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  • Pengkajian Fraktur Patologis

    Diunggah oleh

    Rissa Icha
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    pengkajian fraktur

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    2. PENGKAJIAN FRAKTUR PATOLOGIS

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    4 tayangan10 halaman

    Pengkajian Fraktur Patologis

    Diunggah oleh

    Rissa Icha
    pengkajian fraktur

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 10

    JURUSAN KEPERAWATAN

    FAKULTAS KEDOKTERAN
    UNIVERSITAS BRAWIJAYA

    PENGKAJIAN DASAR KEPERAWATAN


    Nama Mahasiswa : Mohamad Salju Bintoro Tempat Praktik : Ruang 20 RSSA
    NIM : 135070218113020 Tgl. Praktik : 31 Juli 2017

    A. Identitas Klien
    Nama : Ny. N ................................ No. RM : 1707300347 ...................
    Usia : 50 tahun Tgl. Masuk : 30/07/2017 .....................
    Jenis kelamin : Perempuan ...................... Tgl. Pengkajian : 31/07/2017 .....................
    Alamat : Pasuruhan........................ Sumber informasi : ........................................
    No. telepon : -........................................ Nama klg. dekat yg bisa dihubungi:...............
    Status pernikahan : Cerai Mati ......................... .........................................
    Agama : Islam ................................ Status : ........................................
    Suku : Jawa ................................ Alamat : ........................................
    Pendidikan : .......................................... No. telepon : ........................................
    Pekerjaan : Ibu Rumah Tangga........... Pendidikan : ........................................
    Lama berkerja : .......................................... Pekerjaan : ........................................

    B. Status kesehatan Saat Ini


    1. Keluhan utama : Nyeri pada area kaki atas, pergelangan tangan kanan ...........................
    2. Lama keluhan : 2 .............................................................................................................
    3. Kualitas keluhan : sedang ...................................................................................................
    4. Faktor pencetus : Fraktur ...................................................................................................
    5. Faktor pemberat : setiap digerakkan terasa nyeri ................................................................
    6. Upaya yg. telah dilakukan : .................................................................................................
    7. Diagnosa medis :
    a. Ca. Tiroid ................................................................... Tanggal 30 Juli 2017 ..................
    b. Fraktur patologis humerus distal kanan ..................... Tanggal 30 Juli 2017 ..................
    c. Tumor Extra Cranial ................................................... Tanggal 30 Juli 2017 ..................
    d. Fraktur acetabulum kanan ......................................... Tanggal 30 Juli 2017

    C. Riwayat Kesehatan Saat Ini


    Klien masuk rumah sakit dengan keluhan terjatuh saat naik kendaraan. Klien mengalami fraktur
    pada bagian kaki kanan dan pergelangan tangan atas. Saat ini klien terpasang traksi di bagian kaki.
    Klien mengatakan bahwa tangan dan kakinya terasa nyeri saat digerakkan, klien enggan untuk
    bergerak dan meminta bantuan keluarga untuk memenuhi kebutuhan sehari-hari di rumah sakit.
    .....................................................................................................................................................
    .....................................................................................................................................................
    .....................................................................................................................................................
    .....................................................................................................................................................
    .....................................................................................................................................................
    .....................................................................................................................................................
    .....................................................................................................................................................

    D. Riwayat Kesehatan Terdahulu


    1. Penyakit yg pernah dialami:
    a. Kecelakaan (jenis & waktu) : Sepeda motor ................................................................
    b. Operasi (jenis & waktu) : operasi tumor ..................................................................
    c. Penyakit:
     Kronis :Tumor ....................................................................................................
    ...............................................................................................................
    ...............................................................................................................
     Akut : ..............................................................................................................
    d. Terakhir masuki RS : Februari 2015 .................................................................
    2. Alergi (obat, makanan, plester, dll): Tidak ada
    Tipe Reaksi Tindakan
    ................................................... ............................................. ................................................
    ................................................... ............................................. ................................................
    3. Imunisasi: Tidak Pernah
    ( ) BCG ( ) Hepatitis
    ( ) Polio ( ) Campak
    ( ) DPT ( ) ................
    4. Kebiasaan: Tidak ada
    Jenis Frekuensi Jumlah Lamanya
    Merokok .................................. ....................................... .......................................
    Kopi .................................. ....................................... .......................................
    Alkohol .................................. ....................................... .......................................

