SASARAN PEMBELAJARAN:
PENDAHULUAN
Komunikasi efektif merupakan kompetensi yang harus dikuasai oleh seorang dokter. Dokter
harus menerapkan prinsip-prinsip komunikasi untuk menetapkan dan mempertahankan
pengobatan lengkap dan hubungan dokter pasien yang etikal. Juga menerapkan prinsip
kerahasiaan, otonomi pasien, reaksi positif dan aspek pengobatan dalam hubungan pasien
dokter , dalam hal anamnesis, konseling, penjelasan berbagai prosedur, negosiasi pembuatan
keputusan dengan keluarga dan pendidikan pasien. Hubungan dokter-pasien dan keluarga yang
baik sangat menunjang proses terapeutik. Pasien dan keluarga dengan senang hati
menyampaikan keluhan kepada dokter tanpa perasaan curiga. Dokter perlu memahami
spiritulitas, kondisi kejiwaan dan budaya yang mempengaruhi konsep sehat, sakit keinginan
untuk hidup penderita. Pasien yang berbeda memerlukan pendekatan yang berbeda. Pemahaman
tentang hubungan interpersonal meningkatkan sensitifitas dokter dalam memandang penderitaan
dari sudut pandang penderita dan mengembangkan sikap empati.
Anamnesis atau wawancara merupakan langkah pertama dalam tata cara kerja yang harus
ditempuh untuk membuat diagnosis. Mengumpulkan riwayat penyakit yang lengkap merupakan
langkah penting untuk mengerti dan memahami penderita yang sedang dihadapi. Mengambil
riwayat merupakan bagian yang dapat dimengerti serta difahami oleh setiap penderita. Langkah
tersebut perlu ditempuh untuk menegakkan diagnosis, tetapi mempunyai arti yang berbeda-beda
dalam proses diagnostik.
Pasien datang ke dokter untuk meminta bantuan dalam mengatasi masalah yang dapat
disebabkan oleh Disease (penyakitnya), Discomfort (rasa tidak nyaman), Disability (ketidakmampuan),
Dissatisfaction (ketidak puasan) dam Death (kematian). Mahasiswa harus belajar keterampilan untuk
mendapatkan riwayat medis dari pasien sebelum menjadi dokter.
Komunikasi yang tidak efektif sering menurunkan ketepatan diagnosis dokter. Penelitian
menunjukkan hanya 2% pasien yang memperoleh kesempatan menyelesaikan riwayatnya.
Kemampuan untuk mencurahkan perhatian penuh kepada setiap pasien akan sangat
mempengaruhi keberhasilan seorang dokter. Perhatian terhadap kepribadian pasien akan
mencegah dokter melukai perasaannya. Pasien berharap agar seorang dokter bersikap tidak
berlebihan dan peka terhadap hal-hal yang menakutkan dan mengganggunya. Komunikasi efektif
sangat diperlukan pada saat wawancara dengan pasien. Ada beberapa hal yang perlu disiapkan
sebelum memulai interaksi dengan pasien. Persiapan ini merupakan aspek penting untuk dapat
memperoleh informasi tentang kondisi pasien yang sesungguhnya.
Memperoleh riwayat pasien yang akurat adalah langkah kritis pertama dalam menentukan
etiologi masalah pasien. Nilai kualitas riwayat pasien tentunya akan bergantung pada
kemampuan dalam mengkaji informasi yang relevan. Alasan pasien datang kepada dokter adalah
merupakan keluhan utama (chief complaint).
Meningkatkan hubungan dengan pasien
1. Duduklah di luar kawasan pribadi pasien (+ 0,5 - 1 m)
2. Pastikan pencahayaan, tempat menulis dan tempat duduk anda memadai
3. Mintalah ijin kalau diperlukan untuk mengubah ruangan
4. Kalau mungkin duduklah sedemikian rupa sehingga ketinggian mata sama atau dibawah
ketinggian mata pasien
5. Pasien sedapat mungkin dalam posisi duduk tegak
Hal yang harus diperhatikan saat wawancara :
1. Perhatikanlah petunjuk-petunjuk verbal dan non-verbal
2. Semua komunikasi harus dijaga kerahasiaannya
3. Bersikaplah jujur dan bertindak dengan semestinya
4. Hargailah sikap pasien terhadap penyakitnya
Cara mengendalikan wawancara
1. Hindarilah percakapan yang kurang penting dan menyimpang
2. Kendalikan pertanyaan dan jawaban
3. Mulailah dengan pertanyaan yang tidak terbatas dan singkat
4. Batasilah jumlah pertanyaan tertutp
5. Pakailah lebih banyak pertanyaan terbuka
6. Perlihatkanlah respon yang tegas
7. Pakailah pernyataan-pernyataan peralihan untuk mengendalikan pasien yang berbicara
bertele-tele
8. Mintalah izin untuk menyelidiki persoalan yang sensitif
9. Berikanlah respon singkat kalau pasien mengungkapkan emosinya
10. Hindarilah memberikan pertanyaan yang bertubi-tubi
Memulai wawancara
Selalu perkenalkan diri anda pada pasien. Kemudian coba membuat lingkungan tetap
privat dan bebas dari berbagai distraksi. Idealnya, dengarkan pasien ketika menggambarkan
masalah dengan kata-katanya sendiri. Pertanyaan terbuka (open ended questions) merupakan
cara yang terbaik untuk memperoleh informasi yang lengkap. Kesuksesan dalam interview
memerlukan pencegahan dalam penggunaan istilah medis dan gunakan gambaran bahasa yang
familier. Ada beberapa bahasa yang dapat digunakan pada beberapa keluhan, yaitu :
1. Durasi/lama terjadi
2. Karakter/derajat keparahan
3. Lokasi/penyebaran
4. Apakah sudah mencoba mengobati?
5. Apakah ada gejala penyerta lain?
6. Apakah masalah bertambah baik, tetap atau bertambah buruk?
ANAMNESIS
Anamnesis berasal dari kata ana
yang artinya hal-hal yang telah terjadi dan nesa artinya ingatan. Dibedakan 2 anamnesis yaitu :
1. Auto anamnesis yang berasal dari penderita sendiri
2. Allo anamnesis yang berasal dari orang lain seperti keluarga, polisi, penduduk lain. Dikerjakan pada
keadaan sebagai berikut:
Pasien dengan penurunan atau perubahan kesadaran.
