Worddddd.docx

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No

Tindakan Masase Kepala

Hasil Tindakan YA

Masase Kepala

Observasi

TIDAK

Tanda-tanda nyeri Ds:

1

Menurut Bour bamis nyeri: Tidak nyeri = 0 Nyeri ringan =1-3 Nyeri sedang = 4-6 Nyeri berat = 7-9 Sangat nyeri = 10 Skala itensitas nyeri menurut wong Baker berdasarkan tampak ekspresi wajah

1. Klien mengatakan nyri pada daerah kepala 2. 2nyri dirasakan semakin memberat saat beraktivitas DO:

Skala nyeri

1. Klien meringis 2. P: Peningkatan tekananan darah Q: nyeri tajam R :dari kepala menjalar ke bahu S: skala nyeri sedang 5(0-10)

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