PAPER

PYHSICAL EXAMINATION

Drafting Team :

Dewi Nurpitasari 2014401110021

Menik Anggraeni Dwiji Tunggal L 2014401110018
Muhammad Rizal Fahreza 2014401110022
Nazli Khairina 2014401110019
Radifan Ihsan 2014401110023
Rusnita Arini 2014401110020

Supporting Lecturer :

M. Fahrin Azhari, Ns., M.Kep

UNIVERSITY MUHAMMADIYAH BANJARMASIN

FACULTY OF NURSING AND HELTH SCIENCE
STUDY PROGRAM D3 NURSING
2021/2022
 PREFACE

Assamualaikum Wr. Wb.

We give thanks to Allah SWT. who has bestowed many blessings so that we
can compile the Nursing English 2 report well. This report contains a description of
the results of the “Physical Examination”. We compiled this report quickly with the
help and support of the Nursing English 2 course lecturer, Mr. M.Fahrin Azhari, Ns.,
M.Kep.
In preparing this report, we realize that the results of this report are still far
from perfect. Therefore, as the authors, we sincerely hope for constructive criticism
and suggestions from all of you readers.

Banjarmasin, 27th September 2021

Grup 3
 CHAPTER I

A. Background
Physical examination or clinical examination is a process of a medical expert
examining a patien’s body to find clinical signs of disease. The results of the
examination will be recorded in the medical record. The medical record and
physical examination will assist in establishing the diagnosis and planning the
patien’s treatment.
Usually, a physical examination is carried out systematically, starting from the
head and ending at the limbs. After examination of the main organs are examined
by inspection, palpation, percussion, and auscultaion, some special tests may be
required such as neurological tests.
With the clues obtained during the history and physical examination, the
medical professional can develop a differential diagnosis, that is, a list of possible
causes for the symptom. Several tests will be performed to determine the cause.
A complete examination will consist of the patient’s general condition and
specific organ systems. In practice, vital signs or checking temperature, pulse and
blood pressure are always performed first.

B. Formulation of The Problem

1. What is the definition of Physical Examination ?
2. What is physical ecamination techniques ?
3. What is principles in Physical Examination ?
4. What is the purpose of the Physical Examination ?
5. What are the benefits pf Physical Examination ?
6. What are the indications for Physical Examination ?
7. What is the procedure for the Physical Examination ?

C. Writing Purpose
The purpose of writing this paper is to know the definition, techniques,
principles , the purpose , the benefits, indications , and procedure for physical
examinations.
 CHAPTER II

A. Definition Of Physical Examination

Physical examination or clinical examination is a process of a medical
expert examining a patient's body to find clinical signs of disease. The results of
the examination will be recorded in the medical record. The medical record and
physical examination will assist in making the diagnosis and planning the
patient's treatment. Usually, a physical examination is carried out systematically,
starting from the head and ending at the limbs. After the main organs are
examined by inspection, palpation, percussion, and auscultation, some special
tests may be required such as neurological tests. With clues obtained during the
history and physical examination, the medical professional can develop a
differential diagnosis, which is a list of possible causes for the symptom. Several
tests will be done to confirm the cause. A complete examination will consist of a
self-assessment of the patient's general condition and specific organ systems. In
practice, vital signs or checking temperature, pulse and blood pressure are always
performed first.
The physical examination is a head-to-toe review of each body system
that provides objective information about the client and allows the nurse to make
clinical judgments. The accuracy of the physical examination affects the choice
of therapy received by the client and the determination of the response to the
therapy (Potter and Perry, 2005).
Physical examination is an examination of the client's body as a whole or
only certain parts that are considered necessary, to obtain systematic and
comprehensive data, ensure / prove the results of the anamnesis, determine
problems and plan appropriate nursing actions for the client. (Dewi Sartika,
2010).

B. Physical Ecamination Techniques

a) Inspection
Inspection is an examination using the senses of sight, hearing and smell.
A general inspection is carried out when you first meet the patient. A general
description or impression of the state of health that is formed. The examination
 then progresses to a local inspection that focuses on a single system or part and
usually uses special instruments such as ophthalmoscope, otoscope, speculum and
others. (Laura A. Talbot and Mary Meyers, 1997) Inspection is an examination
carried out by looking at the body part being examined through observation (eyes
or a magnifying glass). (Dewi Sartika, 2010). The focus of the inspection on each
body part includes: body size, color, shape, position, symmetry, lesions, and
protrusion/swelling. After inspection it is necessary to compare normal and
abnormal results of one body part with other body parts.
b) Palpation
Palpation is an examination using the sense of touch by placing the hand
on the part of the body that can be reached by the hand. Laura A. Talbot and
Mary Meyers, 1997). Palpation is an examination technique that uses the sense of
touch; hands and fingers, to determine the characteristics of tissues or organs
such as: temperature, elasticity, shape, size, humidity and protrusion (Dewi
Sartika, 2010). Things that are detected are temperature, humidity, texture,
movement, vibration, growth or mass, edema, crepitus and sensation.
c) Percussion
Percussion is an examination that includes tapping the surface of the body
to produce sounds that will assist in determining the density, location, and
position of the underlying structures (Laura A. Talbot and Mary Meyers, 1997).
Percussion is an examination by tapping certain parts of the body surface to
compare with other body parts (left/right) by producing sound, which aims to
identify boundaries/locations and tissue consistency. Dewi Sartika, 2010)
d) Auscultation
Auscultation is the act of listening to sounds produced by various organs
and tissues of the body (Laura A. Talbot and Mary Meyers, 1997). Auscultation
is a physical examination performed by listening to the sounds produced by the
body. Usually using an instrument called a stethoscope. The things that are
heard are: heart sounds, breath sounds, and bowel sounds. (Dewi Sartika, 2010).