Pasien bayi, anak-anak atau orang sangat tua
Untuk konfirmasi auto anamnesis
Anamnesis awal
Identitas pasien merupakan data pokok yang harus dikaji dahulu. Nama penderita yang
anda periksa, umur, jenis kelamin, suku bangsa, status perkawinan, pekerjaan, tempat tinggal,
dokter yang merujuknya harus pula anda catat pada saat pemeriksaan dilakukan. Jika ini bukan
merupakan kunjungan yang pertama, maka jumlah serta tanggal kunjungan sebelumnya harus
juga anda catat. Tambahkan pula suatu pernyataan yang menerangkan sejauh mana seluruh
keterangan yang diberikan oleh penderita dan pelapor dapat dipercaya. Riwayat maupun
pemeriksaan tersebut harus pula ditandatangani dan diberi keterangan kedudukan orang yang
melakukan pemeriksaan.
Keluhan Utama
Keluhan utama adalah pernyataan dengan bahasa sendiri sebagai penyebab utama pasien
untuk mencari bantuan kesehatan. Keluhan utama dapat berupa nyeri (seperti nyeri perut), gejala
tidak enak (seperti kelelahan), kehilangan fungsi normal (seperti fungsi kandung kemih), perubahan
dari tubuh (seperti bengkak) atau keluhan kejiwaan (seperti cemas, depresi), yang tidak harus
merupakan masalah sebenarnya.
Keluhan utama yang dinyatakan oleh pasien merupakan dasar utama untuk memulai
evaluasi masalah pasien. Keluhan tersering yang membuat seseorang datang ke dokter adalah
nyeri atau yang erat hubungannya dengan ketidaknyamanan. Tulislah pernyataan singkat, sejauh
mungkin dengan mempergunakan kalimat yang dipakai oleh penderita itu sendiri, mengenai apa
sebenarnya yang tengah dialaminya, dengan mengemukakan gejala-gejala atau tanda-tanda serta
berapa lama semua gejala-gejala serta tanda-tanda tersebut sudah berlangsung. Hindarkan, jika
memungkinkan, penggunaan kata-kata atau ungkapan-ungkapan yang menggambarkan suatu
diagnosis atau yang mempunyai kaitan diagnostik murni.
Lama waktu terjadinya keluhan utama harus ditanyakan. Apakah gangguan yang
dialaminya bersifat akut atau kronis? Beberapa penyakit timbul dan berakhir secara mendadak,
sedangkan penyakit lain mulai secara perlahan dan tidak nyata. Sudah pasti penting untuk
mengetahui dengan baik lokasi rasa nyeri atau perasaan tidak nyaman tersebut. Lokalisasi rasa
nyeri atau ketidaknyamanan akan membantu memusatkan perhatian kita kepada organ atau
daerah tertentu. Apakah rasa nyeri tersebut tetap terlokalisir ataukah merambat atau memancar
ke daerah yang lain.
Perkembangan gejala-gejala berkaitan erat dengan lamanya penyakit. Apakah gangguan
berkembang cepat atau lambat? Apakah gejala bertambah baik pada waktu-waktu tertentu,
sedangkan waktu lain malah bertambah buruk? Perhatikan sifat rasa nyeri atau perasaan tidak
nyaman yang dikeluhkan oleh pasien. Apakah rasa nyeri bersifat tajam atau tumpul? Apakah
yang dikeluhkan benar-benar rasa nyeri atau perasaan tidak nyaman belaka. Tetapkan dengan
pasti pengaruh kegiatan-kegiatan normal terhadap gejala. Apakah pengaruh sikap tubuh terhadap
gejala tersebut? Tidur, makan dan istirahat apakah mempengaruhi rasa sakit/ ketidaknyamanan
tersebut?
2. Cara komunikasi :
Yakinkan pasien nyaman
Yakinkan pasien siap untuk mendengar
Perkenalkan diri anda
Hormati pasien dengan menyebut nama.
Fasilitasi bila cerita pasien terhenti.
Perlihatkan rasa empati.
Klarifikasikan cerita pasien bila kurang jelas.
Ulangi lagi cerita yang didengar untuk meyakinkan.
Pergunakan pernyataan peralihan
Pergunakan pernyataan atau pertanyaan dari kesimpulan seperti "ada lagi yang bapak mau
kemukakan?, " ada hal-hal yang penting yang bapak mau kemukakan?".
Tinjauan Sistem. Bagaimanakah cara anda melakukan tinjauan berbagai sistem? Bilakah hal itu
anda lakukan? Lakukan hal itu ketika anda sedang memeriksa penderita. Pada waktu anda tengah
memeriksa kepalanya, tanyakan apakah ia menderita sakit kepala. Ketika anda sedang melihat
matanya, tanyakan apakah penderita mengalami kesukaran dengan penglihatannya dan
gangguan-gangguan lainnya. Anda melihat tubuh penderita di hadapan anda. Catatlah semua
tanda, gejala dan nilai-nilai yang berhubungan.
DAFTAR PUSTAKA :
1. Anonim, 2002. History of Present Illness, The School of Medicine, The University of
California, San Diego.
2. Burnside-Mc Glynn, 1995. Adams Diagnosis Fisik, EGC, Jakarta.
3. Delp and Manning, 1996. Major Diagnosis Fisik, EGC, Jakarta.
4. Goldberg, 2001. Practical guide to clinical medicine. University of California, San Diego.
5. Fletcher SW.2000. Clinical decision making: approach to the patient, In: Goldman: Cecil
Textbook of Medicine, 21st ed., London. W. B. Saunders Company, 78-9.
6. DeGowin, RL. and Brown, DD. 2000. .Diagnostic Examination.7th ed. New York. MacGraw-Hill.1-
36.
7. Anonym, Twelve strategies for effective communication and collaboration in medical teams,
BMJ Career Focus.htm
8. Mock, KD. 2001. Effective clinician-patient communication, Published February 2001
9. Lewis, B. 2002. From cradle to Rocker: Providing Care Across the Human Life Cycle. Dalam:
Sloane P D, Slatt Lisa M, Ebell M H, Jacques LB. Essential of Family Medicine. Ed 4,
Philadelphia, Lippincott William & Wilkins, p3-18
Keterangan :
1 = tidak dilakukan
2 = dilakukan tetapi kurang sempurna
3 = dilakukan dengan sempurna
Nilai = ( Jumlah/48 ) x 100 =
Purwokerto, .
