THE DESCRIPTION OF NURSING CARE REPORT OF CLUSTER HEADACHE TO

MR.HS AT BERLIAN WARD Dr.H.MOCH ANSARI SALEH GENERAL

HOSPITAL BANJARMASIN

FINAL PAPER

BY :

NIRMAYA SOFA

SRN. 1614401110054

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

FACULTY OF NURSING AND HEALTH SCIENCES
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2019
THE DESCRIPTION OF NURSING CARE REPORT OF CLUSTER HEADACHE TO
MR.HS AT BERLIAN WARD Dr.H.MOCH ANSARI SALEH GENERAL
HOSPITAL BANJARMASIN

Proposed to Fulfill One of The Requiremenets to

Accomplish International Class of Nursing Diploma Program

BY :
NIRMAYA SOFA
SRN.1614401110054

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

FACULTY OF NURSING AND HEALTH SCIENCES
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2019

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 PREFACE

The praise be to Allah SWT, The lord of the world, and the sequel is for those
who keep their duty unto Him, further, here will be no hostility except against
wrong doers. Blessing and solution be upon he Most Honorable Prophet and
Messenger, His family all His disciples, and those who follow them in goodness
till the Day of Judgement.
The writer offers the expression of gratitude to Allah, due to His favor and
charity, the writer has finished this report entitled “The Description of Nursing
Care Report of Cluster Headache To Mr.HS at Berlian Ward Dr.H.Moch Ansari
Saleh General Hospital Banjarmasin”.
This final paper is submitted to International Class of Nursing Diploma Program
to one of the requirement accomplishing the program.
The writer would like to give great gratitude to:
1. Mr. Prof. Dr. H. Ahmad Khairudin, M. Ag, as the Rector of University of
Muhammadiyah Banjarmasin.
2. Mr. M Syafwani, SKp. M.Kep.Sp.Jiwa, as the Dean Faculty of Nursing and
Health Sciences University of Muhammadiyah Banjarmasin
3. Mrs. Noor Amaliah, Ns., M.Kep, as the Head of Nursing Diploma Program.
4. Mrs. Nurhikmah, SST.,MPH, as the first Advisor of Material Competence and
the fisrt examiner, she was corrected my final report and guide me until I can
completed my final report well.
5. Mrs. Dewi Setya Paramitha, Ns., M.Kep, as the second Advisor of Material
Competenceand the second examiner, she was corrected my final report and
guide me until I can completed my final report and teach me writing in
English well.
6. Mrs. Liniyarti, S.Kep.,Ns, as may Clinical Instructure and the third examiner,
she was guided me during mypractice in the hospital room and thanks for all
the sciences that has been given to me. All nurses at Berlian ward, Dr.H.Moch

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 Ansari Saleh General Hospital of Banjarmasin thanks for all the sciences that
has been given to me.
7. Mr.HS as my client at Berlian Ward, Dr.H.Moch Ansari Saleh General
Hospital of Banjarmasin and client family thank you already trust me to take
care of Mr.HS
8. Lectures and staffs of nursing Diploma Program, University of
Muhammadiyah Banjarmasin.
9. My beloved and blessed parents Mr.H.M.Noor dan Mrs.Hj.Isnawati I love you
so much and my brother Akhmad Shaufi that gave me inspiration, materials,
and motivation. Chance to learn, power and spirit, pray and support with all
the best ways until right now, so that I can passed this awesome and hard three
years and graduated this study.
10. All my lovely friends from International Class of Nursing Diploma Program
9th batch who always encouraging me to finish this final paper.
11. And thank you, who helped me to finish my final report
However, the writer realizes that there are still many mistake in this report, and
will open heartedly welcoming any criticism.
Finally, the writer hopes thatS this report will be useful for the writer herself and
the readers.

Banjarmasin,July 2019

Nirmaya Sofa

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 CONTENTS

TITLE PAGE ..................................................................................................... i

ADVISOR’S APPROVAL SHEET ................................................................... ii
ACKNOWLEDGEMENT ................................................................................. iii
PREFACE .......................................................................................................... iv
CONTENTS ....................................................................................................... vi
ABSTRACK....................................................................................................... xi
STATEMENT OF ORISINALITY.................................................................... xii

CHAPTER 1 INTRODUCTION
1.1 Backgroud ............................................................................. 1
1.2 Formulation of the Problem................................................... 4
1.2 Purpose ................................................................................. 5
1.3 Benefits ................................................................................. 5

CHAPTER 2 THEORETICAL BACKGROUND

2.1 Anatomy Physiology............................................................. 7
2.2 Definition .............................................................................. 11
2.3 Etiology ................................................................................ 12
2.4 Sign and Symptom ............................................................... 13
2.5 Pathophysiology ................................................................... 13
2.6 Pathway ................................................................................ 14
2.7 Classifocation........................................................................ 15
2.8 Complication......................................................................... 15
2.9 Diagnostic Test ..................................................................... 15
2.10 Radiologic Examination...................................................... 16
2.12..............................................................................................Ma
nagement of Pain.................................................................. 16
2.12 Nursing Care Concept ........................................................ 19
2.13 Theoritical Review of Nursing Care of Cluster Headache. . 20

CHAPTER 3 METHODOLOGY OF CASE STUDY

3.1 Final Paper Design ............................................................... 32
3.2 Subject of Case Study and Focus of Study ........................... 32
3.3 Setting and Schedule of Case Study...................................... 33
3.4 Operational Definition........................................................... 33
3.5 Data Collection Techniques and Instrument......................... 33
3.6 Presentation of Data.............................................................. 34
3.7 Case Study Ethics.................................................................. 35

CHAPTER 4 NURSING CARE REPORT

4.1 Client Identity ..................................................................... 37
4.2 Health History .................................................................... 38
4.3 Physical Examination ......................................................... 39

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 4.4 Physical, Psychological, Social and Spiritual Needs .......... 43
4.5 Diagnostic Test ..................................................................... 45
4.6 Pharmacological Therapy ................................................... 47
4.7 Data Analysis and Nursing Diagnosis ................................ 48
4.8 Nursing Plan ....................................................................... 50
4.9 Implementation ................................................................... 52
4.10 Evaluation ........................................................................... 54
4.12 Progress Notes .................................................................... 56
4.13 Home Care Progress Notes ................................................. 66
4.14 Discussion of Case Study ................................................... 68

CHAPTER 5 CONCLUSION AND SUGGESTION

5.1 Conclusion ............................................................................ 73
5.2 Recommendation .................................................................. 75

BIBLIOGHRAPHY............................................................................................ 76

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 THE LIST OF TABLE

TABLE
Table 2.1 Pain Scale..................................................................................... 16
Table 2.2.Indication and dosage of pain pharmacotherapy......................... 17
Table 2.3 Nursing Intervention.................................................................... 24
Table 4.1 Muscle Scale................................................................................ 43
Tbale 4.2 Activity Scale............................................................................... 43
Table 4.3 Blood Examination...................................................................... 45
Table 4.4 Therapy Pharmacology................................................................ 47
Table 4.5 Indication of Drugs...................................................................... 48
Table 4.6 Data Analysis............................................................................... 48
Table 4.7 Nursing Plan ................................................................................ 50
Table 4.8 Implementation............................................................................ 52
Table 4.9 Evaluation.................................................................................... 54
Table 4.10 Progress Notes........................................................................... 56
Table 4.11 Home Care Progress Notes............................................................... 66

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 THE LIST OF PICTURE

PICTURE
2.1 Pathway of Cluster Headache................................................................ 14
4.1 Genogram ..................................................................................................... 38

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 THE LIST OF ATTACHMENT

ATTACHMENT
Attachment 1. EEG: Electroencepaloghraphy......................................... 80
Attachment 2. Results EEG: Electroencepaloghraphy ........................... 81
Attachment 3. Consultation Sheets............................................................ 82
Attachment 4. Student Presence List.......................................................... 92
Attachment 5. Surat Pengantar Pengambilan Data...................................... 93
Attachment 6. Advisors Approval Sheet................................................. 96
Attachment 7. Curiculum Vitae.......................................................................... 97

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NURSING DIPLOMA PROGRAM
UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

Final Paper, July 10th 2019

Nirmaya Sofa
SRN. 1614401110054

THE DESCRIPTION OF NURSING CARE REPORT OF CLUSTER

HEADACHE TO MR.HS AT BERLIAN WARD Dr.H.MOCH ANSARI
SALEH GENERAL HOSPITAL YEAR 2019

Abstract

Theoritical background: Cluster headache is the most severe pain. The symptoms
are very painful and last 15-180 minutes or more. The pain is localized to the
temples and one of the eyes. Most suffer from patients aged 20-45 years.
Domination in men with a ratio 2,5:1. From the results obtained in the field of
research that is client with the case of the cluster headache complaining right head
feel very painfull, with nursing problem acute pain, activity intolerance and
insomnia. Nursing intervention for resolve problem that is with application
pharmacology therapy ergotamine and exercise relaxation. Purpose: Deep
breathing relaxation technique can control pain by minimizing the sympathetic
activity in the autonomic nervous system and increase lung ventilation and
increase blood oxygenation. Method: This scientific paper use method case study
descriptive a client with cluster headache. Data collection is done use observation
and assessment on May 14th-May 18th 2019 at Dr.H.Moch Ansari Saleh General
Hospital Banjarmasin. Result Research: After do nursing action obtained results
need for comfort client fulfilled client able to concentrating and reported a sense
of comfort after pain reduced. Conclusion: pharmacology therapy is done to client
with acute cluster headache, application exercise relaxation is done to client could
decrease the mild pain.

Keywords: cluster headache, exercise relaxation (deep breathing), pain.

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 CHAPTER 1
INTRODUCTION

1.1. Background
Headache is a common symptom of many neurological and non-neurological
diseases. Headache or chepalgia is a condition where there is pain in the head,
which is caused by stimulation of pain sensitivity structures in the cranium or
neck. Headache is usually classified as primier and secondary head
pain (White et al., 2012).

Primary headache is headache experienced by a person without any

underlying abnormalities, while secondary headache occur as a result of
abnormalities, such as due to head trauma and are the result of pathological
conditions such as brain tumors or inflammation of cranial nerves. Primary
headache pain is more common than secondary headache.

Cluster headache is a type of primary headache due to neurovascular disorder.

Cluster headache also called Harton’s headache, histaminic headache. Cluster
headache is the most severe pain. The symptoms are very painful and last 15-
180 minutes or more. Pain is usually localized to the temples and one of the
eyes. Other symptoms that can be found include lacrimation, nasal
congestion, conjunctival injection, miosis, ptosis, nausea, and
bradycardia. Most suffer from patients at 20-45 years old. Domination in men
with a ratio of 2,5:1 (Satyanegara, 2018).

Cluster Headache is a rare condition, where the disease occurs in less than 1%
of the population (British Association for the Study of Haedache, 2010).
Prelevalensi of cluster headache is in estemation approximately 0,5-
1,0/1.000. Cluster headache is an unexpected condition. Some patients
experience only one attack, while in other patients the disease evolves from
episodic forms to chronic forms

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There is no known factors in disease chronicitis. With a decrease, attacks

often decrease, where attacks are rarely found after the age of 75. Cluster
headaches are the most severe vascular primary headaches, pressed with side
pain with ipsilateral autonomic signs, and anxiety. Headache is one of the
main health problems in the community. According to WHO (2012), around
47% of the adult population in the world has experienced at least one
headache in one year. Headache has a negative impact on society. Headache
can reduce activities ofdaily living (ADLs), reduce quality of life, and
increase economic burden (WHO, 2012). Cluster Headache is relatively
uncommon. It affects fewer than 1 in 1000 adults, affecting six men and
women in the most people developing cluster. Their headaches are 20 years
old or older. (WHO, 2012).

Based on the results of a multicenter study based on five hospitals in

Indonesia, the prevalence of headache patients, cluster headache is a rare type
of headache, with a prevalence of around 0,5%, but high pain intensity and
often recurring. Medication-overuse headache is generally a chronic daily
headache, and attacks 2% of the adult population and children. Unlike
migraine, male sufferers are 4-7 times more often than women. Onset can
occur at any age but most often occurs at the end of the 20 th years. Recent
epidemiological studies have shown that the prevalence of cluster headaches
is around one person per 500 persons. The genetic epidemiology survey
shows that at the first level limitations, the risk of occurrence is 5-18 times,
and at the second level of kinship, the probability of occurrence is 1-3 times
the general population. (Ikawati, Z & Anurogo, D, 2018).

Based on the survey at the Dr.H.Moch Ansari Saleh General Hospital of

Banjarmasin, the prevalence of patients with Cluster Headache was a very
rare type of headache. In 2015, only one person was affected by Cluster
Headache throughout the inpatient ward of the Dr.H.Moch Ansari Saleh
General Hospital of Banjarmasin, in 2016 there were also only one person
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affected by the Cluster Headache throughout the inpatient ward of the

Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin, in 2017 Cluster
Headache disease sufferers increased to three persons in all care wards stay in
Dr.H.Moch Ansari Saleh General Hospital Banjarmasin, and in 2018 there
were no patients suffering from Cluster Headache in all inpatient wards at the
Dr.H.Moch Ansari Saleh General Hospital Banjarmasin .

During the period of cluster type headache attacks, as many as 90% of

patients become restless and cannot rest. They can not lie down to rest,
otherwise patient choose to walk and move to and fro. Patients can feel
hopeless their heads on hard surfaces, scream in pain, and roll around (WHO,
2012). In general, cluster type headaches will last a lifetime. Some prognosis
includes recurrent attacks, prolonged remission, and the possibility of
episodic type transformation becoming a chronic type. As many as 80% of
patients with pain episodic type head types remain in their episodic period. In
4-13% of cases, the episodic type changes to the chronic type. Spontaneous
remission occurs in 12% of patients, especially those with the episodic
type. Chronic types persist in 5% of cases. Although rarely chronic type
cluster headaches can turn into episodic types. There are no reports of
mortality that are directly related to cluster type headaches. However, patients
with cluster type headaches have the risk of injuring themselves, committing
suicide attempts, alcohol consumption, smoking, and peptic ulcers. Suicide
attempts have been reported in cases with severe and frequent attacks. The
intensity of the attacks on cluster type headaches often causes patients to be
disturbed in carrying out their activities (WHO, 2012).

Based on results above to diagnose cluster headache very rarely found but
intensity of the pain when attack feels very and torture, then for pain control
and reduce it nurse do intervention deep breathing relaxation technique is a
form of nursing care, which in this case the nurse teaches clients how to do
deep breathing, slow breathing (maximum inspiration) and how to exhale
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slowly, besides reducing pain intensity, deep breathing relaxation techniques

can also increase lung ventilation and increase blood oxygenation. Deep
breathing relaxation techniques can control pain by minimizing sympathetic
activity in the autonomic nervous system (Fitriani. 2013). The patient can
close his eyes and breathe slowly and comfortably. The absolute rhythm can
be maintained by calculating in the heart and slowly with each inhalation
(inhalation) and echalation (blowing) (Smeltzer & Bare, 2002).

Other effects of cluster headache cause sleep disorder due to feel pain. Based
on the results of the study of 35 respondents studied, there were 24 (68.6%)
as many as 19 (54,3%) respondents disrupted their sleep needs this was
caused by respondents' discomfort with perceived pain which made
respondents often experience emotional stress that is often explained in terms
of destructive processes, tissues such as being stabbed, burning heat, twisting,
feeling afraid. Sleep hygiene is a daily habit that is associated with
the sleep process, which has an effect on the quality and duration of sleep
(Lim & Dinges, 2010) which can help clients to get better sleep quality.

Based on that phenomena to reduce the pain for client when had cluster
headache, author interested to do nursing care with cluster headache. This
case written down in a scientific paper with entitled The Description of
Nursing Care Report of Cluster Headache to Mr.HS at Berlian Ward
Dr.H.Moch Ansari Saleh General Hospital Banjarmasin.

1.2. Formulation of the Problem

1.2.1. How is the description of nursing care on client with
cluster headache ?
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1.3. Purpose
1.3.1. General purpose
The general purpose of ths scientific writing is to make a
comprehensive nursing care as well as the report at berlian ward the
client Mr.HS with cluster headache.
1.3.2. Specific purpose
1.3.2.1. Describing the results of assessment on clients with cluster
headache which include bio-psycho-socio-spritual aspect.
1.3.2.2. Formulating a data analysis and nursing diagnose to the
client.
1.3.2.3. Determining nursing interventions that can be performed to
client
1.3.2.4. Giving the implementation of nursing care according to the
intervention
1.3.2.5. Evaluating and documenting the results of nursing care.
1.3.2.6. Describing and discuss the results of nursing care to the
clients with cluster headaches based on supporting theories.