C. Principles In Physical Examination

a) Infection control
This includes washing hands, putting on sterile gloves, putting on a mask,
and helping the client put on a check-up gown if any.
 b) Environmental control
That is to make sure the room is comfortable, warm, and well lit to carry
out a physical examination for both the client and the examiner himself. For
example closing the door/window or skerem to maintain client privacy.

D. Purpose Of Physical Examination

a) To collect basic data about client's health.
b) To add, confirm, or refute the data obtained in the nursing history
c) To confirm and identify nursing diagnoses.
d) To make clinical judgments about changes in the client's health status and
management

E. Benefits of Physical Examinations

a) As data to assist nurses in enforcing nursing diagnoses.
b) Knowing the health problems experienced by the client.
c) As a basis for selecting appropriate nursing interventions
d) As data to evaluate the results of nursing care

F. Indication
An absolute must for every client, especially on:
a) Clients who have just entered the health care facility for treatment.
b) Routinely on clients who are being treated.
c) Anytime according to client's requirement

G. Preparation
a) Tool
Meter, BB Scale, Penlight, Stethesoscope, Tensimeter/spighnomanometer,
Thermometer, Watch/stopwatch, Reflex Hammer, Otoscope, Clean Handschoon
(if necessary), tissue, nurse's notebook.
The device is placed near the client's bed to be examined.
b) Environment
Make sure the room is comfortable, warm, and well lit. For example closing the
door/window or skerem to maintain client privacy.
 c) Client (physical and physiological)

H. Inspection Procedure
1. Wash hands
2. Explain the procedure
3. Perform the examination by standing to the right of the client and attach the
handschoen if needed.
4. General examination includes: general appearance, mental status and
nutrition.

Client's position: sitting/lying down

Method: inspection

5.
a. Awareness, behavior, facial expressions, mood. (Normal: Full
awareness, appropriate expression, no pain/difficulty breathing)
b. Signs of stress/anxiety (Normal :) Relaxed, no signs of anxiety/fear)
c. Gender
d. Age and Gender
e. Stages of development
f. TB, BB (Normal: BMI within normal limits)
g. Personal hygiene (Normal: clean and not smelly)
h. How to dress (Normal: True / not reversed)
i. Posture and gait
j. Body shape and size
k. How to talk. (Relaxed, smooth, not nervous)
l. Evaluation by comparing with normal conditions
m. Document the results of the examination

I. Patient Identity
Name : Dimas
Gender : Male
Age : 45 years old
Address : S.Parman, Banjarmasin
 Education : High school
Work : Farmer
Marital status : Married
Religion : Islam
Ethnic group : Banjar

J. Physical Examination
Vital sign
Blood pressure: 110/80 mmHg
Pulse: 130 x/minute
Breathing: 24 x/min
Temperature: 36.50C.
Anthropometry Weight before illness 53 kg Current weight 50 kg TB 160
cm LILA 24 cm waist circumference 90 cm
BBI: 54-66 kg Skin Pale skin color, no lesions, no edema, no
inflammation. Head and neck Symmetrical head shape, no lesions, no tenderness.
No lump in neck, no tenderness, no thyroid enlargement. Vision and Eyes
Symmetrical eyeball, normal eye movement, pupillary reflex to light normal,
clear cornea, anemic conjunctiva, sclera ikretik, normal visual acuity. Smell and
nose Symmetrical nose shape, good olfactory function, no inflammation, no
polyps, no complaints and abnormalities in the nose. Hearing and ears
Symmetrical ear location, symmetrical earlobe shape, no inflammation, good
hearing function, not using hearing aids Mouth and teeth No swallowing
disorders, no inflammation of the mouth, no deformities and other disorders.
Chest, Breathing and circulation
a) Inspection: Symmetrical chest shape Palpation: Tactile premise of the left
and right lung is normal
b) Percussion: Heart sounds dull, lung sounds resonant Auscultation: vesicular
lung sounds, normal heart sounds circulation: perfusion of blood to the
periphery. The color of the fingertips, moist lips, normal skin moisture,
normal urine output, no complaints of dizziness, 4 seconds CRT, no chest
pain and shortness of breath. Abdomen Inspection: The surface of the
abdomen is ascites. Auscultation: Peristalsis (+), bowel sounds 8 x / min.
c) Palpation: Abdominal bloating, tenderness is felt in the right upper quadrant,
there is an enlarged liver/liver palpable
d) Percussion: Dullness in the upper right area, tympani in the other quadrant.
Genetalia and reproduction There is no inflammation of the external
genitalia, no lesions, regular menstrual cycles, no discharge, no catheter.
Upper and lower extremities There is no restriction of movement, no edema,
no varicose veins, cold akral, no pain and redness, no signs of infection, no
limb weakness.
 CHAPTER III

A. Conclusion
Physical examination is an examination of the client's body as a whole or only
certain parts that are considered necessary, to obtain systematic and comprehensive
data, ensure / prove the results of the anamnesis, determine problems and plan
appropriate nursing actions for the client.
Absolute physical examination is carried out on every client, especially for
clients who have just entered the health care place for treatment, routinely on clients
who are being cared for, at any time according to the client's needs. So this physical
examination is very important and must be done in these conditions, whether the
client is conscious or unconscious.
Physical examination is very important because it is very useful, both for
establishing nursing diagnoses. selecting appropriate interventions for the nursing
process, as well as to evaluate the outcomes of nursing care.

B. Suggestion
In order for a physical examination to be carried out properly, nurses must
understand the science of physical examination perfectly and this physical
examination must be carried out sequentially, systematically, and carried out with the
correct procedur
 REFERENCES

https://text-id.123dok.com/document/nzwo5rly-makalah-pemeriksaan-fisik-1.html
Sunday, 26 September 2021 12.00 a.m