Laporan Kasus Hemiplegia
June 25, 2019 | Author: Yulia M. S | Category: N/A
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Lapsus hemiplegia et cause stroke NHS...
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BAB I PENDAHULUAN
Stroke menimbulkan permasalahan yang komplek baik dari segi kesehatan, ekonomi maupun sosial. Stroke merupakan penyakit yang menyerang orang yang berusia 40 tahun keatas, namun saat ini stroke bukan saja menyerang orang yang sudah tua, tetpai juga menyerang orang pada usia lebih muda. Dari tahun ketahun jumlah orang yang terkena stroke terus mengalami peningkatan (Yastroki, 2008). Rendahnya kesadaran akan faktor risiko stroke, kurang dikenalinya gejala stroke, belum optimalnya optimaln ya pelayanan pela yanan stroke dan ketaatan terhadap program terapi te rapi untuk pencegahan stroke ulang yang rendah merupakan permasalahan yang muncul pada pelayanan stroke di Indonesia. Keempat hal tersebut berkontribusi terhadap peningkatan kejadian stroke baru, tingginya angka kematian akibat stroke, dan tingginya kejadian stroke ulang di Indonesia (Kementerian Kesehatan Republik Indonesia, 2008). Penderita stroke yang mengalami imobilisasi perlu diposisikan dan direposisikan dengan benar di tempat tidur karena dapat mencegah dekubitus, kontraktur sendi dan nyeri bahu. Pada penderitas stroke dekubitus dapat terjadi karena berkurangnya sensasi dan mobilitas. Ikontinensia, malnutrisi, dan dehidrasi dapat meningkatkan resiko timbulnya dekubitus dan juga dapat menghambat proses penyembuhannya. Bagian bagian tubuh yang oaling banyak beresiko adalah punggung bawah (sacrum), pantat, paha, tumit, siku, bahu dan scapula. Pada penderita stroke sring tidak dapat melaporkan keberadaan adanya masalah komunikasi atau mereka tidak menyadarinya (Feigin, 2006). Salah satu pelayanan profesisional untuk penderita stroke yaitu fisioterapi yang berperan untuk mengembalikan fungsi tubuh seoptimal mungkin dan sedini mungkin untuk mencegah komplikasi pada fungsi paru akibat tirah baring yang lama, menghambat spastisitas, pola sinergis ketika ada peningkatan tonus, mengurangi oedema pada anggota gerak atas dan bawah sisi sakit, merangsang timbulnya tonus kearah normal, membentuk pola gerak dan koordinasi gerak normal serta peningkatan kemampuan aktivitas fungsional ( Setiawan, 2008).
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BAB II TINJAUAN PUSTAKA A. Anatomi dan fisiologi otak
Sistem saraf merupakan salah satu sistem dalam tubuh yang dapat berfungsi sebagai media komunikasi antar sel maupun organ dan dapat berfungsi sebagai pengendali berbagai sistem organ lain yang berjalan relatif cepat dibandingkan dengan sistem humoral, karena komunikasi berjalan melalui proses penghantaran impuls listrik disepanjang saraf. Berdasarkan struktur dan fungsinya, sistem saraf secara garis besar dapat dibagi dalam sistem saraf pusat (SSP) yang terdiri dari otak dan medula spinalis dan sistem saraf tepi (SST). Didalam sistem saraf pusat terjadi berbagai proses analisis informasi yang masuk serta proses sintesis dan mengintegrasikannya (Singgih, 2003).
Otak merupakan bagian sistem saraf pusat dimana dalam pembagiannya digolongkan menjadi korteks serebri, ganglia basalis, thalamus dan hypothalamus, mesenchepalon, batang otak, dan serebelum. Bagian ini dilindungi oleh tiga selaput pelindung (meningens) yaitu duramater, arachnoidea, piamater dan dilindungi oleh tulang tengkorak (Chusid, 1993).
Otak terdiri dari neuron – neuron, neuron, sel glia, cairan serebrospinalis, dan pembuluh darah. Semua orang memiliki jumlah neuron yang sama yaitu sekitar 100 miliar tetapi jumlah koneksi diantara berbagai neuron tersebut berbeda – beda. Orang dewasa yang mengkonsumsi sekitar 20% oksigen dan 50% glukosa di dalam darah arterinya hanya membentuk sekitar 2% atau 1,4 kg koneksi neuron dari berat tubuh total (Feigin, 2006).
a. Kortek serebri Cortex cerebri merupakan bagian terluar dari hemispherium cerebri. cerebri. Pada permukaan cortex cerebri terdapat alur – alur alur atau parit – – parit, yang dikenal dengan sulcus. sulcus. Sedangkan bagian yang terletak diantara alur – alur alur atau parit – – parit ini dinamakan gyrus. dinamakan gyrus. Sulcus dan gyrus dan gyrus ini membagi otak menjadi lobus-lobus yang namanya sesuai dengan nama tulang tengkorak yang menutupinya. (Chusid,1993).