1.4. Benefit
1.4.1. For nursing profession
1.4.1.1. For nursing profession
The scientific paper is expected to give contribution in
enlivening, glorifying and enriching the culture of research
and scientific writing. The scientific paper is also exoected
to give more reference of nursing care escpecially for the
case of cluster headache.
1.4.1.2. For client
This scientific paper including the whole process of making
it is expected to help the client in gaining better condition,
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changes behavior, and knowledge about disease as well as

the treatment.
1.4.1.3. For hospital
This scientific paper including the wholeprocess of making
it is expected to give some contribution for the hospital as
reference in giving better service for the clients.
1.4.1.4. For academic institution
This scientific paper is expected to help the other students
or anyone in the academic institution who need reference
and/or comparison in their academic activity
1.4.1.5. For author
This scientific paper give experience for the author in
gaining knowledge about cluster headache, giving
comprehensive nursing care and making scientific paper as
the report of the comprehensive nursing.
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 CHAPTER 2
THEORITICAL BACKGROUND

2.1Medical Theoritical Review

2.1.1 Anatomy and physiology of central nervous system
The brain and spinal cord is the main network of coordination and
control for the body. The brain and spinal cord are protected by the
skull and vertebrae, the meninges, and the cerebrospinal fluid. Three
layers of meninges surround the brain and spinal cord, assisting in
production and drainage of cerebrospinal fluid. Cerebrospinal fluid
circulates between interconnecting systems of ventricles in the brain
and around the brain and spinal cord, serving as a shock absorber
(Seidel, 2011).
2.1.1.1 Brain
The brain is one of the largest organs in adults. It consists, in
round numbers, of almost 100 billion neurons and roughly the
same number of glia. In most adults, it weighs about 1.4 kg (3
pounds). Six major divisions of the brain, named from below,
upward, are as follows: (Kevin T. Patton, 2013) .
a. Cerebrum
Two cerebral hemispheres, each divided into lobes, form
the cerebrum. The gray outer layer, the cerbral cortex, the
higher mental functions and responsible for general
movement, visceral functions, perception, behavior, and
the integration of these functions. Commisural fibers
(corpus collosum) interconnecting each hemisphere area,
permitting the coordination of activities between the
hemispheres. The frontal lobe contains the motor cortex
associated with voluntary skeletal movement and fine
repetitive motor movements, as well as the control of eye
movement (Seidel, 2011).

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b. Cerebellum
The cerebellum (literally "little brain") is located just below
the posterior portion of the cerebrum and is partially
covered by it. A transverse fissure separates the cerebellum
from the cerebrum (Kevin T, Patton, 2013). The cerebellum
aids the motor cortex of the cerebrum in the integration of
voluntary movement. It processes sensory information from
the eyes, ears, touch receptors, and
musculoskeleton. Integrated with the vestibular system, the
cerebellum uses the sensory data for reflexive control of
muscle tone, balance, and posture to produce steady and
precise movements (Seidel, 2011).

c. Medulla oblongata
Mycephalon is called the medulla oblong and forms the
lowest portion of the brainstem. Reflex activities, such as
heart rate, respiration, blood preassure, coughing, sneezing,
swallowing, and vomiting are controlled inthis area. The
nuclei of cranial nerves IX through XII are also located in
this region (Sue E & Kathryn I, 2012).
d. Pons
Just above the medulla lies the pons, composed, like the
medulla, white matter and reticular formation. Fiber that
runs transversely accross the pons and through the middle
cerebellar peduncles into the cerebellum makes up the
external white matter of the punch and gives it its arching,
bridging appearance (Kevin T, Patton, 2013).

e. Diencephalon
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The diencephalon (literally, "between brain") is located

between the cerebrum and the midbrain (mesencephalon).
Although the diagnosis is made of several structures located
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around around the third ventricle, the main ones are

thalamus and hypothalamus (Kevin T. Patton, 2013) .

The thalamus about 80% of the diencephalon, consists of

two oval masses of gray matter that serve as relay stations
for sensory impulses, except for the sense of smell, going to
the cerebral cortex. When the impulses reach the thalamus,
there is general awareness and crude recognition of
sensation. The thalamus channels for impulses to the
appropriate region of the cortex for discrimination,
localization and interpretation (Applegate, 2011).

The hypothalamus and the lower part of the lateral

walls. Prominent among structures composing the
hypothalamus are the supraoptic nuclei, the paraventricular
nuclei, and the mamillary bodies (Kevin T. Patton, 2013) .
The hypothalamus plays a key role in maintaining
homeostasis because it regulates many visceral
activities. The following functions summarize the various
functions of the hypothalamus regulating and integrating
autonomic nervous system, regulating body temperature,
regulates food intake, regulating water balance and thirst,
regulating wake up cycles, and regulating endocrine system
activity ( Applegate, 2011) .
f. Midbrain
The midbrain (mesencephalon) is appropriately named. It is
a brain of the brain, because it is above the pons and below
the cerebrum. Both tracts and reticular formation compose
the midbrain. Tracts in the peduncles conduct impulses
between the midbrain and cerebrum. (Kevin T. Patton,
2013). The functions of midbrain are for the reflex center of
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the eye and head movement, auditory relay pathways, and

corticospinal tract pathways (Seidel, 2011) .

2.1.1.2 Spinal cord

The spinal cord is continuous with the medulla oblongata
above and constitutes the CNS below the brain. (Watson,
2011). Grossly, the spinal cord is divided into vertebral
sections (8 cervicals, 12 thoracics, 5 lumbars, 5 sacrals, and 1
coccygeal) that correspond to paired nerves. A cross section of
the spinal cord is characterized by a butterfly shaoed inner core
of gray matter (containing nerve cell bodies) (Sue E & Kathryn
I, 2012).

The spinal cord performs two general functions. Briefly, it

provides conduction routes to and from the brain and serves as
the integrator or reflex center for all spinal reflexes. Ascending
tracts conduct sensory impulses up the cord to the brain.
Descending tracts conduct motor impulses down the cord from
the brain. Bundles of axons compose all tracts (Kevin T.
Patton, 2013).

2.1.2 Cranial nerves

The cranial nerves are peripheral nerves that arise from the brain rather
than the spinal cord. Each nerve has motor or sensory functions, and
four cranial nerves have parasympathetic functions.
2.1.2.1 Cranial nerve I (olfactory) : Sensory - smell reception and
interpretation.
2.1.2.2 Cranial nerve II (optic) : Sensory – visual acuity and visual
fields.
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2.1.2.3 Cranial nerve III (oculomotor) : Motor – raise eyelids, most

extraocular movements. Parasymphatetic – pupillary
constriction, change lense shape.
2.1.2.4 Cranial nerve IV (trochlear) : Motor – downward, inward eye
movement.
2.1.2.5 Cranial nerve V (trigeminal) : Motor – jaw opening and
clenching, chewing and mastication. Sensory – sensation to
cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead,
nose, nasal, and mouth mucosa, teeth, tongue, ear, facial skin.
2.1.2.6 Cranial nerve VI (abducens) : Motor – lateral eye movement.
2.1.2.7 Cranial nerve VII (facial) : Motor – movement of facial
expression muscles except jaw, close eyelids, labial speech
sound. Sensory – taste, anterior two thirds of tongue, sensation
to pharynx. Parasymphatetic – secretion of salive and tears.
2.1.2.8 Cranial nerve VIII (acoustic) : Sensory – hearing and
equilibrium.
2.1.2.9 Cranial nerve IX (glossopharyngeal) : Motor – voluntary
muscles for swallowing. Sensory – sensation of nasopharynx,
gag reflex, taste-posterior one third of tongue. Parasymphatetic
– secretion of salivary glands, carotid reflex. Motor – voluntary
muscles of phonation (guttural speech sounds) and swallowing.
2.1.2.10 Cranial nerve X (vagus) : Sensory – sensation behind ear and
part of external ear canal. Parasymphatetic – secretion of
digestive enzymes, peristalsis, carotid reflex, involuntary action
of heart, lungs, and digestive tract.
2.1.2.11 Cranial nerve XI (accessory) : Motor - turn head, shrug
shoulders, some actions for phonation.
2.1.2.12 Cranial nerve XII (hypoglossal) : Motor – tongue movement
for speech sound articulation, and swallowing (Seidel, 2011).

2.1.3 Definition of cluster headache.

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Four major groups of primary headache classification based on the

International Headache 2nd edition made by the Classification
Committee Pain Head of the International Headache Society (IHS) is a
tension-type headache (tension-type headache), migrain, cluster
headache and cephalgia trigeminal other-otonomics, as well as other
primary headaches (Perdossi, 2013). Primary head pain generally
occurs in the age group of 18-65 years (Gorelick et al ., 2014).

Cluster headache also called Harton’s headache, histaminic headache.

Cluster headache is headache occurs repeatedly in a particular cycle or
pattern. A cycle of cluster headache can occur every week until every
month, followed by periods of reduction or pain relief when the
headache has stopped. This period known as the remission period can
last for several months to several years (Satyanegara, 2018).

Cluster headache is related to the central nervous system through the

trigeminal nerve ophthalmic branch which innervates pain-sensitive
intracranial structures such as durameters and blood vessels. When the
trigeminal nerve is activated, PCGRP, and serotonin substances are
released which are vasodilatory, which triggers neurogenic
inflammation and dilatation of durameter blood vessels and jugular
veins (Satyanegara, 2014).

2.1.4 Etiology of cluster headache

The exact cause of this disease is unknown. There are hypotheses based
on neurovascular theory, where vasoactive effects are present in this
disease. Disfunction or inflammation of blood vessels in the parasellar
or cavernous sinus can activate trigeminal orbital pain. Cluster
headache is a form of chronic and recurring headache. This condition
appears to be related to sudden release of histamine and
serotonin. The hypothalamus region may be involved in this
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attack. There are several things that can trigger cluster headache attacks,
among them are:
2.1.4.1 Alcohol and smoking,
2.1.4.2 At height
2.1.4.3 Bright light
2.1.4.4 Stress,
2.1.4.5 heavy activity
2.1.4.6 Extreme weather (Jasmin, 2012).

2.1.5 Signs and symptoms of cluster headache

Cluster headache generally occur in a series, and then disappear for
weeks, or months, or years before they occur again. Headache is
periodic, unilateral (one side of the head), and in one period usually
occurs between 15 minutes to 3 hours, but generally around 30-45
minutes. Pathophysiologically similar to migraine, which is vascular,
which means it is caused by abnormal blood vessel activity, which
involves dilation / development of blood vessels excessive around one
eye. Symptoms are unilateral redness on the face, tears from affected
eyes, runny nose, but no symptoms of nausea or sensitivity to light,
sound, etc., such as those that occur in migraines. (Ikawati, Z &
Anurogo, D, 2018). The symptoms are very painful and last 15-180
minutes or more. Pain is usually localized to the temples and one of the
eyes. Other symptoms that can be found include lacrimation, nasal
congestion, conjunctival injection, miosis, ptosis, nausea, and
bradycardia. Most suffer from patients aged 20-45 years. Domination in
men with a ratio of 2.5: 1 (Satyanegara, 2018).

2.1.6 Pathofisiology
The pathophysiology underlying cluster headaches is not fully
known. Periodic attacks of headache suggest involvement of biological
clocks in the hypothalamus, in the absence of central barriers to the
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nociceptive pathway and autonomic pathways, specifically the

trigeminal nasceptive pathway. The hypothalamic posterior section of
" gray matter " is thought to be an important area responsible for this
cluster headache disorder based on neuroimaging imaging results using
positron emission tomography (PET) (Ikawati, Z & Anurogo, D, 2018).

2.1.7 Pathway of cluster headache

Stress, extreme temperatures, heavy activity,

height, smoking, alcohol

The biological clock of Cortisol hormone increases

the hyputalamus is
disrupted
Activation of the Vasoconstriction of
trigeminal system cerebral blood vessels

Activation CN. V
Inadequate O2 blood
The need for O2 in
supply to the brain
the brain increases
Release CRGP and VIP

Cerebral artery vasodilation

Cluster Headache Heart

compensation to
Acute pain other organs is
less O2

Discomfort Difficulty getting to sleep

Activity Intolerance

Insomnia

Sleep deprivation,

fatigue
 15

Risk for fall

2.1.8 Classification Picture Pathway of Cluster Headache

(Modification
2.1.8.1 EpisodicSoemarmo, 2009
pain, where & Ikawati,
there Z &two
are at least Anurogo, D, 2018)that
phase clusters
last for 7 days to 1 year, which are accompanied by a period of
pain free for 1 month or longer.
2.1.8.2 Chronic type, where the cluster phase occurs more than once a
year without remission, or with a free period of less than 1
month ( Ashkenazi A, 2011)

2.1.9 Complication
Cluster Headache is not a life-threatening condition and usually does
not cause permanent changes to the brain (Cluster-type headache can be
classified into two main types:
Jasmin, 2012).

2.1.10 Diagnostic examination of cluster headache

2.1.10.1 Blood specimens if there is an indication of a suspicion of
systemic disease as a cause of headache
2.1.10.2 CSS specimens if there are indications of suspected
subarachnoid hemorrhage or central nervous system
infection.
2.1.10.3 Electroencephalography (EEG) with authentication in the
form of:
a. There is a suspicion of intracranial neoplasms
b. The presence of permanent one-sided headache with
visual, motoric, or sensibility or contralateral sensibility.
c. Presence of visual field defects, motoric deficits, or
persistent sensitivity.
d. Migraine attacks accompanied by syncope.
 16

e. There is a change in the intensity, duration and nature of

headache.

2.1.10.4 Radiologic examination

a. Plain head X-ray with indications of presence of
headache including headache such as intracranial
neoplasm, hydrocephalus, intracranial bleeding.
b. Cervical vertebrae with indications if there is occipital or
subocipital pain that is not caused by tension type
headache
c. Arteriography with indication if there is a suspicion of
aneurysm, angioma, or bleeding in the desal process of
space.
d. Head CT scan with indications if there is suspicion of
brain structural disorders such as neoplasms, intracranial
bleeding, and others.

2.1.11 Management of pain

Table 2.1. Pain sclae
No pain
Pain Level 0 No Pain No pain at all, you feel perfectly normal.
Minor pain : Minor pain levels generally do not interfere with most day to day
activities. Able to adapt to pain psycholo gically and with medication or devices
such as cushions.
Pain Level 1 Very Very light barely noticeable pain, like a mosquito bite or
Mild a poison ivy itch. Most of the time you never think about
the pain
Pain Level 2 Minor pain, like lightly pinching the fold of skin
Discomforting between the thumb and first finger with the other hand,
using the fingernails.
People can react differently to this self-test.
Pain Level 3 Very noticeable pain, like an accidental cut, a blow to
Tolerable the nose causing a bloody nose, or a doctor giving you
an injection. The pain is not so strong that you cannot get
used to it. Eventually, most of the time you don't notice
the pain, as you have adapted to it.
Moderate pain levels : Moderate pain levels i nterfere with many daily activities.
These pain levels usually require some lifestyle changes but you can remain
independent, however, you are unable to adapt to the pain.
Pain Level 4 Strong, deep pain, like an average toothache, the initial
 17

Distressing pain from a bee sting, or minor trauma to part of the

body, such as stubbing your toe real hard. So strong you
notice the pain all the time and cannot completely adapt.
This pain level can be simulated by pinching the fold of
skin between the thumb and first finger with the other
hand, using the fingernails, and squeezing real hard.
Note how the simulated pain is initially piercing but
becomes dull after that.
Pain Level 5 Very Strong, deep, piercing pain, such as a sprained ankle
Distressing when you stand on it wrong or mild back pain. Not only
do you notice the
pain all the time, you are now so preoccupied with
managing it that you normal lifestyle is curtailed.
Temporary personality disorders are frequent.
Pain Level 6 Intense Strong, deep, piercing pain so strong it seems to partially
Pain dominate your senses, causing you to think somewhat
unclearly. At this point you begin to have trouble
holding a job or maintaining normal social relationships.
Comparable to a bad non-migraine headache combined
with several bee stings, or a bad back pain. .

