Data Special The analgesic effect of in20Eur20J20 Pain.pdf .

2013 was recorded incidence Sectio Caesarea deliveries on average each month in 38 patients. This increase is allegedly due to improved techniques and facilities, the operation lasted more aseptic, anesthetic techniques improved, comfort pasectio caesarea higher operating, and the length of the short growing and can choose the date of birth as you wish Roeshadi, 2006. Nevertheless Caesarea operation pharmacological nursing activities that can assist in the relief of pain. One of them is progressive relaxation, non- pharmacological methods of pain relief that has a very low risk. Although such action is not a substitute for drugs, such action is necessary to shorten episodes of pain that lasts only a few seconds or minutes. Based on the above description researchers interested in conducting does not mean free of risks or problems. research on “The Influence Of Research by Hillan about pain post Sectio known that on days 1-2 clients still experiencing pain in the wound, and even almost half of women lasts until they return home, and even about 32 of patients who performed the cesarean is still experiencing pain in injuries, and often pain in the wound after returning gain weight thus requiring analgesics. Steer, 2004 stated that relaxation is a method of transfer of non- pharmacological pain that is often used in the UK. Steer in the study reported that as many as 34 women using relaxation, by induction of relaxation for 15 minutes can significantly reduce the sensory component of pain. Pillips added that the emotional component of pain is also reduced so that the effect of exacerbating anxiety was also reduced due to the impact of the relaxation Mander, 2004. Relaxation can be used in episodes of acute and chronic pain to reduce pain. Usually it takes 5-10 training sessions before a client can effectively minimize pain. Patients who already know about the relaxation techniques may just need to be reminded to use such techniques to reduce or prevent the pain. The basic aim of relaxation is to help people to relax, and thus improve the various aspects of physical health. Besides, there are also some other benefits, which lead to inner peace, reduced anxiety, lower heart rate, reduce blood pressure, a greater resistance to disease, mental health getting better and better memory. Many patients and health teams tend to view drugs as the only method to relieve pain, but many non- 512 Progressive Relaxation To Decrease Pain For Patients Of Sectio Caesarea Surgery In The First And Second Day” in the Maternity Room of the District General Hospital Kediri. Formulation of the Problem Based on the description of the background of the problem, it can be formulated research problem, namely “Is there a The Influence Of Progressive Relaxation To Decrease Pain For Patients Of Sectio Caesarea Surgery In The First And Second Day in the Maternity Room of the District General Hospital Kediri?” Purpose 1. General Purpose To determine differences in the level of pain in patients with postoperative Sectio Caesarea before and after being given the progressive relaxation technique in Maternity Room General Hospital of Kediri. 2. Special Purpose a. Identify the level of pain before the progressive relaxation in patients with postoperative sectio caesarea in the first and second day. b. Identify the level of pain after doing the progressive relaxation in patients with postoperative sectio caesarea in the first and second day. c. Analyzing the influence of progressive relaxation to decrease postoperative pain in patients Code Scale Pain 1 5 2 4 3 4 4 4 5 3 6 7 7 5 8 3 9 7 Mean 4,67 Median 4 Modus 4 Stand. Dev 1,5 3 4 4 5 5 5 6 7 7 6 8 5 9 7 Mean 5,66 Median 6 Modus 6 stand. Dev 1 Code Pain Scale 1 6 2 6 sectio caesarea in the first and second day. Research Design The research design used in this research is the design of pre- experimental design One group pretest- posttest, which in this design there is no comparison group control, but most do not already made the first observation pre-test that allows researchers can test changes occurred after the experiment. Based on the table shows that out of 9 respondents surveyed 11.11 or 1 Pre test test 01 Treatment X Post 02 respondent experienced pain with pain scale 4, 33.33 or 3 respondents experiencing pain with pain scale 5, 33.33 or 3 respondents experiencing pain with pain scale 6 and 22.22 or 2 The independent variable in this study is a progressive relaxation. The dependent variable in this study is the reduction of postoperative pain in patients Sectio Caesarea. The study population was 38 patients with postoperative sectio caesarea experiencing pain in the first and second day. In this study, samples taken part sectio caesarea postoperative mothers who experience pain in the first and second day as many as 9 respondents. In this study, the sampling technique used was purposive sampling, where the technique of determination of sample by choosing among a population sample in accordance with the desired researchers in accordance with the criteria. The data analysis was done through descriptive analysis, the observation of the frequency table. Frequency table consists of a column - a column that contains frequencies and percentages for each category. Research Result 1. Respondents pain scale before action is taken progressive relaxation techniques 513 respondents experiencing pain with pain scale 7. the mean 5.67, median 6, 6 mode and standard deviation 1. 