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Oleh:

Ns. Anis Ika Nur Rohmah




Dalam Perkuliahan Semester Genap Program Studi
Ilmu Keperawatan FIKES-UMM
LEARNING OUTCOMES
Mahasiswa mampu melakukan
pemeriksaan fisik thorak dan
abdomen, secara akurat sebelum
dilakukan analisis data, organisasi data,
perumusan masalah, serta rencana
tindakan keperawatan pada pasien.
Struktur dan fungsi toraks
Tulang toraks terdiri dari 12 vertebra toraksal, 12
pasang iga, klavikula, dan sternum.
Garis imajiner pada torak:
1. Garis midsternal,
2. Garis midklavikular,
3. Garis aksilaris anterior,
4. Garis aksilaris media,
5. Garis aksilaris posterior,
6. Garis skapularis, dan
7. Garis midspinal.

Pemeriksaan paru
Stetoscop
Px.dada posterior pasien posisi duduk, lengan dilipat
dan diletakan dipangkuan.
Px. Dada anterior pasien berbaring :
Bila laki-laki dibuka sampai pinggang
Bila perempuan harus menjada privacy area yg sensitif
Menjaga lingkungan yang aman dan nyaman



Auskultasi dinding dada

Stetoskop biasanya mempu-nyai dua kepala bel
dan diafragma.
4 macam bunyi pernapasan normal, yaitu:
trakeal vesikuler
bronkial bronkovesikuler
Bunyi pernafasan abnormal :
- Ronchi - Pleural Friction Rub
- Wheezing
Suara Nafas Normal

1. Trakeal : bunyi yang terdengar kasar, keras, dan dengan
tinggi nada tinggi pada bagian trakea ekstratoraks
2. Bronkial : bunyi yang dengan tinggi nada tinggi, seperti
udara mengalir melalui pipa didengar di atas
manubrium sternal
3. Vesikular : bunyi yang terdengar lemah dengan tinggi
nada rendah seluruh lapang paru
4. Bronkovesikular : campuran bunyi bronkial dan bunyi
vesikular hanya terdengar pada ICS I dan II

Suara nafas tambahan (Adventitious (Extra) Lung Sounds)

Crackles/ Rales : These are high pitched, discontinuous
sounds similar to the sound produced by rubbing your hair
between your fingers. signs of water in the alveoli (heart
failure), pus in the alveoli (pneumonia), or scarring
(pulmonary fibrosis)
Wheezes/Wheezing: These are generally high pitched and
"musical" in quality. Stridor is an inspiratory wheeze
associated with upper airway obstruction (croup). sign of
asthma or, if localized, of a tumor or foreign body
Rhonchi : These often have a "snoring" or "gurgling" quality.
Any extra sound that is not a crackle or a wheeze is probably a
rhonchi. originate in larger airways than wheezes and are a
sign of bronchitis
Friction rub is a dry, leathery sound heard in inspiration and
expiration. It is a sign of inflammation of the pleura.
Inspeksi
Wajah pasien; terlihat sianosis, pernapasan cuping
hidung.
Perhatikan otot--otot bantu napas:
Suprasternal
Intercostae
Sternokleidomastoideus
Supraclavikula

Bentuk Tulang
1. Bentuk torak :
Barrel Chest
Funnel Chest
Pigeon Chest
2. Bentuk Tulang Belakang
Kifosis
Skoliosis
lordosis




Mengkaji kecepatan dan pola respirasi

Hitunglah frekuensi 30 detik kalikan2, atau dalam 60
detik penuh (N: 12 s/d 20 x/mnt)
Kelaiaanan pola nafas:
Bradipnea
Takepnea
Apnea
Hipernea
Kusmaul
Chanestokes


Palpasi dinding dada posterior
Daerah nyeri tekan
Kesimetrisan pergerakan dada
Fremitus vokal dan fremitus taktil

Perkusi dinding toraks
Intensitas Suara:
1. Resonan / sonor
2. Dullness / Pekak
3. Hiperresonan / Hipersonor