Evaluator
.
II. PEMERIKSAAN TANDA VITAL
TUJUAN PEMBELAJARAN
Pada akhir praktikum pemeriksaan tanda vital, mahasiswa diharapkan mampu:
1. Menjelaskan hal-hal yang tercakup dalam tanda vital.
2. Menjelaskan alat dan bahan yang diperlukan untuk pemeriksaan tanda vital.
3. Melakukan prosedur pemeriksaan tanda vital dengan baik dan benar.
4. Menjelaskan parameter normal hasil pemeriksaan tanda vital.
5. Menginterpretasikan hasil pemeriksaan tanda vital.
TINJAUAN PUSTAKA
Tanda vital merupakan parameter tubuh yang terdiri dari tekanan darah, denyut nadi, laju
pernafasan, dan suhu tubuh.Disebut tanda vital karena penting untuk menilai fungsi fisiologis
organ vital tubuh.
A. Tekanan Darah:
Faktor-faktor yang mempengaruhi tekanan darah adalah curah jantung, tahanan pembuluh darah
tepi, volume darah total, viskositas darah, dan kelenturan dinding arteri.
Sedangkan factor-faktor yang berpengaruh pada interpretasi hasil yaitu:
Komponen suara jantung disebut suara korotkoff yang berasal dari suara vibrasi saat manset
dikempiskan. Suara korotkoff sendiri terbagi menjadi 5 fase yaitu :
B. Denyut Nadi
Denyut nadi adalah gelombang darah yang dapat dirasakan karena dipompa kedalam arteri oleh
kontraksi ventrikel kiri jantung .Denyut nadi diatur oleh system saraf otonom.
Lokasi untuk merasakan denyut nadi adalah :
1. Karotid : Di bagian medial leher, di bawah angulusmandibularis,
hindari pemeriksaan dua sisi sekaligus pada waktu
bersamaan.
2. Brakial : Di atas siku dan medial dari tendobisep.
3. Radial : Bagian distal dan ventral dari pergelangan tangan.
4. Femoral : Di sebelah inferomedialligamentuminguinalis.
5. Popliteal : Di belakang lutut, sedikit ke lateral dari garis tengah.
6. Tibia posterior : Di belakang dan sedikit ke arah inferior dari
maleolusmedialis.
7. Pedisdorsalis : Lateral dari tendom. Extensor hallucislongus.
2. Irama
a. Volume nadi kecil : tahanan terlalu besar terhadap aliran darah, darah
yang dipompa jantung terlalu sedikit (pada efusi
pericardial, stenosis katup mitral, payah jantung,
dehidrasi, syok hemoragik)
b. Volume nadi yang : peningkatan tahanan setempat.
berkurang secara local
c. Volume nadi besar : volume darah yang dipompakan terlalu banyak,
tahanan terlalu rendah (pada bradikardia, anemia,
hamil, hipertiroidisme).
C. Pernafasan
Proses fisiologi yang berperan pada proses pernafasan adalah : ventilasi pulmoner, respirasi
external dan internal. Laju pernafasan meningkat pada keadaan stres, kelainan metabolik,
penyakit jantung paru, dan pada peningkatan suhu tubuh.Pernafasan yang normal bila
kecepatannya 14-20x/menit pada dewasa, dan sampai 44x/menit pada bayi.
Kecepatan dan irama pernafasan serta usaha bernafas perlu diperiksa untuk menilai adanya
kelainan:
1. Kecepatan :
a. Takipnea : pernafasan cepat dan dangkal
b. Bradipnea : pernafasan lambat
c. Hiperpnea/hiperventilasi : pernafasan dalam dan cepat (kussmaul)
d. Hipoventilasi : bradipnea disertai pernafasan dangkal.
2. Irama :
D. Suhu
Suhu tubuh mencerminkan keseimbangan antara pembentukan dan pengeluaran panas. Pusat
pengaturan suhu terdapat di hipotalamus yang menentukan suhu tertentu dan bila suhu tubuh
melebihi suhu yang ditentukan hipotalamus tersebut, maka pengeluaran panas akan meningkat
dan sebaliknya bila suhu tubuh lebih rendah. Suhu tubuh dipengaruhi oleh irama sirkadian, usia,
jenis kelamin, stress, suhu lingkungan hormone, dan olahraga.
Suhu normal berkisar antara 36,5C-37,5C. Lokasi pengukuran suhu adalah oral (di bawah
lidah), aksila, dan rectal. Pada pemeriksaan suhu per rectal tingkat kesalahan lebih kecil daripada
oral atau aksila. Peninggian semua terjadi setelah 15 menit, saat beraktivitas, merokok, dan
minuman hangat, sedangkan pembacaan semu rendah terjadi bila pasien bernafas melalui mulut
dan minum minuman dingin.
ALAT DAN BAHAN
1. Alat dan bahan untuk pemeriksaan tekanan darah :
a. Stetoskop
b. Spigmomanometer
Terdiri dari kantong yang dapat digembungkan dan terbungkus dalam manset yang tidak
dapat mengembang, pompa karet berbentuk bulat, manometer tempat tekanan darah
dibaca, dan lubang pengeluaran.Lebar manset harus sesuai dengan ukuran lengan pasien
karena dapat menyebabkan hasil pengukuran tidak akurat.Ada 2 ukuran yaitu dewasa dan
anak.
Ada 2 jenis manometer yaitu manometer gravitasi air raksa terdiri atas satu lubang kaca
yang dihubungkan dengan reservoir yang berisi air raksa dan manometer aneroid yang
memiliki embusan logam dan menerima tekanan dari manset.
Vital Signs
Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and,
where appropriate, blood oxygen saturation. These numbers provide critical information (hence
the name "vital") about a patient's state of health. In particular, they:
2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is
coping with the resultant physiologic stress. The more deranged the vitals, the sicker the
patient.
Most patients will have had their vital signs measured by an RN or health care assistant before
you have a chance to see them. However, these values are of such great importance that you
should get in the habit of repeating them yourself, particularly if you are going to use these
values as the basis for management decisions. This not only allows you to practice obtaining
vital signs but provides an opportunity to verify their accuracy. As noted below, there is
significant potential for measurement error, so repeat determinations can provide critical
information.
