Pengkajian Keperawatan

Health Assessment
Nursing Assessment
Health history
Physical exam
Nursing History
Patient profile
Chief complaint
Past history
Family history
Medications
Allergies
Review of systems
Pain
Palliative/provocative
Quality/quantity
Regio/ radiation
Severety
Time
Examination Techniques
Inspection
Palpation
Percussion
Auscultation
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Inspection
Visual assessment of the patient and surroundings
Findings that may be significant:
Patient hygiene
Clothing
Eye gaze
Body language
Body position
Skin color
Odor
Inspection
If the emergency response was to the

patient's home, make a visual inspection for
Cleanliness
Prescription medicines
Illegal drug paraphernalia
Weapons
Signs of alcohol use
Palpation
A technique in which the hands and fingers are used to gather

information by touch
Palmar surface of fingers and finger pads are used to palpate for
Texture
Masses
Fluid
Crepitus
And assess skin temperature
Palpation may be either superficial or deep

Deep Bimanual Palpation
Percussion
Used to evaluate for

presence of air or
fluid in body tissues
Sound waves heard

as percussion tones
(resonance)
Procedure
Auscultation
Best performed in a quiet environment
Requires a stethoscope
Body sounds produced by movement of fluids or gases in patient's

organs or tissues
Note:
Intensity
Pitch
Duration
Quality
Stethoscope
Used to evaluate sounds created by

cardiovascular, respiratory, and
gastrointestinal systems
Stethoscopes
Acoustic
Magnetic
Electronic
Stethoscope
Position stethoscope
between index and
middle fingers
Ophthalmoscope
Used to inspect eye

structures:
Retina
Choroid
Optic nerve disc
Macula
Retinal vessels
Otoscope
Used to examine
deep structures of
the external and
middle ear
Blood Pressure Cuff
Sphygmomanometer
Measures systolic and

diastolic blood pressure
Manual or electronic
Comprehensive Physical Examination
Mental status
Chest
General survey
Abdomen
Vital signs
Posterior body
Skin
Extremities
Head, eyes, ears, nose, and

throat (HEENT)
Neurological exam
Mental Status
First step in patient care encounter

Patients appearance and behavior
Level of consciousness
A healthy patient is expected to be alert, responsive

to touch, verbal instruction, and painful stimuli
Mental Status
Appearance and behavior

Posture, gait, and motor activity
Dress, grooming, personal hygiene
Breath or body odors
Facial expression
Mood and affect
Speech and language
Thought and perceptions
Memory and attention
General Survey
Signs of distress
Cardiorespiratory insufficiency
Pain
Labored breathing
Wheezing
Cough
Wincing
Sweating
Protectiveness of a painful body part or area
Anxiety
Restlessness
Anxious expression
Fidgety movement
Cold, moist palms
General Survey
Apparent state of health
Skin color and obvious lesions
Height and build
Sexual development
Weight
Skin Color
Varies from person to person
Varies based on ethnicity
May range in tone from pink or ivory to
deep brown, yellow, or olive
Observe for skin not exposed to sun (e.g.,
palms)
Skin Lesions
Height and Build
Descriptions include:
Average, tall, short, lanky, muscular
May also be affected by age and lifestyle
Sexual Development
Determine if age appropriate
Observe for normal changes associated with

age
Weight
Observe general appearance
Obese to emaciated
Recent changes may be key finding
Recent weight loss or gain
Vital Signs
Pulse
Blood pressure
Respirations
Skin
Pupils
Pulse
Rate
Rhythm
Quality
Consider ECG monitoring
Blood PressureLocations
Respirations
Adult rate
12-24 breaths per minute
Observe
Feel for chest movement
Auscultate
Skin
Texture
Turgor
Hair
Fingernails and toenails
Abnormal findings
Temperature Measurement
Oral temperature
Hold thermometer
firmly under tongue
Tell child to kiss
Caution to avoid biting
Axillary Temperature
Hold arm down
firmly
Should be
approximately 1 F
less than core temp
Tympanic Temperature
Accuracy
questionable
Pull ear back
Insert gently
Rectal Temperature
Risk of perforation
Avoid in
uncooperative, or
immuno-suppressed
patient
Stabilize thermometer
EyesVisual Acuity
Have patient
Read printed material