2. Pain scale respondents action after progressive relaxation techniques Based on the table shows that out of 9 respondents surveyed 22.22 or 2 respondents experiencing pain with pain scale 3, 33.33 or 3 respondents experiencing pain with pain scale 4, 22.22 or 2 respondents experiencing pain with pain scale 5 and 22.22 or 2 respondents experiencing pain with pain scale 7. The Mean Value 4.6, 4 Median, Resp. Number Before After Decrease pain scale 1 6 5 1 2 6 4 2 3 4 4 Tetap 4 5 4 1 5 5 3 2 6 7 7 Tetap 7 6 5 1 8 5 3 2 9 7 7 Tetap Mean 5,66 4,67 1,5 Median 6 4 1,5 Modus 6 4 1 Stand. dev. 1 1,5 0,54 mode 4 and the Standard deviation of 1.5. 3. Analysis of the effect of progressive relaxation in patients with postoperative sectio caesarea in Maternity Room General Hospital District Kediri. Based on the results of research conducted it appears that there is a decrease pain scale by the respondents, the descriptive statistical tests obtained prior to action relaxation techniques mean value of 5.66, the median value of 6.00, the value of 6:00 mode, and standard deviation of 1. After the action is obtained the mean 4.67, median values of 4.00, 4.00 value mode, and standard deviation of 1.5. Value indicates a decrease in the mean value of 1.5, the median value of 1.5, the value of mode 1 and a standard deviation of 0.54 so that H0 is rejected and H1 accepted. It showed no effect of relaxation techniques on a scale decrease postoperative pain in patients sectio caesarea on the first day and the second in the Maternity Room General Hospital of Kediri. 514 Discussion 1. Pain scale before the patient is given the actions of progressive relaxation techniques. Pain scale before being given a progressive relaxation technique that measures of 9 respondents surveyed in the last 2 weeks Mean pain scale score was 5.6, median 6, 6 mode and standard deviation 1. Pain is an uncomfortable feeling, whether mild or severe. Pain is defined as a condition that affects a persons existence is unknown and if someone ever experienced Tamsuri, 2007. According to the International Association for the Study of Pain IASP, pain is an emotional experience unpleasant feelings as a result of actual or potential damage, or describe the condition of the occurrence of damage. According to the researcher scale of perceived pain patients in the Maternity Room District General Hospital Kediri is influenced by several things including the age and experience of sectio caesarea operation. Showed that of the majority of respondents aged 20-30 years and 2 respondents had never undergone surgery sectio caesarea. It can be concluded that the different scale of perceived pain patients due to surgery sectio caesarea experience before. 2. Pain scale after the patient is given the actions of progressive relaxation techniques. The scale of the pain that is felt after the patient is given the actions of progressive relaxation techniques, decreased pain skla into Mean Value 4.6, 4 Median, Mode 4, the standard deviation is 1.5. Progressive relaxation technique is to focus on a muscle activity by identifying the tense muscles then lowers the tension by doing relaxation techniques to get a feeling of relaxation Murphy, 1996. It is also based on the theory of the gate control, explaining that the pain that occurs in a person due to certain stimuli such as surgery can be blocked when the interaction between the pain stimulus and the stimulus to the fibers that transmit sensations of pain blocked on the circuit gate resistor, this reversal can be done through distraction or by the action of relaxation Sutherland, 2005. According to researchers pain scale decline in respondents influenced surgery sectio caesarea experience and capabilities of different respondent in conducting different respondents in performing relaxation techniques are taught, so the impact on respondents perceived pain scale. So the difference in results or the effect of relaxation techniques performed in this study indicate that the need for health workers to improve the ability to analyze the factors that affect pain scale and improve skills in using the techniques of progressive relaxation as one alternative to reduce the pain scale for patients other than use drugs. Conclusion progressive relaxation techniques are taught. So with relaxation techniques is expected patients assisted by nurses can use it as an action to lower the scale of pain experienced, in addition to using the drug. 3. Progressive relaxation influence on reducing postoperative pain in patients sectio caesarea on the first day and the second in the Maternity Room General Hospital District Kediri. Based on the results of the study showed a decrease in the pain scale sixth respondent after given action relaxation techniques, to obtain penurunkan mean values of 1.5, 1.5 median, mode 1, and standard deviation of 0.54 means that there is a decrease in the pain scale of respondents. The factors that affect pain scale include age, gender, culture, anxiety and past experiences and 1. 