Getting Started: The examination room should be quiet, warm and well lit. After you have
finished interviewing the patient, provide them with a gown (a.k.a. "Johnny") and leave the room
(or draw a separating curtain) while they change. Instruct them to remove all of their clothing
(except for briefs) and put on the gown so that the opening is in the rear. Occasionally, patient's
will end up using them as ponchos, capes or in other creative ways. While this may make for a
more attractive ensemble it will also, unfortunately, interfere with your ability to perform an
examination! Prior to measuring vital signs, the patient should have had the opportunity to sit for
approximately five minutes so that the values are not affected by the exertion required to walk to
the exam room. All measurements are made while the patient is seated.
Observation: Before diving in, take a minute or so to look at the patient in their entirety, making
your observations, if possible, from an out-of-the way perch. Does the patient seem anxious, in
pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay
eyes on the patient.
Temperature: This is generally obtained using an oral thermometer that provides a digital
reading when the sensor is placed under the patient's tongue. As most exam rooms do not have
thermometers, it is not necessary to repeat this measurement unless, of course, the recorded value
seems discordant with the patient's clinical condition (e.g. they feel hot but reportedly have no
fever or vice versa). Depending on the bias of a particular institution, temperature is measured in
either Celcius or Farenheit, with a fever defined as greater than 38-38.5 C or 101-101.5 F. Rectal
temperatures, which most closely reflect internal or core values, are approximately 1 degree F
higher than those obtained orally.
Respiratory Rate: Respirations are recorded as breaths per minute. They should be counted for
at least 30 seconds as the total number of breaths in a 15 second period is rather small and any
miscounting can result in rather large errors when multiplied by 4. Try to do this as
surreptitiously as possible so that the patient does not consciously alter their rate of breathing.
This can be done by observing the rise and fall of the patient's hospital gown while you appear to
be taking their pulse. Normal is between 12 and 20. In general, this measurement offers no
relevant information for the routine examination. However, particularly in the setting of cardio-
pulmonary illness, it can be a very reliable marker of disease activity.
Pulse: This can be measured at any place where there is a large artery (e.g. carotid, femoral, or
simply by listening over the heart), though for the sake of convenience it is generally done by
palpating the radial impulse. You may find it helpful to feel both radial arteries simultaneously,
doubling the sensory input and helping to insure the accuracy of your measurements. Place the
tips of your index and middle fingers just proximal to the patients wrist on the thumb side,
orienting them so that they are both over the length of the vessel.
Vascular Anatomy
The pictures below demonstrate the location of the radial artery (surface anatomy on the left,
gross anatomy on the right).
Frequently, you can see transmitted pulsations on careful visual inspection of this region, which
may help in locating this artery. Upper extremity peripheral vascular disease is relatively
uncommon, so the radial artery should be readily palpable in most patients. Push lightly at first,
adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse. If you
push too hard, you might occlude the vessel and mistake your own pulse for that of the patient.
During palpation, note the following:
1. Quantity: Measure the rate of the pulse (recorded in beats per minute). Count for 30
seconds and multiply by 2 (or 15 seconds x 4). If the rate is particularly slow or fast, it is
probably best to measure for a full 60 seconds in order to minimize the impact of any
error in recording over shorter periods of time. Normal is between 60 and 100.
2. Regularity: Is the time between beats constant? In the normal setting, the heart rate
should appear metronomic. Irregular rhythms, however, are quite common. If the pattern
is entirely chaotic with no discernable pattern, it is referred to as irregularly irregular and
likely represents atrial fibrillation. Extra beats can also be added into the normal pattern,
in which case the rhythm is described as regularly irregular. This may occur, for example,
when impulses originating from the ventricle are interposed at regular junctures on the
normal rhythm. If the pulse is irregular, it's a good idea to verify the rate by listening over
the heart (see cardiac exam section). This is because certain rhythm disturbances do not
allow adequate ventricular filling with each beat. The resultant systole may generate a
rather small stroke volume whose impulse is not palpable in the periphery.
3. Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel normal? This
reflects changes in stroke volume. In the setting of hypovolemia, for example, the pulse
volume is relatively low (aka weak or thready). There may even be beat to beat variation
in the volume, occurring occasionally with systolic heart failure.
Blood Pressure: Blood pressure (BP) is measured using mercury based manometers, with
readings reported in millimeters of mercury (mm Hg). The size of the BP cuff will affect the
accuracy of these readings. The inflatable bladder, which can be felt through the vinyl covering
of the cuff, should reach roughly 80% around the circumference of the arm while its width
should cover roughly 40%. If it is too small, the readings will be artificially elevated. The
opposite occurs if the cuff is too large. Clinics should have at least 2 cuff sizes available, normal
and large. Try to use the one that is most appropriate, recognizing that there will rarely be a
perfect fit.
Blood Pressure Cuffs
1. Wrap the cuff around the patient's upper arm so that the line marked "artery" is roughly
over the brachial artery, located towards the medial aspect of the antecubital fossa (i.e.
the crook on the inside of their elbow). The placement does not have to be exact nor do
you actually need to identify this artery by palpation.
Antecubital Fossa
The pictures below demonstrate the antecubital fossa anatomy (surface anatomy on the
left, gross anatomy on the right).
2. Put on your stethescope so that the ear pieces are angled away from your head. Twist the
head piece so that the bell is engaged. This can be verified by gently tapping on the end,
which should produce a sound. With your left hand, place the bell over the area of the
brachial artery. While most practitioners use the diaphragm of the stethescope, the bell is
actually be superior for picking up the low pitched sounds used for measuring BP. It's
worth mentioning that a number of different models of stethescops are available on the
market, each with its own variation on the structure of the diaphragm and bell. Read the
instruction manual accompanying your stethoscope in order to determine how your
device works.
3. Grasp the patient's right elbow with your right hand and raise their arm so that the
brachial artery is roughly at the same height as the heart. The arm should remain
somewhat bent and completely relaxed. You can provide additional support by gently
trapping their hand and forearm between your body and right elbow. If the arm is held too
high, the reading will be artifactually lowered, and vice versa.
4. Turn the valve on the pumping bulb clockwise (may be counter clockwise in some cuffs)
until it no longer moves. This is the position which allows air to enter and remain in the
bladder.
