CHAPTER II

DISCUSSION

PHYSICAL EXAMINATION

a. Defenision
Physical examination was the review from head to toe on every system of
the body that provides information on clients and allows nurses to mebuat clinical
assessment. The accuracy of the physical examination affect selection of treatment
received by the client and the determination of response to therapy. (Potter and
Perry, 2005)
Physical examination is an examination of the client's body as a whole or
only certain parts as may be necessary, to obtain data and comprehensive
sistematif, ensure / prove results diagnose, determine the problem and to plan
appropriate nursing action for a client. (Goddess Sartika 2010) .
b. The purpose of the Physical Examination

To collect baseline data on the health of the client.

To add, confirm, or deny the data obtained in the history of nursing.
To confirm and identify the nursing diagnoses.
To make a clinical judgment about the client's health status and change
management.
To evaluate the physiological outcomes of care.

Nevertheless, each examination also has a specific purpose which will be

explained later in every part of the body that will be a physical examination.

c. Benefits Of Physical Examination

Physical examination has many benefits, both for the nurses themselves, as
well as for other health professionals, including:

As the data to assist nurses in establishing the nursing diagnosis.

Knowing the health problems in a natural client.
As a basis for selecting appropriate nursing interventions
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As the data to evaluate outcomes of nursing care

d. Physical Examination Technique

There are four techniques in physical examination, namely:
1. Inspection
Inspection is the examination by using the senses of sight, hearing and
smell. General inspection done when you first met the patient. A picture or a
general impression about the state of health in shape. Examination then
advanced to a local inspection that focuses on a single system or parts and
typically use special tools such as optalomoskop, otoscope, speculum and
others. (A.Talbot Laura and Mary Meyers, 1997)
Inspection is the examination done by looking at the body part being
examined through observation (eye or a magnifying glass). (Goddess
Sartika 2010)
Focus inspections on any part of the body include: body size, color,
shape, position, symmetry, lesions, and bulging / swelling. After inspection
results need to be compared to normal and abnormal parts of the body with
other body parts. Example: yellow eyes (jaundice), there is a goitre in the
neck, bluish skin (cyanosis), and others.
2. Palpation
Palpation is an examination by using the sense of touch by laying hands
on the body that can be reached hand. A.Talbot Laura and Mary Meyers,
1997). Palpation is the examination technique that uses the sense of touch;
hands and fingers, to determiner characteristics tissues or organs such as:
temperature, elasticity, shape, size, humidity and protrusion. (Dewi Sartika,
2010).
It is detected is the temperature, moisture, texture, motion, vibration,
growth or mass, edema, crackles and sensation. The steps that need to be
considered during palpation:

Create a comfortable and relaxed environment.

Hands should nurse in the warm and dry
Fingernails must be cut short nurse.

All parts are palpable pain at the end For example: the presence of
tumor, edema, crepitus (fractures), and others.

3. Percussion
Percussion is tapping examination covering the body surface
fatherly produce sounds that will assist in helping to determine the density,
location, and position in the underlying structure (A.Talbot Laura and
Mary Meyers, 1997).
Percussion is the examination of the surface of the road knocking
specific body parts to compare with other body parts (left / right) to
produce a sound, which aims to identify limits / location and
consistency of the network. (Dewi Sartika, 2010). The voices are
found in percussion are: Sonor: percussion sounds normal tissue.
Dim: percussion sounds denser network, for example in the area of the
lungs in pneumonia.
Pekak: percussion sounds dense tissue such as the percussion area of
the heart, the liver area percussion.
hipersonor / timpani: the percussion sound more hollow areas, such as
the lung caverna, the client with chronic asthma.
4. Auscultation
Auscultation is the act of listening to sounds generated by various
organs and tissues of the body. (A.Talbot Laura and Mary Meyers, 1997).
Auscultation physical examination is done by listening to the sound
produced by the body. Usually using a tool called a stethoscope. The
things that are heard: heart sounds, breath sounds, and bowel sounds.
(Dewi Sartika, 2010).
Abnormal sound that can be auscultated in breath are:
Rales: sound produced from the sticky exudate while subtle channels
of respiratory expands on inspiration (rales fine, medium, coarse). For
example, the client pneumonia, tuberculosis.
Ronchi: low tone and very rough sounding both during inspiration and
expiration. Characteristic Ronchi is lost when the client coughs. For
example, in pulmonary edema.
Wheezing: sound is heard "ngiii ... .k". can be found in the phase of
inspiration and expiration. For example, in acute bronchitis, asthma.
Pleural Friction Rub; sound that sounds "dry" sound like rubbing
sandpaper on wood. For example, on the client with pleural
inflammation.