Severe pain level Severe pain levels mean you are unable to engage in your
normal activities. The patient is considered disabled and unable to function
independently
Pain Level 7 Very Same as 6 except the pain completely dominates your
Intense Pain senses, causing you to think unclearly about half the
time. At this point you are effectively disabled and
frequently cannot live alone. Comparable to an average
migraine headache.
Pain Level 8 Horrible Pain so intense you can no longer think clearly at all, and
Pain have often undergone severe personality change if the
pain has been present for a long time. Suicide is
frequently contemplated and sometimes tried.
Comparable to childbirth or a real bad migraine
headache.
Pain Level 9 Pain so intense you cannot tolerate it and demand pain
Excruciating killers or surgery, no matter what the side effects or risk.
If this doesn't work, suicide is frequent since there is no
more joy in life whatsoever. Comparable to throat
cancer.
Pain so intense you will go unconscious shortly. Most
Pain Level 10 people have never experienced this level of pain. Those
Unimaginable Pain who have suffered a severe accident, such as a crushed
hand, and lost consciousness as a result of the pain and
not blood loss, have experienced level 10 (Disable World
Towards Tommorow, 2018)

Tabel 2.2. Indication and dosage of pain pharmacotherapy drugs

based on the degree of pain
Minor pain
Level I farmacotherapy
Drugs Dose Time
Aspirin 325-650 mg, Every 4 hour
 18

maxsimal 4 g/day
Asetaminofen 325-650 mg Every4-6 hour
Level II farmacotherapy
Ibuprofen 200 mg Every 4-6 hour
Sodium Naproksen Fisrt 440 mg, next Every 8-12 hour
220 mg
Ketoprofen 12,5 mg Every 4-6 hour
Moderate pain
Level III farmacotherapy
Drugs Dose Time
Asetaminofen Dosage adjustment, Every 4-6 hour
for example: Aspirin
1000 mg
Ibuprofen Dosage adjustment, Every 4-6 hour
for example: Aspirin
1000 mg
Sodium Naproksen Dosage adjustment, Every 8-12 hour
for example: Aspirin
1000 mg
Ketoprofen Dosage adjustment, Every 4-6 hour
for example: Aspirin
1000 mg
Level IV farmacotherapy
If level III pharmacotherapy fails, the selected NSADI can be replaced. Choice of
2nd NSAID preferably from different chemical groups (see frequently used non-
opiod analgesic tablets)
Level V farmacotherapy
Opioid (example:codein)
Moderate pain
Level VI farmacotherapy
Drugs Dose Time
Tramadol 50-100 mg Every 4-6 hour
Severe pain
Level VII farmacotherapy
Drugs Indication Mechanism
Morfin If non-narcotics
therapy is
ineffective & there
is a history of
narcotics therapy for
pain.
Mix agonisantagonis Block activation of the
pentazosin components of the receptor
complex.
Agonis partial Block activation of the
components of the receptor
complex.
2.1.12 Management of cluster headache
Therapeutic goals is although it occurs in a short time, cluster
headaches are generally very painful and patients suffer
greatly. Because of the many frequency of attacks, this headache often
 19

causes disability. The goal of cluster headache therapy is to stop the

total attack or reduction, at least until the next episode. More
conservative, and usually more realistic, the goal is to shorten the
cluster period in episodes of headache and to reduce the frequency and /
or severity of the attack, both in the episodic or chronic type. (Ikawati,
Z & Anurogo, D, 2018).
2.1.12.1 Non-pharmacological therapy
a. For non-drug therapy and preventing attacks, patients must
avoid possible trigger factors including the following:
b. Take a nap or other important changes regarding their sleep
habits
c. Alcohol, especially during the cluster period
d. Prolonged exposure to chemicals such as cleaning fluids
or oil based paint
e. Extreme outbursts of anger or emotion
f. Extreme height changes
2.1.12.2 Pharmacological therapy
Pharmacological therapy for acute attacks of cluster
headache almost the same as migraine headaches, but it is
preferred that provide profilaksis therapy, for acute treatment
of cluster headache often provide small benefits.

However, research report that for standart therapy cluster

headache can be given 100% oxygen inhalation with
a minimum speed of 12 L/minute for 15 minutes. There are
no reported side effects in terms of oxygen use, but caution
must be given to smokers and those whosuffer COPD. Other
drugs that can be given for acute treatment are the triptan and
ergotamine groups (Ikawati, Z & Anurogo, D, 2018).

2.1.12.3 Medicines for prophylactic therapy

 20

For Verapamil's clap headache are the first line of choice for
cluster headache, either for episodic types or for 3 times or 4
times a day may be effective, but up to 960mg a day is needed.
The side effects are constipation. It should not be given
together first for chronic 80 dosage are effective.

Verapamil usually blockers. Prednisolone can also be used, at

a dose of 60-1 once a day for 2-5 days. If this drug works well,
can relieve pain quickly. But due to the large side potential, the
treatment must be completed in a short time. Dosage reduction
should begin after after 2-5 days with a decrease of 10
mg every 3 days, so that treatment can be stopped after 2-3
weeks. The next drug that can be used is Lithium carbonate,
which can be considered for the prophylaxis of cluster
headache, both episodic and chronic, if verapamil is ineffective
(Ikawati, Z & Anurogo, D, 2018).

Management of this disease consists of management when pain

occurs and management to prevent pain from occurring. In
preventing attacks, patients can avoid smoking, alcohol and
other facts that can trigger an attack. Recording of episodes of
pain can help patients identify the trigger of the attack (Jasmin,
2012).

2.2 Theoritical Review of Nursing Care of Cluster Headache

Nursing care is a the trapeutic processs that involves the cooperative
relationship between the nurse with clients, families, or communities to a
chieve optimal health status in providing nursing careby using the method
swhich include nursing process: assessment, nursing diagnosis, planning,
implementation and evaluation (Muttaqin, 2011).
2.2.1 Assessment
 21

The basic concept of nursing care with cluster headache are:

2.2.1.1 The client identity .

Include: name, age, gender, marital status, religion, address,
education, nationality, medical diagnose, date of entry hospital,
and date of assessment
2.2.1.2 Main Complaint
Contains complaint of very painful and sudden headaches
without other symptoms that have never been experienced
before, can be accompanied by neck stiffness, positive signs,
neurological deficits such as eyeball muscle paralysis
(Okulomotorious N.), decreased consciousness and vomiting.
Pain felt on one side only from the back of the head radiating
along the distribution of the neck nerve, especially if the
patient's neck was moved. (Satyanegara, 2018).
2.2.1.3 Health history of current disease
Complaints of abusive and sudden complaints of headache
without other symptoms can be a occurrence ofbrachnoid
hemorrhage, for example due to rupture of cerebral aneurysm,
rupture of arteriovenous malformations (AVM). Pain is
localized to the temples and one of the eyes. Other complaints
that can be found are lacrimation, nasal congestion,
conjunctival injection, miosis, ptosis, nausea and bradycardia
(Satyanegara, 2014).

During a period of cluster-type headache attack, as many as

90% of the patients became agitated and unable to relax. They
cannot lie down to rest, otherwise patients choose to walk and
move to and fro. Patients can feel hopeless and bang their
 22

heads on hard surfaces, scream in pain, and roll around (WHO,

2013).

2.2.1.4 Health history of previous disease

Any history of hypertension and a history of head trauma , use
the oral contra ceptives in the long term , the use
of anti- coagulant drugs , aspirin , vasodilators , clients have a
history of previous cluster headache attacks, daily activities
that give rise to clu ster headache (fatigue, stress, height)
(Jasmin, 2012).

Assessment of the drugs use that are commonly used by clients,

such as the antihyperttensives, antilipidemia, beta-blockers, and
others, history of smoking, alcohol, and the use oral
contraceptives. Assessment of this history can support the
assessment of current disease and the basic data to further
assessment and to providefur theractions .

2.2.1.5 Health history of family disease

There is usually a family history of hypertension, or a history
of cluster headaches and previous generations (Cynthia, 2011).
2.2.1.6 Psychological assessment
Psychological assessment of headache in several culdes
dimensions that allow nurse stoobta in a clear perception of the
status of emotional, cognitive, and client's behavioral. The
assessment of coping mechanisms is also important to assess
the client's emotional response to the disease and changes in the
client's role as family and society responses in their daily lives,
whether in the family or in the community. Is there any impact
 23

arising from the client that arises as the fear of anxiety, a sense
of inability to perform activities optimally, and discomfort.
There is a change in social relations with people because pain
makes it uncomfortable to communicate because the client
focuses on the pain. In the system of values and faith, clients
perform spiritual worship rarely be cause of difficulty moving
due to perceived pain and discomfort (Cynthia, 2011).

2.2.1.7 Physical examination

a. Activity / rest
Tired, tired, malaise, eye strain, difficulty reading, insomnia
(Cynthia, 2011).
b. Circulation
Vascular pulses such as the pale temporal area, the face
looks reddish (Cynthia, 2011).
c. Ego integrity
Anxiety, sensitive to stimulation during headaches
(Cynthia, 2011).
d. Food / liquid
Can nausea / vomiting, anorexia during pain (Cynthia,
2011).
e. Pain / discomfort
Signs: severe headache on one side of the head radiating to
the eye or neck (Cynthia, 2011).
f. Neuro sensory
Dizziness, disorientation (during headaches) (Cynthia,
2011).
g. Convenience
Emotional response / un directed behavior such as crying,
anxiety (Cynthia, 2011).
h. Social interaction
 24

Changes in role responsibility (Cynthia, 2011).

2.2.2 Data analysis

The collected data must be analyzed to determine theclient's problem.
Data analysis is an intellectual process swhich includes grouping the
data, identifing gaps and determining the pattern of the data collected
and compare the composition or groups of data with a standard normal
values, interpreting the data and ultimately make conclusions. The
results of the analysis are nursing problem statement (Muttaqin, 2011).

2.2.3 Nursing diagnose

2.2.3.1 Acute pain releated to biological injury agent.
2.2.3.2 Activity intolerance releated to imbalance between oxygen
supply / demand
2.2.3.3 Insomnia releated to physical comfort
2.2.3.4 Risk of falling (Soemarmo, 2009)

2.2.4 Nursing intervention

Table 2.3. Nursing intervention
No. Nursing Planning
diagnoses
Goal Intervention Rational
(NANDA
International (Amin, Hardi, (Gloria M. Bulechek, et (Ackley, Betty J, et al.,
2018-2020) 2015) al., 2013) 2017)

1. Acute pain NOC NIC 1 To determine the

biological Pain Management level of client pain
injury agent  Pain level 1 Perform a 2 to find out the level
 Pain control comprehensive of discomfort felt
 Comfort level assessment of pain to by the client
include location, 3 to distract clients
After in do nursing characteristics, onset / from pain
actions within 1 x duration, frequency, 4 to find out whether
30 minute of quality, intensity or there is a reduction
reduced pain with, severity of pain, and in pain or pain that
Criteria of results : precipitating factors is felt to increase.
2 Cues of discomfort, 5 so that the pain that
 Able to control especially in those is felt does not
pain (know the unable to communicate increase
 25

cause of pain, be e ectively 6 so that the client is

able to use 3 Use therapeutic able to use non-
nonpharmacolog communication pharmacological
ical techniques strategies to techniques in the
to reduce pain, acknowledge the management of
seek help) pain experience and perceived pain
 Report that pain convey acceptance of 7 administration of
is reduced by the patient'sresponse analgesics can
using pain to pain reduce the pain of
management 4 Control of the client and to
 Able to environmental factors avoid the
recognize pain that may influence the occurrence of
(scale, intensity, patient's wrong drug
frequency and response to discomfort administration
signs of pain) (eg, room temperature, 8 So that there are no
 Express comfort lighting, noise) side effects after
after the pain has 5 Reduce or eliminate administration of
diminished the factors that the drugand so that
precipitate or increase the drug can be
the pain more effective
experience (eg, fear, 9 to prevent the
fatigue, monotony, and occurrence of
lack of knowledge) painreappear
6 Teach the use of
nonpharmacological
techniques (eg,
biofeedback, TENS,
hypnosis, relaxation,
guided imagery, music
therapy,
distraction, play
therapy, activity
therapy, acupressure,
hot / cold
application, and
massage) before, afer,
and, if possible,
during
painful
activities; before pain
occurs or
increases; and along
with
other pain relief
measures
7 Provide the person
optimal pain relief
with prescribed
analgesics
8 Implement the use of
patient-controlled
analgesia (PCA),
ifappropriate
9 Use pain control
measures before pain
 26

becomes severe
2 .. Activity NOC NIC NIC
Intolerance  Energy Activity Therapy Activity Therapy
releated conservation 1. Collaborate with 1 To find out the right
to Imbalance  Tolerance occupational, physical, therapy and
between Activity or recreational intervention for the
oxygen supply  Self Care : ADLs therapists in planning client
/ demand After in do and monitoring an 2 To make it
nursing actions activity program, as easier for clients to
within appropriate move and avoid
3x 24 clients can 2. Assist the patient to danger because of
with identify preferences for certain activities.
Criteria of results: activities
3. Assist patient to choose
3 To make it easier for
 Participate in clients to move
physical activity activities and
achievement goals for according to the
without being client's ability
accompanied by consistent activities
an increase in with physical, 4 Tools can facilitate
psychological, and and help clients
blood pressure,
social move
pulse and
respiration capabilities 5 Make it easier for
 Able to carry out 4. Assist to obtain and clients or families to
daily activities obtain resources get activity tools
(adls) required for the 6 To find out activities
independently desired activity that are according to
 Normal vital 5. Assist patient to obtain the wishes of the
signs transportation to client
 Psychomotor activities, as 7 So that it can be
energy appropriate facilitated by nurses
6. Assist patient to or families
 Level of
explore the personal
weakness
meaning of usual
8 To know the general
 Able to move condition of the
activity(eg, work) and
with or without client after doing the
favorite leisure
the aid of a tool activity
activities
 Adequate 7. Assist patient and
cardiopulmonary family to identify
status defcits in activity level
 Good circulation 8. Monitor emotional,
status physical, social, and
 Respiration spiritual response to
status of gas activity
exchange and
adequate
ventilation

3. Insomnia NOC NIC NIC

releated to  Sleep Sleep Enhancement Sleep Enhancement
physical After in do nursing 1 Determine the eff 1. to find out the
discomfort actions within ects of the patie causes or effects of
3x24 clients can nt's medications on medication on the
with sleep pattern client's sleep
Chriteria of results: 2 Explainthe importance patterns
 Concentration of adequate slee 2. to motivate clients
 Fatigue: p during the importance of
 27

Disruptive Efects pregnancy/ sleep

 Leisure illness, psychosocial 3. in order to make it
Participation stresses, etc. easier for clients to
 Comfort Status: 3 Facilities to maintain sleep fast
Environment activity before bedtime 4. provide comfort
 Discomfort (reading) while sleeping
Leve l 4 Create a comfortable 5. sleeping pills can
 Pain Level environment make clients fall
5 Collaborating on asleep quickly
sleeping pills 6. to find out habits
6 Discuss with patients that make clients
and families about unable to sleep
patient sleep techniques 7. to make regular
7 Monitor patient's sleep patterns
sleep pattern, and note 8. so that clients sleep
physical (eg, sleepapnea, more effectively,
obstructed airway, pain / not wake up from
discomfort and urinary hunger or drinking
frequency) and 9. to find out enough
or psychological and effective sleep
(eg, fear or anxiety) circ for clients
umstances that
interrupt sleep
8 Monitor eating and
drinking time with
bedtime
9 Monitor / record the
patient's sleep needs
every day and hour
4. Risk for fall NOC Fall prevention 1. To reduce the
 Physical trauma for 1Identify cognitive or potential for falling
 Risk for injury physical defcits of the into a new
After in do patient that may environment
nursing actions increase potential of 2. To prevent factors
within 3x24 hours falling in a particular that can aggravate
clients can with environment the risk of falling
Chriteria results 2Identify behaviors and 3. To identify
 Balance factors that affect risk of environments that
 Coordinated falls can increase the
movement 3Identify characteristics of risk of falling
 Fall prevention environment that may clients
behavior increase 4. To minimize injury
 No fall incident potential for falls (e.g., when falling
 Knowledge: fall slippery floors and open 5. To prevent the risk
prevention stairways) of falling due to
prevention, child 4Monitor gait, balance, and lack of energy and
safety, personal fatigue level with physical weakness
security) ambulation to minimize injury
5Suggest changes in gait to when falling
 Level of agitation
patient 6. To facilitate clients
 Risk control
6Encourage patient to use in carrying out
community:
cane or walker, as activities
 Violence appropriate 7. To facilitate clients
 Community 7Instruct patient about use in carrying out
 Level of violence of cane or walker, as activities
 28