Count fingers at a
distance
Demonstrate ability to
tell light from dark
Use eye chart
(e.g., Snellen chart)
EyesPupils
Findings may indicate neurological issues
Examine response to light (PERRL)
Pupils are equal, round, and react to light
Anatomical Regions
Skin
Texture
Turgor
Hair
Fingernails and toenails
Head, ears, eyes, nose, throat

Head and Face

Inspect skull for shape and symmetry
Palpate for swelling, tenderness, lesions,
indentations
Inspect face for symmetry, expression,
edema, involuntary movements
Sinuses
Return to Head and Neck
Eyes
Determine
if contacts are present

Determine that both eyes can see
Assess visual acuity
Inspect orbital area for edema
Examine eyes for drainage or redness
Determine structural integrity
EyesVisual
Fields
Six cardinal fields of gaze
Cardinal Fields of Gaze
Visual Fields
Ask the patient to look at his or her nose
Test peripheral vision by extending your arms

with elbows at right angles and wiggle both
index fingers simultaneously
Observe eyes for normal position and

alignment
Ophthalmoscopic Examination
Used to evaluate:
Cornea
Foreign bodies
Lacerations
Abrasions
Infection
Anterior chamber
Hyphema
Hypopyon
Fundus
Optic nerve
Retina
Vitreous
Eyelid
Cornea and Sclera
Examine conjunctiva
and sclera
Palpate lower orbital

rim
Inspect:
Size, color, and clarity
of the disc
Integrity of vessels
Assess for retinal
lesions and
appearance of the
macula
Normal findings
Clear, yellow optic
nerve disc
Reddish pink
(European-American)
or darkened retina
(African-American)
Light red arteries
Dark red veins
3:2 vein-to-artery ratio
Otoscopic Examination
Otoscope used to:

Evaluate inner ear for discharge and foreign
bodies
Assess eardrum
Select speculum
Turn on otoscope
Insert speculum into ear canal,

slightly down and forward
Look for foreign bodies, lesions,

discharge
Inspect tympanic membrane

Normal findings
Cerumen is dry (tan or light yellow) or moist
(dark yellow or brown)
Ear canal
Not inflamed
Tympanic membrane
Translucent or pearly gray
Nose
Inspect
Palpate
Discharge from the nose
CSF
Epistaxis
Mucous discharge
Mouth and Pharynx
Lips
Gums
Mouth and tongue
Pharynx
Oropharynx
Neck
Inspect
Use spinal precautions

if trauma is suspected
Palpate trachea
Midline position
normal
Neck
Palpate
Place both thumbs along sides of distal trachea
Systematically move toward head
Do not apply bilateral pressure to carotid
arteries
Return to Head and Neck Slide
Measuring JVD
Head and Cervical Spine
Temporomandibular joint (TMJ)
Inspect and palpate cervical spine
Range of motion
Chest
Ribs
Protect thoracic organs
Support respiratory movements of diaphragm
and intercostal muscles
Anatomical landmarks for examination
Topographical Landmarks
Thoracic LandmarksAnterior Chest
Thoracic LandmarksPosterior Chest
Inspection
General appearance of chest
Chest wall configuration

Inspect for symmetry
Chest wall should be symmetrical
Chest Wall Abnormalities
Barrel chest
Funnel chest (pectus

excavatum)
Pigeon chest (pectus

carinatum)
Thoracic kyphosis
Scoliosis
ChestPalpation
Tracheal position
Respiratory excursion
Breast Exam Techniques
Documenting the Breast Exam
Percussion and Auscultation of Chest
Respiratory Effort
Assess:
Respiratory rate, rhythm, symmetry, and quality
Patient position
Accessory muscles
Retractions (intercostal, supraclavicular, or
both)
Nasal flaring
Pausing to take a breath
Respiratory Patterns
Eupnea
Tachypnea
Bradypnea
Hyperpnea
Hyperventilation
Dyspnea
Orthopnea
Paroxysmal nocturnal
dyspnea
Apnea
Cheyne-Stokes respiration
Kussmaul breathing
Biots respirations
Central neurogenic
hyperventilation
Auscultation
Patient in sitting position (if possible)
Instruct to breathe deeply and slowly
through open mouth
Use diaphragm of stethoscope
Evaluate anterior and posterior lung fields
Normal Breath Sounds
Classified as:
Vesicular
Bronchovesicular
Bronchial
Vesicular Breath Sounds
Most of lung fields
Lungs considered "clear" make

