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    Physical Assessment

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    Fatimah Zahra
    The document discusses the process of conducting a physical assessment from a nursing perspective. It begins by explaining that a physical assessment involves using the senses to collect objective health data about a patient. It also notes the importance of understanding normal findings in order to identify any abnormalities. The document then describes different types of assessments, including complete assessments and focused assessments. It provides details on techniques for inspection, palpation, percussion, and auscultation. Key components of a physical assessment are also outlined such as vital signs, documentation, and maintaining a professional demeanor.

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    Physical Assessment

    Uploaded by

    Fatimah Zahra
    82 views44 pages
    The document discusses the process of conducting a physical assessment from a nursing perspective. It begins by explaining that a physical assessment involves using the senses to collect objective health data about a patient. It also notes the importance of understanding normal findings in order to identify any abnormalities. The document then describes different types of assessments, including complete assessments and focused assessments. It provides details on techniques for inspection, palpation, percussion, and auscultation. Key components of a physical assessment are also outlined such as vital signs, documentation, and maintaining a professional demeanor.

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    The document discusses the process of conducting a physical assessment from a nursing perspective. It begins by explaining that a physical assessment involves using the senses to collect objective health data about a patient. It also notes the importance of understanding normal findings in order to identify any abnormalities. The document then describes different types of assessments, including complete assessments and focused assessments. It provides details on techniques for inspection, palpation, percussion, and auscultation. Key components of a physical assessment are also outlined such as vital signs, documentation, and maintaining a professional demeanor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    82 views44 pages

    Physical Assessment

    Uploaded by

    Fatimah Zahra
    The document discusses the process of conducting a physical assessment from a nursing perspective. It begins by explaining that a physical assessment involves using the senses to collect objective health data about a patient. It also notes the importance of understanding normal findings in order to identify any abnormalities. The document then describes different types of assessments, including complete assessments and focused assessments. It provides details on techniques for inspection, palpation, percussion, and auscultation. Key components of a physical assessment are also outlined such as vital signs, documentation, and maintaining a professional demeanor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 44

    INTRODUCTION

    The physical examination is a process during


    which you use your senses to collect objective
    data.
    You also need to know normal findings before
    you can begin to distinguish abnormal ones.
    The best way to perfect your physical
    assessment skills is through PRACTICE.
    INTRODUCTION
    Physical assessment provides another perspective.
    Whereas the health history allows you to see your
    patient subjectively through hers or his eyes, the
    physical examination now allows you to see your
    patient objectively through your senses.
    The objective data complete the patient’s health
    picture.
    PURPOSE OF THE PHYSICAL ASSESSMENT
    Like the health history, the goal of physical assessment
    is not only to identify actual or potential health
    problems but also to discover your patient’s
    strengths.
    Data from the physical assessment can be used to
    validate the health history.
    Combined with the history data, your physical
    assessment findings are essential in formulating
    nursing diagnoses and developing a plan of care for
    your patient.
    TYPES OF PHYSICAL ASSESSMENT

    complete focused
    physical physical
    assessment assessment
    COMPLETE PHYSICAL ASSESSMENT
    The complete physical examination begins with a general
    survey:
    1. patient’s general appearance (frail, posture, stature,
    weight, gait, facial expression)
    2. Behavior (agitated, restless, argumentative,
    oppositional)
    3. Vital signs (temperature,pulse,respirations,blood
    pressure, and pulse oximetry, if available)
    4. Anthropometric measurements (height and weight)
    5. Head-to-toe systematic physical assessment
    COMPLETE PHYSICAL ASSESSMENT
    6. Odors (alcohol, acidosis, poor hygiene)
    7. Speech (fast, slow, hoarse)
    8. Signs of distress (pain, breathing, limping)
    9. Determine if an in depth mental status
    exam is needed prior to continuing.
    COMPLETE PHYSICAL ASSESSMENT

    Because a complete physical assessment takes


    from 30 minutes to an hour, save time by
    asking some of the history questions as you
    perform parts of the physical examination.
    FOCUSED PHYSICAL ASSESSMENT

    The focused physical assessment consists of a


    general survey, vital sign measurements, and
    assessment of the specific area or system of
    concern.
    It also includes a quick head-to-toe scan of the
    patient, checking for changes in every system
    as they relate to the problem
    Apakah sama? Atau berbeda?

    •Medical
    Physical
    Assessment

    vs
    •Nursing
    Physical
    Assessment
    STABILISASI

    INJURY OPERASI

    GANGGUAN
    TIDUR?

