PEMERIKSAAN FISIK PADA

GANGGUAN S. NEUROBEHAVIOUR
NS, ELFIRA HUSNA, M.KEP 1

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 BAHAN KAJIAN

PENGKAJIAN
1. Riwayat kesehatan
a. Keluhan utama pasien (DATA SUBJEKTIF)

Setiap keluhan pasien kita harus yakini itu benar dan harus
DIVALIDASI kebenarannya dengan melakukan
pemeriksaan fisik

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 DATA SUBJEKTIF

Pernyataan pasien secara verbal pada perawat

• Vertigo
• Migrain
• Aphasia
• Disartria
• Tremor
• Disfagia
• Paralisis
• Pain

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 • Riwayat kesehatan dahulu
Terkait gangguan neurologi dan umum
• Riwayat kesehatan keluarga
menentukan apakah ada riwayat secara genetik

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 PEMERIKSAAN FISIK

Pemeriksaan fisik merupakan data OBJEKTIF yang bisa kita

lakukan untuk memvalidasi status klien
1. Status mental :
• orientasi ( waktu, orang dan tempat) hasilnya orientasi baik
/disoreintasi
• dan memori
1. Kemampuan bahasa : afasia broca, wernick atau global
2. Fungsi intelektual : Tidak mampu menghitung mundur,
Tidak mampu menentukan pilihan

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 CONTINUE...

4. Daya pikir : kesulitan berfikir, paranoid, halusinasi

5. Tingkat kesadaran :
bisa diukur dengan cara kualitatif dan kuantitatif
a. Dengan kualitatif : cm, apatis, somnolent, delirium, stopor,
coma
b. Dengan kuantitatif : GCS ( glascow coma scale)

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 Tingkat kesadaran
• ComposMentis (conscious), yaitu kesadaran normal, sadar sepenuhnya,
dapat menjawab semua pertanyaan tentang keadaan sekelilingnya.
• Apatis, yaitu keadaan kesadaran yang segan untuk berhubungan dengan
sekitarnya, sikapnya acuh tak acuh.
• Delirium, yaitu gelisah, disorientasi (orang, tempat, waktu),
memberontak, berteriak-teriak, berhalusinasi, kadang berhayal.
• Somnolen (Obtundasi, Letargi), yaitu kesadaran menurun, respon
psikomotor yang lambat, mudah tertidur, namun kesadaran dapat pulih
bila dirangsang (mudah dibangunkan) tetapi jatuh tertidur lagi, mampu
memberi jawaban verbal.
• Stupor (soporo koma), yaitu keadaan seperti tertidur lelap, tetapi ada
respon terhadap nyeri.
• Coma (comatose), yaitu tidak bisa dibangunkan, tidak ada respon
terhadap rangsangan apapun (tidak ada respon kornea maupun reflek
muntah, mungkin juga tidak ada respon pupil terhadap cahaya).

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 Response score Patient
Behavior score
Eye opening response Spontaneous 4

Respon to verbal comment 3

To pain 2

No respon 1

best verbal response Oriented, conversing 5

Disoriented, conversing 4

Use of inappropriate words 3

Incomprehensible sounds 2

No respons 1

Best motor response Obeys verbal commands 6

Moves to localized pain 5

Flexion withdrawal to pain 4

Abnormal posturing— decorticate 3

Abnormal posturing— decerebrate 2

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 • GCS merupakan pemeriksaan yang objektif dalam menilai
kesadaran pasien . Nilai terendah 3, dan tertinggi 15.

• HAFALKAN POINT2 GCS YA

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 6. penilaian pupil : posisi, bentuk, reaksi terhadap cahaya,
ukuran
7. Penilaian saraf kranial : I-XII
8. Kekuatan otot :

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 Skor Defenition kekuatan otot
5/5 :Full power of contraction
4/5 : Fair or moderate power of contraction
3/5 :Just able to overcome force of gravity
2/5 : Can move, but cannot overcome power of gravity
1/5 : Minimal contractile power
0/5 : No movement

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 • Pemeriksaan Refleks Fisiologis
NILAI NYA:
Respon reflek 4 + : hiperaktif dengan klonus terus menerus 3
+ : hiperaktif
2 + : normal
1 + : hipoaktif
0 : tidak ada reflek