normal vesicular breath sounds
Harsh vesicular breath

sounds
Diminished vesicular breath

sounds
Bronchovesicular Breath Sounds
Major bronchi and upper right

posterior lung field
Louder and harsher than
vesicular breath sounds
Medium pitch
Equal inspiration and
expiration phases
Heard throughout
respiration
Bronchial Breath Sounds
Only over trachea
Highest in pitch
Coarse, harsh, loud sounds
Short inspiratory phase and

long expiration
Bronchial sound anywhere but

over trachea is abnormal
Abnormal Breath Sounds
Absent
Diminished
Incorrectly located
bronchial sounds
Adventitious
Discontinuous
Continuous
Breath Sounds
Fig.
Fig.11-26
11-26
Discontinuous Breath Sounds
Crackles
Formerly called rales
High-pitched discontinuous sounds
Usually at end of inspiration
Disease of small airways or alveoli
Coarse crackles: wet, low-pitched sounds
Fine crackles: dry, high-pitched sounds
Continuous Breath Sounds
Wheezes
Rhonchi
Stridor
Pleural friction rub

Heart
Assessment includes:
Palpation
Auscultation
Pulse
Assess:
Rate
Rhythm
Intensity
Palpate pulses simultaneously on both sides

of body
Except carotid
Pulse
Auscultate for:
Frequency (pitch)
Intensity (loudness)
Duration
Timing in cardiac cycle
Cardiac Circulation
Auscultating Heart Sounds
Heart Sounds
S1
Instruct patient to breathe normally and then

hold breath in expiration
S2
Instruct patient to breathe normally again and

then hold breath in inspiration
Pericardial Friction Rub
Inflammation of pericardial sac
Scratching, grating, or squeaking quality
Louder during inspiration
Differs from pleural friction rubs by

continued presence during breath holding
Heart Murmurs
Prolonged extra sounds
Caused by disruption in flow of blood

through heart
Most caused by valvular defects
Some serious
Others benign
Have no apparent cause

Bruit
Abnormal sound or
murmur
Heard while
auscultating carotid
artery, organ or gland
May be local
obstruction
Often low pitched
Hard to hear
Thrills
Vibrations or tremors
May indicate blood flow obstruction

May palpate over aneurysm or on precordium
Serious or benign
Abdomen
Two imaginary lines

separate abdominal
region into four
quadrants
AbdomenInspection
Skin
Umbilicus
Contour
Abdominal movement
Abdomen
Auscultation
Bowel sounds
Bruits
Percussion and palpation
Detect:
Fluid
Air
Solid masses
Percussion
Evaluate four quadrants of abdomen:
Tympany
Dullness
Air in stomach and intestines

Solid abdominal organs and solid masses
Proceed from tympany to dullness
Change in sound easier to detect

Palpation of the Liver
Palpation of the Spleen
Female Genitalia
If possible, use same-gender paramedics to

examine
Chaperone if possible
Inspect external genitalia for:

Swelling
Discoloration or redness
Bleeding
Trauma
Lesions
Discharge
Female Genitalia
Normal vaginal discharge
Clear or cloudy with little or no odor
Yellow-green discharge
Frothy, gray-green discharge with foul odor
White, curdlike discharge with no odor
Gray discharge with fishy, foul odor
Male Genitalia
Inspect for bleeding or trauma
Penis
Urethral opening
Shaft nontender and flaccid

Priapism
Free of blood and discharge
Scrotum
Nontender and slightly asymmetrical

Male Genitalia
Anus
Exam indicated if:

Rectal bleeding
Trauma to area
Most patients find side-lying position most

comfortable
Protect patients privacy
Male Genitalia
Inspect sacrococcygeal and perineal areas for:

Lumps
Ulcers
Inflammation
Rashes
Excoriations
Inflamed external hemorrhoids common
Adults and pregnant women

