1. Keluhan Utama
Pasien mengeluh mengalami rasa kaku pada tubuh bagian kiri pada kaki kanan dan tangan kiri klien
2. Riwayat Kesehatan Saat Ini
Alasan Masuk Rumah Sakit :
Klien dibawa keluarga ke RS Kedu pada tanggal 14 desember 2021, klien mengatakan sudah merasakan keluhan
sejak tanggal 12 november 2021 klien merasakan kaku pada bagian tubuh bagian kiri dan kaki kanan dan tangan
kiri. Saat dilakukan pengkajian klien mengatakan kepalanya sakit seperti ditusuk-tusuk dengan benda tajam selain
terasa tegang dan kepalanya terasa pusing klien merasa nyeri dan susah tidur dengan hasil pengkajian TD :
160/90 mmHg, RR : 25x/mnt, Nadi : 90x/mnt, Suhu : 36,5 C dan pengkajian nyeri P : Hipertensi/ Pusing, Q :
seperti ditusuk benda tajam , R : daerah leher dan kepala, S : skala 5 , T : hilang timbul nyeri dirasakan saat
bergerak, klien mendapat terapi amplodipin 3x05 mg, infestamim 1x20 mg. Dan klien menjalani perawatan diruang
rawat inap rumah sakit kedu.
3. Riwayat Kesehatan Lalu
Pasien mengatakan memiliki riwayat penyakit hipertensi dan klien mengatakan sudah tidak mengontrol tekanan
darahnya sejak lama dan tidak memeriksakan kesehatannya.
4. Riwayat Kesehatan Keluarga
Kebiasaan Hidup Tidak Sehat: merokok
Penyakit Menular: disangkal/ tidak ada
Penyakit Menurun: disangkal / tidak ada
B. Riwayat Lingkungan Tempat Tinggal
Tipe Tempat Tinggal : Permanen
Jumlah Kamar : 4 buah
Jumlah Penghuni : 5 orang
Kondisi Tempat Tinggal : Pasien mengatakan lingkungan disekitar rumah bersih
dan keadaannya tidak seramai di perkotaan
Sistem Endokrin
Data Subjektif :
Riwayat gangguan pertumbuhan dan perkembangan:
Tidak.
Bentuk dan proporsi tubuh : Normal
Riwayat DM (ditanyakan keluhan trias DM) : Tidak ada
Polidipsi (ya), poliuria (ya), polofagia (ya)
Inspeksi kesimetrisan leher: Leher simetris
Hiperpigmentasi/hipopigmentasi kulit: Tidak ada
Penumpukan massa otot di leher bagian belakang (bufflow
neck): Tidak ada
Perubahan tanda sex sekunder: Tidak ada
Pertumbuhan rambut berlebihan pada dada dan wajah:
Tidak ada
Pembesaran payudara pada laki-laki: Tidak ada
Bentuk abdomen cembung akibat penumpukan lemak:
Tidak ada.
Tremor: Pasien mengatakan tidak mengalami tremor pada
bagian tangan maupun kaki.
Pembesaran kelenjar tiroid: Tidak ada pembesaran
kelenjar
Hasil temuan lain: - PowerPoint Presentation
Sistem Cairan dan Elektrolit
Data Subjektif :
Perasaan haus yang berlebihan: Pasien mengatakan tidak pernah merasa haus yang berlebihan
Faktor risiko kekurangan cairan dan elektrolit: Tidak ada
Kedutan otot: Pasien mengatakan tidak merasakan kedutan pada otot
Kejang/ riwayat kejang: Pasien mengatakan tidak memiliki riwayat kejang
Hasil temuan lain: -
Data objektif :
Intake cairan : 1500cc
Output cairan : 2100cc
Balance cairan : - 600 cc
Muntah : Tidak ada
Diare : Tidak ada
Turgor kulit : Baik
Tekstur kulit : Elastis
Kelembaban kulit : Kulit kering
Kelembaban membrane mukosa: Membran mukosa kering
Tekstur lidah : Kasar dan berwarna merah muda
Tekanan vena jugularis : Tidak ada peningkatan vena jugularis
Edema: Umum : Tidak ada pembengkakan
Lingkar abdomen : 88 cm
Perfusi perifer : tidak ada
Sistem Imunitas
Data Subjektif :
Riwayat alergi/ sensitivtas: Pasien mengatakan tidak memiliki alergi, Sebutkan: -
Reaksinya: -
Perubahan imunitas sebelumnya: Pasien mengatakan sistem imunnya mulai berkurang karena akhir-akhir ini sering sakit, penyebab: faktor
usia, stress, dan pola hidup kurang sehat
Riwayat penyakit hubungan seksual: Pasien mengatakan tidak memiliki riwayat penyakit dalam berhubungan seksual.
Perilaku risiko tinggi: -
Transfusi darah/jumlah: Pasien mengatakan tidak pernah mendapatkan transfusi darah, Kapan: -
Riwayat infeksi kronis: Pasien mengatakan tidak memiliki riwayat infeksi yang parah.