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1. Lobus frontalis : area 4 merupakan daerah motorik yang utama. Terletak disebelah anterior sulkus sentralis. sentralis. Lesi daerah ini akan menghasilkan parese atau paralysis flaccid kontralateral pada kelompok otot yang sesuai. Area 6 merupakan bagian sirkuit traktus extrapiramidalis. extrapiramidalis. Spasitas lebih sering terjadi jika area 6 mengalami ablatio. ablatio. Area 8 berhubungan dengan pergerakan mata dan perubahan pupil. Area 9, 10, 11, 12 adalah daerah asosiasi frontalis. frontalis.
2. Lobus parietalis : area 3, 1, dan 2 merupakan daerah sensorik postsentralis yang utama. Area 5 dan 7 adalah daerah asosiasi sensorik .
3. Lobus temporalis : Area 41 adalah daerah auditorius primer . Area 42 merupakan kortek auditorius sekunder atau asosiasi. Area 38, 40, 20, 21, dan 22 adalah daerah asosiasi, disini terjadi pemrosesan bentuk-bentuk masukan sensorik yang lebih elemental.
4. Lobus occipitalis : Area 17 yaitu kortek striata, striata, kortek visual yang utama, Area 18 dan 19 merupakan daerah asosiasi visual ( Duss, 1996). Lihat Gambar 2.1
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Gambar 2.1 Area-area Cortex cerebri menurut Brodman (Chusid, 1993).
Keterangan gambar 2.1 Area 1 : daerah sensoris postsentralis yang utama Area 2 : daerah sensoris postsentralis yang utama Area 3 : daerah sensoris postsentralis yang utama
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Area 7 : daerah asosiasi sensorik Area 8 : berhubungan dengan gerakan mata dan pupil Area 9 : daerah asosiasi frontalis Area 10 : daerah asosiasi frontalis Area 11 : daerah asosiasi frontalis Area 12 : daerah asosiasi frontalis Area 17 : korteks visual yang utama Area 18 : asosiasi visual Area 19 : asosiasi visual Area 20 : daerah asosiasi (lobus temporalis) Area 21 : daerah asosiasi (lobus temporalis) Area 22 : daerah asosiasi (lobus temporalis) Area 38 : daerah asosiasi (lobus temporalis) Area 40 : daerah asosiasi (lobus temporalis) Area 41 : daerah auditorius primer Area 42 : daerah auditorius sekunder
b. Traktus piramidalis
Traktus piramidalis disebut juga sebagai traktus kortikospinalis, serabut traktus piramidalis muncul sebagai sel-sel sel-s el betz yang terletak dilapisan kelima kortek serebri. Sekitar sepertiga serabut ini berasal dari kortek motorik primer (area 4), sepertiga dari kortek motorik sekunder (area 6), dan sepertiga dari lobus parieta lis (area 3, area 1, dan area 2) (Snell, 2007). Serabut traktus piramidalis akan meninggalkan kortek motorik menuju korona radiata substansia alba serebrum kearah ekstremitas posterior kapsula interna masuk ke diesefalon di teruskan ke mesencephalon, pons varolli varolli sampai medulla oblongata. Pada ujung akhir medulla oblongata, 80-85% serabut-serabut ini akan menyeberang kesisi yang berlawanan menuju ke anterior horn cell (AHC) dari medulla spinalis yang kemudian menjadi traktus kortikospinalis lateralis, Tempat menyilang ini dinamakan decussatio pyramidium (Sistem Piramidal). Sedangkan yang 20% bagian serabut yang tidak menyilang, akan langsung
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Lintasan piramidal ini akan memberikan pengaruh berupa eksitasi terhadap serabut ekstrafusal yang berfungsi dalam gerak volunter. Sehingga bila terjadi gangguan pada lintasan piramidal ini maka akan terjadi gangguan gerak volunter pada otot rangka bagian kontralateral (Chusid, 1993). Lihat Gambar 2.2
Gambar 2.2 Perjalanan traktus pyramidalis (Duus, 1996)
Keterangan gambar 2.2 1. Talamus 2. Traktus kortikopontis
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5. Medulla oblongata 6. Traktus kortikospinalis lateral (menyilang) 7. Lempeng akhir motorik 8. Traktus kortikospinalis anterior (langsung) 9. Dekusasio pyramidalis 10. Pyramida 11. Traktus kortikospinalis (pyramidalis) 12. Traktus kortikonuklearis 13. Traktus kortikomesensefalitis 14. Kaput nukleus kaudatus 15. Kapsula interna 16. Nukleus lentikularis 17. Kauda nukleus kaudatus
c. Traktus ekstrapiramidalis
Sistem ekstrapiramidalis tersusun atas corpus striatum, globus pallidus, thalamus, substantia
nigra,
formatio
lentikularis,
cerebellum
dan
cortex
motorik.