    NYERI ? CEMAS?
    IMPORTANT POINTS BEFORE YOU BEGIN
    Purpose of the Physical Examination is to uncover
    variations from normal – SO, you must know the
    range of normal!
    The history is a continuous process and will continue
    throughout the Physical Examination
    Surprises should be avoided – always explain what
    you are doing
    Professional demeanor is critical- maintain eye
    contact, avoid inappropriate jokes, watch non
    verbal behavior
    Be prepared!
    THE NURSING PROCESS
    Teknik Pemeriksaan Fisik
    Inspeksi
    Pencahayaan cukup & memperluas area yang
    akan diobservasi
    Ada 2: langsung dan tidak langsung
    Palpasi
    Teknik: Ada 2: light (untuk memeriksa suhu, bentuk,
    ukuran ) & deep (untuk mendeteksi massa,
    ukuran organ)
    Perkusi
    Direct percussion atau immediate percussion
    (mengetukan jari langsung ke permukaan
    tubuh)
    Fist atau blunt percussion (mengkaji organ
    tenderness)
    Auskultasi
    Direct auscultation (menempelkan telinga
    langsung) & indirect (Accoustic sthetoscope,
    doppler ultrasonic stethoscope)
    INSPECTION

    Must learn to inspect and observe, not just see!


    Be aware of symmetry and asymmetry.
    Need adequate lighting
    Need adequate exposure
    Helpful instruments: penlight, otoscope,
    opthalmoscope, nasal speculum, vaginal
    speculum.
    PALPATION

    Touch is a diagnostic tool


    Characteristics to note: hard, soft, hot, cold,
    rough, smooth
    Fingertips are the most sensitive to touch, the
    most discriminating for detecting fine
    sensations, such as pulsations
    The palm is most sensitive to vibrations
    Dorsal surface of the hand is most sensitive to
    temperature
    HOW TO PALPATE
    Deep palpation follows (esp. in abdominal exam)
    Technique for deep palpation:
    Place the fingers of one hand over the area to
    be palpated – then place the fingers of the
    other hand right in front of the first set of
    fingers and push deeply with both hands.
    PERCUSSION

    The process of striking a portion of the body to


    evaluate the condition of underlying
    structures.
    Blunt percussion can produce pain when an
    underlying structure is inflamed (as in a kidney
    infection)
    Commonly, percussion uses the fingers to create
    vibrations on the body surface
    HOW TO PERCUSS
    Place the middle finger of the left hand firmly over
    the area to be percussed. This is called the
    pleximeter finger.
    The percussion blow is struck by the tip of the
    middle finger of the right hand.
    If you are left handed you need to switch the above
    instructions.
    You want to use the tip of the finger – not the pad –
    otherwise you won’t get a good, clear sound.
    SO……….nails must be short!
    Hint: The action is in your wrist – not your arm!
    SOUNDS PRODUCED WITH
    PERCUSSION
    The action must be brisk and short in order to
    produce a sharp, clear sound.
    The kind of sounds produced depend on the
    nature of the tissue under the pleximeter.

    PRACTICE…..PRACTICE….PRACTICE
    NORMAL PERCUSSION SOUNDS
    Resonance – low pitched – normal in the lung. To
    hear this - try percussing the right anterior
    thorax above the level of the breast.
    Dullness – Higher pitched sound heard over solid
    tissue……..try the heart or liver.
    Tympany – VERY low pitched – often in the
    abdomen, in areas where air dominates.
    OTHER PERCUSSION SOUNDS
    Flatness – ABSOLUTE dullness…….what you hear
    when you percuss the thigh.
    Hyperresonance – Even lower than resonance –
    what you would hear if you percussed an air-
    filled lung as in a pneumothorax.
    NOTE: Percussion only goes so far – structures
    smaller than 4 or 5 cm or more than 4 or 5 cm
    deep – are out of reach!
    AUSCULTATION

    The stethoscope should be fairly thick,


    about 12-15 inches long and should
    have both a bell and diaphragm.
    It should fit YOU properly – ear canals
    come in all sizes
    The most important part of auscultation is
    what goes on between your ears!
    USES AND SOUNDS
    The diaphragm – transmits higher pitched sounds
    better than lower frequency sounds.
    The diaphragm should be pressed firmly against
    the chest wall.
    The bell transmits low pitched sounds – should be
    placed lightly on the skin – just to make contact.
    The diaphragm is sufficient for lung sounds since
    most of what you hear in the chest is a higher
    pitch.
    PENDEKATAN DALAM PEMERIKSAAN FISIK

    Hal yang harus diperhatikan:


