognitive/behavior; is the patient avoidant, overdoing, or active/passive?) and
the patient’s beliefs (fears, expectations, perception). Meanwhile, the social factors
are social support from the people around the patient, financial and family situation,
and culture, demands on person. All of that factors will lead to depression, loss of
hope, frustration, and will badly impact patient’s quality of life because of the
suffering and disability.
Materi session 3: halaman 20
Nyeri kronis yang ibu rasakan ini bisa disebabkan oleh faktor yang berasal dari
fisik/biologis yaitu kanker serviks yang menyebabkan penekanan, keradangan, dan
rangsangan saraf di daerah tersebut yang berkepanjangan lebih dari 3 bulan sehingga
menyebabkan gangguan aktivitas, mengganggu tidur, harus mengkonsumsi obat nyeri
dalam jangka panjang, dan menyebabkan rasa tidak nyaman, cemas, sedih, merasa
tidak tertolong, merasa tidak ada harapan. Sebaliknya, faktor psikologis seperti
ketakutan, frustasi, dan cemas juga dapat memperberat nyeri yang ibu hadapi,
sehingga ada interaksi timbal balik. Selain faktor fisik dan psikologis, ada faktor
sosial yang mempengaruhi nyeri kronis, misalnya tidak adanya dukungan keluarga,
keadaan finansial, hubungan dengan keluarga, berhenti bekerja, dan budaya sekitar
juga dapat memperberat nyeri yang dialami ibu.
 The chronic pain that you are experiencing can be caused by physical/biological
factors, in which cervical cancer causes suppression, inflammation, and nerve
stimulation in the area that occurs for more than 3 months, causing activity
disturbances, disrupting sleep, having to take pain medication in the long term, and
causes discomfort, anxiety, sadness, helplessness, hopelessness. On the other hand,
psychological factors such as fear, frustration, and anxiety can also worsen your pain,
so there is a reciprocal interaction between pain and psychological condition. In
addition to physical and psychological factors, there are social factors that influence
chronic pain, such as the absence of family support, financial circumstances,
relationships with family, quitting work, and the surrounding culture can also worsen
your pain.

2. Develop and share case formulation diagram

Untuk menyusun rencana pengobatan ibu, kita perlu membuat formulasi kasus
berdasarkan masalah-masalah biologis, psikologis, dan sosial yang dihadapi ibu.
Apabila kita sudah membuat formulasi kasus tersebut maka kita bisa menyusun
manajemen untuk mengatasi nyeri dan untuk meningkatkan aktivitas sehari-hari ibu.
Untuk itu saya harus mengkaji:
1. Biologis: riwayat penyakit ibu, penyakit penyerta lain, tes laboraturium dan scan,
pengobatan apa saja yang telah diterima dan bagaimana respon terhadap
pengobatan
2. Psikologis: skala dan kualitas nyeri, perasaan ibu, dan strategi coping ibu terhadap
nyeri yang dirasakan
3. Aktivitas: apakah nyeri yang dirasakan mengganggu aktivitas sehari-hari, obat-
obatan yang dikonsumsi, dan aktivitas yang dapat dilakukan saat ini
4. Sosial: interaksi dengan orang-orang di sekitar ibu, saran-saran dari orang lain
mengenai penyakit ibu
To help the you to be able to have self-management skill, we have to develop a case
formulation based on the assessment of biological, psychological, and social fators
that contribute to your pain so that we can make a program and treatment plan to
 improve your quality of life and overall to lessen the effects from the pain. For that I
have to assess:
1. Physical: history of your disease, physical examination, co-morbidities, test,
scans, and response to treatment
2. Psychological: pain report, mood, coping strategies, and beliefs (fears,
expectations, perceptions to pain)
3. Behavior/activities: pain interference in activities, medication use, specific
activities (sitting, standing, walking, etc)
4. Social: behavior in social context, interaction with others
Materi session 3: page 21