5. Hold the bell in place with your left hand. Use your right hand to pump the bulb until you
have generated 150 mmHg on the manometer. This is a bit above the top end of normal
for systolic blood pressure (SBP). Then listen. If you immediately hear sound, you have
underestimated the SBP. Pump up an additional 20 mmHg and repeat. Now slowly
deflate the blood pressure cuff (i.e. a few mm Hg per second) by turning the valve in a
counter-clockwise direction while listening over the brachial artery and watching the
pressure gauge. The first sound that you hear reflects the flow of blood through the no
longer completely occluded brachial artery. The value on the manometer at this moment
is the SBP. Note that although the needle may oscillate prior to this time, it is the sound of
blood flow that indicates the SBP.
6. Continue listening while you slowly deflate the cuff. The diastolic blood pressure (DBP)
is measured when the sound completely disappears. This is the point when the pressure
within the vessel is greater then that supplied by the cuff, allowing the free flow of blood
without turbulence and thus no audible sound. These are known as the Sounds of
Korotkoff.
Technique for Measuring Blood Pressure
7. Repeat the measurement on the patient's other arm, reversing the position of your hands.
The two readings should be within 10-15 mm Hg of each other. Differences greater than
this imply that there is differential blood flow to each arm, which most frequently occurs
in the setting of subclavian artery atherosclerosis.
8. Occasionally you will be unsure as to the point where systole or diastole occurred and
wish to repeat the measurement. Ideally, you should allow the cuff to completely deflate,
permit any venous congestion in the arm to resolve (which otherwise may lead to
inaccurate measurements), and then repeat a minute or so later. Furthermore, while no
one has ever lost a limb secondary to BP cuff induced ischemia, repeated measurement
can be uncomfortable for the patient, another good reason for giving the arm a break.
9. Avoid moving your hands or the head of the stethescope while you are taking readings as
this may produce noise that can obscure the Sounds of Koratkoff.
10. You can verify the SBP by palpation. To do this, position the patient's right arm as
described above. Place the index and middle fingers of your right hand over the radial
artery. Inflate the cuff until you can no longer feel the pulse, or simply to a value 10
points above the SBP as determined by auscultation. Slowly deflate the cuff until you can
again detect a radial pulse and note the reading on the manometer. This is the SBP and
should be the same as the value determined with the use of your stethescope.
Normal is between 100/60 and 140/90. Hypertension is thus defined as either SBP greater then
140 or DBP greater than 90. It is important to recognize that blood pressure is rarely elevated to a
level that causes acute symptoms. That is, while hypertension in general is common,
emergencies resulting from extremely high values and subsequent acute end organ dysfunction
are quite rare. Rather, it is the chronically elevated values which lead to target organ damage,
though in a slow and relatively silent fashion. At the other end of the spectrum, the minimal SBP
required to maintain perfusion varies with the individual. Therefore, interpretation of low values
must take into account the clinical situation. Those with poorly functioning hearts, for example,
can adjust to a chronically low SBP (e.g. 80-90) and live without symptoms of hypoperfusion.
However others, used to higher baseline values, might become quite ill if their SBPs were
suddenly decreased to these same levels.
Many things can alter the accuracy of your readings. In order to limit their impact, remember the
following:
1. Do not place the blood pressure cuff over a patients clothing or roll a tight fitting sleeve
above their biceps when determining blood pressure as either can cause elevated
readings.
2. Make sure the patient has had an opportunity to rest before measuring their BP. Try the
following experiment to assess the impact that this can have. Take a patient's BP after
they've rested. Then repeat after they've walked briskly in place for several minutes.
Patients who are not too physically active (i.e. relatively deconditioned) will develop an
elevation in both their SBP and DBP. Also, see what effect raising or lowering the arm,
and thus the position of the brachial artery relative to the heart, has on BP. If you have a
chance, obtain measurements on the same patient with both a large and small cuff. These
exercises should give you an appreciation for the magnitude of error that can be
introduced when improper technique is utilized.
3. If the reading is surprisingly high or low, repeat the measurement towards the end of your
exam.
4. Instruct your patients to avoid coffee, smoking or any other unprescribed drug with
sympathomimetic activity on the day of the measurement.
5. Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are part of the
assessment for hypovolemia. This requires first measuring these values when the patient
is supine and then repeating them after they have stood for 2 minutes, which allows for
equilibration. Normally, SBP does not vary by more then 20 points when a patient moves
from lying to standing. In the setting of significant volume depletion, a greater then 20
point drop may be seen. Changes of lesser magnitude occur when moving from lying to
sitting or sitting to standing. This is frequently associated with symptoms of cerebral
hypoperfusion (e.g.. light headedness). Heart rate should increase by not more than 20
points in a normal physiologic attempt to augment cardiac output by providing
chronotropic compensation. In the setting of GI bleeding, for example, a drop in blood
pressure and/or rise in heart rate after this maneuver is a marker of significant blood loss
and has important prognostic implications. Orthostatic measurements may also be used to
determine if postural dizziness, a common complaint with multiple possible explanations,
is the result of a fall in blood pressure. For example, patients who suffer from diabetes
frequently have autonomic nervous system dysfunction and cannot generate appropriate
arteriolar vaosconstriction when changing positions. This results in postural vital sign
changes and symptoms. The 20 point value is a rough guideline. In general, the greater
the change, the more likely it is to cause symptoms and be of clinical relevance.
6. If possible, measure the blood pressure of a patient who has an indwelling arterial
catheter (these patients can be found in the ICU with the help of a preceptor). Arterial
transducers are an extremely accurate tool for assessing blood pressure and therefore
provide a method for checking your non-invasive technique.
Ideally, several measures on different occasions should verify the finding. One time measures >
160/100 also confirms the diagnosis. It's worth mentioning that normal is 110s/70s, and
cardiovascular risk rises w/any values above these points.
Hypertension (HTN) causes & accelerates the progression of: Renal dysfunction, coronary artery
disease, systolic & diastolic heart, left ventricular hypertrophy, peripheral arterial disease, stroke,
and retinopathy. The risk of HTN induced damage correlates both w/height of BP and chronicity
of elevation (ie longer and higher =s worse). The treatment of HTN prior to the development of
Target Organ Damage (aka TOD) is referred to as "primary prevention;" while treatment to
prevent &/or slow progression once disease has already been established is called "secondary
prevention." Evaluation of patients w/HTN requires careful history, exam, labs, & other studies
to search for co-morbid problems (diabetes, sleep apnea, etc) &/or occult TOD. Most patients
w/HTN are asymptomatic, at least until they develop target organ damage, which can take years
to occur.