 Plunge event appropriate 8. to prevent the risk

 Severity of 8Lock wheels of
physical injury wheelchair, bed, or
 Risk control: gurney during transfer of
alcohol use, drugs, patient
sunlight 9Place articles within easy
 Safe home reach of the patient
environment 10 Instruct patient to call
 Safe to roam for assistance with
 Network integrity movement, as
 Vision compliance appropriate
behavior 11 Teach patient how to fall
as to minimize injury
12 Use proper technique to
transfer patient to and
from wheelchair,
bed, toilet, and so on
13 Use side rails of
appropriate length and
height to prevent falls
from bed, as needed
14 Provide adequate
lighting for increased
visibility
15 Post signs to alert staff
that patient is at high
risk for falls
of falling and
injury when using
assistive devices
9. to reduce activities
that can cause
clients to fall
10. To facilitate and
assist clients in
their activities
11. to minimize injury
when falling
12. For more effective
client transfers
13. to prevent clients
from falling while
sleeping
14. To facilitate the
views of clients
when walking
15. To notify the client
that there are
factors that can
make the client fall

2.3 Pain Management

2.3.1 Pharmacolgy
Pharmacological therapy for acute cluster headache. The drugs that
can be given for acute treatment are the triptan and ergotamine
groups. (Ikawati, Z & Anurogo, D, 2018).
2.3.2 Non Pharmacology
2.3.2.1 Relaxation and Distraction
Deep breathing relaxation technique is a form of nursing care,
which in this case the nurse teaches clients how to do deep
breathing, slow breathing (maximum inspiration) and how to
breathe slowly, besides reducing pain intensity, technique Deep
breathing can also increase lung ventilation and increase blood
oxygenation. Deep breathing relaxation techniques can control
pain by minimizing sympathetic activity in the autonomic
 29

nervous system (Fitriani, 2013).The patient can close his eyes

and breathe slowly and comfortably. The absolute rhythm can
be maintained by calculating in the heart and slowly with each
inhalation (inhalation) and echalation (blowing) (Smeltzer &
Bare, 2002), relaxation techniques through breathing is one of
the conditions that can stimulate the body to form a pain
suppressant system which eventually causes a decrease in pain,
besides that it is also beneficial for the treatment of diseases of
the body enhancing physical abilities and balance of body and
mind,because breathing is considered to make the body relax so
that it has an impact on body balance and blood pressure
control (Hughes, et al ., in Fatmawati (2011)).

Distraction is focusing the client's attention on something other

than pain. Some related research sources about the technique of
distraction that researchers have discovered so far have
effectively been applied to children, especially preschoolers, as
in the 2014 Pangabean study, according to Pangabean, one of
the distraction techniques is storytelling where storytelling
distraction techniques are one pharmacology that can reduce
pain. This is evident in his research where the technique of
distraction with stories is effective in reducing the pain of
preschoolers in infusion, ie from pain scale 3 to pain scale 2.
Sartika , et al , 2015, adding that one of the other distraction
techniques that can be performed by pain management is by
watching animated movie cartons, where it is evident in his
research that by being distracted by watching an animated
cartoon film effective in reducing pain in preschoolers during
infusion.

2.4 Energy Management

 30

Energy management is an effort to regulate energy used to handle or prevent

fatigue and optimize functions (Bulechek, 2013). Actions that can be taken
such as improving exercise that aims to improve fitness, nutrition
management to provide the supply of nutrients the body needs to form
energy, oxygen therapy if the patient needs supply assistance, assistance in
fulfilling ADLs, and improving the quality and strength of sleep
rest (Bulechek, 2013). It was found that to overcome the problem of activities
intolerance focused more on meeting self-care needs and efforts to achieve
independence in the prevention of risk factors. In Alligood & Tomey, (2014),
the role of nurses according to Orem is to achieve optimal independence and
health. On the basis of these thoughts in accordance with the principles of
Orem Self Care nursing theory.

2.5 Sleep Hygiene

The relationship between pain and impaired fulfillment of the client's sleep
needs. Based on the results of the study of 35 respondents studied, there were
24 (68.6%) as many as 19 (54.3%) respondents disrupted their sleep needs
this was caused by respondents' discomfort with perceived pain which made
respondents often experience emotional stress that is often explained in terms
of destructive processes, tissues such as being stabbed, burning heat, twisting,
feeling of fear, nausea (Fauziah. A, et al., 2012). Whereas 5 (14.3%)
respondents who were not disturbed fulfilled their sleep needs, this was due
to the respondents having good coping mechanisms to move the pain stimulus
that was felt or had prior experience which resulted in the client being more
prepared to take the necessary actions to relieving pain (Fauziah, 2012).

The pain experienced causes discomfort which makes it difficult to

sleep. Sleep hygiene is a daily habit that is associated with the sleep process,
which has an effect on the quality and duration of sleep (Lim & Dinges,
2010) which can help clients to get better sleep quality.
 31

Sleep hygiene is divided into 3 activities, namely behavior, environment and

activities before bed. The three activities must be carried out simultaneously
and consistently to get maximum results. Unhealthy behavior and the wrong
sleeping habits can aggravate the condition of insomnia. Things that can be
done to improve sleep hygiene in terms of behavior and sleep habits are to
determine waking and sleeping time, avoid taking a nap, avoiding alcohol 4-6
hours before going to bed, avoiding heavy, sweet or spicy foods before bed
and regular exercise ( Nishinoue et al., 2012).

Sleep environment conditions directly affect sleep activity and increase the
incidence of insomnia. The following are some of the things recommended in
sleep hygiene for the management of insomnia, including using a comfortable
bed in the right way, conditioning the temperature and ventilation and
avoiding noise and bright light . Some things that can be done before going to
bed to improve sleep quality are doing relaxation movements, consuming
protein and protein, forgetting problems before going to bed and doing certain
habits before going to bed (Nishinoue et al., 2012).

Drake's research states that 400 mg of caffeine consumed even 6 hours before
bedtime will still reduce the quantity of sleep by approximately 1 hour
(Drake et al., 2013). Regular exercise is also one of the oenting aspects of
sleep hygiene. An experimental study giving intervention in the form of
physical activity and good application of sleep hygiene in the elderly for 16
weeks has significantly improved sleep quality, improved mood and
improved quality of life (Reid et al., 2010).
32
 CHAPTER 3
METHODOLOGY OF CASE STUDY

3.1 Final Paper Design

This scientific paper made by using descriptive methods with a case study
approach, this method is to collect data, analyze data and describe
conclusions from the data. Method descriptive that is something method
research conducted with main for make description or about something
circumtances to a group object in period time particular, Case study as
descpription and analysis from the bounded system. Study case used on case
on case clinical, with approach interactive or narrative qualitative for
support case, more quantitative and systemic (Merriam & Tisdel, 2015).

The expected result is to report the results of nursing evaluations based on

nursing problems that exist on the client with Cluster Headache at the
Berlian ward Dr.H.Moch Ansari Saleh General Hospital Banjarmasin

3.2 Subject of Case Study and Focus of Study

The subject of the case study in this case report was the client at Berlian
ward of the Dr.H.Moch. Ansari Saleh General Hospital Banjarmasin.
3.2.1 Chriteria of Subject
3.2.1.1 A client with Cluster Headache Disease, whose get treatment
and nursing care at Berlian ward Dr.H.Moch Ansari Saleh
General Hospital Banjarmasin
3.2.1.2 Clients who are willing to do nursing care by nurse and
cooperative.
3.2.2 Focus of study
The focus of the study in this case report is the evaluation of the
results of nursing care based on nursing problems that exist in the
Cluster Headache client.

32
 33

3.3 Setting and Schedule of Case Study

3.3.1 The setting of client with cluster headache was carried out at Berlian
ward Dr.H.Moch Ansari Saleh General Hospital Banjarmasin.
3.3.2 Schedule of case studies
The schedule of case study starts from May to July 2019, which
starts from nursing clinical practice at Berlian Ward Dr.H.Moch
Ansari Saleh General Hospital Banjarmasin to did data collection.
After that continuing by writing scientific paper.

3.4 Operational Definition

3.4.1 Headache is the symptom of pain anywhere in the region of the head
or neck. It occurs in migraines, tension-type headache, cluster
headache.
3.4.2 Relaxation technique is a form of nursing care, which in this case the
nurse teaches clients how to do deep breathing, slow breathing
(maximum inspiration) and how to breathe slowly, besides reducing
pain intensity, technique deep breathing can also increase lung
ventilation and increase blood oxygenation.
3.4.3 Distraction is focusing the client's attention on something other than
pain.
3.4.4 Activity intolerance is defined as insufficient physiological or
psychological energy to support or supplement the required ir
desired daily activities.
3.4.5 Insomnia is a disruption in amount and quality of sleep that impairs
functioning.

3.5 Data Collection Techniques and Instruments

3.5.1 Interview
Interview is something technique data collection with way dialogue
between researche with client or who gives information aims for
exchange information, and produce understanding more high rather
 34

than being achieved by individuals. Interview nursing have purpose

specific that is collection from a specific data set from family patient
and know the closest person pass through conversation (subjective
data) and observation (objective data) (Sugiyono, 2011). Interview
about clients identity, main complaint, history current disease,
history of past disease, family disease, and daily activity at home
(activity, sleep and rest, personal hygiene, nutrition, elimination,
sexuality, psychosocial, and spiritual)

3.5.2 Physical examination

Assessment physical in case study in the form of care courtesy
focusing on IPPA (inspection, palpation, percussion, auscultation)
which is self-contained from client physical examination from head
and neck, skin, sight and eyes, smeel and nose, mouth and teeth,
hearing and ears, chest, breathing, heart and circulation, abdomen,
genitalia and reproduction, extremities client with diagnose cluster
headache and assessment about daily activity in the hospital
(activity, sleep and rest, personal hygiene, nutrition, elimination,
sexuality, psychosocial, and spiritual).

3.5.3 Documentation study

Documentation in case study form of care nursing composed from
diagnostic test (blood examination, EEG examination), and
medication therapy.

3.6 Presentation of Data

Data has been collected through by interview, psycal examination, and
documentation. Displayed systematically use of nursing care report. The
collected data are grouped based on the process of nursing care, including
the results of assessment, data analysis, nursing diagnose, nursing
 35

intervention, nursing implementation, nursing evaluation, and progress

notes.
3.7 Case Study Ethics
Problem study ethics is a issue very important, remember this case study
related with humans (Hidayat,2011). Ethical considerations in this case
study are carried out by fulfilling the principles of the Five Rights of Human
Subjects in Research, which consist of:
3.7.1 Right to self-determination
The client has the autonomy and the right to make conscious and
well-understand decisions, free from coercion participate or not in
this case study, or to resign from this case study. Guaranteeing the
autonomy and approval of the client to take all the action given.
3.7.2 Right to privacy and dignity.
Clients have the right to be valued about what they do and what is do
and to control when and how information about them is shared with
others. In this case study nurse maintain the privacy of clients such
as carrying out nursing actions related to client privacy, nurse use the
curtain to maintain client privacy.
3.7.3 Anonymity and confidentiality rights
All information obtained from clients must be maintained in such a
way that certain individual information cannot be directly linked to
the client, and the client must also be kept confidential for his
involvement in this case study. To guarantee confidentiality, the
researcher stores all documents resulting from data collection in a
special place that can only be accessed by researchers. In compiling
a case study report, the researcher describes the data without
revealing the client's identity.
3.7.4 Justice Rights
Give individuals the same rights to be selected or involved in cases
without discrimination and given the same treatment by respecting
 36

all agreed agreements, and to provide treatment for problems that

arise during participation in case studies
3.7.5 Beneficiary and nonmaleficience rights
The clients are protected from exploitation and researchers must
ensure that all efforts are made to minimize harm (nonmalefecience)
or loss from case studies, as well as maximize the benefits
(benefecience) of case study. In this case study nurse always
prioritize five moments of hand washing and the principle of six
correct drug administration for clients to prevent minimizing the
occurrence of malefecience to client.
37
 CHAPTER 4
NURSING CARE REPORT

4.1 Nursing Care Results

4.1.1 Client identity
Mr. HS 29th years old, male, client from Marabahan, Mr.HS is
moeslem. He is Javanese. The last education is a bachelor. Client job
is private employee. The Client was married. He entered the
Dr.H.Moch Ansari Saleh General Hospital Banjarmasin on
May 12th, 2019 by MRN 14 97 xx, with a medical diagnose of Cluster
Headache.

The next kin of Mr.HS is Mrs.AN. She is 29th years old, she is the
client's wife. She is private employee.

4.1.2 Health history

4.1.2.1 Main complaint
When assessment Tuesday's, May 14th , 2019 the client said
his right head and his right lower ear was very painful like
electrocution followed weakness on both legs, if many moves
the client felt short of breath, when pain the client was
difficult to sleep.
4.1.2.2 History of current disease
The client said that since the evening on May 11 th 2019 at
11:00 p.m., he felt dizziness, blurred vision, short of breath,
ear felt pain, both legs difficult to move, at the night client
took paracetamol. Client complaint was worsening both legs
and could not be moved, then the client brought by his family
to the emergency room on Sunday 12th May 2019 at 7.00
a.m., after getting treatment and the client's condition was
quite stable the client was transferred to the Berlian ward

37
11d at 10:30 a.m. on Sunday morning May 12 th 2019, client
diagnose

38
 38

had cluster headache with the condition weakness,

conscious compos mentis, blood preassure: 140/80 mmhg,
pulse: 98times/ min, respiration rate: 19times/ min, and
temperature: 36.5oC
4.1.2.3 History of previous disease
The client said he had illness and complaint experiences like
this before, when was a student college in 2012. In January
2019 client complaints was relapse. The client said he
didn’t have a history of hypertension and diabetes mellitus
but the client has a history of hepatitis and currently
undergoing hepatitis treatment since 4 mounth ago .
4.1.2.4 History of family disease
The client said his family never had illness and experiences
like client, client said his mother had a hypertention and
diabetes mellitus, clients other family do not have infectious
diseases such as hepatitis, HIV, tuberculosis, and other

Genogram

X X X X

X X X X X

29
 39

Information

: male x : died

: client
: female
: married

: one home : offspring

4.1.3 Physical examination

4.1.3.1 General condition
Client seems weak and client seems just lie in the bed, with
conscious status GCS :E 4, M 5,V 6, compos mentis, blood
preasure 120/90 mmhg, pulse 64x/min, respiration rate
20x/min, body temperature 36,5oc, saturation oxygen 99%,
body weight 50 kg, body hight 175kg, indexs body mass
16,1 (less than normal) upper arm of circumfernce 22,5 cm,
ideal body weight = 67,5 kg
4.1.3.2 Skin
Brown skin color, quite clean, no ulcer, no lesion, good skin
texture, warm feelin , skin turgor returns <2 seconds, no
stretch to the skin
4.1.3.3 Head and neck
a. Symmetrical head assessment, black hair color
short, curly hair, spread of flat hair , client seem often to
hold his right head. Client looks grimace because on the
head right fells pain. Palpation: pain press on the right
head and there is no lumps. Client said on the right
head and lower ear client feels very painful, the pain
increases if the client has too much moved , the pain
feels like being electrocuted, scale 6 of 10, the duration
 40

of pain is about 10- 30 minutes, and the pain arises

suddenly.
b. Assessment neck : It’s quite clean, nothing enlargement
of the jugular vein and no enlargement of the thyroid
gland, there is no limitation of motion, client said on the
head right and lower the ear client feels very painful, the
pain increases if the client has too much moved , the pain
feels like being electrocuted , scale 6 of 10, the duration
of pain is about 10- 30 minutes, and the pain arises
suddenly.
4.1.3.4 Sight and eyes
Symmetrical shape, anemic conjunctiva, looks a
little dirty, good eyeball movement, can look left and
right, up and down, client's right eye looks red, shape round
cheek and isokor, reflex pupil (+) when given a light
stimulus, there is no inflammation, the client uses a visual
aid while working, the client says the cylinder but the client
forgets how many cylinders the client has, there is no
cataract, there is no double vision
4.1.3.5 Smell and nose
Symmetrical shape, looks a bit dirty, no polyps, no
blockage, no bleeding, no inflammation, alittle secret, the
client does not use a respiratory aids. Good olfactory
function (the client can distinguish between wind oil and the
smell of alcohol with the eyes closed).
4.1.3.6 Hearing and ears
Right and left symmetrical, not using hearing aids,
no referral, good hearing function, when hearing is safe
hearing: whisper test: the client is able to repeat the words
spoken nurse, watches tests: right ear: 49 cm, left ear
 41

53 cm, weber test: balanced, rinne test: bone conduction

louder than the air delivery, test swabach:lengthwise
4.1.3.7 Mouth and teeth
Cleanliness fairly clean mouth and tongue, complete
teeth, mucosa pale, lips pale, no swallowing disorders, there
is no inflammation in the mouth, perforated right
teeth, tonsils examination: pink tonsil color, no white spots,
no pain , tonsil size t1: magnitude ¼ anterior-uvola arch
(normal).
4.1.3.8 Chest, breathing, heart and circulation
Examination of the lungs: inspection: symmetrical chest
wall movements, brown color of the chest skin area,
palpation: no pressure, no creativity, percussion: sonor,
auscultation: vesicular breath sounds. Examination
on the heart, inspection: brown skin color, not visible
ictuscordis, palpation: there is no tenderness, palpation,
ictuscordis not palpable, palpate pulsation in the walls of
the piston felt stronger, percussion :upper limit (ICS
II): deaf, lower limit (ICS V): deaf, left boundary (ICS V
mid sinus clavicle): deafness, right border (mid sternalist
ICS IV dextra): deafness, auscultation : the presence of a
heart sound 1 sounds single, loud, regular and 2 sounds
singular, loud, regular , no heart sound 3.