Musculoskeletal System
Assess function and structure
Patient position
Evaluate head, neck, shoulders, and upper

extremities with patient in a sitting position
Evaluate chest, back, and ilium with patient
standing
Evaluate hips, knees, ankles, feet with patient supine
Observe general appearance, body proportions,

and ease of movement
General Principles
Examine normal tissues before those

injured, inflamed, or otherwise affected
Inspect and palpate each body part
Then test range of motion and muscle strength
Note differences between right and left

Extremities
Evaluate:
Skin and tissue over muscles, cartilage, bones
Joints for injury, discoloration, swelling, masses
Circulatory status
Skin color and temperature

Distal pulses
Structural integrity of bones, joints, and tissues

Muscle tone
Abnormal Findings
Signs of inflammation
Swelling
Tenderness
Increased heat
Redness of overlying
skin
Decreased function
Asymmetry
Crepitus
Deformities
Decreased muscle
strength
Atrophy
Joints
Bones move freely over one another
Move each joint through full range of

motion
No clicks, crepitation, or pain
Normal if no pain, deformity, limitation, or

instability
Note:
Limited range of motion
Unusually increased joint mobility
Hands and Wrists
Inspect for swelling, redness,

deformity, nodules, muscular
atrophy
Palpate joint
Note swelling, tenderness,

deformity
Range of motion
Test muscle strength by hand
grip
Clubbing of Fingernails
Elbows
Inspection
Palpation
Examine in flexed and extended

position
Note deformity, swelling, nodules
Lateral and medial epicondyles of

humerus
Groove on sides of olecranon
process
Range of motion
Shoulders and Related Structures
Inspect shoulders, shoulder girdle,

scapulae, and related posterior muscles
Symmetry of size and shape
Note swelling, deformity, muscular atrophy
Palpate for tenderness in:

Sternoclavicular joint
Acromioclavicular joint
Subacromial area
Biceps groove
Note any tenderness or swelling
Range of motion
Ankles and Feet
Skin integrity
Nodules
Contour
Swelling
Position
Calluses
Deformities
Corns
Size
Ankles and Feet
Palpate:
Anterior aspects of each ankle joint
Achilles tendon
Metatarsophalangeal joints
Note tenderness, swelling, deformity
Ankles and Feet
Range of motion
Dorsiflexion
Plantar flexion
Inversion
Eversion
Pelvis
Pelvic structural
integrity
Hands on anterior iliac

crests
Press down and out
Heel of hand on
symphysis pubis
Press down
Hips
Inspect for symmetry
Palpate:
Instability, tenderness, and crepitus
Range of motion (supine patient)

Raises knee to chest, other leg straight
Note flexion at hip and knee
Knees
Inspection
Patella smooth, firm, nontender, midline
Alignment, swelling, and deformity
Note atrophy of quadriceps
Palpation
Note thickening, swelling, tenderness
Range of motion
Bend, straighten each knee without pain

Peripheral Vascular System
Arteries, veins,
lymphatic system
and lymph nodes,
fluids exchanged in
capillary bed
Arms
Inspect fingertips to shoulders, noting:
Size and symmetry

Swelling
Venous pattern
Color of skin and nail beds
Skin texture
Palpate:
Radial pulses bilaterally

Epitrochlear node
If palpable, note its size and consistency

Legs
Patient supine and appropriately draped
Inspect from groin and buttocks to feet:
Size and symmetry

Swelling
Venous pattern and venous enlargement
Pigmentation
Rashes, scars, ulcers
Color and texture of the skin
Presence or absence of hair growth
Legs
Palpate superficial inguinal nodes
Swelling and tenderness
Palpate pulses:
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Temperature of feet and legs

Legs
Check for pitting edema:
Press firmly but gently with the thumb for at

least 5 seconds
Over dorsum of foot
Behind medial malleolus
Over shins
Abnormal Findings
Swollen or asymmetrical extremities
Pale or cyanotic skin
Weak or diminished pulses
Skin cold to the touch
Absence of hair growth
Pitting edema
Spine
Inspection
Cervical, thoracic, and

lumbar curves
Lordosis (swayback)
Kyphosis (hunchback)
Scoliosis (razorback)
Height differences of
shoulders
Height differences of
iliac crest
Cervical Spine
Inspection
Should be in a midline position
Look for deformities and abnormal posture
Palpation
If patient is alert and denies neck pain, palpate

posterior aspect of neck for point tenderness and
swelling
Cervical Spine
Range of motion
If no suspected injury:
Bend head forward,

chin to chest (flexion)
Bend head backward
(hyperextension)
Move head side-to-side
(lateral bending)
Should be no pain or
discomfort
Thoracic and Lumbar Spine