The majority of patients w/HTN (> 60%) will require at least 2 meds for treatment. For a BP
between 140-160/80-100, best initial drug treatment is typically with hydrochlorthiazide, a very
mild diuretic w/potent anti-hypertensive properties. For those w/starting values > 160/100, it's
best to start w/2 meds simultaneously. A few more thoughts:
1. Where you start isn't where you end - so expect to reassess BP in a short time (several
weeks) and make adjustments as necessary
2. Most drugs w/in the same class (e.g. any of the 8 or so ACE-Inhibitors) work equally
well.
3. Effective treatment requires continual reassessment of medication adherence - a major
reason for lack of response to Rx. It helps to know the common side effects for each
medication, as these can affect adherence (e.g. ACE-I cough; HCTZ mild increase in
urination, erectile dysfunction; all anti-htn meds hypotension)
4. HTN is directly related to weight, inactivity, ETOH consumption, & salt intake. As such,
life style interventions are absolutely worth addressing, though they are relatively
ineffective as sole treatments (due to the inability of patients & clinicians to achieve
sustained and meaningful changes). That said, you'll never know the impact until you try
to address - and readdress - and readdress @ each visit.
5. HTN "swims" in the same vascular risk factor "soup" as diabetes, hyperlipidemia, and
smoking. These other areas must also be addressed.
6. Treatment goals vary a bit from patient to patient - those with established vascular
disease are treated w/goal of reaching BP 120s/70s. Those in primary prevention group
w/o diabetes, target BP < 140/90.
7. Most patients have primary hypertension (ie the elevation in BP is the primary disorder).
Secondary HTN (elevation in BP secondary to another, treatable condition) is rather
uncommon - though worth thinking about in the right situation. Secondary causes
include: pheochromocytoma, excess cortisol production, hyper adlosteronism,
hypo/hyper-thyroidism, renal artery stenosis, & chronic kidney disease.
9. The use of 3 or more meds for refractory HTN isn't uncommon - in particular w/very
obese patients.
10. Acute interventions to immediately lower BP are largely reserved for those times when
there is clear evidence of acute symptoms from acute TOD (e.g. CHF, coronary ischemia,
increased intra-cranial pressure) secondary to very high values.
Oxygen Saturation: Over the past decade, this non-invasive measurement of gas exchange and
red blood cell oxygen carrying capacity has become available in all hospitals and many clinics.
While imperfect, it can provide important information about cardio-pulmonary dysfunction and
is considered by many to be a fifth vital sign. In particular, for those suffering from either acute
or chronic cardio-pulmonary disorders, it can help quantify the degree of impairment.
Pulse Oxymeter
Vital Signs
Equipment Needed
A Stethoscope
A Blood Pressure Cuff
A Watch Displaying Seconds
A Thermometer
General Considerations
The patient should not have had alcohol, tobacco, caffeine, or performed vigorous
exercise within30 minutes of the exam.
Ideally the patient should be sitting with feet on the floor and their back supported.
Theexamination room should be quiet and the patient comfortable.
History of hypertension, slow or rapid pulse, and current medications should always be
obtained.
Temperature
Temperature can be measured is several different ways:
Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
Of these, axillary is the least and rectal is the most accurate.
Respiration
1. Best done immediately after taking the patient's pulse. Do not announce that you are
measuringrespirations. [p129, p237] [2]
2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it
normal orlabored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per
minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid
respiration iscalled tachypnea.
Pulse
1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with
your rightor patient's left with your left). There is no reason for the patient's arm to be in
an awkwardposition, just imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Note whether the pulse is regular or irregular:
Regular - evenly spaced beats, may vary slightly with respiration
Regularly Irregular - regular pattern overall with "skipped" beats
Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
5. Count the pulse for 15 seconds and multiply by 4.
6. Count for a full minute if the pulse is irregular.
7. Record the rate and rhythm.
Interpretation
A normal adult heart rate is between 60 and 100 beats per minute.
A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than
60beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not
necessarilyabnormal. Athletes tend to be bradycardic at rest (superior conditioning).
Tachycardia is a normalresponse to stress or exercise.
Blood Pressure
1. Position the patient's arm so the anticubital fold is level with the heart. Support the
patient's armwith your arm or a bedside table.
2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the
anticubitalfold. Proper cuff size is essential to obtain an accurate reading. Be sure the
index line fallsbetween the size marks when you apply the cuff. Position the patient's arm
so it is slightly flexedat the elbow.
3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough
estimate ofthe systolic pressure.
4. Place the stetescope over the brachial artery.
5. Inflate the cuff to 30 mmHg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmHg per second.
7. The level at which you consistantly hear beats is the systolic pressure.
8. Continue to lower the pressure until the sounds muffle and disappear. This is the
diastolicpressure.
9. Record the blood pressure as systolic over diastolic ("120/70" for example).
Interpretation
Higher blood pressures are normal during exertion or other stress. Systolic blood
pressures below80 may be a sign of serious illness or shock.
Blood pressure should be taken in both arms on the first encounter. If there is more than
10mmHg difference between the two arms, use the arm with the higher reading for
subsequentmeasurements.
It is frequently helpful to retake the blood pressure near the end of the visit. Earlier
pressures maybe higher due to the "white coat" effect.
Always recheck "unexpected" blood pressures yourself.
Blood Pressure Classification in Adults
Category (systolic/diastolic):
Normal: <140/<90
Isolated Systolic Hypertension: >140/<90
Mild Hypertension: 140-159/90-99
Moderate Hypertension: 160-179/100-109
Severe Hypertension: 180-209/110-119
Crisis Hypertension: >210/>120
In children, pulse and blood pressure vary with the age. The following list should serve as
a rough guide. Average Pulse and Blood Pressure in Normal Children:
Birth: Pulse 140; Systolic BP 70
6 month: Pulse 130; Systolic BP 90
1 year: Pulse 115; Systolic BP 90
2 year: Pulse 110; Systolic BP 92
6 year: Pulse 103; Systolic BP 95
8 year: Pulse 100; Systolic BP 100
10 year: Pulse 95; Systolic BP 105
Notes
1. Unlike pulse, respirations are very much under voluntary control. If you tell the patient
you arecounting their breaths, they may change their breathing pattern. You cannot tell
someone to"breath normally," normal breathing is involuntary.