Clients do not use breathing aids, there is no

tightness, tightness occurs when the headache is very
painful, but by adjusting the tightness position is resolved ,
the client appears pale, no chest pain, Respiration: 20times/
min, spo2: 99 %, vein color peripheral pink, CRT <3
seconds.
 42

4.1.3.9 Abdomen
Inspection: the movement of the abdominal wall
between the left and right symmetrical, no bloating, the
clien breaths not use the abdominal muscle, there is no
lumps, there is no ascities, auscultation: peristaltic intestine
12 times/minute, percussion:timpani, palpation : there is no
pain press
4.1.3.10 Genitalia and reproduction
Pubic hair inspection: not examined, the client said the
genital area has no lesions/lumps, no blockages in the
urethral opening, penile palpation : not examined, the client
says there is no pain in the penis area, scrotum: not
examined, the client says there is no hernia or
swelling, there is no interference with the genetalia and
reproduction of the client. The client doesn’t use dower
cateter, the client has 3 children,
4.1.3.11 Extremities
Upper right extremity: attached Nacl infusion 20 dpm,
range of blocked catheter infusion, no pain, delayed
mobilization, no trauma or deformity, normal pitiing
edema: 0 (back in 1-2 seconds) ,upper left extremity:
infusion set is not attached, there are no obstacles, able to
do mobilization, no trauma, no pain, pitting edema: 0 (back
in 1-2 seconds) normal , lower right extremity: no attaced
infusion set, client said if pain the head appear the legs feel
weak to move, lower left extremity: no infusion set, the
client said if the headache appear the legs feel weak to
move.

Muscle scale
D 5555 5555 S
 43

5555 5555

Information
Table 4.1. Muscle scale

Scale Percent (%) of Information

normal
0 0 There is no contraction.
1 10 There is contraction but can not shift.
2 25 Just shifting and moving the joints.
3 50 Can resist gravity, but can not resist.
4 75 Can not resist resistance (weak), but can resist
gravity.
5 100 Can resist the nurse resistance with full force.

Reference: Wartonah & Tarwoto (2015)

4.1.4 Physical, psychological, social and spiritual needs

4.1.4.1 Activity
Activity at home scale: 0, eat and drink, wearing clothes and
dress up, walk and bathing, urinate/defecate is independently.
In the hospital scale: 2 eat and drink, wearing clothes and
dress up, walking, and bathing, defecate/urinate assisted.

Difference of Vital sign both before and after change of

position, before change of position: blood pressure: 120/90
mmhg, pulse:64times/minute, breathing: 20 times/minute,
body temperature::36.5oC, SPO2: 99% and after change of
position: blood pressure: 130/90mmHg, pulse: 99
times/minute, breathing: 25 times / minute, body temperature:
36,6oC, SPO2: 96 %
Activity scale
Table 4.2. Activity scale

Scale Information
0 Able to care for themselves fully / independently.
1Reference: Lyndon., S, the
Need to use (2013)
tool.
2 Need help or supervision of others.
3 Need help or supervision of others and need use the tool.
4 Dependence and can not perform or participate in the treatment
 44

4.1.4.2 Sleep and rest

Client's at home rest 1-2 hours per day, take a nap 1-2 hours
per day, sleep day 6-8 hours, no complaints about sleep. In
the hospital rest every day, take a nap 1 hour per day,
sleep day 2-3 hours client was difficulty sleeping because
headaches appear suddenly, and most pain arises at night when
the client is sleeping and he said sleep is irregular if pain
arises, the client always rests, the client is just lying on the bed.
4.1.4.3 Personal hygiene
Personal hygiene was good at home, take 1-2 baths every day,
brush his teeth and wash his hair when bathing. At the hospital
The client does not take a shower, does not brush his teeth,
does not wash his hair, the client is assisted by his wife and
nurse to wipe it with a small towel .
4.1.4.4 Nutrition
At home clients eat 2-3 times a day, 1 portion of fish,
vegetables, and clients have food allergies for chicken and
shrimp. At the hospital clients eat 3 times a day, clients eat
food that is provided by the hospital.
4.1.4.5 Elimination
Frequency of defecation at home once every morning after
waking up with soft consistency, do not use laxative, no
constipation or diarrhea and no pain when defecating,
frequency of urination at home 5-6 times a day with a clear
yellow color and smelly, no pain when urinating. In the
hospital, when admitted the hospital on the third day can
defecate, defecate 2-3 times a day and no pain during
urination, the client is not to be installed catheter.
4.1.4.6 Sexuality
Clients gender is male, there is no interference with genital, the
client has 3 children.
 45

4.1.4.7 Psychosocial
Client’s wife said client relationship with another family good,
clients family and neighbors often visit clients in the hospital,
the wife of clients cells pestle keep the client in addition to
bed the client, the client is very anxious and afraid of the
condition of the client if it does not improve, client looks
anxiety the client hopes his condition quickly improve and
run activities as usual because the client is the head of the
household.
4.1.4.8 Spiritual
Client is moeslem, the client said before the client was sick,
always do prayers 5 times, reading the qur’an rarely, when at
the hospital the client did not do the prayer, the client believed
that this was a test of Allah subhana wata'ala

4.1.5. Diagnostic examination

4.1.5.1. Blood examination ( Sunday, May 12th 2019)
Table 4.3. Blood examination
Examination Results Normal Unit

Wbc 8.5 3.5-10.0 10 ^ 9/1

Lym 2.2 0.9-5.0 10 ^ 9/1

Lym% 25.7 15.0 - 50.0 %

Mid 0.2 0.1-1.5 10 ^ 9/1

Mid% 3.2 2.0-15.0 %

Gra 6.1 1.2-8.0 10 ^ 9/1

Gra% 71.1 35.0-80.0 %

Hgb 14.5 11.5-16.5 G / dl

Mch 31.2 25.0-35.0 Pg

Mchc 36.1* 11.5-16.5 G / dl

Rbc 4.66* 25.0-35.0 10 ^ 12/1

 46

Mcv 86.4 75.0-100.0 Fl

Hct 40.3 35.0-55.0 %

Rdwa 57.2 0.1-250.0 Fl

Rdw% 12.6 11.0-16.0 %

Plt 255 130-400 10 ^ 9/1

Mpv 7.5 6.5-11.0 Fl

Pdwa 9.9 0.1-30.0 Fl

Pdw% 40.1 0.1-99.9 %

Pct 0.19 0.01-9.99 %

P-lcr 12.1 0.1-99.9 %

P-lcc 30 1-1999 1

4.1.5.2. Blood examination (Sunday, May 12th 2019)

Examination Results Normal Unit

Hemoglobin 14.5 14.0 - 18.0 G/dl

Chloride (cl) 18.5 46.0-100.0 Mmol / l

Alt-gpt 18 12 -40 U/l

Ast-got 17 10 -37 U/l

Creatinine 0 .8 0.6 -50.0 U/l

Ureu-bun-uv 13.5* 10.0 Mg/dl

 47

4.1.5.3. Eeg examination (Wednesday May 15th , 2019)

4.1.6. Therapy pharmacology (medications)

Table 4.4. Therapy pharmacology
Client Drug Dose Route Frequency Documentation

Nacl 20 dpm IV Every 8 hours Given

Cetorolac 3x30mg IV 9:00 am / 05.30 Given

 48

pm / 11:30 pm

Mr.HS Ranitidine 2x50mg IV 09.00.am/05.30 pm Given

Ceftriaxone 2x1gr IV 09.00.am/05.30 pm Given

Mecobalamin 2x500mcg IV 09.00.am/05.30 pm Given

Defacote 2x500mg PO 09.00.am/05.30 pm Given

Ergotamine 2x2mg Subling 09.00.am/05.30 pm Given

ual

Table 4.5. Indication of drugs

No. Drugs Indication
1. Ranitidin Indicated for gastritis, gastric ulcers (Nuryati 2017)
2. Ketorolac Indicated for pain post operative (Formularium, Obat Rsud Dr.Saiful
Anwar, 2017)
3. Ceftriaxone Infection of respiratory system, bones, joints, and skin:septicemia
(Schull, P.D. 2013).
4. Defacote Indicated for treatment of maniac episodes, treat various types of
seizure disorder (Schull, P.D. 2013).
5. Ergotamine Indicated as therapy about or prevent vascular headache;e.g., cluster
headache, migraine, migraine variants or so-called “histaminic
chepalgia” (Schull, P.D. 2013).
6. Mecobalamin Deficiency of vitamin b12 (Schull, P.D. 2013).

4.1.7. Data analysis

Table 4.6. Data analysis
No. Data Problem Etiology
1. DS: Acute pain Biological
 The client said that since Saturday injury agent
night May 11th 2019 at 11:00p.m. 00132
felt headache and earache.
 Client said on the his right head and
right lower the ear client feels
very painful, the pain increases if
the client has too much moved , the
pain feels like being electrocuted ,
scale 6 of 10, the duration of pain is
about 10- 30 minutes, and the pain
arises suddenly.

DO:
 The client looks grimace and
anxiety
 49

 The client seem often to hold his

head on the right
 The client's right eye looks red
 EEG results: found epiliptiform
waves are generalized
2. DS: Activity intolerance Imbalance
 The client said his right head and 00092 between
right lower ear was very
painful like electrocution followed
oxygen
weakness on both legs , if many supply /
moves the client fell short of breath. demand
 Client said if many moves he fell
short of breath
DO:

 General Condition: looks weak and

just lying in the bed
 Awareness: Compos mentis
 EEG results: found epiliptiform
waves are generalized
 Scale of activity in the hospital:2
Eat, drink, wear clothes, walking,
bathing, elimination assissted and
need help supervior
 Difference of Vital sign both before
and after change of position before
change of position: blood pressure:
120/90 mmhg, pulse: 64
times/minute, breathing
:20times/minute, body
temperature:36.5oC, SPO2: 99% and
after change of position: blood
pressure: 130/90mmHg, pulse: 99
times/minute, breathing: 25 times /
minute, body temperature: 36,6oC,
SPO2: 96 %
DS: Insomnia Physical
 Client said was difficulty sleeping 00095 Discomfort
because headaches appear
suddenly, and most pain arises at
night when the client is sleeping.
 The client said sleep is irregular if
pain arises

DO:

 The client looks weak and pale

 The client's right eye looks red
 The client seemed to just lie in bed
 Client rest every day, take a nap 1
hour per day, sleep day 2-3 hours
client was difficulty sleeping
because headaches appear
suddenly, and most pain arises at
 50

night when the client is sleeping

and he said sleep is irregular if pain
arises, the client always rests, the
client is just lying on the bed
4.2. Priority of the Problem
4.2.5. Acute pain realeted to biological injury agent
4.2.6. Activity Intolerance releated to Imbalance between oxygen
supply/demand
4.2.7. Insomnia releated to physical discomfort

4.3. Nursing Plan (Based on Nics and Nocs)

Table 4.7. Nursing Plan
Nursing Planning
diagnoses
Goal Intervention Rational

Acute pain NOC NIC 1. To determine the

biological Pain Management level of client
injury agent  Pain level 1 Perform a comprehensive pain
 Pain control assessment of pain to include 2. To find out the level
location, of discomfort felt by
After in do nursing characteristics, onset / duration, the client
actions within 1 x 30 frequency, quality, intensity or 3. To distract clients
minute of reduced pain severity of pain, and from pain
with, Criteria of results : precipitating factors 4. To find out whether
2 Cues of discomfort, especially there is a reduction
 Able to control pain in those in pain or pain that is
(know the cause of unable to communicate e felt to increase.
pain, be able to use ectively 5. To that the pain that
nonpharmacological 3 Use therapeutic communication is felt does not
techniques to reduce strategies to acknowledge the increase
pain, seek help) pain experience and convey 6. To that the client is
 Report that pain is acceptance of the able to use non-
reduced by using patient'sresponse pharmacological
pain management to pain techniques in the
 Able to recognize 4 Control of environmental management of
pain (scale, intensity, factors that may influence the perceived pain
frequency and signs patient's 7. Administration of
of pain) response to discomfort (eg, analgesics can
 Express comfort room temperature, lighting, reduce the pain of
after the pain has noise) the client and to
diminished 5 Reduce or eliminate the factors avoid the occurrence
that precipitate or increase the of wrong drug
pain administration
experience (eg, fear, fatigue, 8. To that there are no
monotony, and lack of side effects after
knowledge) administration of the
6 Teach the use of drugand so that the
nonpharmacological techniques drug can be more
 51

(eg, biofeedback, TENS, effective

hypnosis, relaxation, guided 9. To prevent the
imagery, music therapy, occurrence of
distraction, play therapy, painreappear
activity therapy, acupressure,
hot / cold
application, and massage)
before, afer, and, if possible,
during
painful activities; before pain
occurs or increases; and along
with
other pain relief measures
7 Provide the person optimal pain
relief with prescribed analgesics
8 Implement the use of patient-
controlled analgesia (PCA),
ifappropriate
9 Use pain control measures
before pain becomes severe
Activity NOC Nic Nic
Intolerance  Energy conservation Activity therapy Activity therapy
releated  Tolerance Activity 1Collaborate with occupational, 1 To find out the right
to Imbalanc  Self Care : ADLs physical, or recreational therapy and
e between After in do nursing therapists in planning and intervention for the
oxygen actions within monitoring an activity program, client
supply / 3x 24 hours clients as 2 To make it
demand can with appropriate easier for clients to
Criteria of results: 2Assist the patient to identify move and avoid
 Participate in preferences for activities danger because of
physical activity 3Assist patient to choose activities certain activities.
without being and achievement goals for 3 To make it easier for
accompanied by an consistent activities with clients to move
increase in blood physical, psychological, and according to the
pressure, pulse and social client's ability
respiration capabilities 4 Tools can facilitate
 Able to carry out 4Assist to obtain and obtain and help clients mov
daily activities (adls) resources required for the 5 Make it easier for
independently desired activity clients or families to
 Normal vital signs 5Assist patient to obtain get activity tools
 Psychomotor energy transportation to activities, as 6 To find out activities
appropriate that are according to
 Level of weakness
6Assist patient to explore the the wishes of the
 Able to move with or
personal meaning of usual client
without the aid of a
activity(eg, work) and favorite 7 To that it can be
tool
leisure activities facilitated by nurses
 Good circulation 7Assist patient and family to or families
status identify defcits in activity level 8 To know the general
 Respiration status of 8Monitor emotional, physical, condition of the
gas exchange and social, and spiritual response to client after doing the
adequate ventilation activity activity