    Budaya
    Komunikasi nonverbal
    Privasi, cuci tangan sebelum-sesudah
    POSISI DALAM PEMERIKSAAN FISIK

    Posisi Area

    Supine Dada anterior untuk pernapasan,


    jantung dan payudara Nadi dan
    ekstremitas

    Duduk Kepala dan leher anterior dan posterior


    dada untuk pemeriksaan pernapasan,
    jantung, dan kanker payudara. Tanda-
    tanda vital dan ekstremitas atas

    Dorsal recumbent Abdomen dengan posisi terlentang, lutut


    sedikit ditekuk. Daerah panggul wanita
    Posisi litotomi untuk perempuan

    Sims
    Prone Pemeriksaan sistem
    muskuloskeletal

    Left Lateral Recumbent Area Dada untuk


    auskultasi jantung,
    khususnya S3, S4 dan
    murmur
    Knee cest Area dubur dan prostat

    Berdiri Tulang belakang dan


    sendi (ROM). Terbaik
    untuk area
    muskuloskeletal,
    digunakan untuk
    pemeriksaan
    neurologis, gait dan
    fungsi serebelum .
    PEMERIKSAAN UMUM

    Karakteristik Wajah : wajah simetris,


    kelopak mata ptosis, terkulai di satu
    sisi wajah

    Postur dan gait: ukuran tubuh, gerakan,


    kemampuan berpindah

    Gaya bicara: aphasia, kualitas suara

    Berpakaian & kebersihan

    Mental: terjaga, waspada, berorietasi


    TANDA-TANDA VITAL
     Suhu
    Dipengaruhi usia, jenis kelamin, irama sirkardian,
    latihan dan stres dan lingkungan.
     Nadi
    pastikan kembali jika nadi tidak normal dengan
    auskultasi
     Pernafasan
    memeriksa tingkat, irama, dan kedalaman,
    abnormalitas
     Tekanan darah
     Berat badan – tinggi badan
    SUHU, NADI DAN PERNAFASAN

    Usia Temperatur Nadi Pernafasan


    Bayi 37–37.7 120–160 30–80
    3 tahun 36.9–37.5 80–125 20–30
    10 tahun 36.3–37 70–110 16–22
    16 tahun 36.4–37.1 55–100 15–20
    Dewasa
    36–37.5 60–100 12–20

    Lansia
    35.9–36.3 60–100 15–25
    DOKUMENTASI

    Akurat dan objektif.


    Gunakan kalimat yang ringkas langsung pada intinya
    Gunakan singkatan-singkatan medis standar atau yang biasa
    digunakan
    Jangan menggunakan kata “normal”.
    Catat semua data yang diperoleh, termasuk pernyataan yang
    negatif
    Catat tanggal dan tanda tangani hasil dokumentasi
    DAFTAR PUSTAKA
    Baid, H. (2006). The process of conducting a physical assessment: a nursing perspective. British
    Journal of Nursing.15, 710-714
    College of Registered Nurses of Nova Scotia. (2012). Documentation Guidelines for Registered
    Nurses. Retrieved from:
    http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&s
    qi=2&ved=0CCAQFjAA&url=http%3A%2F%2Fwww.crnns.ca%2Fdocuments%2FDocumentatio
    nGuidelines.pdf&ei=FurvVIPGLcGSuASl1IHQBg&usg=AFQjCNGV6thE6ZVrh0Qx1U4fsRdRAhT
    1aA&sig2=3uaf8vF2TTKfFkynLQp7Sg
    Cox, C. L., Turner, R., & Blackwood, R. (2008). Physical Assessment for Nurses. United Kongdom,
    UK: Blackwell Publishing Ltd.
    Dillon, P. M. (2007). Nursing Health Assessment: A Critical Thinking Case Study Approach.
    Philadelphia: F. A. Davis Company
    Pejmankhah, S. (2014). Evaluate Nurses’ Self-Assessment and Educational NeedsiIn Term of
    Physical Examination of Patients in Hospitals of Birjand University of Medical Sciences.
    Procedia-Social and Behavioral Sciences, 141, 597-601. doi: 10.1016/j.sbspro.2014.05.104
    Secrest, J. A., Norwood, B. R., & Dumont, P. M. (2005). Physical Assessment Skills: A Descriptive
    Study of What is Taught and What is Practiced. Journal of Professional Nursing, 21, 114-118.
    doi:10.1016/j.profnurs.2005.01.004
    West, S. L. (2006). Physical assessment: whose role is it anyway?. Nurse Critical Care, 11 (4),
    161-167. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/16869522

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