2. With an irregular pulse, the beats counted in any 15 second period may not represent the
overallrate. The longer you measure, the more these variations are averaged out.
3. Do not rely on pressures obtained using a cuff that is too small or too large. This is
frequently aproblem with obese or muscular adults where the regular cuff is too small.
The pressure recordedwill most often be 10, 20, even 50 mmHg too high! Finding a large
cuff may be inconvenient, butyou will also "cure" a lot of high blood pressure.
4. Maximum Cuff Pressure - When the baseline blood pressure is alreadyknown or
hypertension is not suspected, it is acceptable in adults toinflate the cuff to 200 mmHg
and go directly to auscultating the bloodpressure. Be aware that there could be
an auscultory gap (a silentinterval between the true systolic and diastolic pressures).
5. Bell or Diaphragm? - Even though the Korotkoff sounds are low frequency and should be
heardbetter with the bell, it is often difficult to apply the bell properly in the anticubital
fold. For thisreason, it is common practice to use the diaphragm when taking blood
pressure.
6. Systolic Pressure - In situations where ausculation is not possible, you can determine
systolicblood pressure by palpation alone. Deflate the cuff until you feel the radial or
brachial pulsereturn. The pressure by auscultation would be approximately 10 mmHg
higher. Record thepressure indicating it was taken by palpation (60/palp).
7. Diastolic Pressure - If there is more than 10 mmHg difference between the muffling and
thedisappearance of the sounds, record all three numbers (120/80/45)
DAFTAR TILIK PEMERIKSAAN TANDA VITAL *
KETERAMPILAN 0 1 2
A. PERSIAPAN
1. Persiapan alat yaitu stetoskop, termometer, dan tensimeter (ukuran cuff
manometer yang tepat, mengecek kunci reservoir air raksa, skrup sambungan,
serta memastikan skala akan terbaca sejajar ketinggian mata pemeriksa).
2. Mengucapkan salam (menyapa pasien dengan namanya) DAN
memperkenalkan diri.
Keterangan:
Perkenalkan diri terlebih dahulu sebelum menanyakan nama/identitas pasien
3. Menginformasikan tujuan DAN prosedurringkas pemeriksaan tanda vital
4. Menjaga privasi, ketenangan ruangan dan memastikan kenyamanan pasien.
Keterangan:
Contoh dengan menutup gordin atau pintu
5. Mencuci tangan, mempersiapkan peralatan dan mendekatkannya sehingga
mudah dijangkau dari tempat pemeriksaan.
Keterangan:
Mencuci tangan sesuai dengan standar WHO
6. Memposisikan diri di sebelah kanan pasien
B. PELAKSANAAN
PENGUKURAN TEMPERATUR AXILAR
7. Tawarkan kepada pasien kertas tissue untuk menyeka ketiak kirinya. Siapkan
wadah untuk membuang kertas tissue yang telah kotor.
Keterangan:
Menunjukkan kepada pasien di mana harus membuang kertas tissue.
8. Pegang termometer pada ujung yang berlawanan dengan bulbus air raksa,
bersihkan ujung termometer dengan kapas beralkohol dan keringkan.
9. Kibaskan termometer dengan gerakan mengibas cepat pada pergelangan tangan,
pastikan termometer menunjukkan angka di bawah skala pengukuran
Keterangan:
Perhatikan sekitar, jangan sampai membenturkan termometer sehingga pecah
atau pun lepas dari genggaman.
10. Tempatkan ujung termometer pada puncak fossa axillaris lengan kiri
11. Minta pasien menahan termometer dengan lengan atas sambil lengan bawah
disilangkan di depan dada, tangan berpegangan pada bahu kanan
12. Biarkan termometer di tempatnya hingga minimal 5 menit sambil pemeriksa
mengukur tanda vital selanjutnya.
PENGHITUNGAN DENYUT NADI
13. Pegang pergelangan tangan kanan dan kiri pasien pada arteri radialis dengan
menggunakan jari telunjuk dan jari tengah. Pastikan kedua denyut nadi memiliki
frekuensi, irama, isi, dan tegangan yang sama.
14. Lepaskan salah satu pergelangan tangan. Pegang pergelangan tangan kanan
pasien dengan tangan kanan pada arteri radialis dengan jari telunjuk dan jari
tengah.
15. Perhatikan irama, isi, dan tegangan denyut nadi.
Keterangan:
Sampaikan/narasikan
16. Jika nadi teratur, hitung denyutan selama 15 detik dan dikalikan 4 (Jika tidak
teratur hitung selama 1 menit)
Keterangan:
Sampaikan/narasikan hasil pengukuran
PENGHITUNGAN KECEPATAN RESPIRASI
17. Segera setelah menghitung nadi, tanpa memberitahu pasien dan tanpa
melepaskan pergelangan tangan pasien, perhatikan pengembangan dada.
Keterangan :
Sampaikan/narasikan
18. Perhatikan pola pernafasan
Keterangan:
Narasikan, apakah pernafasan normal atau tampak usaha bernafas
19. Hitung frekuensi nafas selama 15 detik dan dikalikan 4
Keterangan:
Sampaikan/narasikan hasil pengukuran
LANJUTAN PENGUKURAN TEMPERATUR
20. Beritahu pasien bahwa termometer akan diambil. Minta untuk tidak melepas
tahanan lengannya hingga pemeriksa memegang ujung luar termometer (supaya
tidak terjatuh).
21. Pegang ujung termometer di luar ketiak. Ambil dan baca segera termometer pada
posisi horizontal, setinggi mata pemeriksa
Keterangan:
Sampaikan/narasikan hasil pengukuran
22. Seka termometer dengan kapas beralkohol, kemudian letakkan di tempat aman
atau masukkan ke dalam gelas berisi desinfektan.
PENGUKURAN TEKANAN DARAH
23. Beritahu pasien bahwa akan dilakukan pengukuran tekanan darah pada lengan
kanannya. Minta pasien untuk melipat lengan bajunya hingga mendekati bahu.