Physical assessment approaches can be used:

1. Head-to-toe (head to toe)
With this approach, starting from the head and sequentially to the foot.
Starting from: general condition, vital signs, head, face, eyes, ears, nose, mouth
and throat, neck, chest, lungs, heart, abdomen, kidneys, back, genitalia, rectum,
extremities.
2. ROS (Review of Systems / body system)
Assessments were conducted covering all systems of the body, namely:
general condition, vital signs, respiratory system, cardiovascular system, nervous
system, urinary system, digestive system, musculoskeletal system and integument,
reproductive system. The information obtained helps nurses to determine which
body systems need special attention.
3. The pattern of health function Gordon, 1982
Nurses collect data systematically by evaluating patterns of health functions
and physical assessment focuses on specific issues include: health perceptionhealth management, nutritional-metabolic pattern, the pattern of elimination,
sleep-rest patterns, cognitive-perceptual pattern, role-related pattern, aktifitasexercise patterns, sexual-reproductive patterns, coping-stress tolerance pattern,
value-belief pattern.
In conducting a physical examination, there are principles that need to be noticed,
which is as follows:

Control of infection
Includes washing hands, put sterile gloves, masks installing, and help clients
wearing check if there is.
Control the environment
Ie make sure the room in a state of comfortable, warm, and enough light to
perform a physical examination both for clients and for the inspectors
themselves. For example, closing the door / jendala or skerem to maintain the
privacy of clients.
Communication (explanation of the procedure)
Privacy and comfort of clients
Systematic and consistent (head to toe, internal to the external dr, dr normal
to ABN)
Being on the right side of the client

Efficiency
Documentation

e. Examination Vital Signs

a. Examination Nadi
The pulse is a pulse or impulse that is felt from the heart pumping.
Pulse examination should be done in a state of sleep or rest. Hyperthermia
conditions can increase heart rate as much as 15-20 times per minute every
1 degree Celsius increase in temperature.
Another pulse assessment is sinus tachycardia is characterized by
variations in 10-15 pulses from minute to minute and supraventricular
tachycardia is characterized by pulse paroksimal difficult to quantify
because it is too fast (over 200 beats per minute) .Bradikardia a heart rate
slower than normal . Pulse checks the other is the rhythm, normal or not.
Dysrhythmias (arrhythmia) is a disorder sine pulse, faster pulse during
inspiration and slow expiration.
b. Examination of Blood Pressure
Blood pressure checks important indicator in assessing
cardiovascular function. In the process changes in blood pressure is
influenced by various factors, among others;
1. Peripheral repulsion.
A circulatory system which has the highest pressure system (artery) and
low pressure systems (capillary and venous), among both arterioles and
veins are very smooth muscles.
2. Movement pumping by the heart.
The more blood that is pumped into the arteries causes the arteries to be
more bloated and resulting in increased blood pressure. Vice versa.
3. The blood volume.
Increasing the amount of blood causes pressure on the artery.
4. blood viscosity.
Blood viscosity depends on the ratio of blood cells to plasma.
c. Examination of Respiratory
Examination is performed to assess the oxygen uptake and carbon dioxide
spending. Assess the frequency, rhythm, depth and type or pattern of
breathing

d. Examination of the temperature

Temperature probe is used to assess the condition of the metabolism in the
body, where the body produces heat through the metabolic blood
chemistry. Equilibrium temperature must be set in the disposal and storage
in the body is regulated by the hypothalamus. Disposal or heat loss can
occur through a variety of processes, including;
1. Radiation, which is the process of spreading of heat through
electromagnetic waves.
2. Convection, namely the spread of heat due to the shift between the area
density of the body is not the same as the cold air moves in or on the
water pool.
3. Evaporation, the process of changing a liquid to a vapor.
4. conduction, ie heat transfer process on another object by direct contact
without apparent movement, such as contact with a cold surface and
others - others.
f. Physical Examination Head To Toe
Before performing a physical exam nurse must make a contract with the
patient, in which there is no explanation of the intent and purpose, the time
needed and termination / end.Stages of physical examination required to be
done in sequence and thorough and starts from the following body parts:
1.
2.
3.
4.
5.
6.
7.
8.

