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Assestment pada Cerebral Palsy

A. Anamnesis
I. Identitas Pasien
a. Nama : ........................................................................................
b. Umur : ........................................................................................
c. Alamat : ........................................................................................
d. Diagnosa Medik : ........................................................................................
II. Riwayat penyakit (anamnesa tanggal ..........)
a. Keluhan Utama :
(perkembangan anak yang belum bisa dilakukan)
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b. Riwayat Penyakit Sekarang :


(berhubungan dengan keluhan utama, yaitu perjalanan penyakit sejak
timbul keluhan sampai dilakukan tindakan sekarang)
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c. Riwayat Prenatal :
(kondisi kandungan sebelum melahirkan. apakah kehamilan
direncanakan, merupakan kehamilan ke berapa, usia ibu saat hamil,
adakah pendarahan, jatuh, dan berapa kali kontrol kandungan)
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d. Riwayat Natal :
(kondisi bayi saat melahirkan. usia kandungan saat melahirkan, tempat
melahirkan, lahir spontan atau caesar, apakah bayi menangis, biru,
kuning, BBL, dan PBL)
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e. Riwayat Post Natal :


(kondisi bayi setelah melahirkan apakah bayi biru, kuning)
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f. Riwayat Penyakit Dahulu :


(riwayat penyakit yang pernah diderita pasien)
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g. Riwayat Penyakit Keluarga :


(riwayat penyakit yang sama seperti pasien yang diderita oleh anggota
keluarga lain)
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h. Riwayat Imunisasi :
(lengkap atau tidaknya imunisasi yang diberikan pada anak)
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i. Riwayat Tumbuh Kembang :


(perkembangan gross motor, fine motor, bicara dan bahasa, makan)
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j. Riwayat Psikososial :
(anak diasuh oleh siapa, pekerjaan orang tua, dan usia orang tua)
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III. Pemeriksaan Umum (vital)


a. Denyut nadi : ........................................................................................
b. Pernapasan : ........................................................................................
c. Temperatur : ........................................................................................
d. Tinggi badan : ........................................................................................
e. Berat badan : ........................................................................................

(data tersebut digunakan untuk mengetahui apakah ada hipertensi,


hipotensi, tacikardi, obesitas, dan sebagainya)

IV. Pemeriksaan Fisioterapi


a. Pemeriksaan Khusus
a) Pengamatan Pola Gerak
1) Terlentang
(gerakan tubuh, posisi shoulder, elbow, wrist, finger, trunk, hip, knee,
ankle)
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2) Berguling
(cara ke berguling via apa, adakah rotasi trunk dan head control)
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3) Telungkup
(adakah head lifting, head control, forearm support, hand support,
bagaimana posisi trunk, hip, knee, dan ankle)
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4) Merayap
(adakah head control forearm support, rotasi trunk, gerakan maju ke
depan)
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5) Duduk
(adakah head control, trunk control, hand support, weight bearing,
protective reaction, dan sitting balance)
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6) Ke duduk
(posisi awal ke duduk bagaimana, adakah forearm support, hand
support, rotasi trunk, dan transfer weight bearing)
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7) Berdiri
(adakah head control, posisi shoulder, elbow, wrist, trunk control,
trunk asimetris atau tidak, hip, knee, ankle, weight bearing dimana,
dan balance berdiri)
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8) Berjalan
(walking balance, rotasi trunk, transfer weight bearing)
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b) Spesifik Test
1) Ankle clonus
(klonus adalah kontraksi ritmis yang menetap dari suatu otot yang
spastik, yang mengalami peregangan mendadak yang menetap.
Dengan cara dorso fleksikan kaki anak, positif bila ada kontraksi
ritmik dari otot)
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2) Tes spastisitas
(fisioterapis memfleksikan dan ekstensikan keempat ekstremitas anak
secara cepat dan berulang. Rasakan peningkatan tonusnya pada
lingkup gerak sendinya)
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3) Tes 7 refleks berjalan


(ATNR, STNR, Moro reflex, neck righting, extensor thrust, foot
placement, parachute)
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4) Tes panjang otot


Tightness pada Iliopsoas (fleksor hip), Hamstring (fleksor knee),
Tendon achilles (fleksor ankle)
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5) Pemeriksaan fungsi bermain


(dilihat sesuai usia anak)
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V. Daftar masalah dan diagnosa fisioterapi


a. Daftar masalah
(Tonus postural, spastisitas, gangguan perkembangan, gangguan
koordinasi dan keseimbangan, refleks primitif, tightness)
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b. Diagnosa fisioterapi
(Ketidakmampuan anak mencapai level motorik kasar atau gangguan pola
gerak (sesuai dengan keluhan utama) yang disebabkan oleh hal-hal yang
ditemukan pada pemeriksaan khusus)
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VI. Program Fisioterapi


a. Tujuan program fisioterapi
1. Tujuan jangka pendek
(mencapai level motorik kasar sesuai ketidakmampuan motorik kasar
pada keluhan utama dan diagnosa fisioterapi. Dapat berdiri stabil,
mengurangi spasme, mengulur otot tightness)
2. Tujuan jangka panjang
Maintenance

b. Metode Fisioterapi
1. Massage : untuk rileksasi otot dan inhibisi tonus postural
2. Stretching : untuk mengulur otot yang tightness
3. NDT : inhibisi, stimulasi, fasilitasi

c. Pelaksanaan fisioterapi
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d. Home program
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e. Pelaksanaan evaluasi
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