Insomnia NOC NIC NIC

releated to  Sleep Sleep Enhancement Sleep Enhancement
physical After in do nursing 1Determine the effects of the 1 To find out the
 52

discomfort actions within 3x24 patients medication on sleep causes or effects of

hours clients can with pattern. medication on the
Chriteria of results: 2Explain the importance of client's sleep
 Concentration adequate sleep during patterns
 Fatigue: Disruptive pregnancy/illness, psychosocial 2 To motivate clients
Efects stress, etc. the importance of
 Leisure Participation 3Facilities to maintain activity sleep
 Comfort Status: before bedtime (reading) 3 In order to make it
Environment 4Create a comfortable environment easier for clients to
 Pain Level 5Collaborating on sleeping pills sleep fast
6Discuss with patients and families 4 Provide comfort
about patient sleep techniques while sleeping
7Monitor patient's sleep pattern, and 5 Sleeping pills can
note physical (eg, sleepapnea, make clients fall
obstructed airway, pain / asleep quickly
discomfort and urinary 6 To find out habits
frequency) and psychological that make clients
(eg, fear or anxiety) unable to sleep
circumstance that interrupt 7 To make regular
sleep. sleep patterns
8Monitor eating and drinking time 8 To that clients
with bedtime sleep more
9Monitor / record the patient's sleep effectively, not
needs every day and hour wake up from
hunger or drinking
9 To find out enough
and effective sleep
for clients

4.4. Implementation
Table 4.9. Implementation

No. Day/ Time No. Diag Implementation Action Evaluation Signa

Date nose ture

1. Tuesday , 08.30 1 1. Performed a 1. The client said headache

14 May am comprehensive on the right and below
2019 assessment of pain to the ear, like a
include location, electrocuted, pain
characteristics, onset / increases if too much
duration, frequency, moves, scale 6, 15-30
quality, intensity or minutes (sudden pain).
severity of pain, and 2. The client appears to be
precipitating factors grimacing and agitated
08.35
2. Controled of by pain, if noisy client
am
environmental factors pain increase
that may influence the 3. The client said it will
patient's limit the move
response to discomfort 4. Client seem follow
(eg, room temperature, instruction by nurse.
lighting, noise) 5. The client said after the
 53

3. Reduced or eliminated administration of the

the factors that pain injection drug is
08.40 precipitate or increase reduced
am the pain 6. Nurses do 6 ways of
experience (eg, fear, administering the right
fatigue, monotony, and medicine
lack of knowledge)
08.44 4. Taught the use of
am nonpharmacological
techniques (relaxation,
guided imagery,
08.50 distraction)
am 5. Provided the person
optimal pain relief with
prescribed analgesics
6. Implemented the use of
09.00 patient-controlled
am analgesia (PCA), if
appropriate
2. Tuesday, 09.04 2 1. Collaborated with 1. Clients say activities that
14 May am occupational, physical, can only be done lying
2019 or recreational therapists in bed, eating and
in planning and drinking need help.
monitoring an activity Vital sign: Before
program, as activity
appropriate - Blood pressure:
09.08 2. Assisted the patient to 120/90 mmHg
am identify preferences for - Pulse: 64 times /
activities minute
09.10
3. Assisted patient to obtain - Breathing: 20 times/
am
transportation to minute
activities, as appropriate - Body temperature:
4. Assisted patient to 36.5 o C
09.15 explore the personal - SpO 2 : 99 %
am meaning of usual After activity
activity(eg, work) and  Blood pressure:
favorite leisure activities 120/90 mmHg
5. Assisted patient and  Pulse: 89 times /
12.45 family to identify defcits minute
pm in activity level  Breathing: 25 times/
6. Monitored emotional, minute
12.50 physical, social, and  Body temperature:
am spiritual response to 36.6 o C
activity  SpO 2 : 98 %

2. Train clients to change

positions every 15
minutes.
3. The client said that he
did not need a tool to
move, the client only
needed family
assistance.
4. The client said he likes
outdoor activities.
 54

5. The client says if

standing and walking
needs help from
someone because of the
pain that is felt.
6. Client's physical weakne
ss, good emotions,
social: difficult to
communicate if pain
arises, spiritual: client
does not carry out
prayers at the hospital.
3. Tuesday, 10.00 2 1. Explained the imp 1. The client said he
14 May am ortance of adequate understood the
2019 sleep during importance of sleep for
pregnancy , the health of the body.
illness, psychosocial 2. The client said he was
stresses, etc. used to a room that was
2. Facilited to maintain not bright to sleep
10.05 activity before going to 3. Wife’s clien said will
am bed (reading) limit visitors to client
3. Created a comfortable breaks
10.10
environment 4. client said if headache
am
4. Monitored patient's appears client difficukt
10.15 sleep pattern, an to sleep
am d note physical 5. Clien said take a nap 1-2
(eg, sleep apnea, hours per day, sleep day
obstructed airway, 6-8 hours
pain /
discomfort and uri
nary frequency)
and/ or psychological
(eg, fear or anxiety)
circumstances that
interrupt sleep
10.30 5. Monitored / recorded the
am patient's sleep needs
every day and hour

4.5. Evaluation
Table 4.10. Evaluation
No. Day/ Time No. Dia Evaluation of results Signa
Date gnose ture

1. Selas a , 14 12.30 1 S:
May2019 pm -
01.00  The client said headache on the right and below
pm the ear, like a electrocuted, pain increases if too
much moves, scale 6, 15-30 minutes (sudden
pain).
 The client said it will limit the move
 The client said after the administration of the pain
 55

injection drug is reduced 4 of 10

O
 The client appears to be grimacing and agitated
by pain, if noisy client pain increase
 Client seem follow instruction by nurse.
 Nurses do 6 ways of administering the right
medicine
A: Acute pain partial resolved

 Clients can’t pain control (to know the cause of

pain, was able to use nonpharmacological
techniques to reduce pain, seek help)
 The client reported the pain reduce was using
pharmacological pain therapy
 Clients are able to recognize pain (scale,
intensity , frequency and signs of pain)
 The client expresses comfort after the pain has
diminished

P: continue intervention no. 1, 2, 3, 4, 5, 6.

2. Tuesday, 14 12.45 2 S
May 2019 am -  Clients said activities that can only be done lying in
01.14 bed, eating and drinking need help.
pm  The client said that he did not need a tool to move,
the client only needed family assistance.
 The client said he likes outdoor activities.
 The client said if standing and walking needs help
from someone because of the pain that is felt.
O:

 Train clients to change positions every 15 minutes.

 Client's physical weakness, client's emotions are
good, social: difficult to communicate if pain
arises, spiritual: client does not carry out prayers at
the hospital.
 Vital sign:
Before activity
- Blood pressure: 120/90 mmHg
- Pulse: 64 times / minute
- Breathing: 20 times/ minute
- Body temperature: 36.5 o C
- SpO 2 : 99 %
After activity
- Blood pressure: 130/90 mmHg
- Pulse: 99 times / minute
- Breathing: 25 times/ minute
- Body temperature: 36.6 o C
- SpO 2 : 96 %
A: Activity Intolerance releated to Imbalance between
oxygen supply / demand
 Participate in physical activity without
accompanied by an increase in blood pressure,
pulse and RR not resolved
 Able to carry out daily activities (ADLs)
 56

independently not resolved

 Normal vital signs
 Able to move: with or without the aid of a tool not
resolved
 Adequate cardiopulmonary status not resolved
 Good status circulation not resolved
 Respiratory status: gas exchange and adequate
ventilation not resolved
P: Coninue intervention No 1, 2, 3, 4, 5.

3. Tuesday, 14 01.15 3 S
May 2019 pm -  The client said he understood the importance of
02.00 sleep for the health of the body.
pm  The client said he was used to a room that was not
bright to sleep
 Wife’s client said will limit visitors to client breaks
 Client said if headache appears client difficukt to
sleep
 Clien said take a nap 1-2 hours per day, sleep day
6-8 hours
O
 Seem only he father who visite the client
 Client seem take a nap

A : Insomnia not resolved

 Can’t little Concentration

 Fatigue: Disruptive Efects: fatigue after activity
 Leisure Participation: don’t resolved
 Environment : partial resolved
P: Continue intervention No.1, 2, 3, 4.

4.6. Progress Notes

4.6.5. Progress note 1st day
Table 4.11. Progress note 1st day

No. Day/ Hour No. Dx Implementation and results Evaluation of results Sign
Date

1. Wednesday, 08.3 1 1. Performed a S:

May 15 0 am comprehensive
2019 assessment of pain to The client said headache
include location, on the right and below
characteristics, onset / the ear, like a
duration, frequency, electrocuted, pain
quality, intensity or increases if too much
severity of pain, and moves, scale 5, 20
precipitating factors minutea minutes (sudden
08.35
 57

am 2. Controled of pain).the
environmental factors Client appears to be
that may influence the grimacing and agitated
patient's by pain, if noisy client
response to discomfort pain increase
(eg, room temperature, The client said he was
08.40 lighting, noise) limit the move
am 3. Reduced or eliminate the Client said if pain appear
factors that precipitate or he don’t concentration
increase the pain doing nonfarmacology
experience (eg, fear, technique.
fatigue, monotony, and The client said after the
08.44 lack of knowledge) administration of the
am 4. Taught the use of pain injection drug is
nonpharmacological reduce. Scale to 4
techniques (relaxation, O:
guided imagery, Client seem follow
08.50 distraction) instruction by nurse.
am 5. Provided the person Nurses do 6 ways of
optimal pain relief with administering the right
09.00 prescribed analgesics
am medicine
6. Implemented the use of Client seem hold he head.
patient-controlled A:
analgesia (PCA), if Acute pain partial resolved
appropriate
 clients can’t pain control
Evaluation (to know the cause of
12.30 pain, was able to use
1. The client said
pm nonpharmacological
headache on the right
and below the ear, like a techniques to reduce
electrocuted, pain pain, seek help) because
increases if too much don’t concentration
moves, scale 5, 15-30  The client reported the
minutes (sudden pain reduce was using
12.35
pain).the pharmacological
pm
2. Client appears to be therapy
grimacing and agitated  Clients are able
by pain, if noisy client to recognize pain (scale,
12.40 pain increase intensity , frequency and
pm 3. The client said he was signs of pain)
limit the move  The client expresses
12.43 4. Client seem follow comfort after the pain
pm instruction by nurse. has diminished
Client said if pain appear
he don’t concentration P: Continue intervention
doing nonfarmacology no. 1, 2, 3, 4, 5, 6.
01.00
technique.
pm
5. The client said after the
administration of the
pain injection drug is
01.02 reduce.
pm 6. Nurses do 6 ways of
administering the right
medicine
2. Wednesday, 09.0 2 1. Collaborated with S:
 58

May 15 4 am occupational, physical, Clients said activities that

2019 or recreational therapists can only be done lying
in planning and in bed, eating and
monitoring an activity drinking need help.
program, as The client said he likes
appropriate outdoor activities.
09.08 2. Assisted the patient to
am The client said if standing
identify preferences for and walking needs help
activities from someone because
09.10
3. Assisted patient to of the pain that is felt.
am
explore the personal
meaning of usual
O:
activity(eg, work) and Client instruct diet high
09.15 favorite leisure activitiescalori hih protein, if
am 4. Assisedt patient and shortbreath give oxygen
family to identify defcits when needed.
in activity level Vital sign: Before activity
5. Monitored emotional, - Blood pressure:
09.18 physical, social, and 130/90 mmHg
am spiritual response to - Pulse: 84 times /
activity minute
Evaluation Action - Breathing: 22 times/
1. Clients said activities minute
09.21 that can only be done
am - Body temperature:
lying in bed, eating and 36.8 o C
drinking need help. - SpO 2 : 98 %
Client instruct diet high After activity
calori hih protein, if  Blood pressure:
shortbreath give oxygen 120/90 mmHg
when needed.  Pulse: 89 times /
Vital sign: Before minute
activity  Breathing: 27 times/
- Blood pressure: minute
130/90 mmHg
 Body temperature:
- Pulse: 84 times /
37.0 o C
minute
 SpO 2 : 97 %
- Breathing: 22 times/
minute Trainclients to change
- Body temperature: positions every 15
36.8 o C minutes.
- SpO 2 : 98 % Client physical weakness,
12.45 good emotions, social:
After activity
pm difficult to communicate
 Blood pressure:
120/90 mmHg if pain arises, spiritual:
client does not carry out
 Pulse: 89 times /
prayers at the hospital.
minute
A:Activity Intolerance
 Breathing: 27 times/
releated to Imbalance
minute
between oxygen supply /
 Body temperature: demand don’t resolved
37.0 o C
 Participate in physical
 SpO 2 : 97 % activity without
accompanied by an
12.50 2. Train clients to change increase in blood
am positions every 15 pressure, pulse and RR
minutes.
 59

01.05 3. The client said he likes not resolved

pm outdoor activities.  Able to carry out daily
4. The client said if activities (ADLs)
01.10 standing and walking independently not
om needs help from resolved
someone because of the  Normal vital signs
pain that is felt.  Able to move: with or
5. Client's physical weakne without the aid of a tool
ss, good emotions, not resolved
social: difficult to  Adequate
01.14
communicate if pain cardiopulmonary status
pm
arises, spiritual: client not resolved
does not carry out  Good status circulation
prayers at the hospital. not resolved
 Respiratory status: gas
exchange and adequate
ventilation not resolved
P: Continue intervention
No.1,2,3,4,5.

3. Wednesday, 10.0 3 1. Explained the impo S:

May 15 0 am rtance of adequate  The client said he
2019 sleep during understood the
pregnancy,illness, psych importance of sleep for
osocial stresses, etc. the health of the body.
10.05 2. Facilited to maintain  The client said he was
am activity before going to used to a room that was
bed (determine wake not bright to sleep and
time and sleep time, client can sleep
menghindari alcohol 4-  Wife’s client said will
6hour before sleep, limit visitors to client
avoid heavy food, sweet breaks
atau spicy before sleep)  Client said if headache
10.10 3. Createed a comfortable relapse so client difficult
am environment (Condition to sleep
temperature and  Client said take a nap 1-
ventilation and avoid 2 hours per day,
noise and bright light) sleep day 6-8 hours
10.15 4. Monitored patient's O:
am sleep pattern, and  Seem only he father who
note physical visite the client
(eg,  Client seem take a nap
pain/discomfort circumst A:Insomnia partial
ance that interrupt sleep resolved
Evaluation Action
01.30
1. The client said he  Can little Concentration
understood the  Fatigue: Disruptive
importance of sleep for Efects: fatigue after
01.35 the health of the body. activity
pm 2. The client said akan
 Leisure Participation
menuruti sesuai saran
 Environment : partial
01.40 perawat
resolved
pm 3. Wife’s client said will
P:Continue intervention
limit visitors to client
No.1, 2, 3, 4.
breaks, client said if
 60

headah relapse so client

difficult to sleep.
01.50 4. Client said take a nap 1-
pm 2 hours per day,
sleep day 6-8 hours

4.6.6. Progress note 2nd day

1. Thursday, 16 08.3 1 1. Performed a S:

May 2019 0 am comprehensive
assessment of pain to The client said headache
include location, on the right and below
characteristics, onset the ear, like a
/duration, frequency, electrocuted, pain
quality, intensity or increases if too much
severity of pain, and moves, scale 4, 10
precipitating factors minutes (sudden pain)
08.35
2. Controled of The client said he was
am
environmental factors limit the move
that may influence the Client said if pain appear
patient's he don’t concentration
response to discomfort doing nonfarmacology
(eg, room temperature, technique.
lighting, noise) The client said after the
3. Reduced or eliminate the administration of the
08.40 factors that precipitate or pain injection drug is
am increase the pain reduce. scale to 4
experience (eg, fear, O:
fatigue, monotony, and client appears to be
lack of knowledge) grimacing and agitated
08.44 4. Taught the use of by pain, if noisy client
am nonpharmacological pain increase
techniques (relaxation, client seem follow
guided imagery, instruction by nurse.
08.50 distraction) nurses do 6 ways of
am 5. Provided the person administering the right
optimal pain relief with medicine
prescribed analgesics client seem don’t hold he
6. Implemented the use of head again.
09.00 patient-controlled A:
am analgesia (PCA), if Acute pain partial resolved
appropriate  clients little pain control
(to know the cause of
Evaluation Action
pain, was able to use
12.30 1. The client said headache
nonpharmacological
pm on the right and below
techniques to reduce
the ear, like a
pain, seek help) because
electrocuted, pain
don’t concentraton
increases if too much
moves, scale 4, 10  The client reported the
minutes (sudden pain reduce was using
pain).the pharmacological
2. Client appears to be therapy but pain still
12.35 suddenly.
grimacing and agitated
 61

pm by pain, if noisy client  clients are able

pain increase to recognize pain (scale,
12.40 3. The client said he was intensity , frequency and
pm limit the move signs of pain)
4. Client seem follow  The client expresses
12.43 instruction by nurse. comfort after the pain
pm Client said if pain appear has diminished
he don’t concentration
doing nonfarmacology P: Continue intervention
technique. no. 1,2,3,4,5,6
5. The client said after the
01.00 administration of the
pm pain injection drug is
reduce.
6. Nurses do 6 ways of
administering the right
01.10 medicine
pm