Pemeriksaan jantung
Inspeksi keadaan umum pasien
Penampilan pasien
Kondisi kulit , ekstremitas inferior lebih dingin dibanding
ekstremitas superior (Anemia)
Kelainan pada wajah dan kepala, Stenosis aorta kongenital
(mata berjauhan, strabismus, telinga letak rendah, hidung
yang menengadah, dan hipoplasia mandibula), Wajah
bulat ,mata terbelalak berjauhan (stenosis pulmonal),
kardiomiopati (Lipatan daun telinga/Lichtstein bilateral)
Mata dapat memperlihatkan arkus senilis (Hipercolesterol)
Perdarahan konjungtiva (endocarditis)

Palatum yang melengkung tinggi kongenital
seperti prolaps katup mitral.
Petekie pada palatum karena endokarditis
bakterial.
Pasien dengan defek septum atrium mungkin
mempunyai falang ekstra, jari tangan ekstra, atau
jari kaki ekstra. Jari tangan yang panjang dan
kurus mengarah kepada kemung-kinan regurgitasi
aorta.

Perkusi batas-batas jantung
Pada kondisi normal akan didapatkan bunyi redup
pada :
- ICS (Intercostal Space) II midsternalis kiri
(batas atas),
- ICS (Intercostae Space) V (batas bawah),
- Midklavikula kiri (batas kiri), dan
- ICS (Intercostal Space) II dekstra midsternalis
kanan (batas kanan).

PERCUSION
A. Proper Technique
1. Hyperextend the middle finger of one hand and
place the distal interphalangeal joint firmly against
the patient's chest.
2. With the end (not the pad) of the opposite middle
finger, use a quick flick of the wrist to strike first
finger.
3. Categorize what you hear as normal, dull, or
hyperresonant.
4. Practice your technique until you can consistantly
produce a "normal" percussion note on your
(presumably normal) partner before you work with
patients.

B. Posterior Chest
1. Percuss from side to side and top to bottom using the
pattern shown in the illustration. Omit the areas
covered by the scapulae.
2. Compare one side to the other looking for
asymmetry.
3. Note the location and quality of the percussion
sounds you hear.
4. Find the level of the diaphragmatic dullness on both
sides.
Interpretation
C. Anterior Chest
1. Percuss from side to side
and top to bottom using
the pattern shown in the
illustration.
2. Compare one side to the
other looking for
asymmetry.
3. Note the location and
quality of the percussion
sounds you hear.
Percussion Notes and Their
Meaning
Flat or
Dullness
liquid or solid
1. Pleural Effusion
2. Lobar Pneumonia
lung area full of pus
Normal Healthy Lung or
Bronchitis
Hyperresonant
Emphysema or
Pneumothorax
PALPATION
1. Identify any areas of tenderness or deformity by
palpating the ribs and sternum Daerah nyeri
tekan
2. Assess expansion and symmetry of the chest by
placing your hands on the patient's back, thumbs
together at the midline, and ask them to breath
deeply.
Kesimetrisan pergerakan dada
Vokal Fremitus dan Fremitus taktil
Tactile fremitus: Chest wall vibrations
from speech (patient says "ninety-nine").
Compare sides. Fremitus should be
symmetric - the same on both sides.
Abnormal fremitus can help you
diagnose several lung abnormalities:
Decreased fremitus occurs if
something gets between the lung and
chest wall:
Air in the pleural space ( pneumothorax
or "collapsed lung")
Fluid in the pleural space (pleural
effusion)
Scarred, thickened pleura
Increased fremitus:
In pneumonia, thick pus in the airways
and alveoli increases vibration
transmission (like wobbling jello).
Patients with pneumonia may have
increased fremitus on that side.
Auskultasi jantung
Cara yang paling dapat diandalkan untuk mengenali Sl dan
S2 adalah menentukan waktu terjadinya bunyi itu dengan
palpasi arteri karotis.
Sementara tangan kanan pemeriksa mengubah-ubah posisi
stetoskop, tangan kiri diletakkan pada arteri karotis pasien.
Bunyi yang mendahului denyut karotis adalah S1.
Sedangkan S2 terdengar setelah denyut tersebut.
Ketika mendengarkan pada apeks dan batas sternal kiri
dengan bel stetoskop, pemeriksa harus menentukan
apakah ada bunyi jantung III (S3) atau tidak.
Pemeriksaan bising jantung
waktu dalam siklus jantung tinggi nada
lokasi dan penyebaran kualitas
intensitas