Traktus
ekstrapiramidalis merupakan suatu mekanisme yang tersusun dari jalur - jalur dari cortex motorik menuju Anterior Horn Cell (AHC). (AHC). Fungsi utama dari sistem ekstrapiramidalis berhubungan dengan gerakan yang berkaitan, pengaturan sikap tubuh, dan integrasi otonom. otonom. Lesi pada setiap tingkat dalam sistem sistem ekstrapiramidalis dapat mengaburkan atau menghilangkan gerakan dibawah sadar dan sadar dan menggantikannya dengan gerakan dibawah sadar dan menggantikannya dengan gerakan diluar sadar ( involuntary movement ) (Chusid, 1993).
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movement ) dan timbulnya spastisitas dianggap menunjukkan gangguan pada lintasan ekstrapiramidal (Chusid, 1993). Lihat Gambar 2.3
Gambar 2.3 Perjalanan traktus extrapiramidalis (Duus, 1996)
Keterangan Gambar 2.3 1. Traktus frontopontin
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11. Traktus retikulospinalis 12. Traktus tektospinalis 13. Traktus kortikospinalis anterior 14. Traktus kortikospinalis lateral 15. Traktus vestibulospinalis 16. Traktus rubrospinalis 17. Nukleus lateral nervus vestibularis 18. Formasio retikularis 19. Dari cerebellum (nukleus fastigialis) 20. Nuklei pontis 21. Nukleus lentikularis 22. Traktus oksipitomesensefalik 23. Traktus parietotemporopontin
d. Vaskularisasi otak
Otak merupakan organ terpenting dalam tubuh, yang membutuhkan suplai darah yang memadai untuk nutrisi dan pembuangan sisa-sisa metabolisme. Otak juga membutuhkan banyak oksigen. Menurut penelitian kebutuhan fital jaringan otak akan oksigen dicerminkan dic erminkan dengan melakukan percobaan dengan menggunakan kucing. Para peneliti menemukan lesi permanen yang berat didalam kortek kucing setelah sirkulasi darah otaknya di hentikan selama 3 menit.
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membentuk sirkulus ini (Snell, 2007). Vaskularisasi susunan saraf pusat sangat berkaitan dengan tingkat kegiatam metabolisme pada bagian tertentu dan ini berkaitan dengan banyak sedikitnya dendrit dan sinaps di daerah tersebut (Sidharta, 1995). Menurut Chusid (1993), pokok anastomose pembuluh darah arteri yang penting didalam jaringan otak adalah circulus willisi. willisi. Darah mencapai circulus willisi interna dan arteri vertebralis. vertebralis. Sebagian anastomose terjadi diantara cabang-cabang arteriole di circulus willisi pada substantia pada substantia alba subscortex.
Arteria carotis interna berakhir interna berakhir pada arteri cerebri anterior dan arteri cerebri media. media. Di dekat akhir arteri carotis interna dari pembuluh arteri comunicans posterior yang bersatu kearah caudal dengan arteri cerebri posterior . Arteri cerebri anterior saling berhubungan melalui arteri comunicans anterior . Arteri basilaris dibentuk dari persambungan antara arteri-arteri vertebralis. vertebralis. Pemberian darah ke certex terutama melalui cabang-cabang kortikal dari arteri cerebri anterior, arteri cerebri media dan arteri cerebri posterior , yang mencapai cortex di dalam piamater.
Faktor yang mempengaruhi mempengaruhi aliran darah di otak, otak, diantaranya adalah :
1. Keadaan arteri, dapat menyempit karena tersumbat oleh thrombus dan embolus 2. Keadaan darah, dapat mempengaruhi aliran darah dan suplai oksigen 3. Keadaan
jantung,
bila
(Lumbantobing, 2004).
ada
kelainan
dapat
mengakibatkan
iskemia
di
otak
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Gambar 2.4 Circulus Willisi (Chusid, 1993)
1. Anterior communicating artery 2. Middle cerebral artery 3. Lenticulostriate artery 4. Posterior cofmmunicating artery 5. Basilar artery 6. Pontine artery 7. Internal auditory artery 8. Posterior inferior cerebellar artery 9. Verteral artery
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B. Stroke
1. Definisi
Stroke adalah cedera vaskuler akut pada otak. Ini berarti bahwa stroke adalah suatu cedera mendadak dan berat pada pembuluh-pembuluh darah otak. Cedera dapat disebabkan oleh sumbatan bekuan darah, penyempitan pembuluh darah, sumbatan dan penyempitan, atau pecahnya pembuluh darah. Semua ini menyebabkan kurangnya pasokan darah yang memadai (Feigin, 2006).