2. 3. Pain scale measures a patient prior to relaxation techniques obtained a mean value of 5.6, the median 6, 6 mode and standard deviation 1. The scale of the patients pain after the relaxation techniques implemented measures showed that the mean value of 4.6 median value of 4.00 mode value of 4.00 and a standard deviation of 1.5. Patient pain scale before and after the implemented measures showed a decrease in mean values of 1.5 median value of 1.5 mode value of 1 and a standard deviation of 0.54. There dilakukanya influence action relaxation techniques to decrease pain scale figures on maternal postoperative sectio caesarea in Maternity Room General Hospital District Kediri. progressive relaxation techniques. Suggestion Progressive relaxation is an effective way to rest the muscles through an appropriate manner, followed by mental relaxation and mind Davis, 2005. According to researchers, the differences decrease pain scale on each individual is different. That is because many factors ranging from differences in age, experience sectio caesarea operations, and the ability of 515 1. 2. For health agencies Progressive relaxation technique is one of the nursing treatment that is easy and inexpensive can be selected to be applied to nursing actions for clients with problems of pain. For educational institutions Relaxation techniques are one option for clients with problems of pain, so it can be entered into the Farrer, Hellen. 2001.Pearawatan laboratory skills of students in the achievement of competence. Maternitas.Edisi ECG.Jakarta 2 : 3. For the general public Mothers with post Sectio Caesarea expected to apply relaxation techniques as a non- pharmacological therapies that are Astuti, Puji. 2010, cermin Dunia Kebidanan. www.cermin dunia kebidanan.com download safe and easy to reduce pain. Notoatmojo, soekidjo. 2003. Metodologi Penelitian 4. For further research This study can be used as a source of information for further research Kesehatan. Jakarta : PT Rineka Cipta. pengembangkan. Future studies Notoatmojo, soekidjo. 2005. may consider factors that affect Metodologi Penelitian pain scale such as age, experience sectio caesarea operations and the ability of respondents to do relaxation techniques taught. Reference Potter, P.A Perry, A.G.2005 Kesehatan. Jakarta : PT Rineka Cipta. Notoatmodjo, S. 2010. Metodologi Penelitian Kesehatan , Ed.Rev 1 .Jakarta : PT Rineka Cipta Fundamental Keperawatan Konsep, Proses Dan Praktik, Jakarta: EGC Nursalam. 2003. Konsep dan Penerapan Metodologi Keperawatan. Jakarta : Salemba Medika Smeltzer, S. C, Bare.2001. Buku Ajar Keperawatan Medikal Bedah. Jakarta. EGC Smeltzer, S. C, Bare.2002. Buku Ajar Keperawatan Medikal Bedah. Jakarta. EGC Torrance, C Serginson. E 1997. Surgical Nursing. Bridgend, Midglanmorgan:WBC Book Manufactured. Ltd Tamsuri, A. 2007. Konsep Dan Penatalaksanaan Nyeri.jakarata : EGC Cuninghamm. F.G, 2007 Obstetri William, vol ipenerbiy buku kedokteran egc, Jakarta 516 THE INFLUECING OUTCOME FACTORS OF CAESAREA SECTIO PATIENTS IN PREPARATION FOR THE CLINICAL PATHWAYS COSTING OF DRGS AT PARE – KEDIRI HOSPITAL Suryono Akademi Keperawatan Pamenang Pare, Jl. Mahakan No. 05 Pare- Kediri, Email suryono.sanjayagmail.com Abstract Clinical Pathway is a concept of comprehensive service to plan the patient that are using standard of medical service and Nursing care during hospitalization. Research design is correlational approach observation with secondary input variables including Hb, age, class of service, indication, medicine, wound care, and nutrition. The output variables are LOS Length of Stay, cost, wound, mobilization, and complication using statistical analysis with multiple linear regression. Populations in this study were all patients hospitalized with caesarean section at Pare Hospital, Kediri, east Java, Indonesia. Multiple linear regression analysis showed that Hb variable positive correlate to the LOSr=0,136. Antibiotic variables also showed positive correlation with the hospital cost p=0,041. From multiple logistic regression analysis, wound care is more influenced B=161,98 to wound healing process, mobilization and complications more than another variables. This result can be used for early basic to arranged clinical pathway at caesarean section patient with some consideration such as age, infant indications, nutrition, antibiotic combinations, wound care, diabetic mellitus, prolonged delivery, and hypertension with complications. Key words : Clinical pathway, caesarean section Background On July 1st, 2007 the Ministry of Health of Indonesia has introduced Diagnosis Related Groups DRGs INA which will be used as the basis for a claim payment insurance patient mobilization and complications of caesarean sectio patients at Delivery Room Pare Kediri Hospital. The benefits of this research can be used as the initial data for the hospital to arrange Clinical Pathway. hospital. But the government in implementing