2. Thursday, 16 09.0 2 1. Collaborated with S:

May 2019 4 am occupational, physical,  Clients said activities
or recreational therapists that can only be done
in planning and lying in bed, eating and
monitoring an activity drinking need help.
program, as The client said he likes
appropriate outdoor activities
2. Assisted the patient to because tired in room.
identify preferences for The client said if standing
09.08
activities and walking still needs
am
3. Assisted patient to help from someone but
09.10 explore the personal some activity can doing
am meaning of usual self because of the pain
activity(eg, work) and is felt reduce.
favorite leisure activities O:
4. Assist edpatient and Client's physical weakness,
09.15 family to identify defcits good emotions, social:
am in activity level difficult to communicate
5. Monitord emotional, if pain arises but reduce,
09.18 physical, social, and spiritual: client does not
am spiritual response to carry out prayers at the
activity hospital.
Evaluation Action Client instruct diet high
1. Clients said activities calori hih protein, if
12.45 that can only be done
pm shortbreath give oxygen
lying in bed, eating and when needed.
drinking need help. Vital sign: Before activity
Client instruct diet high - Blood pressure:
calori high protein, if 130/90 mmhg
shortbreath give oxygen - Pulse: 84 times /
when needed. minute
Vital sign: Before - Breathing: 22 times/
activity minute
- Blood pressure: - Body temperature:
130/90 mmhg 36.8 o C
- Pulse: 84 times / - Spo 2 : 98 %
 62

minute After activity

- Breathing: 18 times/ - Blood pressure:
minute 120/90 mmhg
- Body temperature: - Pulse: 89 times /
36.9 o C minute
- Spo 2 : 99 % - Breathing: 27 times/
12.55 After activity minute
pm
 Blood pressure: - Body temperature:
120/90 mmhg 37.0 o C
 Pulse: 90 times / - Spo 2 : 97 %
minute Instruct clients to change
 Breathing: 25 times/ positions every 15
minute minutes
 Body temperature: A:Activity Intolerance
o
37.3 C releated to Imbalance
 Spo 2 : 98 % between oxygen supply /
demand partial resolved
2. Train clients to change  Participate in physical
positions every 15 activity without
minutes. accompanied by an
12.50
3. The client said he likes increase in blood
am
outdoor activities pressure, pulse and RR
01.05 because tired in room. not resolved
pm 4. The client said if  Able to carry out daily
standing and walking activities (adls)
01.10 still needs help from independently not
pm someone but some resolved
activity can doing self  Normal vital signs not
because of the pain is resolved
felt reduce.  Able to move: with or
5. Client physical weaknes without the aid of a tool
s, good emotions, social: partial resolved
01.14 difficult to communicate  Adequate
pm if pain arises but reduce, cardiopulmonary status
spiritual: client does not resolved
carry out prayers at the  Good status circulation
hospital. resolved
 Respiratory status: gas
exchange and adequate
ventilation not resolved
P: Continue intervention
No. 1,2,3,4,5.

3. Thursday, 16 10.0 3 1. Facilitaed to maintain S:

May 2019 0 am activity before going to  The client said he
bed (determine wake understood the
time and sleep time, importance of sleep for
menghindari alcohol 4- the health of the body
6hour before sleep, and client said he don’t
avoid heavy food, sweet eat junk food, spicy food
atau spicy before sleep) before sleep yesterday
2. Create a comfortable  The client said he was
10.05
environment (condition used to a room that was
am
temperature and not bright to sleep
ventilation and avoid
 63

noise and bright light)  Wife’s client said will

3. Monitored patient's limit visitors to client
10.10 sleep pattern, an breaks
am d note physical  Client said if headache
(eg, client difficult to sleep
pain/discomfort circumst  Client said yesterday
ance that interrupt sleep take a nap 1 hours per
10.15 4. Monitored / recorded the
am day, sleep day 5 hours
patient's sleep needs O:
every day and hour  Client family only 1-2
01.3
Evaluation Action person who visite to
0
1. The client said he client
understood the A:Insomnia partial
importance of sleep for resolved
01.35 the health of the body.
pm 2. The client said will  Not Concentration
follow instruct by nurse  Fatigue: Disruptive
01.40 3. Wife’s client said will Efects: fatigue after
pm limit visitors to client activity there is no
breaks, client said if  Leisure Participation
headache relapse client  Environment : partial
difficult to sleep resolved
01.50 4. Client said yesterday
pm  Discomfort : clients
take a nap 1 day, little pain
sleep day 4-5 hours P:Continue intervention
No.1,2,3,4.

4.6.7. Progress note 3rd day

1. Friday, 17 08.30 1 1. Performed a S:

May 2019 am comprehensive assessment
of pain to include The client said headache
location, on the right and below
characteristics, onset / the ear, like a
duration, frequency, electrocuted, pain
quality, intensity or increases if too much
severity of pain, and moves, scale 3, 20
precipitating factors minutes (sudden pain).
08.35
2. Controled of The client said he was
am
environmental factors that limit the move
may influence the Client said if pain appear
patient's he don’t concentration
08.40 response to discomfort doing nonfarmacology
am (eg, room temperature, technique.
lighting, noise) The client said after the
3. Reduced or eliminate the administration of the
factors that precipitate or pain injection drug is
increase the pain reduce. scale to 1
experience (eg, fear, O:
08.44 fatigue, monotony, and Client seem follow
am lack of knowledge) instruction by nurse.
4. Taught the use of Nurses do 6 ways of
nonpharmacological administering the right
 64

techniques (relaxation, medicine

guided imagery, Client seem don’t hold he
08.50 distraction) head again.
am 5. Provided the person Client seem more calm
optimal pain relief with A:
09.00 prescribed analgesics Acute pain most resolved
am 6. Implemented the use of  Clients can’t pain
patient-controlled control (to know the
analgesia (PCA), if cause of pain, was able
appropriate to use
nonpharmacological
Evaluation techniques to reduce
12.30
1. the client said headache pain, seek help) because
pm
on the right and below the don’t concentraton
ear, like a electrocuted,  The client reported the
pain increases if too much pain reduce was using
moves, scale 3, 5 minutes pharmacological
(sudden pain) therapy
12.35 2. Client appears to be
 Clients are able
pm grimacing and agitated by
to recognize pain (scale,
pain, if noisy client pain
intensity , frequency and
12.40 increase
signs of pain)
pm 3. The client said he was
 The client expresses
limit the move
12.43 comfort after the pain
4. Client seem follow
pm has diminished
instruction by nurse.
Client said if pain appear P: Continue intervention
he don’t concentration and explain the importance
doing nonfarmacology about relaxation and
01.0pm
technique. distraction if pain relapse.
5. The client said after the
administration of the pain
injection drug is reduce1
but pain suddenly
01.03 6. Nurses do 6 ways of
pm administering the right
medicine
2. Friday, 17 09.04 2 1. Collaborated with S:
May 2019 am occupational, physical, or Clients said activities that
recreational therapists in can independent
planning and monitoring The client said if standing
an activity program, as and walking can
appropriate independent
2. Assisted the patient to O:
09.08 identify preferences for Client instruct diet high
am activities calori high protein
3. Assisted patient and Vital sign: Before
09.10
family to identify defcits activity
am
in activity level  Blood pressure:
09.15 4. Monitored emotional, 120/90 mmHg
am physical, social, and  Pulse: 78 times /
spiritual response to minute
activity  Breathing: 19
Evaluation Action times/ minute
12.45 1. Clients said activities  Body
 65

pm that can independent temperature:

2. Client instruct diet high 36.9 o C
12.50 calori high protein, if  SpO 2 : 99 %
am shortbreath give oxygen After activity
when needed.  Blood pressure:
Vital sign: Before 120/90 mmHg
activity  Pulse: 90 times /
- Blood pressure: minute
120/90 mmHg  Breathing: 20
- Pulse: 78 times / times/ minute
minute  Body
- Breathing: 19 times/ temperature:
minute 37.3 o C
- Body temperature:  SpO 2 : 99 %.
36.9 o C Client's physical good,
- SpO 2 : 99 % good emotions, social:
01.00 After activity communicate good
am  Blood pressure: because pain reduce,
120/90 mmHg spiritual: client does not
 Pulse: 90 times / carry out prayers at the
minute hospital.
 Breathing: 20 times/ A:Activity Intolerance
minute releated to Imbalance
 Body temperature: between oxygen supply /
37.3 o C demand resolved
 SpO 2 : 99 %.  Participate in physical
01.05 3. The client said he likes activity without
pm outdoor activities accompanied by an
because tired in room. increase in blood
01.10 4. The client said if pressure pulse and RR
om standing and walking can not resolved
independent  Able to carry out daily
01.14 5. Client's physical good, activities (ADLs)
pm good emotions, social: independently
communicate good  Normal vital signs
because pain reduce,  Able to move: with or
spiritual: client does not without the aid of a
carry out prayers at the tool not resolved
hospital.  Adequate
cardiopulmonary status
not resolved
 Good status circulation
not resolved
 Respiratory status: gas
exchange and adequate
ventilation not
resolved
P: Stop intervention

3. Friday, 17 10.00 3 1. Facilited to maintain S:

May 2019 am activity before going to  The client said he
bed (determine wake time understood the
and sleep time, importance of sleep for
menghindari alcohol 4- the health of the body
 66

6hour before sleep, avoid and client said he don’t

heavy food, sweet atau eat junk food, spicy food
10.05 spicy before sleep) before sleep yesterday
am 2. Createed a comfortable  Will limit visitors to
environment (condition client breaks
temperature and  client said when
ventilation, avoid noise headache relapse client
10.10 and bright light) can overcome by
am 3. Monitored patient's relaxation and
sleep pattern, and distraxtion
note physical (eg,  Client said yesterday
pain/discomfort circumsta take a nap 3 hours per
nce that interrupt sleep day, sleep day 7 hours
10.15 4. Monitored / record the O:
am patient's sleep needs every Client room bright light
day and hour
01.30 Evaluation Action A:insomnia resolved
pm 2. The client said he
understood the importance  Concentration
01.35 of sleep for the health of  Fatigue: disruptive
pm the body. efects: fatigue after
3. The client said will follow activity
01.40 instruct by nurse  Leisure participation
pm 4. Wife’s client said will  Environment : calm
limit visitors to client  Discomfort : there is no
01.50 breaks
pm P:Stop intervention
5. Client said yesterday take
a nap 3 hour/day,
sleep day 6hours/day

4.6.8. Progress note 4th day

Home Care Progress Notes
On May 18th, 2019, in afternoon client allowed to go home, because
client's situation has recovering condition client and to control whether
the complaints was relapse, nurse do home care in client's home in 2
days from April 18th and 20th, 2019.

1. Saturday, 18 04.05 1 1. Performed a comprehensive S:

May 2019 pm assessment of pain to
include location, The client said headache
characteristics, onset / on the right and below the
duration, frequency, quality, ear, like a electrocuted,
intensity or pain increases if too much
severity of pain, and moves, scale 1, 5 minutes
precipitating factors (sudden pain).
2. Controled of environmental The client said he was
04.08
factors that may influence limit the move
pm
the patient's Client said if pain appear
response to discomfort (eg, he can concentration
room temperature, lighting, doing nonfarmacology
 67

noise) technique.
3. Reduced or eliminate the The client said he always
04.12 factors that precipitate or take a medicine like
pm increase the pain advice doctor
experience (eg, fear, fatigue, O:
monotony, and lack of Client seem follow
knowledge) instruction by nurse.
4. Taught the use of Client seem can do
nonpharmacological everyday activities as
04.15
techniques (relaxation, usual because pain reduce.
pm
guided imagery, A:
distraction) Acute pain partial resolved
5. Provided the person optimal  Clients can pain control
04.25 pain relief with prescribed (to know the cause of
pm analgesics pain, was able to use
Evaluation Action nonpharmacological
04.50 1. The client said headache on techniques to reduce
pm the right and below the ear, pain, seek help) because
like a electrocuted, pain don’t concentraton
increases if too much  The client reported the
moves, scale 1, 5 minutes pain reduce was using
(sudden pain). pharmacological
2. The client said he was limit therapy
04.55 the move  Clients are able
3. Client seem follow to recognize pain (scale,
04.58
instruction by nurse. intensity , frequency and
pm
Client said if pain appear he signs of pain)
can concentration doing  The client expresses
nonfarmacology technique. comfort after the pain
05.00 4. The client said he always has diminished
pm take a medicine like advice
doctor P: Continue intervention
no. 1,2,3,4,5

4.6.9. Progress note 5th day

1. Monday, 20 03.p 1 1.Performed a comprehensive S:

May 2019 m assessment of pain to include
location, 5. The client said headache
characteristics, onset / on the right and below the
duration, frequency, quality, ear, like a electrocuted,
intensity or pain increases if too much
severity of pain, and moves, scale 1, 5 minutes
precipitating factors (sudden pain).
2.Controled of environmental 6. The client said he was limit
03.15
factors that may influence the the move
pm 7. client seem follow
patient's
response to discomfort (eg, instruction by nurse.
room temperature, lighting, Client said if pain appear
noise) he can concentration doing
3.Reduced or eliminate the nonfarmacology technique.
03.20 factors that precipitate or 8. The client said he always
 68

pm increase the pain take a medicine like advice

experience (eg, fear, fatigue, doctor
monotony, and lack of O:
knowledge) 9. client seem follow
03.24 4.Taught the use of instruction by nurse.
pm nonpharmacological 10. client seem can do everyday
techniques (relaxation, guided activities as usual because
imagery, pain reduce.
distraction) A: Acute pain resolved
5.Do Provide dthe person  clients can’t pain control
03.30 optimal pain relief with (to know the cause of pain,
pm prescribed analgesics was able to use
Evaluation of Action nonpharmacological
04.05 1.The client said headache on techniques to reduce pain,
pm the right and below the ear, seek help) because don’t
like a electrocuted, pain concentration
increases if too much moves,  The client reported the pain
scale 1, 5 minutes (sudden reduce was using
pain). pharmacological therapy
2.The client said he was limit  clients are able
04.07 the move to recognize pain (scale,
pm 3.Client seem follow instruction intensity , frequency and
by nurse. signs of pain)
04.10 4.Client said if pain appear he  The
pm client expresses
can concentration doing comfort after the pain has
nonfarmacology technique. diminished
04.15
5.The client said he always take
pm
a medicine like advice doctor P: Stop intervention

4.7. Discussion of Case Studies

4.7.5. Acute pain related with a biological injury agent. Data that supports
the nursing diagnosis of acute pain includes subjective data and
objective data in accordance with the characteristic limits that exist in
NANDA 2018-2020.

The client subjective data: client said that since Saturday night 11th
May 2019 at 11:00 pm felt headache and earache and client said on
the head right and lower the ear client feels very painful, the pain
increase if the client has too much moved, the pain feels like being
electrocuted, scale 6 of 10, the duration of pain is about 10-30
minutes, and the pain arises suddenly. Objective data: the client looks
 69

grimace and anxiety, the client often holds the right eye looks red, and
the EEG results: found epiliptiform waves are generalized.

The nursing problem of acute pain related to biological injury agents

resolved after 4 days of treatment. These results are based on
predetermined evaluation criteria. The author gets the fact that all
evaluation criteria can be achieved. Client able to control pain (know
the cause of pain, to be able to use nonpharmacological techniques to
reduce pain), able to recognize pain (scale, intensity, frequency and
signs of pain) , and express comfort after the pain has diminished .