Stroke Non haemoragik atau iskemik, yaitu suatu gangguan fungsional otak akibat gangguan aliran darah ke otak karena adanya bekuan darah yang telah menyumbat aliran darah (Yastoki, 2007). Pada stroke non haemoragik aliran darah ke sebagian jaringan otak berkurang atau berhenti. Hal ini biasa disebabkan oleh sumbatan thrombus, embolus atau kelainan jantung yang mengakibatkan curah jantung berkurang atau oleh tekanan perfusi yang menurun (Lumbantobing,20 ( Lumbantobing,2004). 04).
Sedangkan menurut Feigin, (2006) stroke haemoragik disebabkan oleh perdarahan kedalam jaringan otak (disebut haemoragia intraserebrum atau hematom intraserebrum) atau
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2. Etiologi
Berdasarkan etiologi Hinton (1995) membagi stroke menjadi dua :
1. Stroke hemoragik yaitu suatu gangguan fungsi saraf yang disebabkan kerusakan pembuluh darah otak sehingga sehingga menyebabkan pendarahan pada area tersebut. 2. Stroke nonhemoragik, yaitu gangguan fungsi saraf yang disebabkan oleh tersumbatnya pembuluh darah otak sehingga distribusi oksigen dan nutrien ke area yang mendapat suplai terganggu.
Berdasarkan perjalanan klinisnya stroke non haemoragik dibagi menjadi 4, yaitu:
1. TIA (transient (transient ischemik attack) merupakan serangan stroke sementara yang berlangsung kurang dari 24 jam 2. RIND (reversible (reversible ischemic neurologic deficit) merupakan gejala neurologis yang akan menghilang antara > 24 jam sampai dengan 21 hari 3. progressing stroke atau stroke atau stroke in evolution merupakan kelainan atau defisit neurologis yang berlangsung secara bertahap dari yang ringan sampai menjadi berat 4. complete stroke atau stroke komplit merupakan kelainan neurologis yang sudah
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b. Penyakit jantung
Emboli yang terbentuk dijantung akibat adanya kelainan pada arteri jantung trutama arteria coronaria dapat terlepas dan dapat mengalir ke otak sehingga dapat menyumbat arteri di otak dan dapat mencetuskan stroke ische mia (Feigin, 2006).
c. Diabetes mellitus
Diabetes mellitus dapat menimbulkan perubahan pada system vaskuler (pembuluh darah dan jantung) serta memicu terjadinya aterosklerosis (Feigin, 2006).
d. Merokok
Asap rokok yang mengandung nikotin yang memacu pengeluaran zat-zat seperti adrenalin
dapat
merangsang
denyut
jantung
dan
tekanan
darah.
Kandungan
carbonmonoksida dalam rokok memiliki kemampuan jauh lebih kuat daripada sel darah merah (hemoglobin) untuk menarik atau menyerap oksigen sehingga kapasitas darah yang mengangkut oksigen ke jaringan lain terutama jantung menjadi berkurang. Hal ini
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Disfungsi motorik paling umum adalah hemiplegia (paralisis pada salah satu sisi) dan hemiparesis (kelemahan salah satu sisi) dan disfagia 2. Kehilangan komunikasi Disfungsi
bahasa
dan
komunikasi
adalah disatria (kesulitan
berbicara)
atau afasia (kehilangan berbicara). 3. Gangguan persepsi Meliputi disfungsi persepsi visual humanus, heminapsia atau kehilangan penglihatan perifer dan diplopia, gangguan hubungan visual, spesial dan kehilangan sensori. 4. Kerusakan fungsi kognitif parestesia kognitif parestesia (terjadi pada sisi yang berlawanan). 5. Disfungsi kandung kemih meliputi: inkontinensiaurinarius transier, inkontinensia urinarius peristen atau retensi urin (mungkin simtomatik dari kerusakan otak bilateral), Inkontinensia bilateral), Inkontinensia urinarius dan defekasiyang defekasiyang berlanjut (dapat mencerminkan kerusakan neurologi ekstensif).