• Pemeriksaan refleks patologis : contoh pasien meningitis

• Gaya berjalan

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 • Pemeriksaan diagnostik
1. Lumbal pungsi/ tes cairan serebro spinal: Analisis cairan
serebrospinal :
2. Diagnostik testing :
A. Non invasive tests of strukture
Skull and spinal X- Ray studies
Computed Tomography scanning
B. Noninvasive Tests of Function : EEG

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 • Gerontologic Considerations
During the normal aging process, the nervous system
undergoes many changes, and is more vulnerable to illness.
Changes throughout the nervous system that occur with age
vary in degree.
Nervous system changes due to aging must be distinguished
from those due to disease; it is important for clinicians not to
attribute abnormality or dysfunction to aging without
appropriate investigation (Neal-Boylan,2017). For example,
while diminished strength and agility are a normal part of
aging, localized weakness can only be attributed to disease.

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 • Structural and Physiologic Changes
A number of alterations occur with increasing age. A loss of
neurons occurs, leading to a decrease in the number of
synapses and neurotransmitters. This results in slowed nerve
conduction and response time. Brain weight is decreased and
the ventricle size increases to maintain cranial volume.
Cerebral blood flow and metabolism are reduced, leading to
slower mental functions. Temperature regulation becomes less
efficient.
In the peripheral nervous system, myelin is lost, resulting in a
decrease in conduction velocity in some nerves. Visual and
auditory nerves degenerate, leading to loss of visual acuity
and hearing. Taste buds atrophy and nerve cell fibers in the
olfactory bulb degenerate (Jarvis,
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2007). 15
 • Motor Alterations
Reduced nerve input into muscle contributes to an overall
reduction in muscle bulk, with atrophy most easily noted in
the hands. Changes in motor function often result in decreased
strength and agility, with increased reaction time. Gait is often
slowed and wide based. These changes can create difficulties
in maintaining balance, predisposing the older person to falls

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 • Sensory Alterations
Tactile sensation is dulled in the elderly person due to a
decrease in the number of sensory receptors. There may be
difficulty in identifying objects by touch, because fewer tactile
cues are received from the bottom of the feet and the person
may become confused about body position and location
(Wickremaratchi & Llewelyn, 2006).

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 • Nursing Implications
Nursing care for patients with age-related changes to the
nervous system and for patients with long-term neurologic
disability who are aging should include the previously
described modifications. In addition, the consequences of any
neurologic deficit and its impact on overall function such as
activities of daily living, use of assistive devices, and
individual coping should be assessed and considered in
planning patient care

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 Fall risk must be evaluated, and fall prevention measures
instituted for the hospitalized patient as well as in the home.
The nurse must understand the altered responses and the
changing needs of the elderly patient before providing
education. Visual and hearing deficits require adaptations in
activities such as preoperative teaching, diet therapy, and
instruction about new medications.

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 • Analisa data
• Analisa data didapatkan dari hasil pemeriksaan fisik dan
pemeriksaan diagnostik

HARI DATA MASALAH ETIOLOGI

/TGGL KEPERAWATA
N
DS:

DO:

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 DAFTAR DIAGNOSA KEPERAWATAN YANG BISA
MUNCUL PADA GANGGUAN NEUROLOGI (NANDA)
1.Resiko perfusi cerebral tidak efektif
2.Hambatan komunikasi verbal
3. Hambatan mobilitas fisik
4. Kerusakan memori
5. disfagia
6. Gangguan harga diri

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 • PRIORITAS DX ( berdasarkan maslow )
1.
2.
3.
4.
5.

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 • IMPLEMENTASI ( NOC DAN NIC) sesuaikan denagn SDKI,
SIKI, DAN SLKI
dx NOC NIC AKTIFITAS
NYERI 1. PAIN LEVEL MANAJEMEN 1.
AKUT 2. PAIN NYERI (PAIN 2.
CONTROL MANGEMEN 3.
3. COMFORT T) 4.
LEVEL
KRITERIA HASIL :
1.
2.
ANALGESIC 1.
ADMINISTRA 2.
TION 3.

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 • EVALUASI (SOAP)

SUBJEKTIF :
OBJEKTIF :
ANALISA :
PLANNING :

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 • Semoga bisa dipahami dengan baik
• JIKA ADA PERTANYAAN HARAP DI KUMPULKAN
OLEH SIPEND, NANTI IBU AKAN JAWAB DI AUDIO
AGAR BISA DI DENGAR OLEH SEMUANYA

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