SUARA UCAPAN

1. Bronchophony is increased clarity of words,
e.g. in area of pneumonia
2. Whispered pectoriloquy -- even a whisper is
clear to the stethoscope - is an extreme form of
bronchophony (Suara terdengar jauh dan tidak
jelas)
3. Egophony: patient says EE and stethoscope
hears A - is similar to increased tactile fremitus.
Egophony may be the only physical examination
abnormality in early pneumonia.
JANTUNG/CARDIO
Examination of the heart
includes:
Inspection: of jugular venous
pulse and point of maximal
impulse
Palpation: of point of
maximum impulse, and
precordium for lifts, heaves and
thrills
Auscultation: for valve closing
sounds (S1 and S2), extra sounds
(S3 and S4), murmurs, clicks and
rubs
PEMERIKSAAN ABDOMEN
1. The patient should have an empty bladder.
2. The patient should be lying supine on the exam table and
appropriately draped.
3. The examination room must be quiet to perform adequate
auscultation and percussion.
4. Watch the patient's face for signs of discomfort during the
examination.
5. Use the appropriate terminology to locate your findings
6. Disorders in the chest will often manifest with abdominal
symptoms. It is always wise to examine the chest when
evaluating an abdominal complaint.
7. Consider the inguinal/rectal examination in males. Consider
the pelvic/rectal examination in females.

EXAM SECTIONS
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
General Considerations
1. INSPECTION
Physicians locate findings in the abdomen in one of
four quadrants or one of nine regions.
The four quadrants are:
right upper (RUQ),
right lower (RLQ),
left upper (LUQ) and
left lower (LLQ).

THE NINE REGIONS
epigastric,
umbilical,
hypogastric/suprapubic,
right hypochondriac,
left hypochondriac,
right lumbar,
left lumbar,
right inguinal and
left inguinal.

LOCATIONS of ABDOMINAL ORGANS
The schematic below is a reminder of what
organs are likely to produce findings in each
region.
For example:
Right hypochondriac (RUQ) : liver and gall
bladder
left hypochondriac (LUQ) : the spleen and
stomach
epigastric : the pancreas, stomach and
common bile duct
umbilical : the small intestine
lumbar : the kidneys
iliac regions : the ovaries
left iliac/LLQ : the sigmoid colon
right iliac or lumbar (RLQ): the cecum and
appendix
suprapubic : the bladder and uterus
SOME COMMON FINDINGS on ABDOMINAL
INSPECTION
Scars : Jaringan parut
Striae (stretch marks) : tanda peregangan ibu hamil
Colors : - Bluish color at the umbilicus is Cullen's sign a sign
of bleeding in the peritoneum.
- Bruises on the flanks are Grey Turner's sign
(retroperitoneal bleeding - e.g. from inflamed
pancreas)
Jaundice : warna kuning pada kulit
Prominent veins : may be due to portal vein
obstruction or inferior vena cava obstruction
ABDOMINAL DISTENSION
Distension of the lower abdomen only can be caused
by pregnancy, full bladder, ovarian tumor, or uterine
fibroids (common benign growths)
Diffuse abdominal distension can be caused by any
of the 6 Fs:
Fat (obesity)
Fluid (ascites - peritoneal fluid - or obstructed viscera
filled with fluid)
Flatus (air) - e.g. from air swallowing or intestinal
obstruction
Feces (constipation
Fetus (pregnancy)
Fatal cancer.
2. AUSCULTATION
GUT SOUNDS

