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:
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1aA&sig2=3uaf8vF2TTKfFkynLQp7Sg
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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