    5. Obat-obatan yg digunakan:
    Jenis Lamanya Dosis
    ................................................... ............................................. ................................................
    ................................................... ............................................. ................................................

    E. Riwayat Keluarga
    Keluarga mempunyai riwayat diabetes mellitus tipe 2 ..........................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    GENOGRAM
    F. Riwayat Lingkungan
    Jenis Rumah Pekerjaan (IRT)
     Kebersihan bersih ............................................ ......................................................
     Bahaya kecelakaan tidak ada ........................................ ......................................................
     Polusi tidak ada ........................................ ......................................................
     Ventilasi cukup ............................................. ......................................................
     Pencahayaan cukup ............................................. ......................................................
    ............................... ................................................... .........................................................

    G. Pola Aktifitas-Latihan
    Rumah Rumah Sakit
     Makan/minum 0 ................................... 3 ............................
     Mandi 0................................... 3 ...........................
     Berpakaian/berdandan 0................................... 3 ..........................
     Toileting 0 .................................. 3 ...........................
     Mobilitas di tempat tidur 0.................................. 3...........................
     Berpindah 0 .................................. 4 ...........................
     Berjalan 0 .................................. 4 ..........................
     Naik tangga 0................................. 4 ..........................
    Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

    H. Pola Nutrisi Metabolik


    Rumah Rumah Sakit
     Jenis diit/makanan semua dimakan ................... makanan rumah sakit ..............
     Frekuensi/pola 2x ........................ 3x ...............................
     Porsi yg dihabiskan 1 ......................... 1/2..........................
     Komposisi menu susu, roti, buah, sayuran ...... susu, nasi, buah, sayuran
     Pantangan tidak ada ............. tidak ada ....................
     Napsu makan ............................................. ................................................
     Fluktuasi BB 6 bln. terakhir tidak ada.............. tidak ada ....................
     Jenis minuman air putih ............... air putih .....................
     Frekuensi/pola minum sering .................. sering ........................
     Gelas yg dihabiskan 1,5 l .................... 1,5 l .........................
     Sukar menelan (padat/cair) tidak ................. tidak .....................
     Pemakaian gigi palsu (area) tidak .................. tidak ......................
     Riw. masalah penyembuhan luka tidak ada ............ tidak ada ..................
    I. Pola Eliminasi
    Rumah Rumah Sakit
     BAB:
    - Frekuensi/pola 1x ............................. 1x
    - Konsistensi lembek ........................... lembek ............................
    - Warna & bau kuning............................. kuning .............................
    - Kesulitan tidak ada ........................ tidak ada .........................
    - Upaya mengatasi ................................................... .................................................
     BAK:
    - Frekuensi/pola sering........................ sering..........................
    - Konsistensi jernih ......................... jernih ..........................
    - Warna & bau kuning ....................... kuning ........................
    - Kesulitan tidak ada ................... tidak ada ....................
    - Upaya mengatasi ................................................... .................................................

    J. Pola Tidur-Istirahat
    Rumah (tidak terkaji) Rumah Sakit
     Tidur siang:Lamanya ............................................. tidak tidur
    - Jam …s/d… ............................................ .....................................
    - Kenyamanan stlh. tidur ............................................ tidak nyaman ................
     Tidur malam: Lamanya ............................................. ...................................................
    - Jam …s/d… 21:00-04:00.............. 00:00-04:00 ..................
    - Kenyamanan stlh. tidur nyaman .................... tidak nyaman ................
    - Kebiasaan sblm. tidur suasana gelap dan menyalan kipas tidak dilakukan ..............
    - Kesulitan tidak ada .................. ada ...............................
    - Upaya mengatasi ............................................ tidak ada ......................

    K. Pola Kebersihan Diri


    Rumah Rumah Sakit
     Mandi:Frekuensi ................................................ tidak mandi ...................
    - Penggunaan sabun .............................................. ...............................................
     Keramas: Frekuensi ................................................ tidak kramas .................
    - Penggunaan shampoo .............................................. ...............................................
     Gososok gigi: Frekuensi ................................................ tidak gosok gigi .............
    - Penggunaan odol .............................................. ...............................................
     Ganti baju:Frekuensi ................................................ tidak ganti baju .............
     Memotong kuku: Frekuensi ................................................ tidak memotong kuku....
     Kesulitan ................................................ tidak berani bergerak lebih ......
     Upaya yg dilakukan ................................................ tidak ada .......................
    L. Pola Toleransi-Koping Stres
    1. Pengambilan keputusan: (√) sendiri ( ) dibantu orang lain, sebutkan, .....................................
    2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll): ..............

