Professional Documents
Culture Documents
PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama
: Tn. I
Umur
: 34 tahun
Agama
: kong hu cu
Jenis Kelamin
: laki - laki
Status
: menikah
Pendidikan
: d3
Pekerjaan
: swasta
Suku Bangsa
: jawa
Alamat
: jogjakarta
Tanggal Masuk
: 31 desember 2011
Tanggal Pengkajian
: 1 januari 2012
No. Register
:-
Diagnosa Medis
: abses cerebri
2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Sakit kepala
2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini
Sakit kepala dirasakan selama 2 minggu SMRS dan dirasakan semakin
memberat. Sakit kepala terkadang dirasakan berdenyut dan terasa seperti kepala
sedang diregangkan. Sakit kepala dirasakan di semua bagian kepala terutama
pada kepala bagian belakang. Apabila sakit kepalanya timbul, Os terkadang
a.
b. Pola Nutrisi-Metabolik
Sebelum sakit :
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Saat sakit
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c.
Pola Eliminasi
1) BAB
Sebelum sakit :
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Saat sakit
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2) BAK
Sebelum sakit :
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Saat sakit
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Perawatan Diri
Makan dan minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
2) Latihan
Sebelum sakit
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Saat sakit
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e.
f.
g.
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h. Pola Peran-Hubungan
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i.
Pola Seksual-Reproduksi
Sebelum sakit :
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Saat sakit
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j.
k. Pola Nilai-Kepercayaan
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Status Generalis
Keadaan umum : tampak sakit sedang, gelisah
Kesadaran : Apatis
Status gizi : cukup
Tekanan darah : 130/70 mmHg
Nadi : 88x/ menit, teratur, isi cukup
Nafas : 21x/ menit, teratur, kedalaman cukup
Suhu : 38,50C
Mata : konjungtiva tidak pucat, sklera tidak ikterik
Telinga : sekret (-)
Hidung : sekret (-), deviasi septum (-)
Tenggorokan : faring tidak hiperemis
Jantung : bunyi jantung I/II normal, murmur (-), gallop (-)
Paru : suara dasar vesikuler , rhonki (-/-), wheezing (-/-)
Abdomen : perut datar, lemas, tidak teraba hati maupun limpa
bising usus 3x/menit
Ekstremitas : akral hangat, perfusi perifer baik
lakrimasi baik.
_ N. VIII : pendengaran suara baik pada telinga kanan dan kiri
_ N.IX & X : arkus faring simetris, bersuara baik, tidak sengau,
menelan baik
_ N.XI : bisa memalingkan kepala dan mengangkat bahu
_ N.XII : artikulasi baik, kekuatan lidah baik, deviasi (-),
tremor (-)
Motorik: Kekuatan : 4 4 4 4 4 4 4 4
44444444
Tonus : N N
NN
Trofi : atrofi - - Sensorik: Eksteroseptif: - Ekstremitas atas: baik
- Ekstremitas bawah: baik
Refleks fisiologis: bisep (+/+)
trisep (+/+)
radius (+/+)
patella (+/+)
achilles (+/+)
Refleks patologis: Hoffman-Trommer (-/-)
Babinsky (-/-)
Oppenheim (-/-)
Gordon (-/-)
Gonda (-/-)
Schaffer (-/-)
Chaddock (-/-)
Otonom: retensio urin (-), inkotinensia alvi (-)
III. PEMERIKSAA_ PE_U_JA_G
1. Laboratorium ( hasil pemeriksaan tanggal 2 April 2010)
Hb : 13,4 g/dL
Ht : 41,6 %
Leukosit : 8.900/JL
Trombosit : 319.000 /JL
2. Radiologi ( hasil pemeriksaan tanggal 7 April 2010 )
Foto thorak : Cor Pulmo tidak tampak kelainan
CT Scan Kepala : Tampak midline shift ke kiri, tampak gambaran hipodens
di temporofrontalis dekstra dan temporooksipitalis sinistra
yang pada pemberian larutan kontras tampak gambaran
ring enhancement di frontalis dekstra dengan ukuran
3,5 x 2,8 cm.
3. Laboratorium (hasil pemeriksaan tanggal 9 April 2010)
Waktu perdarahan : 230
Waktu pembekuan : 730