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LAPORAN STATUS KLINIK

PROGRAM STUDI D IV FISIOTERAPI
STIKES AISYIYAH SURAKARTA

NAMA MAHASISWA : Kelompok 2

TEMPAT PRAKTIK :
PEMBIMBING :

Tanggal Pembuatan Laporan : 26 Februari 2021

Kondisi : FT A/FT B/FT C/FT D/FT E
FT A (obsgin, pediatri) FT B (muskuluskeletal) FT C (neuromuskular) FT D (kardiovaskular) FT
E (kesehatan masyarakat)
A. KETERANGAN UMUM PENDERITA
Nama : #Video2
Umur :-
Jenis Kelamin : Laki-laki
Agama :-
Pekerjaan :-
Alamat :-
No RM :-
Tempat Perawatan : -

B. DATA-DATA MEDIS RUMAH SAKIT

1. DIAGNOSA MEDIS :
 Tanggal,
-

2. CATATAN KLINIS :
(Hasil : Rontgen, Uji Laboratorium, Ct scan, MRI, EMG, dll yang terkait dengan
permasalahan fisioterapi)
-
*) Coret yang tidak perlu
3. TERAPI UMUM ( GENERAL TREATMENT )
-
4. RUJUKAN FISIOTERAPI DARI DOKTER :
-

C. SEGI FISIOTERAPI
1. ANAMNESIS (AUTO / HETERO *)
a. KELUHAN UTAMA :
Pasien merasakan kesemutan dari pantat sebelah kanan hingga ke tungkai kanan.
b. RIWAYAT PENYAKIT SEKARANG :
Sekitar 3 hari yang lalu pasien mengeluhkan nyeri pada bagian bokong kanan
menjalar sampai ke kaki bagian kanan. Pasien juga mengeluhkan adanya kesemutan
pada kaki kanan.
c. RIWAYAT PENYAKIT DAHULU :
-
d. RIWAYAT PENYAKIT PENYERTA :
-
e. RIWAYAT PRIBADI (KETERANGAN UMUM PENDERITA):
-
f. RIWAYAT KELUARGA :
-
2. ANAMNESIS SISTEM :
 1) Kepala & Leher :
-
2) Kardiovaskuler :
-
3) Respirasi (tidak ada batasan normal)
-
4) Gastrointestinalis :
-
5) Urogenitalis :
-
6) Muskuloskeletal:
Nyeri tekan pada m. piriformis
7) Nervorum :
Adanya kesemutan dari tungkai atas ke tungkai bawah sebelah kanan.

D. P E M E R I K S A A N
1. PEMERIKSAAN FISIK
a. TANDA - TANDA VITAL
1) Tekanan darah: -
2) Denyut nadi :-
3) Pernapasan :-
4) Temperatur :-
5) Tiggi badan :-
6) Berat badan :-
b. INSPEKSI :
1) Statis:
 Raut wajah pasien terlihat gelisah
 Kepala sedikit forward
2) Dinamis:
Terlihat adanya keterbatasan gerak ke arah fleksi trunk
c. PALPASI :
 Adanya nyeri tekan pada otot piriformis
d. PERKUSI :
-
e. AUSKULTASI :
-
f. GERAKAN DASAR :
1) Gerak Aktif :
Fleksi Lumbal Full ROM
Ekstensi Lumbal Keterbatasan
Lateral Fleksi Lumbal Dextra Full ROM
Latreal Fleksi Lumbal Sinistra keterbatasan

2) Gerak Pasif :
Fleksi Hip Full ROM
Abduksi Hip Full ROM
Adduksi Hip Keterbatasan

3) Gerak Isometrik Melawan Tahanan :

Tidak dilakukan.
g. KOGNITIF, INTRA PERSONAL & INTER
PERSONAL :
 Pasien mampu mengingat dan menjawab pertanyaan yang diberikan terapis
 Pasien dapat berkominikasi dan melaksanakan instruksi terapis dengan baik.
h. KEMAMPUAN FUNGSIONAL & LINGKUNGAN
AKTIVITAS
1) Kemampuan Fungsional Dasar :
-
2) Aktivitas Fungsional :
-
3) Lingkungan Aktivitas :
-
i. PEMERIKSAAN SPESIFIK ( FT A / FT B / FT C / FT
D / FT E *)
1) Nyeri Gerak :
 Fleksi Lumbal (+)
 Ekstensi Lumbal (-)
 Lateral Fleksi Lumbal Dekstra (+)
 Lateral Fleksi Lumbal Sininstra (-)
2) Lassage Test (+)
3) Patrick’s of Faber Test (-)
 j. CLINICAL REASONING

