STANDARD OPERATING PROCEDURE for HEART PHYSICAL EXAMINATION

No. STANDARD OPERATING HEART PHYSICAL EXAMINATION

PROCEDURE
Cardiac physical examination is a non-invasive examination
1. DEFINITION used to determine the condition of the heart, through a physical
examination consisting of Inspection, Palpation, Percussion,
and Auscultation.

2. PURPOSE Examination is done to determine the physical condition of the

heart.

Patients in:
3. INDICATION 1. Routine physical examination (check up)
2. Assess for symptoms such as chest pain, shortness of
breath, dizziness, fainting, or palpitations.

4. OFFICER Nurse
5. EQUIPMENT Stetoscope
6. IMPLEMENTATION A. PRE-INTERACTION STAGE
PROCEDURE 1. Check patient needs and equipment

B. WORKING STAGE
1. Wash your hands
2. Give greetings
3. Explain the purpose of the examination
4. Explain the steps and work procedures
5. Ask the patient readiness
6. Lay the patient quietly and comfortably in bed
7. INSPECTION : Inspection by observation
Purpose :
 Thoracic examination to see if the shape of the
chest wall is normal or there are abnormalities
such as pectus carinatum, pectus excavatum, or
barrel chest
 Identify the location of the ictus cordis and
whether there are other pulses in the chest wall
area.
 Check pulse for cyanosis, clubbing, and
capillary refill
 Examination of edema in the legs
 See if there are venous dams on the chest wall
 Look at the pulse iktus cordis
Results :
 Normal : Pulsasi terlihat pada pasien yang kurus,
tidak terlihat pada pasien yang gemuk
 Abnormal : Pulsasi terlihat pada pasien yang
gemuk
 8. PALPASI : Pemeriksaan dengan cara sentuhan, rabaan,
dan tekanan
Tujuan :
 Mencari pulsasi iktus cordis (secara normal :
iktus cordis terletak di garis midklavikula
sinistra Intercostae V)
 Denyut jantung dapat dihitung pada iktus cordis
(wlaupun cara ini tidak lazim dilakukan)
Hasil :
 Normal : Pulsasi teraba pada pasien yang kurus,
tidak teraba pada pasien yang gemuk
 Abnormal : Pulsasi teraba pada pasien gemuk

9. PERKUSI : Pemeriksaan dengan cara mengetuk jari

tengah tangan kiri yang diletakkan pada tubuh pasien.
Tujuan :
 Menentukan batas kanan jantung
 Batas kanan jantung ditentukan setelah batas
paru hepar ditemukan
 Menentukan batas kiri jantung
 Batas kiri jantung ditentukan setelah batas paru
– lambung ditemukan
Hasil :
 Normal : Bunyi pekak/datar
 Abnormal : Bunyi pekak datar karena
cardiomegali
10. AUSKULTASI : Pemeriksaan dengan menggunakan
stetoscope.
Tujuan :
Mendengarkan bunyi jantung I (saat katup mitral dan
trikuspidal menutup) dan bunyi jantung 2 (saat katup
aorta dan pulmonal menutup ) pada masing-masing
katup jantung.
NOTE :
 Katup mitral terletak di garis midklavikula
sinistra intercostae V
 Katup trikuspidal terletak di garis parasternal
sinistra intercostae IV
 Katup aorta terletak di garis sternalis dextra
intercostae II
 Katup pulmonal terletak di garis sternalis sinistra
intercostae II
HASIL :
 Normal : Lup-Dup
 Abnormal : Terdapat bunyi tambahan

C. TERMINATION STAGE
1. Open the curtains and take the equipment to the storage
area
 2. Wash your hands
3. Document the actions anda result that have been carried
out

D. DOCUMENTATION STAGE
1. Record the date and time of the implementation of the
action.
2. Record the result of the assesment before, during, and
after the procedure.
3. Record the result of patient observation during and after
the procedure.