Skin, hair and nails

Head include: eyes, nose, ears and mouth
Neck: the position and movement of the trachea, JVP
Chest: cardiac and pulmonary
Abdomen: inspection of shallow and deep
genetalia
Muscle strength 7 / musculosekletal
Neurology

Stages of implementation are as follows:

a. Examination Skin, Hair and Nails:
Skin
To determine skin turgor and texture of the skin
To determine the presence of lesions or scars
actions:

I = Inspection: see the presence / absence of lesions, hyperpigmentation (color

black / brown), edema, skin and hair distribution.
P = Palpation: in touch and elastic skin turgor specified or not, texture: rough /
smooth, temperature: akral cold or warm.

Hair:
To determine the color, texture and branching in the hair
To find out easily fall out and dirty

actions:
I = disribusi hair evenly or not, dirty or not, branched
P = easy to fall / no, texture: rough / smooth

Nails:

To know the state of your nails: color and length

To determine capillary refill
actions:
I = note about color: blue: cyanosis, red: Hb increased visibility, shape: clubbing
due to hypoxia in lung cancer, beau's lines on fe difisisensi disease / anemia fe
P = note tenderness, and count how many seconds capillary refill (in patients with
hypoxia slower s / d for 5-15 seconds.

b. Examination of the Head:

To determine the shape and function of the head
To determine the injury and abnormalities in head
actions:
I = See if facial symmetry, a different face or such ka.ki more inclined to the
right or to the left it shows no parese / paralysis, eg in patients with SH.
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P = Look for cuts, bulges pathologic, and response to pain by pressing the
head as needed

Eyes:
To determine the shape and function of the eye (field vision, visual acuity
and eye muscles)
To determine the presence of abnormalities or inflammation of the eye

actions:
I = no inflammation of the eyelids or not, the right and left symmetrical or not,
blink reflex good / not, conjunctiva and sclera: red / conjunctivitis, jaundice /
indication Hiperbilirubin / disorders of the liver, the pupil: isokor right and left
(normal), miosis / shrink, pin point / very small (suspected SOL), medriasis /
landscape / dilatation (deceased patients)Inspection of eye movements:

Instruct the patient to look straight ahead

Observe for nystagmus / rhythmic eye movement (fast / slow)
Observe whether the two eyes looking forward or there is a deviation
Tell patient to see and follow your finger, and keep the patient's head position
and then move your finger to the 8-way to determine the function of the eye
muscles.

Inspection field of vision:

Stand in front of the patient

Assess both eyes separately with closed eyes is not in check
Tell patient to look straight ahead and focus on one point of view, for
example: the patient was told to look at the examiner's nose.
Then take the object / ball-point pen and hold your nose fore checker then
drag or minimize the patient's right and left aside, tell the patient to say when
and where things started to point it did not look (remember the patient should
not be glanced at for accurate results).
Examination of the eye visual acuity:
Prepare snllen cards (adult and child images letters)
Adjust the seat the patient, and determine the distance between the seat and
the card, eg 5 meters (as per the policy of each there are 6 and 7 meters).
Adjust the lighting is adequate, in order to see clearly.
Close your eyes were not examined and alternating right and left
Starting checked by asking the patient to read from the letters of the largest to
the smallest that can be read clearly by the patient.
Record the test results and determine the results of the examination.
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For example: visual acuity results:

OD (Optical Dekstra / right): 5/5

Means: at a distance of 5 m, the eye can still see the letters that should be seen /
read at a distance of 5 m
OS (Optical Sinistra / left): 5/2
Means: at a distance of 5 m, the eye can still see / read that should be read at a
distance of 2 m.
P = Press lightly to determine the IOP (intra ocular pressure) will increase if there
is a palpable hard (glaucoma patient / dikus damage the optic), assess for
tenderness.
Nose:
To determine the form and function of the nose
To determine the presence of inflammation / sinusitis
actions:
I = Is symmetrical nose, if there is inflammation, is there a secret
P = Is there tenderness, masses