Trauma

Piriformis Ischiadicus

Terlalu lama duduk Tidak ada aktivitas Penekanan saraf

Otot menjepit saraf

Spasme otot

Atrofi

Koreksi postur Nyeri Manual Therapy

Mengurangi spasme

Relaksasi otot

Mengembalikan fungsional
E. KODE DAN KETERANGAN PEMERIKSAAN ICF
1. Body Stucture
 Spasme pada otot Piriformis
 Adanya otot menjepit saraf
2. Body Function
 Adanya nyeri tekan pantat yang menjalar sampai ke kaki sebelah kanan.
 Adanya kesemutan yang menjalar dari pantat hingga ke kaki sebelah kanan.
 Adanya keterbatasan ROM .
3. Activity Limitation
 Kesulitan duduk
 Kesulitan jongkok
 Kesulitan tidur terlentang dan tengkurap
 Kesulitan membungkuk
4. Participation Restriction
Pasien belum sepenuhnya mengikuti kegiatan sosial dilingkungan sekitar
5. Enviromental & Personal Factors
-
F. DIAGNOSA FISIOTERAPI
Piriformis Syndrome / sciatic syndrome
G. RENCANA INTERVENSI
1. TUJUAN
a. Jangka Pendek
 Mengurangi spasme
 Mengurangi nyeri
 Meningkatkan rom
b. Jangka Panjang
Mengembalikan aktifitas fungsional

2. TINDAKAN FISIOTERAPI
a. Teknologi Fisioterapi :
 1) Teknologi Alternatif :
 IR
 Tens
 US
 Manual Therapy

2) Teknologi Terpilih
(Jelaskan argumentasi / alasan metode teknologi tersebut di lakukan)
 Teknik Friction yaitu melakukan gerakan melingkar kecil-kecil dengan
penekanan yang lebih dalam dengan menggunakan ibu jari tersebut. Dalam
melakukan gerakan friction boleh menggunakan ujung jari, buku jari bahkan
siku tangan. Untuk melepaskan bagian otot yang tegang dapat menggunakan
gerakan memutar (putaran kecil) dari jari jempol. Teknik ini bermanfaat
untuk melepaskan bagian-bagian otot yang kejang yang terbentuk sebagian
akibat stress dan ketegangan, dapat menghilangkan akumulasi dari sisa-sisa
metabolisme.
 Teknik Stripping Menggunakan Kepalan tangan. Hal ini harus dilakukan agar
tidak terjadi cidera pada Ibu jari Anda. Untuk melepaskan bagian otot yang
tegang dapat menggunakan gerakan memutar (putaran kecil) dari jari jempol.
Teknik ini bermanfaat untuk melepaskan bagian-bagian otot yang kejang
yang terbentuk sebagian akibat stress dan ketegangan, dapat menghilangkan
akumulasi dari sisa-sisa metabolisme.
 Neuromobilisasi tujuannya untuk memperbaiki elastisitas jaringan saraf
maupun jaringan sekitarnya.
 Piriformis Stretch tujuannya yaitu untuk memperbaiki elastisitas jaringan otot
dan sekitarnya. Sehingga spasme otot berkurang yang kemudian diikuti
berkurangnya penekanan pada saraf.
b. Edukasi
 Tidak di benarkan duduk pada permukaan/ kursi yang keras.
 Hindari duduk lebih dari 1 jam
  Gunakan celana yang longgar dan jangan meletakkan dompet pada saku celana
belakang.
c. Rencana Evaluasi
 Penurunan nyeri
 Penurunan spasme otot
 Meningkatkan ROM

H. Prognosis
1. Quo Ad Vitam : .............................................................................................
2. Quo Ad Sanam : .............................................................................................
3. Quo Ad Fungsionam : .............................................................................................
4. Quo Ad Cosmeticam : .............................................................................................
I. 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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J. Evaluasi
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K. Hasil Evaluasi Akhir
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Pembimbing,

NIP.