Inspect for injury, swelling, discoloration
Palpate from first thoracic vertebra
Move downward to sacrum
Range of motion
Bend forward at waist
Bend backward at waist
Bend to each side
Rotate upper trunk in a circular motion
Nervous System
Detail of neurological examination varies
Depends on patients complaint
Peripheral nervous system vs. CNS problems
Neurological Examination
Mental status and speech
Cranial nerves
Motor system
Sensory system
Reflexes
Mental Status and Speech
Oriented to person, place, and time
Organizes thoughts and converses freely
If no hearing or speech impediments
Mental Status and Speech
Abnormal findings
Unconsciousness
Confusion
Slurred speech
Aphasia
Dysphonia
Dysarthria
Cranial Nerve Assessment
Cranial nerve I
Cranial nerve II
Olfactory: Test sense of smell with spirits of ammonia
Optic: Visual acuity
Cranial nerve II and III
Optic and oculomotor
Size and shape of pupils

Pupil response to light
Cranial nerves III, IV, VI
Oculomotor, trochlear, abducens

Extraocular movements
Six cardinal directions of gaze
Cranial nerve V
Trigeminal
Ask patient to clench teeth while palpating temporal
and masseter muscles
Test sensation by touching forehead, cheeks, jaw on
each side
Cranial nerve VII
Facial
Inspect face: note symmetry, tics, abnormal movements
Raise eyebrows, frown, show both upper and lower
teeth, smile, puff out cheeks
Close eyes tightly so they cannot be opened, gently
attempt to raise eyelids
Observe for weakness or asymmetry
Cranial nerve VIII
Acoustic: Assess hearing acuity
Cranial nerves IX and X
Glossopharyngeal and vagus

Ability to swallow with ease; to produce saliva;
produce normal voice sounds
Patient holds breath: assess for normal slowing of
heart rate
Testing for gag reflex will test cranial nerves
Cranial nerve XI
Spinal Accessory
Raise and lower shoulders, turn head
Cranial nerve XII
Hypoglossal
Stick out tongue and move it in several directions

Motor System
Observe patient during movement and at rest
Abnormal involuntary movements evaluated
for:
Quality
Rate
Rhythm
Amplitude
Motor System
Other body movement assessments:

Posture
Level of activity
Fatigue
Emotion
Muscle strength
Bilaterally symmetrical
Resistance to opposition
Muscle Strength
Patient to move against resistance:

No muscular contraction detected
A barely detectable flicker or trace of contraction
Active movement of body part with gravity eliminated
Active movement against gravity
Active movement against gravity and some resistance
Active movement against full resistance
This is normal muscle tone
Upper Extremity Evaluation
Patient to extend
elbow and pull it
toward the chest
against resistance
Lower Extremity Evaluation
Patient pushes soles of

feet against examiners
palms
Patient pulls toes
toward head against
resistance
Should be easily
performed by patient
without fatigue
Muscle Strength
Other methods can be used to evaluate

muscle strength, including tests for:
Flexion
Extension
Abduction
Upper and lower extremities
Coordination
Point-to-point movements
Gait
Stance
Romberg test
Pronator drift test
Romberg Test
Pronator Drift Test
Sensory System
Conduct sensations of:

Pain
Temperature
Position
Vibration
Touch
A healthy patient is responsive to these

stimuli
Sensory System
Patients response to pain and light touch
Response considered in relation to dermatomes
Perform light touch on hands and feet
If patient cannot feel or is unconscious, gently

prick extremities with sharp object that will not
penetrate skin
Head to toe
Compare symmetrical areas
Approaching the Pediatric Patient

Remain calm, confident
Avoid separating child from parent
Establish rapport with parents and child
Be honest with child and parent
Have one paramedic stay with child
Observe child before physical examination
Begin assessment without touching patient
Note:
Skin color
Respiratory rate
Assess behavior
Note area of body that appears painful

