Format-Pengkajian-Reumatik-Medikal.docx

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FORMAT PENGKAJIAN

FORMAT PENGKAJIAN KEPERAWAKEPERAWATTAN MEDIKAN MEDIKAL (RAL (REUMATIK)EUMATIK) Na

Nama ma MaMahashasiswiswa a :: N

NIIMM ::

T

Tempat Pempat Pengkajian :engkajian : T Tanggal anggal :: I. Identitas Kien I. Identitas Kien N Naamma a : : NNoo. . RRM M :: Umur

Umur : : PekPekerjaan erjaan :: Jenis Jenis Kelamin Kelamin : : SSttaattuuss Perkawinan Perkawinan :: A Aggaamma a : : TTaannggggaal l MMRRS S :: P

Peenniiiikkaan n : : TTaannggggaall Pengkajian Pengkajian :: A Allaammaat t : : SSuumm!!eerr In"ormasi In"ormasi ::

II. Ri!a"at Kese#atan II. Ri!a"at Kese#atan

#.

#. $iagnosa $iagnosa Meik:Meik:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%..

...%%%%%%.. &.

&. KeKeluhan luhan Utama: Utama: %%%%%..%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%%.%%%.... %%%%%%%%%%%%%%%%%%%%%%%%%%%%.%%%.... %%%%%%%%%. %%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%% '.

'. Riwa(at Riwa(at pen(akit pen(akit sekasekarang:rang:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%... %%... ... ...

Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* #+#+

Page # Page #

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%... %%%%%%%%... +.

+. Riwa(at Riwa(at kesekesehatan hatan terahulu:terahulu: a. Pen(akit (ang pernah ialami: a. Pen(akit (ang pernah ialami:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%... %%%%%%.. %%%%%%..

!. Alergi ,o!at- makanan- plester- ll: !. Alergi ,o!at- makanan- plester- ll:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. /.Imunisasi: /.Imunisasi: %%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% .Ke!iasaa

.Ke!iasaan0pola hiup0li"e n0pola hiup0li"e st(le:st(le:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%...%%%%%%.. %%%%%%%...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%...%%%%%%.. %%%%%%%...%%%%%%.. e. 1!at2o!at (ang igunakan:

e. 1!at2o!at (ang igunakan:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%...%%%%%%.. %%%%%%%...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. ...%%%%%%..

Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* #+#+

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...%%%%%%.. 3. Riwa(at pen(akit keluarga:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%... ...%%%%%%.. Gen$%&a'

III. Pen%a*ian Ke+e&a!atan

#. Persepsi kesehatan 4 pemeliharaan kesehatan

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%

Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* #+

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Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% &. Pola nutrisi0 meta!olik ,A56$

2 Antropometeri %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% 2 Biomedical sign : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%% 2 Clinical Sign : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%

2 Diet Pattern ,intake makanan an /airan:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%% '. Pola eliminasi: 5AK 2 7rekuensi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Jumlah : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 8arna : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 5au : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Karakter : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 5J : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Alat 5antu : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Kemanirian : maniri0i!antu 2 9ain : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 5A5 2 7rekuensi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Jumlah : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Konsistensi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. .

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2 8arna : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 5au : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Karakter : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 5J : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Alat 5antu : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . 2 Kemanirian : maniri0i!antu 2 9ain : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%. . Interpretasi : 5alan/e /airan: %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%

+. Pola aktiitas 4 latihan

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%

,.-. Atiitas #a&ian (A,tiit" Dai" Liin%)

Ke'a'+/an +e&a!atan di&i 0 - 1 2 3

Makan 0 minum Toileting

5erpakaian

Mo!ilitas i tempat tiur 5erpinah

Am!ulasi 0 R1M

Ket: *: tergantung total- #: i!antu petugas an alat- &: i!antu petugas- ': i!antu alat- +: maniri

Status 1ksigenasi :

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%% 7ungsi karioaskuler : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Terapi oksigen : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% 3. Pola tiur 4 istirahat

$urasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%% <angguan tiur : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %.

Keaaan !angun tiur :

%%%%%%%%%%%%%%%%%%%%%%%%..%%%%% 9ain2lain : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% ;. Pola kogniti" 4 per/eptual

7ungsi Kogniti" an Memori :

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%

7ungsi an keaaan inera :

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%... ... ... Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%% =. Pola persepsi iri

<am!aran iri : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Ientitas iri : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% >arga iri : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Ieal $iri : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Peran $iri : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% ?. Pola seksualitas 4 reprouksi

Pola seksualitas %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %7ungsi reprouksi %%%%%%%%%%%%%%... ... ... ... Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% @. Pola peran 4 hu!ungan

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%... ... ... ... ... Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% #*.Pola manajemen koping2stress

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% ##.S(stem nilai 4 ke(akinan

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%% Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%

IV. Pe'e&isaan Fisi Keaaan umum: %%%%%%%%%%%%%%%%%%%%%%%.. %%%%%%%%%%%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%% Tana ital:

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2 Tekanan $arah : mm0>g 2 Nai : 0mnt 2 RR : 0mnt 2 Suhu : 6 Interpretasi : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%% Pengkajian 7isik ,Inspeksi- Palpasi- Perkusi- Auskultasi

#. Kepala %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% &. Mata %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% '. Telinga . %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.. ... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%% +. >iung %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% 3. Mulut %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% ;. 9eher %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% =. $aa . %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %...%. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%% ?. A!omen %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%% @. Urogenital %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%% #*.)kstremitas %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%

##.Kulit an kuku

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%% #&.Keaaan lokal %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% % Pemeriksaan 1. Tangan

Teknik untuk memeriksa sendi kecil dari tangan dan kaki. Ibu jari dan jari telunjuk tangan pemeriksa digunakan dengan lembut untuk mengembalikan cairan intaartikular dan untuk mengetahui nyeri tekan pada garis sendi.

