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LAPORAN STATUS KLINIK

PROGRAM STUDI D IV FISIOTERAPI
STIKES AISYIYAH SURAKARTA

NAMA MAHASISWA :
TEMPAT PRAKTIK :
PEMBIMBING :

Tanggal Pembuatan Laporan : 2 september 2019

Kondisi : FT A/FT B/FT C/FT D/FT E
A. KETERANGAN UMUM PENDERITA
Nama : Bp. Sularto
Umur : 59 tahun
Jenis Kelamin : Laki - Laki
Agama : Islam
Pekerjaan : petani
Alamat : Banyak 01/06, kadipiro, Jumapolo, karangayar, Jawa
Tengah
No. Ft : 00.33.50.58
Tempat Perawatan : Bangsal edelweis RSO
DATA-DATA MEDIS RUMAH SAKIT
1. DIAGNOSA MEDIS :
Close fraktur oblique 1/3 medial femur sinistra
2. CATATAN KLINIS :
Pasien rawat inap di RSO.prof Dr.R. Soeharso Surakarta pada tanggal 2
September 2019 dan di lakukan oprasi pada tanggal tersebut.
 Hasil Rontgen pre oprasi : Tampak adanya fraktur oblique 1/3 medial femur
sinistra.
Hasil Rontgen post oprasi : Tampak pemasangan plate and screw pada 1/3
medial femur sinistra
3. TERAPI UMUM ( GENERAL TREATMENT )
a. Cefadroxil 500 mg 2 x 1
b. Meloxicam 5 mg 2 x 1
c. Kalk 500 mg 2x1
4. RUJUKAN FISIOTERAPI DARI DOKTER :
Mohon di lakukan tindakan fisioterapi pada Bp.S usia 59 tahun dengan
diagnosa medis fraktur 1/3 medial femur sinistra.
B. SEGI FISIOTERAPI
TANGGAL :
1. A N A M N E S I S ( AUTO / HETERO *) )
a. KELUHAN UTAMA :
Nyeri dan susah menggerakan paha kiri
b. RIWAYAT PENYAKIT SEKARANG :
Pada hari senin tanggal 2 september 2019 pukul 09.00 WIB pasien terjatuh
sendiri di pekarangan sawah milik nya. Pasien terpereset ketika hendak
kembali ke rumah setelah kejadian pasien langsung di bawa ke puskesmas
terdekat dan kemudian di rujuk ke RSO. Pukul 12.00 WIB pasien Sampai
di IGD RSO dan kemudian pasien menjalani pemeriksaan rontgen dan di
ketahui adanya fraktur femur pada pasien maka pasien langsung di berikan
tindakan oprasi.
c. RIWAYAT PENYAKIT DAHULU :
Pasien belum pernah mengalami kecelakaan hingga oprasi.
d. RIWAYAT PENYAKIT PENYERTA :
- Pasien tidak mempunyai riwayat hipertensi
- Pasien tidak mempunyai riwayat diabetes militus
e. RIWAYAT PRIBADI (KETERANGAN UMUM PENDERITA):
 Pasien adalah seorang petani
f. RIWAYAT KELUARGA :
Pasien adalah seorang suami dan kepala rumah tangga dengan 5 orang anak
yang sudah hidup mandiri semua.
Keluarga pasien tidak ada yang memiliki penyakit serupa seperti yang
dialami pasien sekarang.
g. ANAMNESIS SISTEM :
1) Kepala & Leher :
Pasien tidak mengeluhkan adanya gangguan pada kepala dan leher
2) Kardiovaskuler :
Pasien tidak mengeluhkan adanya gangguan pada jantung
3) Respirasi
Pasien tidak mengeluh sesak nafas
4) Gastrointestinalis :
BAB pasien terkontrol
5) Urogenitalis :
BAK pasien terkontrol
6) Muskuloskeletal :
- Adanya spasme pada tungkai kiri
- Adanya keterbatasan gerak pada Hip dan Knee
- Adanya penurunan kekuatan otot pada tungkai kiri
7) Nervorum :
Pasien tidak mengeluh adanya kesemutan
C. PEMERIKSAAN
1. PEMERIKSAAN FISIK
a. TANDA - TANDA VITAL
1) Tekanan darah : 130 / 80 mmHg
2) Denyut nadi : 70 x / menit
3) Pernapasan : 12 x / menit
4) Temperatur : 37 x / menit
 5) Tiggi badan : 158 cm
6) Berat badan : 60 kg

b. INSPEKSI :
Statis :
- Masih tampak terpasang infus pada lengan kiri.
- Masih tampak terpasang kateter.
- Tampak adanya oedema pada kaki kanan.
- Tampak terpasang elastis bandange pada paha kanan.
Dinamis :
- Tampak keterbatasan gerak hip dan knee kanan saat pasien
menggerakkannya ke segala arah.
- Tampak wajah pasien menahan sakit.