Ear
To determine the state of the outer ear, ear canal, eardrum
To determine the function of hearing

actions:
Outer ear:
I = auricle symmetrical or not, color, size, shape, cleanliness, presence of Lesy.
P = Press earlobe whether there is a response to pain, feel the resiliency of
cartilage.
Ear in:
Note: Adult: Leaves the ear is pulled up so you can easily see
Children: Leaves ears pulled down
I = inner ear with an otoscope note memberan tympani (color, shape) the presence
of cerumen, inflammation and foreign body, and blood.
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Examination of hearing:
1) Examination with a whisper
Set the patient standing back to the examiner at a distance of 4-6 m
instructed the client to cover one ear that is not checked.
gasped out a number like "6 or 5"
Telling the patient to repeat what is heard
Examining the ear
Compare the left and right ear hearing ability
2) Examination of the timepiece
Set susasana calm.
Hold a watch in addition to the client's ear.
Telling a client state whether hear the beating of a watch.
Move the watch slowly away. ear and told the patient said he did not hear
anymore.
Normally at a distance of 30 cm can still be heard.
Examination of the tuning fork:
a. Rinne test
Hold the tuning fork (GT) on the stalk and hit into the palm of the
hand
Put the client's GT on the mastoid process
Encourage the client has told the examiner does not feel any vibration
Then lift GT quickly and place it in front of the outer ear canal a
distance of 1-2 cm, with a position parallel with the ear.
Mengistrusikan on whether the client is still mendengara or not.
Record the results of the examination
b. Weber test
Grasp the handle and hit the GT on the palm of the hand or fingers
Put the stalk in the middle of the top of the head GT / os. Frontal
above.
Tanayakan on the client if the voice sounds the same clear distinction
between right and left ear or only apparent on one side only.
Record the results of the examination
c. tests Swebeck
To find out comparing patients with a hearing examiner
Put your GT in the client's ear and then quickly hold your ear to the
examiner.
Mouth and Pharynx:
To determine the shape and abnormalities in the mouth
To determine the oral hygiene
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actions:
Observe what I = no abnormalities kogenital lip (cleft lip), color, symmetry,
moisture, swelling, lesions.
Observe the number and shape of teeth, cavities, color, plaque, and dental hygiene
Inspection of the mouth and pharynx:

Telling the patient open mouth mucosa observed: texture, color, moisture,
and the presence of lesions
Observe the tongue texture, color, moisture, lesions
To see the pharynx use tongspatel already wrapped sterile gauze, then ask
the client stuck out his tongue and said "AH" observe ovules / epiglottis is
not symmetrical to the pharynx, observe inflamed tonsils or not (tonsillitis
/ tonsillectomy).

P = Hold and press the cheek then felt what no mass / tumor, swelling and
pain.
Palpate floor of the mouth using the index finger using handscond, then
tell the patient to say the word "EL" as he stuck out his tongue, hold the tip of
the tongue with gauze and press the tongue with a finger, thumb hold the
position of the chin. Note whether there is a response to pain on the action.
d. neck
To determine the structural integrity of the neck
To determine the shape of the neck and organs associated
To check the lymphatic system
actions:
I=Observe the shape, color of skin, scar tissue
Observe for swelling glands tirod / goiter, and the presence of mass
Observe kesimeterisan neck from the front, back and sides of the right and
left
Ask the patient to work the neck (flexion-extension ka.ki), and
merotasi- can easily observe whether and what pain response.
P = Put both hands on the neck of the client, tell the patient to swallow and
feel the presence of the thyroid gland (examine the size, shape, a surface.)
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The position of the trachea tracheal palpation whether symmetrical or not.

e. Chest / Thorax
Lung / pulmonary
To determine the shape, symmetry, lung expansion
To determine the frequency, the respiratory rhythm
To determine the presence of tenderness, masses, inflammation,
edema, tactile fremitus.
To determine the limits of the lung with surrounding organs
Listens to lung / air flow obstruction
actions:
I = Observe the symmetry of right and left chest, observe for intercostal
retractions, observe the movement of the lung.
Observe the clavicle and scapula symmetrical or not
P = Palpation lung expansion:

Stand in front of the client and put both hands in the chest under the papilla
examiner, instruct the patient took a deep breath, feel the same if the right and
left lung
Standing behind the patient, place the palms on the bottom line of scapula /
high costa 10th, right thumb and left on hold do not get stuck, and stretch
your fingers at approximately 5 cm from the thumb. Have the patient back
breathing in and observe the movement of the right thumb and left the same
or not.
Palpation of the posterior and anterior Tactile vremitus:

Place your right palm on the back of the chest right at the apex of the
lung / stinggi supra scapula (posterior position).
instruct the patient to say "Ninety-nine" (low tone)
Ask the client to repeat the word mengucapkkan, while the examiner
moving the position to the right and left then down to the basal lung or
vertebral height thoraxkal 12th.
Compare vremitus on both sides of the lung
When the patient asked to speak fremitus dim lower
Repeat / do on the anterior chest

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Pe / Percussion =
Set the patients with supination
For anterior percussion began last clavikula limit down to fifth
intercostal tentukkan limit the right lung and the left (normal lung
sounds: resonant entire lung field, limits liver lung and heart: dim)
If there is pulmonary edema and effusion plura voice faded.
Aus / auscultation =
Gunakkan diaphragm bell stethoscope for adults and children
Place the stethoscope on the intercostals, menginstruksikkan patient
to breath slowly and listen later in the breath sounds: vesicular /
wheezing / creckels
Heart / Cordis
I = Observe the heart rate in the area of moldy midsternu approximately
2 cm below the xiphoid besides.
P = Sensing pulsation

Palpation spasium right intercostal 2 to determine the area of the

aorta and spasium 2nd left intercostal pulmonary layout left.
Palpation spasium 5th intercostal left to see the tricuspid area /
ventikuler observe for pulsation
From the 5th intercostal hand moved laterally 5-7 cm to the left of
the line where it will be found midklavicula the apical region of the
heart or PMI (point of maximal impulse) found a strong pulse in this
area.
To determine the aortic pulse palpation on epigastika or below the
sternum area.

percussion =

Percussion from lateral to medial direction to determine the left side of

the heart,
Perform percussion from the right to the left to find the right cardiac
border.
Perform from top to bottom to determine the upper and lower limits of
heart
The sound of the organ showed faint of heart there on the percussion.

auscultation =

Advise the patient to breathe normally and his menaha expiratory

completed
13

Listen to heart sounds with a stethoscope putting on the 5th intercostal

while pressing the carotid artery S1 sound: listen to the sound of "LUB"
the sound of the closing of the mitral valve (bicuspid) and tikuspidalis
on systolic time.
S2 sounds: listen to the sound of "DUB" is the sound of closing the
semilunar valves (aortic and pulmonary) during the diastolic.
As for the sound: S3: heart failure "LUB-DUB-CEE ..." S4: in
hypertensive patients "..- LUB-DUB DEE".

f. Stomach / Abdomen
To determine the shape and wiggle stomach
To listen to the sound of gut pristaltik
To study the response of tenderness in the abdominal organs
actions:
I = Observe the general shape of the stomach, skin color, presence of retraction,
protrusion, the existence of the simetrisan, the presence of ascites.
P = mild Palpation: To determine the response of a mass and tenderness in the
abdomen place the palms are crossed, and evenly press the appropriate quadrant.
Palpation in: To determine the position of internal organs are like liver, kidney,
spleen with bimanual method / 2 hands.
hepatic:

Place the examiner's hand with finger up position on the right hypochondria,
think; sometime in the intercostal to 11-12
Press when the patient inhaled approximately 4-5 cm deep, feel the presence
of
the
liver
organ.
Assess
hepatomegaly.
spleen:
Method of tools such as the examination hapar
Instruct the patient tilted to the right and place your hand under the left
intercostal and asking the patient take a deep breath and press when inhaled
determine the presence of the spleen.
In normal adults are not palpable

renal:

To place the hand palpation of the right kidney on the upper and lower
abdomen as high as 3-4 under the right costal lumbar.

