Pasien tn D dirujuk dari bagian Neurology hari ke 3 perawatan dgn diagnosa stroke infark fase akut sistem karotis kiri FR KE e.c kelainan jantung dan merokok S: Kelemahan anggota gerak kananO: pasien supine terpasang IVFD dan kateterTD 110/70 HR 84 X/mnt R: 20 X/mntKu : CM kontak adequatKomunikasi : ekspresif : good Reseptif : gooda/r H+N: ROM F,MMT :5Parese n.cranialis: VII kiri central XII kiri V kiri (motorik) IX X kiria/r Thorax : dbna/r UE/LE : ROM FF

FF

MMT : 3333/5555 3333/5555RF: +++/++ RP: -/- +++/++ -/-Spastis: all ; clonus: -/-

Sensibilitas: all goodPropiosepsi: all goodKoordinasi : all goodBalance: sitting : goodProblem: ADL, hemodinamik, mobilisasiGoal: reassest and improve functional ability in ADL and mobilization after medical condition stabie. Prevent defects of prolong immobilizationAsst: Gangguan ADL, mobilisasi e.c stroke infark fase akut sist karotis kiri FR KE e.c kelainan jantung dan merokokProgram:1. Edukasi2. Positioning ( head up 30 degree)3. Turning/2hours4. Saran: diet via NGT5. AAROM exc UE/LE dextra; AROM exc UE/LE sinistra6. Mobilization to sit with support7. Plan to do CIMT for right extrimities8. EvaluationDisscussion:Positioning: aim : decrease ICP, Prevent aspiration pneumonia and VAP Avoid flat, supine position/elevate head of bed 30. Avoid head and neck positions compressing jugular veins.The team showed that for all patients, blood flow was reduced by 9 percent to the brain hemisphere with the stroke damage if the head-of-bed was elevated 15 degrees, but 17 percent lower when elevated to 30 degreesStroke,2014, online:"Optical Bedside Monitoring of Cerebral Blood Flow in Acute Ischemic Stroke Patients During Head-of-Bed Manipulation"The American Thoracic Society

Goals of Positioning There are six basic goals of proper positioning: 1) The client should be as comfortable as possible.In efforts to provide the client with excellent care, providing comfort is the first step. Taking an extra moment to fluff and align a pillow or providing an extra blanket can significantly impact someones perception of his or her experience at our facility. 2) The client should have access to his environment. Providing the client with access to his environmentwill not only improve the clients level of comfort but also improve their level of safety and independence. Any needed item that is out of reach can be a source offrustration to a client that is restricted to their bed. A critical item, such as aphone or urinal, out of reach will endanger a client by tempting them to perform an unsafe maneuver to retrieve the item, which may result in a fall. 3) Maintain and promote normal joint range of motion. Proper bed positioning will encourage normal joint range and help to prevent contractures. If increased tone is present, it may cause joints to flex (bend). If allowed to remain in a flexed position for extendedperiods of time, there will be shortening of the muscles which will lead to a lossof motion or tissue contracture. Positioning the client so that the joints with hightone are extended and the associated muscle groups are lengthened will assistin inhibition of high tone and the prevention of loss of motion. 4) Promote healthy and intact skin. Establishing a proper positioning and turning schedule is essential in the prevention of pressure sores. Decubitus ulcers, or bed sores, are caused by prolonged exposure to pressure against the skin. Bony areas of the body that are especially susceptible to pressure sores include the sacrum, heels, malleoli and the trochanters. 5) Help to control edema. Positioning can be an effective tool in combating or preventing edema in the extremities. Edema is an abnormal build up of excess tissue fluid that can limit range of motion and decrease skin integrity. Because water flows downhill, the at risk of swelling or swollen extremity should be positionedabove the heart. This allows gravity to have an effect on the excess fluids and return the fluids to the clients trunk and therefore aid in the prevention or reduction of edema.6) Medically necessary precautions for respiration and swallowing should be followed. Clients may have medical restrictions that require the headof their bed to be elevated at all times. This may be to aid in respiration for clients with COPD or Respiratory difficulties. It can also be required to aid in the swallowingof secretions for clients with dysphagia or swallowing difficulties. Some clients may only need the head of the bed elevated at specific times, such as after meals for clients with GERD / acid reflux, dysphagia or congestive heart failure.Davis, J.Z. (2001). Neurodevelopment treatment of adult hemiplegia: The Bobath Approach. In Pedretti, L.W., & Early, M.B. (Eds.). Occupational therapy practice skills for physical dysfunction (5thed.). (pp 624-640). St.Louis, MO: Mosby. Minor, M.A.D., & Minor, S.D. (1995). Patient care skills (3rded.). Norwalk, CT: Appleton & Lange. Umphred, D.A. (Ed.). (1995). Neurological rehabilitation (3rded.). St. Louis,MD: Mosby.

2 Turning/2 hoursThe current standard of care is to reposition patients every 2 hours. This standard is based on 2 studies conducted in the early 1960s in healthy individuals.67. Kosiak M. Etiology of decubitus ulcers. Arch Phys MedRehabil. 1961;42(1):1929.68. Stacy KM. Pulmonary disorders. In: Unden LD, Stacy KM, Lough ME, eds. Thelans Critical Care Nursing:Diagnosis and Management.4th ed. St Louis, MO:Mosby; 2002:551585.3 CIMTConstraint-induced movement therapy (CIMT)has been statistically shown to produce linically significant improvements in arm motor function that persist > 1 year (EXCITE Trial, Wolf 2006). CIMT requires that patients be able to extend their wrists and actively move their digits. In the EXCITE trial, participants were required to have at least 10 degreesof active wrist extension, at least 10 degrees of thumb abduction/extension,and at least 10 degrees of extension in at least 2 additional digits. (Cucurulo).4 AARomDisuse atrophy is defined as an alteration of metabolism and muscle cell homeostasis in response to muscle inactivity. Recent studies indicate that muscle protein synthesis as well as whole body protein production is significantly reduced during immobility and is considered the main contributor to muscle atrophy. The rate of muscle wasting during bed rest is slow during the first 2 days but becomes rapid thereafter. By 10 days, it reaches 50% of eventual muscle weightloss. Similarly, muscle protein synthesis is reduced to 50% of the baseline level at 14 days of immobilization and then gradually tapers off to reach a new steady state.