c. PALPASI :
- Terdapat nyeri tekan pada oedema daerah postero lateral dari paha
kanan.
- Terdapat nyeri tekan ke arah fleksi lutut kanan.
- Paha kanan sampai kaki kanan terasa hangat dari pada paha kiri dan
kaki kiri.
- Teraba adanya pitting oedema pada ankle kanan.
- Sensibilitas pada seluruh ekstremitas normal.

d. PERKUSI :
Dalam batas normal
e. AUSKULTASI :
Dalam batas normal
f. GERAKAN DASAR :
1) Gerak Aktif :
HIP Dextra Sinistra Nyeri
Fleksi Full ROM Terbatas +
Ekstensi Full ROM Terbatas +
Adduksi Full ROM Terbatas +
Abduksi Full ROM Terbatas +
Endorotasi Full ROM Terbatas +
Eksorotasi Full ROM Terbatas +

Knee Dextra Sinistra Nyeri

Fleksi Full ROM Terbatas +
Ekstensi Full ROM Full ROM +

Ankle Dextra Sinistra Nyeri

Plantar fleksi Full ROM Full ROM -
Dorsal fleksi Full ROM Full ROM -
Inversi Full ROM Full ROM -
Eversi Full ROM Full ROM -

2) Gerak Pasif :
HIP Dextra Sinistra End feel
Fleksi Full ROM Terbatas elastis
Ekstensi Full ROM Terbatas elastis
Adduksi Full ROM Terbatas elastis
Abduksi Full ROM Terbatas elastis
 Endorotasi Full ROM Terbatas elastis
Eksorotasi Full ROM Terbatas elastis

Knee Dextra Sinistra End feel

Fleksi Full ROM Terbatas Soft
Ekstensi Full ROM Full ROM Hard

Ankle Dextra Sinistra End Feel

Plantar fleksi Full ROM Full ROM Hard
Dorsal fleksi Full ROM Full ROM Hard
Inversi Full ROM Full ROM Soft
Eversi Full ROM Full ROM Soft

3) Gerak Isometrik Melawan Tahanan :

Belum bisa di lakukan
g. KOGNITIF, INTRA PERSONAL & INTER PERSONAL :
Kognitif : pasien mampu menceritakan prihal munculnya kejadian yang
dialami dari awal kejadian dengan jelas.
Intra personal : pasien bersemangat dan mempunyai keinginan besar untuk
sembuh.
Inter personal : pasien dapat berkomunikasi dengan terapis secara jelas.
h. KEMAMPUAN FUNGSIONAL & LINGKUNGAN AKTIVITAS
1) Kemampuan Fungsional Dasar :
a. Pasien mampu miring kanan dan kiri
b. Pasien belum mampu duduk
c. Pasien belum mampu berdiri
d. Pasien belum mampu berjalan
 2) Aktivitas Fungsional :
Pasien belum mampu melakukan aktivitas sehari- hari seperti mandi,
makan, jalan, bekerja secara mandiri.

3) Lingkungan Aktivitas :
Lingkungan aktivitas pasien tidak berlantai licin dan tidak bertangga
sehingga mendukung kesembuhan pasien.

i. PEMERIKSAAN SPESIFIK ( FT A / FT B / FT C / FT D / FT E *)
a. Pemeriksaan sensoris
Anggota Atas Anggota Bawah
Jenis Sensasi
Kanan Kiri Kanan Kiri
Temperatur
1 1 1 1
(Panas dan Dingin)
Tajam Tumpul 1 1 1 1

Parameter penilaian :
1. Utuh : Respon normal
2. Menurun : Ada gangguan mengidentifikasi stimulus
3. Hipersensitif : Adanya peningkatan persepsi terhadap stimulus
4. Absen : Tidak dapat menerima atau mengidentifikasi rangsang
5. Tak konsentrasi : Respon tidak cukup untuk memeriksa fungsi sensorik
secara akurat.

b. Pemeriksaan kemampuan fungsional

Indek Barthel
No Aktivitas Nilai Penilaian
1. Makan 10 (5 – 10)
Berpindah dari kursi roda ke tempat tidur dan
2. 7 (5 – 15)
sebaliknya, termasuk duduk di tempat tidur.
 Kebersihan diri, mencuci muka, menyisir, mencukur,
3. 3 (0 – 5)
dan menggosok gigi.
4. Aktivitas di toilet (menyemprot, mengelap) 5 (5 – 10)
5. Mandi 2 (0 – 5)
Berjalan di jalan yang datar (jika tidak mampu
6. 11 (10 – 15)
berjalan, lakukan dengan kursi roda, wolker, kruk)
7. Naik turun tangga 5 (5 – 10)
8. Berpakaian termasuk mengenakan sepatu. 6 (5 – 10)
9. Mengontrol defekasi 10 (5 – 10)
10. Mengontrol berkemih 10 (5 – 10)
JUMLAH 69