2. Pergelangan tangan

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mengetahui nyeri tekan dan pembengkakan. Pergelangan tangan harus diperiksa dalam posisi sedikit fleksi untuk menunjukkan secara optimal garis sendi yang dipalpasi dari radiocarpal, metakarpal, dan sendi carpometacarpal.

3. ahu

!erak sendi glenohumeral diperiksa dengan siku tertekuk sampai "#o_{dan lengan}

atas di abduksi parsial. Posisi rotasi internal dan eksternal bahu kemudian diperiksa. Pera$atan harus diambil untuk memobilisasi tulang skapula menggunakan teknik tersebut.

%. &utut

!aris sendi lutut yang di palpasi pada aspek medial dan lateral untuk mengetahui nyeri tekan sugestif dari sino'itis. (tabilitas ligamen cruciatum juga dapat dinilai Panuan Pro"esi Ners Keperawatan Meikal PSIK UN)J &* #+

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dalam posisi ini menggunakan tanda tonjolan atau pattella tanda tekan, efusi dapat dideteksi di lutut dengan sendi sepenuhnya diperluas.

). Pergelangan kaki

Palpasi untuk nyeri tekan dan pembengkakan di pergelangan kaki, dilakukan di medial dan lateral tendon ekstensor pada bagian anterior sendi ba$ag malleoli.

V. Te&a+i (*enis te&a+i4 d$sis4 &/te4 indiasi4 KI4 i'+iasi e+e&a!atan) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...

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#. $isease moi"(ing anti2rheumati/ rugs ,$RMAR$s seperti aBathioprine- /i/losporin A- $2peni/iallamine- gol salts-h(roC(/hloroDuine- leEunomie- merhotreCate ,MT-mino/(/line sulasalaBine ,SSF: o!at (ang i!erikan seini mungkin setelah tim!uln(a gejala

&. Para/etamol engan atau tanpa /oein- an non steroial anti inEammator( rugs ,NSAI$s: untuk pen(akit kronis

'. NSAI$ seperti i!upro"en- naproCen- i/lo"ena/.

VI. Pe'e&isaan Pen/n*an% 5 La6$&at$&i/' (!isa ikem!angkan) N $ Jenis +e'e&isaan Niai n$&'a (&/*/an) 7asi (#a&i8tan%%a) niai Sat/a n Pemeriksaan Penunjang 1. Digital *adiography

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3. agnetic *esonance Imaging

%. (cintigraphic Techni-ues

). rthrography

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%...&*... Pengam!il

$ata-,2 GGGGGGGGGGGGGGGGGGGGGGGGGG

NIM

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La'+i&an 9

ANALISA DATA N

O

DATA PENUNJANG ETIOLOGI MASALA7

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DIAGNOSA KEPERAWATAN

$a"tar $iagnosa Keperawatan ,sesuai prioritas: N $ Dia%n$sa Tan%%a +e&/'/san Tan%%a +en,a+ai an Kete&an% an

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La'+i&an

--PEREN:ANAAN KEPERAWATAN N

O

DIAGNOSA TUJUAN DAN KRITERIA 7ASIL

INTERVENSI RASIONAL

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:ATATAN PERKEMBANGAN DIAGNOSA

WAKTU IMPLEMENTASI PARAF EVALUASI

JAM

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La'+i&an -2

FORMAT RESUME KASUS KELOLAAN 7ARIAN S (S/6*eti;) ... ... ... ... ... ... O (O6*eti;) ... ... ... ... ... ...

A(Anaisa0$iagnosa Keperawatan (ang itegakkan !erasar $S an $1: ... ... ... ... P(Pe&en,anaan) ... ... ... ... ... ... ... ... I (I'+e'entasi) ... ...

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... ... ... ... ... ... ... ... ... E (Ea/asi) S ,Su!jekti" : ... ... ... ... ... ... ... ... ... ... ... ... O ,1!jekti": ... ... ... ... ... ... ... ... ... ... ... ... A ,analisa : ... ... ... ... ... ... ... ...

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... ... ... ... P ,Peren/anaan: ... ... ... ... ... ... ... ... ... ... ... ...

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$epartment o" So/ial Prote/tion. &**@. Rheumatoi Arthritis. Hserial online www.welfare.ie/en/downloads/protocol14.pdf .H; Agustus &*#;.

Klippel et al. &**?. Primer on the Rheumati/ $iseases. Hserial online http:00www.springer./om. H; Agustus &*#;.

Singh et al. &*#3. American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Special Article Arthritis Care & Research American College of Rheumatology . Hserial online www.rheumatolog(.org0Portals0*07iles0A6R &*#3 RA <uieline.p" H; Agustus &*#;.