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To place the hand palpation of the left kidney as high as 1-2 Lumbar under
the left rib.
Press the 4-5 cm depth after inhalation if patients feel palpable kidney shape,
contour,
size,
and
response
to
pain.
genetalia
To determine the presence of lesions
To determine the presence of infection (gonorrhea, shipilis, etc.)
To determine the cleanliness of the genetalia

actions:

male genetalia:

I = Observe the skin of the penis, size and other abnormalities.

In the penis in uncircumcised foreskin open and observe the head of the penis
lesion
Observe whether there scrotal hernia inguinal, observe the shape and size
P = Press the soft shaft of the penis to determine the presence of pain
Press the sperm duct with finger and thumb

female genitalia:

I = Inspection of quantity and spread evenly pubis

Observe the presence of lesions, erythema, whitish / candidiasis

or

not

P = Pull the labia majora gently with the fingers of the one hand to determine the
state of the clitoris, hymen, orifice and perineum.
Rectum and Anal

To determine the condition of the rectum and anus

To determine the presence of a mass on rectal
To determine the broadening of the rectal veins / haemorrhoids
action
The position of the man standing half bent, the woman with the position
lithotomy / supine leg in the lift and in the crutch.
Inspection perineal tissue and surrounding tissue examined for lesions and
ulcers
Palpation: apply a lubricant and insert fingers into rectum and feel the
presence of nodules and or widening of the veins in the rectum.
Musculoskeletal examination
-To obtain the basic data about the muscles, bones and joints

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-To determine the mobility, muscle strength, and disturbances in certain areas.
actions:
Muskuli / Muscle:

Inspection of the size and the presence of atrophy and hypertrophy (measure
and record if there is a difference with the meter)
Palpation of the muscles rest and during muscle contraction to find a
weakness and a sudden contraction
Perform test of muscle strength by having the patient pull or push the
examiner's hand and compare hands ka.ki
Observe the strength of a muscle to give custody to the upper and lower
limbs, tell the patient to hold hands or feet while pulling inspectors from the
weak to the strongest observed whether the patient can withstand.
Bone / ostium:
Observe normality and bone composition abnormalan
palpation to determine the presence of tenderness and swelling
Joints / Articulasi:
Inspection of all joints for the presence of joint disorder.
Palpation of the joints is no tenderness
Assess the range of mosion / range of motion (abduction-adduction, rotation,
flexion-extension, etc.)

Examination System Neurology

To determine the integrity of the system persyrafan which include cranial

nerve function, sensory motor and reflexes

actions:
Assessment of cranial nerve 12 (O.O.O.T.T.A.F.A.G.V.A.H)
1. olfactory / smell:
Asking the patient smell a rat smell of coffee and vanilla or other scent that
is not overpowering. Whether the patient can recognize the scent.
2. Optic / vision:
Asking the client to read material and identify objects around, clear or not.
3. Oculomotor / contraction and dilation of the pupil:
Assess the direction of view, measuring pupillary reaction to light and
accommodation reflection.
4. Trokhlear / move your eyeballs up and down:
Assess the direction of gaze, ask the patient to see k Etas and under

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5. Trigeminal / sensory skin of the face, jaw muscle activator:

Touch the cornea lightly with a cotton swab to test the corneal reflex
(negative reflex (silent) / positive (there gerkan))
Measure the sensation of light touch on the face to strong cross examine
pain on the face biscuits
Assess the client's ability to clench teeth while palpating the muscles of
the jaw
6. Abdusen / sideways move the eyeball:
Assess the direction of gaze, ask the patient to look laterally left and right
7. Facial / facial expressions and the tasting:
Asking the client to smile, facial toning, puffed cheeks, raising and lowering
the eyebrows, note to simetrisanya.
8. Auditory / hearing:
assess the client's words in talking, tell the client to repeat the word / phrase.
9. Glosofaringeal / tasting, swallowing ability, movement of the tongue:
Ask the patient to identify taste sour, salty, at the base of the tongue.
Use a tongue depressor to inflict "gag reflex"
Ask the client to mobilize his tongue
10. Vagus / pharyngeal sensation, movement of the vocal cords:
Tell patient to say "ah" examine move palate and pharyngeal
Check the patient's loudness
11. Accessory / head and shoulder movement:
Ask the patient shrugs and turns her head towards detained by the examiner,
the client can examine the resistance against light
12. hypoglossal / tongue positions:
Asking clients for sticking her tongue out towards the center line and
move to different sides.
Assessment of sensory nerves:
actions:

Ask the client closed eyes

Berikkan rasangan on the client:
-Superficial pain: use a blunt needle and stress on the patient's skin at
points that examiners want, ask the patient to express their level of pain
and where
Temperature: client touch with hot and cold bottle, tell the patient to say
the sensation is felt.
-Vibration: paste the tuning fork that has been in getarakan and paste
the falangeal / fingertips, ask the patient to mengatakkan vibration.
-Position: tap your toes by the examiner's hand and move up and down
and then stop tell patients say over / under.

17

-Stereognosis: give patients a familiar object (a coin or spoon) and give

it a few seconds, and told the patient to say what it was.
Assessment reflex:
1. Reflexes Biceps
client flex the arm at the elbow to 45 degrees, with the hands pronated
(facing downwards)
Place your thumb on the examiner antekubital fossa at the base of the
biceps tendon and the other fingers on the biceps tendon
Hit your thumb with harmmer reflex, reflex studied
2. Tricep Reflexes
Place your hands under the patient's arm above the examiner's hand
Place the forearm between flexion and extension
Ask the patient to merilekkan arm
Feel terisep for muscle mmeastikan not teggang
At the tendons on olekrani fossa, assess reflexes
3. Patellar Reflex
Ask the patient to sit down and legs dangling in bed / chair
Rilexkan patients and divert attention to pull both hands in front of
chest
At the patellar tendon, assess reflex
4. Reflex Brakhioradialis
Place your hands under the patient's arm above the examiner's hand
Place the forearm between flexion and extension as well as slight
pronation
At brachial tendon at the distal radius with a flat section harmmer,
record reflex.
5. Reflex Achilles
Ask the patient to sit down and legs dangling in the bed / chair such as
the examination of the patella
Dorsofleksikan feet with the examiner's hand
At the Achilles tendon, assess reflexes
6. Plantar Reflex (Babinsky)

Use objects with moderate sharpness (pencil / ballpoint pen) or the end of
the stick harmmer
scratched in the lateral part of the patient's foot, starting from the end of the
soles of the feet up to the corner and turn the palm of the little finger to the
thumb. Positive reflexes feet will be drawn into.

7. reflex cutaneous
a. gluteal
Ask the patient to perform a position lying on her side and open
the necessary briefs

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Stimulation of the perineal section lightly with a cotton tipped

object
positive reflex contraction spingter ani
b. Abdominal
Ask the client standing / lying
Press the abdominal skin with a cotton tipped object of lateal to
medial, assess abdominal muscle reflex move
Repeat the 4th quadrant (upper and lower ki.ka ki.ka)
c. Kremasterik / in men
Press the top of the thigh using a pointed object Cotton
Normally the scrotum will rise / increase in the stimulated area
CHAPTER III
CLOSING

a. Conclusion
Physical examination dalah checks the client's body as a whole or just certain
sections as deemed necessary, to obtain systematic and comprehensive data,
ensure / prove results diagnose, determine the problem and to plan appropriate
nursing action for a client.
Physical examination to be conducted on every client, especially on clients,
new to the health service for in-patient, routine on the client being treated, at any
time as per client requirements. So the physical examination is very important and
should be done on these conditions, both the client in a state of conscious or
unconscious.
Physical examination is very important because it is very helpful, either for
nursing diagnosis, selecting appropriate interventions for the nursing process, as
well as to evaluate the outcomes of nursing care.
b. suggestion
In order for physical examination can be done well, then the nurse must
understand the science of physical examination perfectly and physical
examination must be performed sequentially, systematic, and done with proper
procedures.

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BIBLIOGRAPHY

http//senyum perawat.blogspot.com/pemeriksaan fisik head to toe Suara, Mahyar

dkk.2010. Konsep Dasar Keperawatan.Jakarta : Trans Info Media
www.nursingbegin.com/pengkajiankeperawatan

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