INDIVIDUAL ASSIGMENT

CRITICAL NURSING COURSES

CRITICAL NURSING PRACTICE REPORT

SUPPORTING LECTURER:

Wenny Trisnaningtyas, S. Kep, Ns, M. Kep

ARRAGED BY:

Name : Rizka Yuliasih Kussanty

Him : P1337420620039

Class : 3A3 RKI

BACHELOR OF APPLIED NURSING IN SEMARANG

NURSING DEPARTEMENT

HEALTH POLYTECHNIC OF HEALTH MINISTRY SEMARANG

2023
 Practice Report

Pain Management
I. Practicum goals

Pain management practice using the Behavioral Pain Scale (BPS) is an instrument to
measure the level of pain in ICU patients. This instrument assesses based on the
behavior or behavior of ICU patients because generally in the ICU, patients cannot
express pain so that it can be shown from movements and behaviors that can be
observed. The purpose of this practicum is to measure the level of pain in patients in
the ICU who cannot communicate their pain. To measure the pain scale felt by
patients in critical condition, to ensure the accuracy and effectiveness of patient pain
assessment for the right diagnosis in patients, and to ensure that patients get
appropriate, safe, and effective pain management efforts.

II. Necessary Tools

CPOT scale form as well as stationery and books

III. Practicum Work Procedure

1. Patient Assessment / Indications

This pain measurement is very important to assess the patient's body metabolic
processes. and this pain scale measurement can be carried out for all patients in the
ICU, including patients who are given sedatives and are attached to a ventilator.

2. Planning and Implementation

Measuring pain in patients in the ICU usually uses the Critical Pain Observation
Tool (CPOT) measurement scale. In the Pre-Interaction Stage, ensure the identity
and condition of the patient by checking the patient's medical record, preparing the
tools to be used, washing hands and wearing a mask.

The orientation stage includes greeting and asking the name of the patient's family
members. Introducing the identity of the nurse. Explaining the procedure, purpose
of action, place and duration of activities to be carried out. Asking for
approval/readiness (informed consent) to the family. Give the patient's family the
opportunity to ask before activity begins, keep the privacy of the patient's family

Work Stage with Observation of the patient's condition or expression when the
condition is at rest. The nurse makes observations on the facial area to see changes
in expression every one minute. The nurse looks at the patient's face and body to
note any visible reactions. The nurse gives a score for the facial expression table on
the observation sheet. Observation of patient repositioning or patient movement,
value according to the body movement table on the observation sheet. The nurse
feels muscle tension through the patient's movement resistance, the value is
 according to the muscle tension table on the observation sheet. Make observations
on patients who use mechanical ventilators, pay attention to whether there are signs
of sounding the alarm to stop spontaneously or even requiring calming measures or
administration of drugs, value according to the table of compatibility with the
ventilator on the observation sheet.

Finally, at the Termination Stage, conclude the results of the activity. Clean up
again after taking action. Plan a follow-up plan for the patient.

3. Documentation

IV. Practicum Results and Discussion

Score of 0 = No pain

Score of 1-2 = Mild pain

Score of 3-4 = Moderate pain

Score of 5-6 = Severe pain

Score of 7-8 = Very severe pain

V. Conclusion

Things that need to be noticed include a weak or unresponsive patient response. Pay
attention and be aware of the assistive devices installed to support the patient's life.
The highest score is taken from the CPOT value.

VI. Reference

Cade, C. H. (2008). Clinical tools for the assessment of pain in sedated critically ill
adults. Nursing in Critical Care, 13(6), 288–297. doi:10.1111/j.1478-
5153.2008.00294.x

Wahyuningsih, I. (2019). Sensitivitas dan Spesifisitas Critical Care Pain

Observational Tool (CPOT) sebagai Instrumen Nyeri pada Pasien Kritis Dewasa
Paska Pembedahan dengan Ventilator. Jurnal Keperawatan BSI, 7(1), 25–31.
http://ejournal.bsi.ac.id/ejurnal/index.php/jk 25

Nur, Achmad Ilham, et al. 2022. Gambaran Nyeri Pada Pasien Dengan Penurunan
Kesadaran Menggunakan Metode Critical Pain Observation Tool (CPOT) Di Ruang
ICU RSUD R.A Basoeni dan RSUD Dr. Wahidin Sudirohusodo Mojokerto.
https://repositori.stikes ppni.ac.id/handle/123456789/1148