1. Framework Concept

the INA DRGs not give the basis for calculating the financing so detailed yet clearly the cost of each component of health care. As a basis for determining the cost of health Scheme 3.1 research conceptual framework insurance services can be used Clinical pathway theoretical cost driver. Clinical pathway is one component of the DRG system casemix consisting of codefication and action procedures and the calculation of costs. Clinical pathway into something that should be developed by each hospital, where the insurance company or the government would require hospitals to provide quality health services at a reasonable costYunita,2009. Formulation of the problem in this study are the factors that affect the LOS, costs, wound healing time, mobilization and complications of caesarea sectio patients in maternity room Pare Kediri hospital. While the goal of this research is to identify factors that affect the LOS, costs, wound healing time, 518 Hypothesis: there is influence of the characteristics Hb, age, class of service indication, medicine, doctor, nurse intervention, and nutrients to the LOS, costs, wound healing time, infusion time off , catheters time off and complications. 3.Researchmethods The study design: a correlational approach observational using retrospective secondary data aims to identify factors - factors that affect patient outcomes caesarea sectio. The population in this study were all hospitalized patients with cesarea sectio in the General Hospital of Pare Kediri. While the independent variables examined included the data Hb, age, class of service, indications, medications, nutrition, the actions of doctors, nurses, and The mean of hospitalization long days patients with poor insurance is 4.85 or 5 days. Patients with Health Insurance the mean of hospitalization is 4 days, while in the general patient have 4 days of LOS include the dependent variable, the cost, hospitalization. Statistical results test time healing wounds, immobilization time, and complications. 4.Research result The result showed that the distribution of respondents mother who gave birth by cesarea sectio mean age was 31.1 years. The general status of the mother when viewed from the maternal haemoglobin concentration was 9.4 mg. The majority of respondents in this study using a class of service insurance as 74 respondents 92.5. Most caesarea sectio conducted with mothers indicated that 59 73.8. The majority of doctors use obtained p = 0.437, which means it can be concluded there was no effect of financing sources with LOS. While the average long day of hospitalization of caesarea sectio patients with an indication is 4.95 days. Statistical test results obtained value of p = 0.067, meaning there is no influence between caesarea sectio with a long day of hospitalization. The mean long days of hospitalization patients with amoxicllin injection therapy and oral amoxicillin is 4.92 or 5 days. The mean of patients with amoxicillin injection amoxicillin antibiotic injection and oral therapy and oral cipro is 4.25 days of amoxcillin 48 60, wound care nurse performed, a majority of only 1 x during care after surgery 64 80.8. While the lenght of stay LOS of respondents found that the average patient is treated for 4.8 days. The total cost incurred respondents means is 3.910.000 rupiah. Majority of the wound healing time for 7 days, as many as 64 respondents 80, the distribution of respondents by the ability start to mobilize, a majority on the first day of 52 respondents 65. hospitalization, cipotaxim injection therapy and oral amoxicillin has average of 4.60 days, while in patients with therapy oral cipro and cipotaxim injection means 4.85 days. Statistical test results obtained value p = 0,470 which means there is no influencing between medicine therapy with LOS. The mean long days of hospitalization patients with one time wound care is 4.44 days, patients with wound care 2 times the average length of stay was 6.13 days and 1 The Influencing Factors To LOS patient with three times wound care the