Riwayat pembedahan: Pasien mengatakan tidak memiliki riwayat operasi
Riwayat imunitas dewasa: Tidak ada
Riwayat penggunaan obat-obatan steroid: Pasien mengatakan tidak pernah mengonsumsi obat tersebut
Keluhan nyeri tekan pada kelenjar limfe: Pasien mengatakan tidak merasakan nyeri
Pembesaran kelenjar limfe: Tidak ada
Hasil temuan lain: Pasien mengatakan akan mencoba menerapkan pola hidup sehat
Data Objektif :
Inspeksi kulit dan mukosa: elastis
Purpura/ perdarahan subkutan: Tidak ada
Dermatitis : Tidak ada
Inflamasi : Tidak ada
Pengeluaran secret : Tidak ada
Ultearia : Tidak ada
Dimana : Tidak ada
Banyaknya : Tidak ada
Kemerahan di kulit: Tidak ada kemerahan pada kulit
Palpasi kelenjar limfe servikal, aksilaris dan inguinalis:
Ukuran : Tidak ada
Konsistensi : Tidak ada
Hasil temuan lain : -
Sistem Reproduksi
Data Subjektif :
Aktif melakukan hubungan seksual : Tidak
Penggunaan kondom saat berhubungan : Tidak
Masalah/kesulitan dalam berhubungan seks : Tidak
Data Objektif :
Pria
Rabbas penis: tidak ada, warna : -
Gangguan prostas: ada
Sirkumsisi: pasien mengatakan sunat
Vasektomi: tidak pernah
Hasil temuan lain: -
Sistem Hematologi
Riwayat transfuse darah : Tidak, Kapan:-, Jumlah: -
Data Tambahan
Pola Aktifitas, Istirahat Dan Tidur
Data subjektif :
Aktifitas yang biasa dilakukan: menanam padi di sawah
Perasaan bosan/ tidak puas: Pasien mengatakan tidak pernah merasa bosan
Keterbatasan karena kondisi: Pasien mengatakan mengalami kesulitan dan keterbatasan bergerak
Lama waktu tidur: Malam: ± 6 jam, Siang: ± 1 jam sering terbangun dan terjaga
Hasil temuan lain: -
Data objektif :
Respon terhadap aktifitas yang teramati :
Kardiovaskuler : 160/90 mmHg
Pernafasan : 25x/menit
Status mental : Pasien terlihat mengantuk
Mata merah : Tidak ada
Kelopak mata bewarna gelap: Ya
Terlihat menguap: Ya
Hasil temuan lain: -
Ketidaknyamanan
Data Subjektif:
Perasaan nyeri : Pasien mengatakan ada nyeri
Intensitas : nyeri 2 menit
Frekuensi : nyeri hilang timbul nyeri muncul saat bergerak
Durasi : 2 menit
Kualitas : nyeri seperti ditusuk benda tajam
Penjalaran : Tidak ada
Faktor-faktor pencetus : nyeri leher dan kepala
Faktor pemberat :-
Cara menghilangkan :-
Keberhasilan :-
Hasil temuan lain :-
Data Objektif :
Mengerutkan muka : Ada
Menjaga area nyeri : Iya
Respon emosional : Ada
Penyempitan focus : Ada
Hasil temuan lain :-
DATA PENUNJANG
PEMERIKSAAN LABORATORIUM
Hemoglobin HEMOGLOBIN 10 g %
•Analisa Data
1
Rabu, 15 DS: Hipertensi Nyeri Akut (D.0077)
Desember 2021 - Pasien mengatakan bahwa dirinya merasa
Pukul 20.30 nyeri karena hipertensi kaku leher P: Kerusakan vaskuler pembuluh darah
Hipertensi, Q: Seperti ditusuk benda
tajam, R: leher dan kepala, S: Skala 5, T: Penyumbatan pembuluh darah
Hilang timbul selama 2 menit nyeri terasa
jika bergerak Vasokontriksi
DO:
- Pasien tampak mengerutkan muka saat Gangguan sirkulasi
nyeri
- Pasien tampak menjaga area nyeri Otak
- Pasien lebih sering marah saat nyerinya
terasa sakit sekali Resistensi pembuluh darah otak
- Pasien jadi lebih sering fokus pada cara meningkat
menghilangkan nyerinya yang tak
kunjung berkurang Nyeri kepala
Ra.30 DS: klien mengatakan mengalami rasa kaku pada bagian Pembuluh darah
tubuh bagian kiri dan pada kaki kanan dan tangan kiri
DO Sistemik
- Pasien tampak gelisah dengan kondisinya saat ini
- Saturasi Oksigen 94% Vasokontriksi
- Tekanan Darah: 160/90 mmHg
- RR: 25x/menit Afterload meningkat
- Klien bedrest
- Adanya nyeri yang hilang timbul saat melakukan Fatique
pergerakan
Intoleransi aktivitas
Nyeri kepala
Gangguan pola tidur
Diagnosa Keperawatan
Intoleransi aktivitas
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