Tanda dan gejala yang muncul sangat tergantung dengan daerah otak yang terkena:
1. Pengaruh terhadap status mental: tidak sadar, konfus, lupa tubuh sebelah 2. Pengaruh secara fisik: paralise, disfagia, gangguan sentuhan dan sensasi, gangguan penglihatan 3. Pengaruh terhadap komunikasi, bicara tidak jelas, kehilangan bahasa.
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4. Proses Patologi Gangguan Gerak dan Fungsi akibat stroke ischemic Infark
ischemic
cerebri sangat
dengan aterosklerosis dan arteriosklerosis.
erat
Aterosklerosis dapat
hubungannya menimbulkan
bermacam-macam manifestasi klinis dengan cara:
1. Menyempitkan lumen pembuluh darah dan mengakibatkan insufisiensi aliran darah. 2. Oklusi mendadak pembuluh darah karena terjadinya thrombus dan perdarahan aterm. 3. Dapat terbentuk thrombus yang kemudian terlepas sebagai emboli. 4. Menyebabkan aneurisma yaitu lemahnya dinding pembuluh darah atau menjadi lebih tipis sehingga dapat dengan mudah robek.
Faktor yang mempengaruhi aliran darah ke otak: 1. Keadaan pembuluh darah. 2. Keadan darah : viskositas darah meningkat, hematokrit meningkat, aliran darah ke otak menjadi lebih lambat, anemia berat, oksigenasi ke otak menjadi menurun. 3. Tekanan darah sistemik memegang peranan perfusi otak. Otoregulasi otak yaitu kemampuan intrinsik pembuluh darah otak untuk mengatur agar pembuluh darah
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dapat anoksia lebih dari 10 menit. Anoksia serebral dapat terjadi oleh karena gangguan yang bervariasi, salah satunya cardiac arrest.
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C. Pendekatan Pendekatan intervensi fisioterapi
1.
IRR (Infra red radiating) Tujuan : untuk melancarkan sirkulasi darah Dosis Frekuensi
: 3x seminggu
Intensitas
: 40-50 cm (dengan IRR 2 lampu)
Tekhnik
: non lominous
Time
: 10 menit
2. PNF Tujuan : meningkatkan kekuatan otot dan meningkatkan ADL Dosis Frekuensi
: 3x seminggu
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5. Terapi Manipulasi Tujuan : Untuk melepaskan Perlengketan dan meningkatkan ROM Dosis Frekuensi
: 3x seminggu
Intensitas
: Sesuai toleransi pasien
Tekhnik
: Traksi- translasi shoulder
Time
: 8x pengulangan
6. Streching pasif Tujuan : Mencegah kontraktur Dosis Frekuensi
: 3x seminggu
Intensitas
: Sesuai Toleransi pasien
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BAB III PROSES FISIOTERAPI
a. Identitas umum pasien Diagnosa ICF
: Gangguan motor function akibat Hemiplegia Sinistra et causa
Stroke NHS No. Register
: 00-82-44-40
Nama
: Ny. E
Umur
: 30 tahun
Jenis kelamin
: Wanita
Ruangan
: Bangsal neurologi
Pekerjaan
: Honorer
Alamat
: Palopo
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Pemeriksaan Vital sign : BP
: 140/100 mmHg
HR
: 100x/menit
RR
: 20x/menit
T
: 36,5 oC
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Verbal (respon verbal) : (5) : orientasi baik (4) : bingung, berbicara mengacau ( sering bertanya berulang-ulang ) disorientasi tempat dan waktu. (3) : kata-kata saja (berbicara tidak jelas, tapi kata-kata masih jelas, namun tidak dalam
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4.
MCP, PIP,
Palmar fleksi
4
1
Fleksi
4
1
Ekstensi
4
1
Fleksi
4
1
Ekstensi
4
1
Abduksi
4
1
DIP
5.
Hip
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Romberg tes
: gangguan gangguan koordinasi
Tumit ke lutut
: gangguan koordinasi
Tes pegang jari
: gangguan koordinasi
Keseimbangan
:
Belum bisa duduk sendiri
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3.
4.
Saya dapat memlihara diri : (muka, rambut, gigi,
0 = tidak dapat
cukur)
1 = selalu
Saya dapat menggunakan toilet
0 = sepenuhnya dibantu
1 = bantu jika perlu 2 = bisa 5.
Makan
0 = bergantung orang lain
1 = bantu jika perlu
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1 = ada gairah, tidak mampu
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e. Diagnosa dan problematik fisioterapi
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b. Tujuan jangak panjang :
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T : 2 menit
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6.
Potensial terjadi kaku
Terdapat kekakuan pada
Tidak ada perubahan yang
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