Avoid painful area until end of examination
Warn child before you touch painful area(s)
General Appearance
Assess from a distance:

Spontaneous movement
Respiratory effort
Skin color
Body position
Seriously ill or injured child does not

hide or disguise condition
Birth to 6 Months
Maintain body temperature
Poor head control normal under 3 months of
age
Infants are abdominal breathers
Stomach protrudes and chest wall retracts

during inspiration
Birth to 6 Months
Assess anterior fontanel:

Present up to 18 months
Bulges during crying
Firm if child is supine
If sunken, may be
dehydration
Bulging fontanel may
mean increased
intracranial pressure
7 Months to 3 Years
Usually cooperative
Minimal speech, unreliable history
May have separation anxiety
If possible, have parent hold child for exam
May see illness or injury as punishment
Approach slowly and speak in reassuring tones
Use simple and direct questions
4 to 10 Years
May be cooperative
May provide limited history of event
May have separation anxiety and view illness or
injury as punishment
Approach slowly
Speak in quiet, reassuring tones
Allow child to "help"
Reluctant to show "private parts
Advise of any expected pain or discomfort
Adolescents (11 to 18 years)

Generally calm, mature, helpful
Concerned about modesty, disfigurement,
pain, disability, and death
Reassure when appropriate
Respect patient's need for privacy
If possible, interview privately
Consider alcohol, drug use, pregnancy
Communicating with the Older Adult
Allow time for effective communication
Stay close to patient during interview
Repetition of questions may be needed
Do not patronize or offend patient

Patient History
Multiple health problems
Difficult to isolate injury or illness
Decreased sensory function may disguise signs and symptoms
Watch for illness from medication use or misuse
Consider relationship between drug interactions, disease, and

aging process
Patient History
Functional ability and daily activities
Walking
Getting out of bed
Dressing
Driving a car
Using public transportation
Preparing meals
Taking medications
Sleeping habits
Bathroom habits
Physical Examination
Try to ensure patient comfort

Offer clear explanations
Answer questions
Be alert to chronic pain
If hospital transport necessary
Attempt to calm patient
Reassure patient he or she will be cared for in
hospital
Record examination findings
Conclusion
The Nurse must have a wide range of
knowledge and skills to perform a
comprehensive physical examination and to
make effective clinical patient care
decisions.
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Health Assessment

Visual assessment of the patient and surroundings

Findings that may be significant:

If the emergency response was to the

A technique in which the hands and fingers are used to gather

Palpation may be either superficial or deep

Deep Bimanual Palpation

Used to evaluate for

Sound waves heard

Best performed in a quiet environment

Body sounds produced by movement of fluids or gases in patient's

Used to evaluate sounds created by

Used to inspect eye

Blood Pressure Cuff

Measures systolic and

Comprehensive Physical Examination

Head, eyes, ears, nose, and

First step in patient care encounter

A healthy patient is expected to be alert, responsive

Appearance and behavior

Height and Build

Average, tall, short, lanky, muscular

May also be affected by age and lifestyle

Determine if age appropriate

Observe for normal changes associated with

Observe general appearance

Recent changes may be key finding

Recent weight loss or gain

12-24 breaths per minute

Pull ear back

Read printed material

Findings may indicate neurological issues

Examine response to light (PERRL)

Pupils are equal, round, and react to light

Head, ears, eyes, nose, throat

Head and Face

Return to Head and Neck

if contacts are present

Cardinal Fields of Gaze

Return to Head and Neck

Ask the patient to look at his or her nose

Test peripheral vision by extending your arms

Observe eyes for normal position and

Cornea and Sclera

Palpate lower orbital

Otoscope used to:

Insert speculum into ear canal,

Look for foreign bodies, lesions,

Inspect tympanic membrane

Translucent or pearly gray

Mouth and Pharynx

Mouth and tongue

Return to Head and Neck

Use spinal precautions

Return to Head and Neck Slide

Head and Cervical Spine

Temporomandibular joint (TMJ)

Inspect and palpate cervical spine

Thoracic LandmarksAnterior Chest

Thoracic LandmarksPosterior Chest

General appearance of chest

Chest wall configuration

Chest Wall Abnormalities