BS Physical Examination 1

Basic Concepts of Physical Examination Physical examination is an ongoing action in identifying clients who aims to obtain basic client data. The physical examination is divided into two, including data subjective and objective data. Subjective data is a statement conveyed by the client or family which is then perceived and written on the client assessment sheet by the nurse Objective data is data obtained from inspection (observation), palpation (touching), percussion (knocking) and auscultation (hearing). II. Physical Examination Tools - Gloves. - Cotton Sticks - Penlight - Specimen Glass - Meter - Sterile safety pin - Stethoscope - Hammer reflex - Nasal speculum III. IPPA 1. Inspection (observation) - Face mask - Ruler - Snellen Chart - Otoscope - Tongue spatula - Scales - Spygmanometer - Ophthalmoscope - Vaginal Speculum Inspection is a physical examination technique or observation process that uses examiner's observation ability (eyes) Inspection carried out Data obtained from observations by looking at: - Symmetry of an area of the body - Color change - There are lesions and wounds - Pathological changes in the area of the body being examined. - Physical signs related to physical status - Client behavior Example: Miss S, 20 years old, was taken to the emergency room with a diagnosis of Myocardial Infarction (MCI). When a physical examination is carried out using inspection techniques: General condition is weak, consciousness compos mentis, rapid breathing, cyanotic lips, jugular vein +...., , second lower limb edema +2. 2. Palpation Palpation is a physical examination technique that relies on the sensitivity of the examiner's hands of the inspection area through touch or touch. There are two types of palpation viz light palpation and deep palpation. Light palpation using fingertips on one or two hands where the fingers are pressed down slowly until they are found results. Deep palpation using two hands (bimanual). One hand is used for feel the part being palpated, the other hand to press downwards. Palpation steps: 1. Look at the palpable area that is clearly visible (not covered by blankets or clothes). 2. Wash your hands 3. Tell the patient about what is being done. 4. In principle, palpation is done with all fingers but to determine the shape and organ structure use fingers 2,3,4 simultaneously. For abdominal palpation (abdominal area) use the palm of your hand and apply pressure with your fingers light. 5. If necessary, perform bimanual palpation. Pay attention to the patient's face during palpation and then write it on the assessment sheet 3. Percussion Percussion is a physical examination action carried out by tapping and relies on the ability to distinguish the sound of hand tapping examiner in the inspection area. There are 2 types of percussion techniques, namely: a. Direct percussion is a technique that uses the examiner's hands without use bearings. For example, examining the sinuses and face. b. Indirect percussion is a technique performed with the examiner dominant as a knocker and the non-dominant hand as a cushion. For example chest examination, back, liver and abdomen. How percussion works: 1. Open / remove the patient's clothes. 2. Straighten your left middle finger, press on the tip of the finger and place it firmly on the surface which is percussed. 3. Tap the middle finger of the right hand to the middle finger of the left hand and repeat quickly, clearly and relaxed. Example: NY R, 28 years old with a medical diagnosis of chronic asthma. Results Physical examination heard hypersonor percussion in the right lung area. 4. Auscultation Auscultation is a physical examination technique using a stethoscope to Listen to internal organ sounds. How to use a stethoscope is: 1. Place the ear piece in your ear. 2. Make sure the stethoscope is really attached to your ear. 3. Select the diaphragm or bell section depending on what you hear. Example: Mr. S, 50 years old with a medical diagnosis of chronic asthma. Check up result Auscultation revealed wheezing sounds in the lungs. IV. Head To Toe 1. Amnessa/health history interview. a. History of current illness: the course of the patient's illness from 3 days ago (or a week) until he was admitted to the hospital. b. Main complaint: the priority (main) complaint felt by the patient at the time Nurse assessment based on P (Problem/main problem perceived patient), Q ( Qualitative / what kind of complaint does the patient feel / description patient complaints), R (Region/area/place of illness felt by the patient), S (Severe/ level or intensity of patient severity), T (Time/ length of time the disease felt by the patient / what the patient feels when he is experiencing the disease, Can the disease you feel be resolved, if it can be resolved, how? with what the patient does). c. Past medical history: illnesses that the patient has experienced in the past. d. Family history of disease: Family hereditary disease. Example: On December 1, 2016, Mr. 59 year old S came to the hospital emergency room. Sumber Waras with a medical diagnosis of colorectal cancer metastases to the liver. Since three days ago Mr. S complained of stomach ache, nausea, lack of appetite, defecating in small pieces like a pencil sharpener, breathing feels heavy and body weight decreased by 13 kg over 2 months. Mr. S feels pain the stomach looks like it has been sliced from the top left spreading downwards on a scale of 5 (110). The stomach ache subsided when Mr. S rests. Mr. S has had an illness KP duplex and receive regular OAT drug therapy for 6 months. Mr. S He died due to tongue cancer. Answer: a. History of current illness The patient feels abdominal pain like being cut into pieces from the left side of the abdomen top spreads to the bottom, on a scale of 5 (1-10) and is felt continuously continuously since three days ago at home. Pain decreases when the patient rest. The patient feels heavy breathing, nausea, lack of appetite eating, defecating in small pieces like a pencil sharpener and weight loss as much as 13 kg for 2 months.