2
Subjective data
Main complain
Important Health history:
Past health history:
TBC, poliomyelitis, diabetes, inflammatory & degenerative
arthritis
Medication:
Kinds of medication
Reason for taking medication
GI distress / ulceration
Surgery or other treatment:
Previous hospitalization
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Subjective data (cont’d)
Functional health patterns:
1. Health perception-health management
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-self-concept
8. Role-relationship pattern
9. Sexually-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-believe pattern
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OBJECTIVE DATA
Physical examination
Inspection
Palpation
Movement
Measurement
Muscle-strength testing
Gait
Other
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MOVEMENT MODEL’S
Musculoskeletal system 6
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Pemeriksaan Dasar
Look (inspeksi)
Feel (palpasi)
Move (pergerakan t/u lingkup gerak)
Disamping gerak perlu dilakukan pengukuran bagian
yang penting untuk membuat kesimpulan kelainan,
merupakan pembengkakan atau atrofi serta melihat
adanya discrepancy (selisih panjang).
Look (inspeksi)
APLEY test
penderita tidur tengkurap knee fleksi 90°,
plantar pedis ditekan bila nyeri dalam knee
harus dicurigai robekan meniscus
Fraktur patella
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OBJECTIVE DATA
T-score
+ sampai -1 (normal)
-1 sampai -2.5 (osteopenia)
< sampai = -2.5 (osteoporosis)
Z-score
-2 atau lebih rendah (kelainan selain penuaan yang
menyebabkan hilangnya tulang yang abnormal)
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Lanjut….
II.DIAGNOSA KEPERAWATAN
III.INTERVENSI KEPERAWATAN
IV. IMPLEMENTASI KEPERAWATAN
V.EVALUASI KEPERAWATAN
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orthopedic nursing/snt/2022