The results criteria are reached after the client gets the client's
intervention to farmachology therapy (ergotamine 2x2mg) for acute
treatment of cluster headache (Ikawati, Z & Anurogo, D, 2018) and to
control pain with exercise deep breathing and distraction for moderate
pain. this is in accordance Fitriani (2013). deep breathing relaxation
techniques can control pain by minimizing the sympathetic activity in
the autonomic nervous system . In this case study giving deep
breathing exercises when the client experiences headaches until the
client feels less pain

This is also according to Hughes, et al., in Fatmawati

(2011) relaxation techniques that can stimulate the body to form a
pain suppressant system which eventually causes a decrease in pain,
besides that it can stimulate the body. Physical ability and balance of
body and mind, because breathing is a body to relax and has an impact
on body balancing and blood pressure control.

4.7.6. Activity intolerance releated to imbalance between oxygen

supply/demand includes subjective data and objective data in
accordance with the characteristics boundary of NANDA 2018-2020.
 70

Subjective data: client said the head on the right and lower on right
the ear was very painful like electrocution followed weakness on both
legs, if many moves the client fell short of breath, an client said if
many moves he fell short of breath. Objective data:general condition:
looks weak and just lying in the bed, awareness: compos mentis, EEG
results: found epiliptiform waves are generalized, scale of activity in
the hospital: 2 eat, drink, wear clothes, walking, bathing, elimination
need help or supervisior, and other,and difference of Vital sign both
before and after change of position before change of position: blood
pressure: 120/90 mmhg, pulse: 64 times/minute, breathing
:20times/minute, body temperature:36.5oC, SPO2: 99% and after
change of position: blood pressure: 130/90mmHg, pulse: 99
times/minute, breathing: 25 times/ minute, body temperature: 36,6 oC,
SPO2: 96 %.

Activity intolerance releated to imbalance between oxygen

supply/demand resolved after 4 days of treatment. These results are
based on predetermined evaluation criteria. The author gets the fact
that all evaluation criteria can be achieved. Client can Participate in
physical activity without being accompanied by an increase in blood
pressure, pulse and respiration, able to carry out activities (ADLs)
independently, normal vital signs, psychomotor energy, level of
weakness, able to move with or without the aid of a tool, equivalent
cardiopulmonary status, circulation status good, respiration status of
gas exchange and adequate ventilation.

The results criteria are achieved after the client has received a client's
intervention for implementation assist the patient to identify
preferences for activities and explain the importance of energy
management. This is according to Alligood & Tomey (2014) It was
 71

found that to overcome the problem of intolerance, activities focused

on meeting self-care needs and efforts to achieve independence in the
prevention of risk factors.

This is also true with Bulechek (2013) actions that can be used to
improve fitness, nutrition management to provide a supply of health,
assistance, and assistance in fulfilling ADLs, and improving the
quality and strength of sleep rest. In this study the administration of
energy management in fulfilling nutrition for clients on the
move. Intolerance activity is not present in the third day of evaluation.

4.7.7. Insomnia is related to physical discomfort including subjective data

and objective data in accordance with the characteristics of the
NANDA 2018-2020.

Subjective data: client said was difficulty sleeping because headaches

appear suddenly, and most pain arises at night when the client is
sleeping, the client said sleep is irregular if pain arises. Objective data:
the client looks weak and pale, client right eye looks red, client seems
to be just lie in bed.

Insomnia related to physical discomfort resolved after 4 days of

treatment. These results are based on predetermined evaluation
criteria. The author gets the fact that all evaluation criteria can be
achieved. Client can concentration, fatigue:disruptive effect, leisure
participation, comfort status: environment good, pain level 1.

The results criteria were reached after the client received client
assistance interventions for the implementation and explanation of
sleep hygiene to improve the quality of the client's sleep. In this case
study the application of sleep hygiene to clients effectively makes the
 72

client to sleep. Insomnia was resolved in the third day of evaluation.

This is in line with Lim & Dinges (2010) the pain causes discomfort
experienced the which makes it difficult, to sleep. Sleep hygiene is a
daily habit that has an effect on quality and duration of sleep, which
can help clients get better sleep quality.

Based on the description above it is proven that the problem of acute

pain is related to biological injury agents, activity intolerance releated
to imbalance between oxygen supply/demand, and insomnia related
physical discomfort resolved. These results are in accordance with the
expected goals and proven appropriate.
73
 CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS

1 Conclusion
1.1 Assessment
Results Cluster headache assessment May 14th 2019 at 09:00 a.m.
client of Mr.HS, client said his right head and he right lower ear was
very painful like electrocution followed weakness on both legs, if
many moves the client felt short of breath, when pain the client was
difficult to sleep.
1.2 Nursing diagnosis
Based on Cluster headache assessment found nursing problem acute
pain related to biological injury agent, activity intolerance related to
imbalance between oxygen/suplay demand, and insomnia related with
physical discomfort.
1.3 Nursing intervention
Based on nursing diagnosis acute pain related to biological injury
agent author make some intervention, such relaxation, for intolerance
activity author give intervention management energy and self care
acoording with orem, and for nursing diagnosis insomnia author give
intervention about sleep hygiene.
1.4 Nursing implementation
May 14th to May 20th, 2019. Results assessment acute pain when
assessment pain scale 6. Client get pharmacological therapy
ergotamine 2x2mg for acute treatment of cluster headache when pain
occurs and application technique nonfarmacology for client relaxation
(deep breath) when pain appears for reduce mild pain.

73
 74

For activity intolerance implementation on May 14 th-May 17th

2019.Application Assist the clientt to identify preferences for
activities and explain importance management energy for the client.

And for implementation Insomnia on May 14 th-May 17th, 2019.

Results assessment client said difficult to sleep because fell pain,
application explanation sleep hygiene for help clients get better sleep
quality.

1.5 Evaluation.
Acute pain was resolved, nursing problem after 6th days care, results
that was accordance with the expected goals. Activity intolerance was
resolved, this resolved after 4th days care, results that was accordance
with the expected goals. Insomnia was resolved, this resolved after 4 th
days care, results that was accordance with the expected goals.

1.6 Analysis results care nursing based on theory

Diagnosis of acute pain related to biological injury agent, activity
intolerance related to imbalance between oxygen supply/demand and
insomnia related to physical discomfort resolved because it has met
the predetermined chriteria results. On intervention client get
pharmacological therapy ergotamine 2x2mg for acute treatment of
cluster headache according Ikawati, Z & Anurogo, D, (2018).
According with Fitriani (2013) deep breathing relaxation techniques
can control mild pain.

According to Alligood & Tomey (2014) it was found that to overcome

the problem of activity intolerance focused on self-care needs
according theory Orem. And according to Lim & Dinges (2010) sleep
hygiene is a daily habit that has an effect on quality and duration of
sleep, which can help clients get better sleep quality.
 75

2 Recommendations
2.1 For client
It is expected client will continue to carry out by nurse
recommendations, that have been given such as relaxation to reduce
the pain of mild levels felt by the client when the cluster headache.
2.2 For Hospital
Expected improve the nurse performance in service at hospital
Every nurse should be have answer and skills in give away care
nursing especially in the rehabilitation program client with cluster
headache. Nurse involving family client in gift care nursing and able
to act as inside educator gift exercise relaxation, as specialist nutrition
in gift nutrition, and motivator for more reduce strees and multiply
break and enough to sleep.
2.3 For institution education
Expected could improve quality performance education for
application research in every action nursing is done so that able to
produce professional, skilled, innovative, and quality in give away
care a comprehensive nursing client with cluster headache based on
science and ethical nursing.
2.4 For next author
Expected next author could apply exercise relaxation, energy
management, and sleep hygiene at case others and could apply other
evidence based nursing practice that can reduce to client pain, provide
enough energy, and for sleep effective. And other actions or
interventions can be added that can help the client’s problems with
cluster headaches.
 76

BIBLIOGHRAPHY

Ackley, B.J., Ladwig, G.B. & Makic, M.B.F. Eds. (2017). Nursing Diagnosis
Handbook An Evidence-Based Guide Planning Care. (8th ed.). United States
of America: Elsevier Mosby.

Applegate, E. (2011). The Anatomy and Physiology Learning System (4th ed.).
United States of America: Saunders Elsevier.

Ashkenazi, A & Schwedt, T. (2011) Cluster Headache-Acute and Prophylactic

Therapy. USA: Wiley Periodicals, Inc.

BCGuidelines.ca.(2011).:
<http://www2.gov.bc.ca/gov/content/health/practitioner-professional-
resources/bc-guidelines/palliative-pain-management >.

British Association for the Study of Headache. (2010). Guidelines for All
Healthcare Professional in the Diagnosis and Management of Migraine,
Tension-Type Headache, Cluster Headache, Medication-Overuse Headache.

Bulechek, G.M., Butcher, H.K., dochterman, J.M. & Wagner, C. Eds. (2013).
Nursing Intervention Classification (NIC). (6th ed.). United States of
America: Elsevier Mosby.

Cynthia. M.T. & Sheila. S.R. (2011). Diagnosis Keperawatan Dengan Rencana
Asuhan. Jakarta:EGC

Disable World Towards Tommorow. (2018, July Tuesday). Pain Scale Chart.
Diambil kembali dari Disabled World.com: https://
www.disabledworld.com /health /pain/scale .php (Access at May 29,
2018)

Education and Research Field of Dr.H.Moch Ansari Saleh General Hospital.

(2019). Cluster Headache from 2015-2018. Banjarmasin

Fatmawati, L. (2011). Pengaruh Teknik Relaksasi Pernafasan Terhadap Tingkat

Rasa Nyeri Pada Ibu Bersalin Kala I di BPS Mu’rofah.
 77

Farmakologi, Bahan Ajar Rekam Medis Dan Informasi Kesehatan (RMIK).

Schull, P.D. (2013). Nurse’s Drug Handbook. (7th ed.). United State: Mc Graw
Hill.Education

Fitriani, R. (2013). Pengaruh Teknik Relaksasi Nafas Dalam Terhdap Respon

Adaptasi Nyeri pada Pasien Inpartu Kala 1 Fase Laten di RSKDIA Siti
Fatimah Makasar.

Gorelick, P..B., Testai, F.D., Hankey, G.J., Wardlaw, J.M. Eds. (2014). Hankey’s
Clinical Neurology. Edisi ke-2. Florida:CRC Press.

Gramedia Pustaka Utama Notoadmodjo, S. (2012). Metodologi Penelitian

Kesehatan. Jakarta:Rineka Cipta.

Hidayat, (2011). Metode Penelitian Kebidanan Dan Teknik Analisa Data. Jakarta:
Salemba Medika

Ikawati, Z. & Anurogo. D. (2018). Tata Laksana Terapi Penyakit Sistem Syaraf
Pusat. Yogyakarta: Bursa Ilmu

Iliopulos, P., damigos, D., Kerezoudi, E., Limpitaki, G., Xifaras, M., Skida, D.,
Tsagkovits, A., et al. (2015). Trigger Factors in Primary Headaches
Subtypes: a Cross-Sctional study from a Tertiary centre in Greece. BMC
Res Notes.8:393-402.

Jasmin, L. (2012). Cluster Headache. http:// www.nlm.nih.gov/ medlineplus/ency/

article/000786.htm. [diakses pada April.2013].

Kevin T. Patton, P. (2013). Anatomy and Physiology (8th ed.). United States of
America: Mosby Elsevier.

Lim, J. & Dinges, D.F. (2010). A Meta-analysis of the Impact of Short-term Sleep
Depripation on cognitive Variables. Psychological Bulletin.

Lyndon, S. (2013). Pengantar Kebutuhan Dasar Manusia. Tanggerang Selatan:

Binarupa Aksara Publisher.
 78

Merriam, S. B., & Tisdel, E. J. (2015). Qualitative research: Guide to design and
implementation. Fourth edition. San Fransisco: Jossey-Bass

Moorhead, S., Johnson, M., Maas, M. & Swanson, E. Eds. (2013). Nursing
Outcomes Classification (NOC) Measurement of Health Outcome. (5th ed.).
United States of America: Elsevier Mosby.

Muttaqin, A. (2011). Asuhan Keperawatan dengan Gangguan Sistem Persarafan.

Jakarta: Salemba Medika.

NANDA International, Inc. (2018). NANDA International Nursing Diagnoses:

Defintion & Classification, 2018-2020. (11th ed.). Canada by Marquis:
Thieme Publishers

Nurarif, A.H. & Kusuma, H. (2015). Asuhan Keperawatan Berdasarkan

Diagnosa Medis & Nanda Nic-Noc. Jakarta: EGC.

Nuryati. (2017). Bahan Ajar Rekam Medis dan Informasi Kesehatan

(RMIK):Farmakologi. Jakarta Selatan: Kementrian Kesehatan RI.

Pangabean, S.U.A. (2014). Pengaruh Tekknik Distraksi Bercerita Terhadap

Tingkat Nyeri Anak Usia Prasekolah Yang Dilakukan Pemasangan Infus di
EKA Hospital BSD. Abstrak.

Perdossi. (2013). Konsensus Nasional IV Diagnostik dan Penatalaksanaan Nyeri

Kepala. Surabaya: Airlangga University Press.

Saputra, L. (2013). Pengantar Kebutuhan Dasar Manusia. Pamulang – Tangeran

Selatan.

Satyanegara. (2014). Ilmu Bedah Saraf. (ed.5th). Jakarta:Pt Gramedia Pustaka

Utama

Satyanegara. (2018). Ilmu Bedah Saraf. (ed.6th). Jakarta:PT Sinar Surya Megah
Perkasa
 79

Schull, P.D. (2013). Nurse’s Drug Handbook. (7th ed.). United State: Mc Graw
Hill.Education

Seidel, H. M. (2011). Mosby's guide to Physical Examination (7th ed.). United

States of America: Mosby Elsevier

Soemarmo, Markam. (2009). Pununtun Neurologi. Jakarta: Binarupa Aksara

Sue E, H., & Kathryn I, M. (2012). Understanding Pathophysiology (5th ed.).

United States of America: Elsevier Mosby.

Sugiyono, 2011. Metode Penelitian Kuantitatif, Kualitatif dan R&d. Bandung:

Alpabet.

Susilo, H.W. (2015). Riset Kualitatif & Aplikasi Penelitian Ilmu Keperawatan.
Jakarta: Trans Info Media.

Watson, R. (2011). Anatomy and Physiology for Nurses (13th ed.). China:
Bailliere Tindall Elsevier.

Wartonah & Tarwoto. (2015). Kebutuhan Dasar Manusia dan Proses

Keperawatan. Kelima. Jakarta:Selemba Medika.

White. L., Duncan. G & Baumle. W. (2012). Medical Surgical Nursing: An

Integrated approach 3rd edition. USA: Delmar.

WHO. (2012). Headache Disorders. Tersedia di <:http//www.who.int/

mediacentre/ factsheets/fs277/en> [diakses 6 Juli 2015]

WHO. The International Classification of Headache Disorders. In: Cephalgia

International Journal of Headache. p. 629-808. UK: sage Publication; 2013.

WHO. (2012). Headache Disorders. World Health Organization.

<http://www.who.int/mediacentre/factsheets/fs277/en/# >.
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ATTACHMENT

Attachment 1.

EEG : Electroencephalography

Source: Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin Medical

Record Result with Mr.HS on ,May 15th, 2019
 81

Attachment 2.
Results EEG : Electroencephalography

Source: Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin Medical

Record Result with Mr.HS on ,May 15th, 2019
 82

Attachment 3. Consultation Sheets

83
84
85
86
87
88
89
90
91
92
 93

Attachment 4. Student Presence List

 94

Attachment 5. Surat Pengantar Pengambilan Data

Source: Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin

 95

Source: Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin

 96

Source: Dr.H.Moch Ansari Saleh General Hospital of Banjarmasin

 97

Attachment 6. Advisor’s Approval Sheet

 98

Attachment 7. Curriculum vitae

Name : Nirmaya Sofa

Place, Date of Birth : Hamparaya, March 3rd , 1998
Religion : Islam
Address : Hamparaya Rt. 02. Balangan
Father : H. Muhammad Noor
Mother : Hj. Isnawati
Religion : Islam
Email : nirmayasofa0303@gmail.com
Graduated
MIN Bangkal 2 Batumandi (2004-2010)
SMPN 1 Batumandi (2010-2013)
SMK Kesehatan Mursyidiyah Barabai (2013-2016)
International Class of Diploma Program for Nursing, Faculty of Nursing
And Health Sciences, University Of Muhammadiyah Banjarmasin
Academic Year (2016-2019).
99