a. The Influence of Age and Hb

The relationship between LOS and age shows with a low correlation r = 0.241 and a positive pattern means that the older have average is 9 days. Statistical test results obtained p = 0.000, which means there is significant influence between the LOS wound care. higher of LOS . Statistical test results found The mean of long days of relationshipsignificant influence of maternal hospitalization caesarea sectio patients with age with LOS 0.031 Table 4.1. nutritional dietary high-calorie high- protein is 4.75 days, while the dietary high- calorie high-protein-low salt means was 5.80 days. Statistical results test obtained value of p = 0.019, meaning there is influence between nutritiondiet with long Table 4.1. Correlation and regression analysis days of hospitalization. table4.2. of age and Hb with LOS Table 4.2. Distribution The mean LOS According Class Service

a. The Effect of Nursing Class, Caesarea Sectio Indication, Medicine, Wound

care and Mutrition To LOS. 519 0.822, which means there is no class effect with the cost of hospital care. The mean cost of hospital patients on caesarean sectio with an indication of the capital is 3.950.000 rupiah - 797,642.991 rupiah. While the mean with baby indication is 3.800.000 rupiah - 297,905.704 rupiah. Statistical results test obtained value of p = 0.275, meaning there is no influence between patients caesarean sectio with hospital cost. The Mean hospital costs patients with amoxicillin injection therapy and oral amoxicillin is 3.770.000 rupiah -. 231.590.4 rupiah ,-. Patients with amoxicillin injection therapy with oral ciprofloxacin the means days of hospitalization is Rp. 4.010.000,-, - 359.290.6 rupiah, cipotaxim injection and oral amoxicillin its average 3.920.000 rupiah - 860.610.9 rupiah whereas in patients with 2 The Influential Factors To Cost a. The Influence of age and Hb The relationship of age with the cost of the hospital showed a low correlation r = 0.105 and a positive pattern means that the older the higher cost of RS. Statistical results test found no significant effect p = 0.000 between age and hospital costs. While the relationship haemoglobin with hospital cost shows a low correlation r = 0.078 and a positive pattern means higher Hb levels will make higher hospital costs. Statistical results test found no significant effect p = 0.000 between Hb with hospital costsTable4.3. therapy cipotaxim injection and oral ciprofloxacin means 4.390.000 rupiah,- 1.346.163.5 rupiah. Statistical test results obtained p = 0.041, which means there is the influence of medicine therapy with hospital costs. The Mean hospital costs in patients with wound care one time is 3.940.000 rupiah, - 756.545.9 rupiah, in patients with wound care 2 times the average cost of hospital is 3.770.000 rupiah, - and wound care 3 times its average 4,020.000 rupiah -. Statistical test results obtained p = 0.690, which means there is no significant influence of the wound care with hospital costs. The mean of hospital cost patients Table 4.3. Linear Regression Results The caesarea sectio with nutrition dietary high- effect of age and Hb Against Hospital Costs

b. The Effect of Nursing Class, Caesarea Sectio Indication, Medicine, Wound Care

and Nutrition Mean hospital costs patients with poor insurance is 3.920.000 rupiah -. Patients HI calorie high-protein is 3.870.000 rupiah - with a standard deviation of 636.348.4 rupiah while the high-calorie high- protein low salt diet means is Rp 4.430.00 with a standard deviation of 1380550.6 rupiah. Statistical test results obtained value of p = 0.088, meaning there is no influence between nutritiondiet with long days of hospitalization Table 4.4. Table 4.4. Distribution The mean cost of hospital According Class Service Health Insurance the average cost is 3.610.000 rupiah - while the general patient means is 3.770.000 rupiah - 174.300,281 rupiah. Statistical test results obtained p = 520