3. The difference of acute and chronic pain

Pain is an unpleasant sensory and emotional experience associated with or resembling
that associated with actual or potential tissue damage. Acute pain occurs for short-
term that only lasts for seconds-days-weeks and can be resolved with healing or
treatment, for example: bone fracture because of a workplace accident. Meanwhile,
chronic pain can last for a long time (> 3 months to many years) and is often thought
of as beyond expected healing time. This is because for certain cases, like cancer, the
disease still exists and is not healing yet so the patient will experience chronic pain.
The common features of chronic pain is that it will interfere with normal activities
and work, and also will cause disturbed mood and sleep disturbance and overall will
affect the patient’s quality of life.
Nyeri dibedakan menjadi dua berdasarkan lama nyeri, yaitu nyeri akut dan nyeri
kronik. Nyeri akut terjadi dalam waktu yang singkat, bisa dalam hitungan detik, hari,
atau minggu dan dapat sembuh dengan pengobatan, misalnya patah tulang akibat
jatuh. Sedangkan nyeri kronik adalah nyeri yang berlangsung dalam periode waktu
yang lama, yaitu lebih dari 3 bulan bahkan hingga bertahun-tahun, dan nyeri kronik
biasanya sembuhnya akan lebih lama. Hal ini dikarenakan pada kasus seperti kanker,
kankernya belum teratasi atau belum hilang sehingga nyerinya masih terus timbul.
Materi session 3: page 6
4. Help patient to identify the goal using SMART
To overcome the pain and improving the quality of life, the patient has to set a goal.
The goal can be identified using SMART tools:
S = specific (for example: sitting, standing, walking, taking a bath by themselves, etc)
M = measurable, can be measured by units (for example: sitting for 10 minutes,
walking for 20 m distance, etc)
A = achieveable, the activity is possible to be done by the patient even with some
effort
R = relevant, the goal has to be relevant for the patient (example: sitting, standing,
walking is relevant to patient because they do not want to be dependent to their
family)
T = time frame (example: the patient want to reach the goal in 3 months)

Untuk meningkatkan mobilitas ibu, mengatasi nyeri, dan meningkatkan kualitas

hidup ibu perlu menentukan goal atau tujuan dengan menggunakan panduan SMART.
S = specific (contoh: duduk, beridi, berjalan, mandi sendiri, menyiapkan makan
sendiri, dll)
M = measurable, bisa diukur dengan unit pengukuran (contoh: duduk selama 20
menit, berdiri selama 10 menit, mengangkat benda 500 gr, berjalan sejauh 20 m, dsb)
A = achieveable, aktivitas dapat dilakukan oleh ibu (tidak terlalu berat, tidak terlalu
ringan, sesuai dengan kapasitas dan kemampuan ibu)
R = relevant, goal harus relevan atau penting bagi ibu (contoh: bisa makan sendiri dan
mandi sendiri penting bagi ibu karena ibu tidak ingin bergantung pada keluarganya)
T = time frame atau jangka waktu penting dilakukan untuk dapat meengevaluasi
progress yang dicapai (contoh: ibu ingin mencapai goal dalam 3 bulan)
Materi session 4: page 12
5. Menjelaskan activity pacing
To help you achieving your goals, it needs to be done gradually by activity pacing.
Pacing means gradually increase the level of activity despite the pain by using quotas
and step-by-step. This can be done by exercise in a planned way. The most important
thing is to not let the pain be the guide. If your behavior is dependent on your pain
 you can end up doing less and less and will get weaker, that behavior will also
promote disability and hypersensitivity to pain.
Instruction:
- Set baseline level of each activity limited by pain or what you can manage
comfortably now (example: if you can sit comfortably for 20 minutes, then the
baseline is reduced by about 20% = 4 minutes)
- Set quota (amount) for each of these activities each day
- Keep quotas unchanged for first 3-4 days and stop when reach quota, rest or do
something easier
- When ready, resume the activity, stop at quota
- Raise quota every 3-4 days, not too much, not too little
- Maintain until you reach the goal for that activity
Materi session 4: page 22

6. Help develop weekly plan

Ibu mengalami nyeri kronis dan menjalankan aktivitas sehari-hari berdasarkan nyeri
yang ibu rasakan sehingga aktivitas yang dilakukan terbatas. Oleh karena itu perlu
menyusun rencana aktivitas harian supaya ibu bisa mobilisasi lebih banyak dan
mencegah supaya tidak semakin lemah. Aktivitas yang dilakukan sebaiknya dibagi
sama beratnya sepanjang hari (tidak hanya berat di pagi saja atau sore saja) agar
meminimalisir timbulnya nyeri (tunjukkan contoh yang sudah dibuat). Setelah
menentukan rencana aktivitas harian, ibu harus mengecek rencana ini setiap hari dan
mencatat progress yang sudah dicapai.

You experience chronic pain and carries out daily activities based on the pain you feel
so that the activities are limited. Therefore, it is necessary to develop a weekly
activity plan so that you can mobilize more and prevent you getting weaker.
Activities should be divided equally throughout the day (not too much in the morning
or evening only) in order to minimize the occurrence of pain (show examples that
have been made). After determining the daily activity plan, you must check this plan
every day and record the progress that has been achieved.
 Materi session 4: page 30

7. Introduce a basic exercise plan

Ibu perlu melakukan exercise atau latihan fisik untuk meningkatkan kebugaran tubuh
dan supaya lebih aktif. Latihan fisik juga dapat meringankan nyeri yang dialami ibu,
namun efek dari latihan ini bisa terasa setelah dilakukan dengan rutin (tidak langsung
berkurang nyerinya). Pada awal melakukan latihan fisik mungkin akan terasa nyeri
otot, namun nyeri itu akan hilang apabila ibu terus latihan secara rutin karena tubuh
ibu akan terbiasa dengan peningkatan aktivitas yang ibu lakukan sehingga tubuh ibu
akan lebih bugar. Latihan fisik bisa dilakukan di rumah dengan alat-alat yang
tersedia, dan akan dilakukan secara bertahap dengan cara mengukur kemampuan ibu
sekarang dan akan dinaikkan secara bertahap sampai mencapai goal ibu. Latihan-
latihan yang bisa dilakukan misalnya gerakan duduk berdiri, mengangkat botol air,
membawa kantung berisi beras, berjalan di sekitar rumah, dan lain-lain.