Use the diaphragm of your stethoscope to listen to gut sounds
Normal gut sounds are gurgling, 5 to 35 per minute
Borborygmi are loud, easily audible sounds. They are normal, too.
High pitched , tinkling (raindrops in a barrel) sounds are a sign of
early intestinal obstruction
Decreased sounds: (none for a minute) are a sign of decreased gut
activity. Gut sounds may be markedly decreased after abdominal
surgery; abdominal infection (peritonitis) or injury.
Absent Sounds : (no sounds for 5 minutes) are a bad sign. They can
be caused by longer-lasting intestinal obstruction, intestinal
perforation or intestinal (mesenteric) ischemia or infarction
3. PERCUSSION
What it finds: liver size (kind of), spleen, fluid.
Percussing the body gives one of three notes:
Tympany is found in most of the abdomen,
caused by air in the gut. It has a higher pitch than
the lung.
Resonance is found in normal lung. It is lower
pitched and hollow.
Dullness is a flat sound, without echoes. The liver
and spleen, and fluid in the peritoneum (ascites:
ah-SY-teez), give a dull note.
A. Liver Span
Percuss downward from the chest in the right midclavicular line
until you detect the top edge of liver dullness.
Percuss upward from the abdomen in the same line until you detect
the bottom edge of liver dullness.
Measure the liver span between these two points. This measurement
should be 6-12 cm in a normal adult.

B. Splenic Dullness
Percuss the lowest costal interspace in the left anterior axillary line.
This area is normally tympanitic.
Ask the patient to take a deep breath and percuss this area again.
Dullness in this area is a sign of splenic enlargement.
Shifting Dullness
This is a test for peritoneal fluid (ascites). ++
Percuss the patient's abdomen to outline areas of dullness and tympany.
Have the patient roll away from you.
Percuss and again outline areas of dullness and tympany. If the dullness has
shifted to areas of prior tympany, the patient may have excess peritoneal fluid.

Psoas Sign
This is a test for appendicitis. ++
Place your hand above the patient's right knee.
Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.

Obturator Sign
This is a test for appendicitis. ++
Raise the patient's right leg with the knee flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign.

4. PALPATION
General Palpation
1. Begin with light palpation.
At this point you are mostly
looking for areas of
tenderness. The most
sensitive indicator of
tenderness is the patient's
facial expression (so watch
the patient's face, not your
hands). Voluntary or
involuntary guarding may
also be present.
2. Proceed to deep palpation
after surveying the abdomen
lightly. Try to identify
abdominal masses or areas of
deep tenderness
Palpasi Lien
Posis pasien tetap telentang,
buatlah garis bayangan Schuffner
ari midclavikula kiri ke arcus
costae- melalui umbilicus
berakhir pada SIAS kemudian garis
dari arcus costae ke SIAS di bagi
delapan. Dengan Bimanual
lakukan palpasi dan diskrisikan
nyeri tekan terletak pada garis
Scuffner ke berapa ? ( menunjukan
pembesaran lien )

Palpasi Hepar
Atur posisi pasien telentang dan
kaki ditekuk
Perawat berdiri di sebelah kanan
klien, dan meletakan tangan di
bawah arcus costai 12, pada saat
isnpirasi lakukan palpasi dan
diskripsikan :
Ada atau tidak nyeri tekan, ada
atau tidak pembesaran berapa jari
dari arcus costae, perabaan keras
atau lunak, permukaan halus atau
berbenjol-benjol, tepi hepar
tumpul atau tajam. Normalnya
hepar tidak teraba.

Palpasi Ginjal
Dengan bimanual tangan kiri mengangkat
ginjal ke anterior pada area lumbal posterior,
tangan kanan diletakan pada bawah arcus
costae, kemudian lakukan palpasi dan
diskripsikan adakah nyeri tekan, bentuk dan
ukuran.
Normalnya ginjal tidak teraba.
Palpasi Appendik

Posisi pasien tetap telentang, Buatlah garis
bayangan untuk menentukan titik Mc. Burney
yaitu dengan cara menarik garis bayangan dari
umbilicus ke SIAS dan bagi menjadi 3 bagian.
Tekan pada sepertiga luar titik Mc Burney : Bila
ada nyeri tekan ,nyeri lepas dan nyeri menjalar
kontralateral berarti ada peradangan pada
appendik.