24. Minta pasien untuk memposisikan lengan kanan pasien dengan benar, bantu jika
perlu:
- Longgarkan ikat pinggang
- Lepaskan seluruh perhiasan pada lengan yang akan diukur
- Telapak tangan menghadap ke atas (supinasi)
Keterangan:
Narasikan
25. Palpasi arteri Brachialis di medial tendo m. Biceps brachi pada fossa cubiti
26. Tempatkan bagian tengah cuff manometer di atas jalannya arteri, dengan batas
bawah cuff terletak setinggi 2,5 cm di atas fossa cubiti.
Keterangan:
Perhatikan: tempatkan gambar garis arteri () tepat di atas arteri. Jika gambar
tidak ada, pastikan bahwa bagian yang ditempatkan tepat di atas arteri adalah
bagian tengah cuff manometer.
Perhatikan: cuff jangan kendor, mengikatkan tali dengan rapi
27. Palpasi arteri radialis atau arteri brachialis dengan jari telunjuk dan jari tengah
tangan kiri
28. Tanyakan tekanan darah pada pemeriksaan sebelumnya
29. Putar klep hingga maksimal, kemudian pompa hingga denyut arteri radialis atau
arteri brachialis tidak teraba lagi, baca skala yang ditunjukkan saat itu. Ini adalah
tekanan sistolik palpasi.
Keterangan :
Sampaikan/narasikan hasil pengukuran
30. Kempiskan cuff kembali hingga benar-benar kempis, cek kembali posisi cuff
31. Tangan kiri menempatkan bellstetoskop di atas arteri brachialis antara
pertengahan fossa cubiti dan batas bawah cuff
32. Pompa kembali hingga 30 mmHg di atas tekanan sistolik palpasi
33. Turunkan kembali perlahan, tidak lebih dari 2 mmHg per detik.
34. Baca skala pada saat terdengar bunyi Korotkoff I (tekanan sistolik) dan terus
identifikasi bunyi Korotkoff hingga menghilang (Korotkoff V).
Keterangan:
Sampaikan/narasikan hasil pengukuran
35. Kempiskan cuff dengan cepat setelah Korotkoff V terdengar, lepas cuff, rapikan
manometer dan persilahkan pasien merapikan kembali lengan bajunya.
36. Mengembalikan peralatan pada tempatnya dan mencuci tangan
37. Mendokumentasikan hasil pemeriksaan dan menyampaikan hasilnya pada
pasien
TOTAL
KETERANGAN:
SKOR 2: dilakukan dengan sempurna
SKOR 1: dlakukan tapi belum sempurna
SKOR 0: tidak dilakukan
Nilai : (.................../ 74 ) x 100 =.............
Purwokerto,.............................
Penguji
.. ..
PEMERIKSAAN FISIK KEPALA DAN LEHER
Pemeriksaan fisik kepala dan leher secara umum dimulai dari menilai :
These nodes are usually smaller and smoother than the lobulated
submandibular gland against which they lie.
1. Submental : in the midline a few centimeters behind the tip of the mandible
2. Superficial cervical : superficial to the sternomastoid
8. Posterior cervical : along the anterior edge of the trapezius
10. Supraclavicular : deep in the angle formed by the clavicle and the
sternomastoid
Lokasi Kelenjar Limfe (Bates, 1995)
E. Pemeriksaan ekstremitas
Bates B, ed. A pocket guide to physical examination and history taking. 2 ed. Philadelphia: J.B.
Lippincot 1995.
Nama Mahasiswa :
NIM :
KETERAMPILAN 0 1 2
A. PERSIAPAN
2. Mengucapkan salam dan memperkenalkan diri
3. Menginformasikan tujuan dan prosedur ringkas pemeriksaan fisik
4. Memberi kesempatan bertanya dan mempersiapkan diri
5. Menjaga privasi dan memastikan kenyamanan pasien
6. Mencuci tangan
B. PELAKSANAAN
7. Inspeksi :Bentuk kepala, kulit, mata dan organ aksesorinya, hidung,
mulut, telinga
8. Palpasi: kulit kepala, rambut
MATA
9. Periksa refleks cahaya langsung dan konsensual (1 mata saja)
10. Periksa gerakan otot ekstrinsik bola mata
11. Periksa ada/tidaknya eksoftalmus. Bola mata diukur dari kantus
lateralis dengan menggunakan penggaris N < 16 mm
TELINGA
11. Inspeksi dan palpasi aurikula, tragus & antitragus
12. Inspeksi canalis auditivus melalui otoskop (disebutkan saja)
HIDUNG DAN SINUS PARANASALES
13. Inspeksi rongga hidung dengan spekulum hidung (disebutkan saja)
14. Palpasi sinus maksilaris & frontalis terhadap nyeri tekan
MULUT DAN FARING
15. Inspeksi seluruh penyusun rongga mulut dan orofaring (menggunakan
spatula lidah &senter)
16. Uji kesimetrisan palatum mole dengan mengucapkan
AAAAAAAAA
LEHER
17. Inspeksi leher: kulit, asimetri, posisi trakea, kelenjar tiroid
18. Palpasi kelenjar limfe: preaurikuler,occipital,posterior
auricular,tonsillar,submandibular,submental,superficial
cervical,posterior cervical & supraclavicular.Nilai adanya
benjolan,bentuk,ukuran,jumlah,mobile/imobile,konsistensi,nyeri,tanda
2 peradangan.
19. Palpasi posisi trakea dengan menggunakan satu jari & bandingkan
dengan sisi satunya, normal jarak kanan & kiri sama. Perhatikan
apakah trakhea mengalami deviasi/tidak.
20. Palpasi kelenjar tiroid dari belakang saat istirahat dan saat menelan air,
diraba sampai kelateral dinilai simetris /asimetris,tepi & konsistensi.
EKSTREMITAS
21. Inspeksi (eritema palmar, hiperhidrosis)
22. Pemeriksaan tremor halus, jika tidak yakin adanya tremor halus dapat
menggunakan kertas.
C DOKUMENTASI
23. DOKUMENTASI HASIL PEMERIKSAAN DAN
MENGINFORMASIKAN HASIL PEMERIKSAAN KEPADA
PASIEN
KETERANGAN:
Nilai 2 : Dilakukan dengan:
- Teknik lege artis DAN
- Berurutan (kepala dan wajah diselesaikan dahulu, baru periksa leher) DAN
- Penggunaan alat bantu yang tepat DAN
- Menyebutkan secara ringkas apa yang dinilai/diinterpretasi, atau organ/bagian organ
apa yang diamati
..............................................