b. The Effect of Nursing Class, Caesarea Sectio Indication, Medicine, Wound care

and Nutrition for Wound Healing Time Average time of wound healing patients with poor insuranc is 8.08 days. For Health Insurance Patients mean of wound healing time is 7 days, whereas in the general patient means also 7 days. Statistical test results obtained p = 0.455, which means there is no influence of the class of service with the wound healing time. Average time healing wounds of patients caesarea sectio with an indication is 8.19 days. While the baby with indication means is 7.48 days. Statistical results test obtained value of p = 0.166, meaning there is no effect between the caesarean sectio indication with wound healing time. Average time of wound healing in patients with amoxcilin injection therapy and 3 The Influential Factors of Wound Healing Time

a. The Influence of age and Hb

The relationship of age with wound healing time showed a low correlation r = 0.204 and a positive pattern means that the older have longer of the wounds healing time. Statistical results test found no correlationsignificant influence of maternal age and the healing time of wound 0.069. The relationship of haemoglobin with wound healing time showed a low correlation r = 0.085 and a positive pattern means higher Hb levels will have longer of healing time wounds. Statistical results test found no correlationsignificant effect p = 0.453 between Hb with wound healing time Table 4.5. Table 4.5. Correlation and regression analysis of age and Hb with Wound Healing Time 521 oral amoxicillin is 8.15 days. Patients with amoxicillin injection therapy and oral cipro have mean of long days of hospitalization is 7.00 days, cipotaxim injection and oral amoxicillin its average 7.67 days, while in patients with therapy oral cipro and cipotaxim injection means 8.15 days. Statistical results test obtained p = 0.639, which means there is no influence of medicine therapy with wound healing time. Average time of wound healing in patients with wound care one time is 7.16 days, patients with wounds care 2 times the average hospitalization time is 11.33 days wound healing and wound care 3 times its average 12.00 days. Statistical results test obtained p = 0.000, which means there is significant influence between the wound care and healing time. Average time of wound healing with means dietary high-calorie high-protein is 10 days. Statistical results test obtained value of p = 0.090, there is no difference or effect between nutrition diet with wound healing time Table 4.6. Table 4.6. Mean Distribution According Wound Healing Care Class, Indication, Medicine, Treat Wounds and Nutrition 60. On the results of statistical tests on wound care obtained p = 0.000, which means there is significant influence between the wound care wound healing time. Table 4.8. Table 4.8. Mean Distribution According Wound Healing Care Class, Indication, Drug, Wound Care and Nutrition 4 The Influencing Factors of Patient Mobilization To Caesarea Sectio In Delivery Room Pare Kediri Hospital. a. The Influence of age and Hb The results test found no statistically significant relationship between maternal age at the time of wound healing 0.069. Likewise, the results of statistical tests between Hb with wound healing time no significant effect p = 0.453 Table 4.7.. Table 4.7. Logistic regression analysis with age and Hb Wound Healing Time 5 The Factors that influence the occurrence of complications

a. The Influence of age and Hb

The test results found no statistically significant relationship between maternal age with complications p = 0.061. Likewise, the results of statistical tests between Hb with complications no significant effect p = 0.453. More can be seen in Table 4.9.

c. The Effect of Nursing Class, Indication,

Medicine, Wound Care and Nutrition Results of the analysis of the majority of Table 4.9. Logistic regression analysis of age and Hb with Time Mobilization the average wound healing time for 7 days occurred in treatment classes HI 1 100 and General 5 100, and indication of babies were 19 90.5, antibiotics that used a combination of injection and amoxcicilin oral ciprofloxacin 4 100, wound care one time as many as 62 96.9 and with dietary high- calorie high-protein were 62 82.7. While the wound healing time will be longer median 12 days in patients with wound care 2 x 13 86.7, three times as many as 1 100 and dietary high-calorie high-protein-low salt 3 522 Effect of Nursing Class, Indication, Medicine , Wound care, and Nutrition Results of the analysis do not occur the majority of complications in the treatment of class HI 1 100 and General 5 100, and indication of babies were 19 90.5, which used a combination of antibiotics oral ciprofloxacin and amoxcicilin injection 4 100 , wound care one time as many as 62