Penilaian :
0 – 20 Ketergantungan penuh
21 – 61 Ketergantungan berat (sangat tergantung)
62 – 90 Ketergantungan sedang
91 – 99 Ketergantungan ringan
100 Mandiri

c. Pemeriksaan Nyeri dengan VAS (Verbal Analog Scale)

Nyeri diam
4

0 10

Nyeri tekan
6

0 10

Nyeri gerak
9

0 10

d. Pemeriksaan LGS dengan Goneometer

 Pemeriksaan Kanan Kiri
Ekstensi-fleksi S : 15 – 0 – 120 S:0–0–5
Abduksi-adduksi F : 45 – 0 – 25 F : 15 – 0 – 10
Hip
Eskternal rotasi-internal
R(S90) : 45 – 0 – 45 R(S90) : 10 – 0 – 10
rotasi
Knee Ekstensi-fleksi S : 0 – 0 – 130 S : 0 – 0 – 50

Ankle Eversi-inversi R : 20 – 0 – 30 R : 20 – 0 – 30

e. Pemeriksaan Antropometri dengan menggunakan pita ukur dan dilakukan pada

tungkai kiri atas (dalam posisi tungkai kiri atas masih terpasang elastis bandage)
Patokan Kanan Kiri
Proximal
20 cm 40 cm 50 cm
10 cm 30 cm 40 cm
Epicondylus lateralis
10 cm 30 cm 35 cm
20 cm 28 cm 42 cm
30 cm 25 cm 31 cm
Distal

C. DIAGNOSE FISIOTERAPI
a. Impairment
- Adanya nyeri tekan pada oedema daerah postero lateral pada kiri
- Adanya nyeri saat bergerak pada tungkai kiri
- Adanya oedema pada tungkai kiri
- Adanya keterbatasan gerak pada tungkai kiri
b. Fungtional Limitations
- Pasien belum mampu melakukan aktivitas fungsional
c. Disability
- Pasien belum mampu melakuakan aktivitas sosial dengan baik
D. RENCANA INTERVENSI
1. TUJUAN
a. Jangka Pendek
- Mengurangi nyeri tekan pada oedema daerah postero lateral pada kiri
- Mengurangi nyeri saat bergerak pada tungkai kiri
- Mengurangi oedema pada tungkai kiri
- Meningkatkan lingkup gerak sendi pada tungkai kiri

b. Jangka Panjang
- Meneruskan jangka pendek
- Meningkatkan aktivitas fisik dan kemampuan fungsional

2. TINDAKAN FISIOTERAPI
a. Teknologi Fisioterapi :
1) Teknologi Alternatif :
a. Exercise
b. Edukasi

2) Teknologi Terpilih
- Exercise
Adanya gerakan aktif bertujuan untuk merangsang propioseftif pada
persendian sehingga akan meningkatkan, merangsang, menjaga ke
elastisan jaringan sendi maka akan terjadi peningkatan lingkup gerak
sendi dan kekuatan otot
- Edukasi
Bertujuan untuk memberikan arahan terhadap pasien mengenai
managemen proses penyembuhan dari pasien terkait gerakan-gerakan
yang harus di lakukan di rumah, anjuran untuk supaya pasien mampu
menjalani aktivitas secara mandiri.
b. Edukasi
Pasien dianjurkan untuk tetap aktif dan semangat untuk selalu mengulangi
latihan yang sudah dianjurkan.
3. Rencana Evaluasi
1. Pemeriksaan kekuatan otot dengan MMT
2. Pemeriksaan kemampuan fungsional dengan Indeks Bartel
 3. Pemeriksaan nyeri dengan VAS
4. Pemeriksaan antropometri dengan pita ukur
5. Pemeriksaan LGS dengan goneometer
E. Prognosis

1. Quo Ad Vitam : Baik

2. Quo Ad Sanam : Baik
3. Quo Ad Fungsionam : Baik
4. Quo Ad Cosmeticam : Baik
F. Pelaksanaan Fisioterapi
1. Hari: Tgl:
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2. Hari: Tgl:
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3. Hari: Tgl:
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4. Hari: Tgl:
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5. Hari: Tgl:
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G. Evaluasi
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H. Hasil Evaluasi Akhir
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