You need to do exercise to improve body fitness and to be more active. Physical
exercise can also relieve the pain, but the effects of this exercise can be felt after
being done regularly (it does not immediately reduce the pain). At the beginning of
doing physical exercise, you may feel muscle pain, but the pain will disappear if you
continue to exercise regularly so that your body will get used to the increased activity
and will be more fit. Physical exercise can be done at home with the available tools,
and should be done gradually by measuring your current ability and should be
increased gradually until it reaches your goal. Exercises that can be done including
sitting and standing, lifting a water bottle, carrying a bag of rice, walking around the
house, and so on.
Materi session 5: page 7
8. Introduce relaxation technique
Saya ingin mengenalkan teknik relaksasi kepada ibu. Teknik relaksasi berguna untuk
menenangkan pikiran ibu ketika merasa nyeri atau stress. Poin yang penting adalah
relaksasi harus dilakukan ketika ibu merasa nyeri dan juga stress, tidak hanya ketika
ada waktu luang. Relaksasi saja tidak mengurangi rasa nyeri tapi bisa membuat ibu
lebih tenang dalam mengatasi nyeri (coping dengan rasa nyeri), sehingga perlu untuk
melakukan relaksasi secara rutin untuk mencapai hasil yang optimal.

Cara relaksasi adalah:

- Biarkan tubuh merasa rileks
- Fokuskan pikiran pada suatu hal (bisa berupa apa saja, misalkan suara air atau
suatu angka atau hembusan dan tarikan nafas ibu sendiri) dan terus arahkan
perhatian terhadap hal tersebut
- Setiap ibu menghembuskan nafas keluar, tubuh akan semakin rileks dan tidak
tegang
Relaksasi dapat mulai dilakukan minimal 7 kali sehari selama minimal 30 detik per
sesi relaksasi, dan dapat dilakukan di mana saja. Kemudian akan ditambah frekuensi
dan durasinya secara bertahap, terutama harus dilakukan ketika merasakan nyeri.

I want to introduce relaxation techniques to you. Relaxation techniques are useful for
calming your mind when you feel pain or stress. The important point is that relaxation
should be done when you feel pain and stress, not only when you have free time and
at peace. Relaxation alone does not reduce pain but can make you calmer in dealing
with pain (coping with pain), so it is necessary to do relaxation regularly to achieve
optimal results.
Ways of relaxation are:
- Let your body feel relaxed
- Focus your mind on one thing (it can be anything, for example the sound of water
or a number or your own inhale and exhale breathing) and continue to direct your
attention to it
- Every time you exhales the body will be more relaxed and less tense
Relaxation can be done at least 7 times a day for a minimum of 30 seconds per
session, and can be done anywhere. Then the frequency and duration will be increased
gradually, especially when you feel pain.
Materi session 5: page 25
9. Introduce simple problem solving method to manage problems like flare up
pain, sleep disturbance, stress etc
Dalam aktivitas sehari-hari mungkin ibu akan mengalami masalah-masalah yang
tidak diharapkan seperti nyeri hebat yang kambuh, sulit tidur, stress, dan lain-lain,
maka saya akan membantu ibu untuk menentukan solusi untuk mengatasi masalah-
masalah tersebut.
Caranya adalah (ada contoh):
- Menyebutkan masalah yang dihadapi, misalnya sulit tidur di malam hari
- Menyebutkan solusi-solusi yang mungkin dapat mengatasi masalah tersebut,
misalnya: minum susu/minuman hangat, mendengarkan music, dan lain-lain
- Setelah menilai setiap solusi dan kekurangan dan kelebihan setiap solusi, pilih
solusi yang paling praktis dan terbaik
- Lakukan solusi tersebut setiap masalah muncul
- Evaluasi apakah solusi tersebut dapat mengatasi masalah ibu

During daily activities, you may experience unexpected problems such as flare-up
pain, difficulty sleeping, stress, etc., so I will help you to identify solutions to
overcome these problems.
The method is (ada contohnya):
- Mention the problems, such as difficulty sleeping at night
- Mention possible solutions to overcome the problem, for example: drinking
milk/warm drinks, listening to music, and others
- After assessing each solution and the advantages and disadvantages of each
solution, choose the most practical and best solution
- Perform the solution every time a problem arises
- Evaluate whether the solution can solve your problem
Materi session 5: page 38