    3. Yang biasa dilakukan apabila stress/mengalami masalah: ...............................................................


    4. Harapan setelah menjalani perawatan: bisa sembuh dan segera berkumpul dengan keluarga .......
    5. Perubahan yang dirasa setelah sakit: tidak bisa beraktivitas dan berkumpul keluarga .....................

    M. Konsep Diri
    1. Gambaran diri: klien tidak mempunyai masalah dengan apa yang terjadi pada tubuhnya ................
    2. Ideal diri: ..........................................................................................................................................
    3. Harga diri: klien tetap percaya diri dengan keaadannya dan pasrah ................................................
    4. Peran: ..............................................................................................................................................
    5. Identitas diri......................................................................................................................................

    N. Pola Peran & Hubungan


    1. Peran dalam keluarga: ibu rumah tangga .........................................................................................
    2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan: .............

    3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan


    ( ) Hub. dengan sanak saudara ( ) Hub.dengan anak
    ( ) Lain-lain sebutkan, ...............................................................
    4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS: ................................
    ........................................................................................................................................................
    5. Upaya yg dilakukan untuk mengatasi: ..............................................................................................
    O. Pola Komunikasi
    1. Bicara: ( √ )Normal ( )Bahasa utama: ....................................
    ( ) Tidak jelas ( ) Bahasa daerah: .................................
    ( ) Bicara berputar-putar ( ) Rentang perhatian: ............................
    ( ) Mampu mengerti pembicaraan orang lain( ) Afek: ..................................................
    2. Tempat tinggal: (√) Sendiri
    ( ) Kos/asrama
    ( ) Bersama orang lain, yaitu: ...............................................................................
    3. Kehidupan keluarga
    a. Adat istiadat yg dianut: ...............................................................................................................
    b. Pantangan & agama yg dianut: ...................................................................................................
    c. Penghasilan keluarga: ( ) < Rp. 250.000 ( ) Rp. 1 juta – 1.5 juta
    ( ) Rp. 250.000 – 500.000 ( ) Rp. 1.5 juta – 2 juta
    ( ) Rp. 500.000 – 1 juta ( ) > 2 juta
    P. Pola Seksualitas
    1. Masalah dalam hubungan seksual selama sakit: (√) tidak ada ( ) ada
    2. Upaya yang dilakukan pasangan: Keluarga
    (√) perhatian ( ) sentuhan ( ) lain-lain, seperti, ...........................................................

    Q. Pola Nilai & Kepercayaan


    1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
    2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi): ikut pengajian ketika
    masih bisa beraktivitas ....................................................................................................................
    ...................................................................................................................................................
    3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS: tidak ada ..............................................
    4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: ...................................................
    R. Pemeriksaan Fisik
    1. Keadaan Umum: Kompos mentis .....................................................................................................
    ....................................................................................................................................................
     Kesadaran:GCS 4,5,6..................................................................................................................
     Tanda-tanda vital: - Tekanan darah 140/90 mmHg - Suhu 37,3oC
    - Nadi : 118 x/meni - RR 26 x/menit
     Tinggi badan: - cm Berat Badan: -kg LLA: 35 cm %LLA: 117%
    2. Kepala & Leher
    a. Kepala:
    Terdapat benjolan pada area atas mata kanan hingga ke mata sebesar >10 cm ..........
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    b. Mata:
    konjungtiva anemis, sklera ikterik, mata tidak cowong, pupil isokor...............................
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    c. Hidung:
    Tidak ada gangguan .....................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    d. Mulut & tenggorokan:
    Tidak ada gangguan, ...................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................

    e. Telinga:
    Tidak ada gangguan .....................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    f. Leher:
    Tidak ada gangguan .....................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    .....................................................................................................................................
    3. Thorak & Dada:

     Jantung
    - Inspeksi: bentuk dada simetris ...............................................................................................
    ...............................................................................................................................................
    - Palpasi: ..................................................................................................................................
    ...............................................................................................................................................
    - Perkusi: ..................................................................................................................................
    ...............................................................................................................................................
    - Auskultasi: bunyi jantung S1 dan S2, suara denyut jantung terasa cepat ...............................
    ...............................................................................................................................................
     Paru
    - Inspeksi: ................................................................................................................................
    ...............................................................................................................................................
    - Palpasi: ..................................................................................................................................
    ...............................................................................................................................................
    - Perkusi: ..................................................................................................................................
    ...............................................................................................................................................
    - Auskultasi: suara
    vesikuler
    ................................................................................................................................................
    ................................................................................................................................................
    ................................................................................................................................................

    4. Payudara & Ketiak


    Tidak terkaji .............................................................................................................................
    5. Punggung & Tulang Belakang
    Tidak terkaji .............................................................................................................................

    6. Abdomen
     Inspeksi: ......................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
     Palpasi:........................................................................................................................................
    ...................................................................................................................................................
     Perkusi: .......................................................................................................................................

    ....................................................................................................................................................
     Auskultasi:BU 7 x menit ...............................................................................................................
    ....................................................................................................................................................
    7. Genetalia & Anus tidak terkaji
     Inspeksi: ......................................................................................................................................
    ...........................................................................................................................................
    ...........................................................................................................................................
     Palpasi:.......................................................................................................................................
    8. Ekstermitas
     Atas: Lengan kanan: deformitas, terlihat benjolan pada sendi, nyeri saat digerakkan, nyeri
    tekan, terpasang elastic bandage
    Pulseless (-), Pain (+), Pallor (-), Parasthesia (-), Paralisis (-), Poikilothermia (-)
    ..........................................................................................................................................
    ..........................................................................................................................................
     Bawah: Femur kanan: nyeri pada area bokong, ketika digerakkan nyeri, terpasang traksi
    Pulseless (-), Pain (+), Pallor (-), Parasthesia (-), Paralisis (-), Poikilothermia (-)
    ..........................................................................................................................................
    ..........................................................................................................................................
    9. Sistem Neorologi
    N. Olfactory : Tidak ada gangguan N. Trigememinal : tidak ada gangguan ...........
    N. Optik : Tidak ada gangguan N. Abducens : tidak ada gangguan ................
    N. Oculomotor : Tidak ada gangguan N. Facial : tidak dapat mengerutkan dahi dan
    menaikkan alis sebelah kiri ............................
    N. Throclear : Tidak ada gangguan N. Vestibulocochlear : tidak ada gangguan
    N. Glossopharyngeal : tidak ada gangguan N. Vagus : tidak ada gangguan ......................
    N. Spinal : tidak ada gangguan N. Hypoglosal : tidak ada gangguan
    10. Kulit & Kuku
     Kulit: kulit lembab, tidak ada sianosis, tidak ada lesi,
    Ada tonjolan di area kepala diatas mata kiri sebesar > 10 cm
    Ada kemerahan pada kulit bagian punggung

     Kuku: CRT < 2 Detik

    S. Hasil Pemeriksaan Penunjang


    TERLAMPIR

    T. Terapi
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................

    U. Persepsi Klien Terhadap Penyakitnya


    Klien merasa penyakitnya tidak kunjung sembuh dan selalu bertambah, akan tetapi klien sudah
    pasrah kepada Tuhan dengan keadaannya sekarang .........................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................

    V. Kesimpulan
    Masalah keperawatan yang muncul adalah hambatan mobilitas fisik di tempat tidur, gangguan pola
    tidur, defisit perawatan diri: mandi .......................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................
    ............................................................................................................................................................

    W. Perencanaan Pulang
     Tujuan pulang: .................................................................................................................................
     Transportasi pulang: ........................................................................................................................
     Dukungan keluarga: .........................................................................................................................
     Antisipasi bantuan biaya setelah pulang:..........................................................................................
     Antisipasi masalah perawatan diri setalah pulang: ...........................................................................
     Pengobatan:.....................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
     Rawat jalan ke:.................................................................................................................................
    ...................................................................................................................................................
     Hal-hal yang perlu diperhatikan di rumah: .......................................................................................
    ...................................................................................................................................................
    ........................................................................................................................................................
     Keterangan lain: ...............................................................................................................................

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