PENGKAJIAN FISIK KEPERAWATAN PENGANTAR UNTUK MAHASISWA KEPERAWATAN Outline
Pendahuluan 1. Wawancara Wawancara Keperawatan 2. Pengkajian Fisik : Pendekatan, tehnik pengkajian, kriteria, metode Pengkajian Fisik sistem "head "head to toe" toe " meliputi : a. <!!endi#$!!%&istem &'ara# Pusat (. <!!endi#$!!%&istem )antung dan pem(uluh darah c. <!!endi#$!!%&istem Perna#asan d. <!!endi#$!!%&istem Pencernaan e. <!!endi#$!!%&istem Perkemihan #. <!!endi#$!!%&istem *ntegumen g. <!!endi#$!!%&istem +uskuloskeletal h. <!!endi#$!!%&istem Ph'sikososial . -okumentasi Keperawatan Pendahuluan
Pengkajian #isik keperawatan pada klien dalam kondisi sehat!sakit penting dilakukan oleh perawat untuk menentukan data su(jekti# dan data o(jekti# 'ang Asuhan akan dipergunakan dalam merumuskan Diagnosa dan Renana Asuhan Ke!e"a#atan .
Proses pengkajian #isik keperawatan meliputi tiga tahap :
1. Wawanc Wawancara ara (Inte (Intervi rview) ew) 2. Peme Pemeri riks ksaa aan n fisi fisik k
3. Pendokumentasian : yang meliputi taapan perumusan diagnosa keperawatan! tu"uan dan rencana intervensi keperawatan.
$% <!!endi#$!!%Wa#ana"a &Inte"'ie#(
ujuan dari wawancara adalah untuk merumuskan data base 'ang lengkap 'ang nantin'a (erhu(ungan dengan data sekarang dan masa lalu status kesehatan klien, 'ang nantin'a mem(antu perawat men'usun /suhan keperawatan dan mem(ina hu(ungan saling perca'a 0 trust relationship dengan klien. asil wawancara ini juga akan mampu menggali in#ormasi tentang persepsi pasien terhadap kesehatan, perhatian tentang sehat!sakit dan ke(utuhan pen'uluhan kesehatan. Ke(erhasilan dalam wawancara sangat (ergantung terhadap ketrampilan komunikasi keperawatan si perawat 'ang (ersangkutan dan penerimaan klien, serta kondisi dan situasi lingkungan. Faktor 'ang mempengaruhi hasil suatu wawancara adalah : keter(atasan privacy, stress emosional dan #isik, ham(atan (ahasa dan adan'a interupsi dari pihak lain. /pa(ila tidak memungkinkan melakukan wawancara dengan klien, maka sum(er data dapat diperoleh dari file3rekam medik, catatan keperawatan, dan riwa'at pengo(atan, pen'akit dan dari keluarga. 4e(erapa kriteria penting dalam wawancara meliputi : status kesehatan saat ini, keluhatan utama dan gejala 'ang dirasakan, riwa'at pen'akit masa lalu, riwa'at sosial dan keluarga, manajemen pengo(atan dan perawatan saat ini, persepsi tentang pen'akit 'ang diderita dan pemahaman akan penatalaksanaan medis dan rencana keperawatan Wawancara 'ang dilakukan hendakn'a mengarahkan perawat untuk memudahkan dalam pengkajian #isik terkait dengan keluhan klien, sehingga ter#okus kepada satu sistem tu(uh 'ang terkena pen'akit. 2. Pemeriksaan Fisik
-ari hasil wawancara maka perawat akan dapat le(ih ter#okus kepada satu sistem tu(uh 'ang terkait dengan pen'akit 'ang diderita klien. /da 2 metode pendekatan dalam pemeriksaan #isik 'aitu pendekatan sistem tubuh dan pendekatan head to toe 0ujung kepala 5 ke kaki. &angat direkomendasikan kita mengkom(inasikan
kedua pendekatan terse(ut &angat (aik jika kita se(agai perawat memulai pemeriksaan #isik dari kepala dan leher, kemudian ke dada, dan a(domen, daerah pel6is, genital area, dan terakhir di ekstremitas 0tangan dan kaki. -alam hal ini dapat saja (e(erapa sistem tu(uh dapat die6aluasi sekaligus, sehingga pendokumentasiann'a dapat dilakukan melalui pendekatan sistem tu(uh. ehnik 'ang dilakukan meliputi inspeksi, palpasi, perkusi dan auskultasi . 7mumn'a semua (erurutan, kecuali pengakajian #isik di a(domen 'ang auskultasi dilakukan setelah inspeksi. *nspeksi dilakukan melalui pengamatan langsung, termasuk dengan pendengaran dan penciuman. &edangkan palpasi dengan menggunakan tangan kita untuk merasakan tekstur kulit, mera(a adan'a massa di (awah kulit, suhu tu(uh dan 6i(rasi3getaran juga dapat dipalpasi. 4er(eda dengan perkusi 'ang digunakan untuk mendengar suara 'ang dipantulkan jaringan tu(uh di (awah kulit atau struktur organ. &uara 'ang dihasilkan dari ketukan tangan kita dapat dinilai dari timpani atau resonan dan dull atau flat . &edangkan auskultasi dengan menggunakan stetoskop untuk mendengarkan suara organ tu(uh, dan penting untuk mengkaji sistem pernapasan, jantung dan sistem pencernaan. &edangkan kriteria pemeriksaan #isik 'ang penting adalah meliputi : a. anda!tanda 6ital 3 vital sign 0suhu, nadi, pernapasan dan tekanan darah (. 8(ser6asi keaadaan umum pasien dan perilakun'a c. Kaji adan'a peru(ahan penglihatan dan pendengaran d. Pengakajian head to toe seluruh sistem tu(uh dengan memaksimalkan tehnik inspeksi, palpasi, perkusi dan auskultasi 4erikut ini merupakan detail pemeriksaan #isik, 'ang meliputi head to toe dan pendekatan sistem tu(uh adalah : <!!i# support9ists$!!%a. <!!endi#$!!% Sistem syaraf pusat
1. #a"i $%& (level of consiousness) atau tingkat kesadaran : dengan melakukan pertanyaan tentang kesadaran pasien teradap waktu! tempat dan orang 2. #a"i status mental 3. #a"i tingkat kenyamanan! adanya nyeri dan termasuk lokasi! durasi! tipe dan pengo'atannya. . #a"i fungsi sensoris dan tentukan apaka normal atau mengalami gangguan. #a"i adanya ilang rasa! rasa ter'akarpanas dan 'aal. *. #a"i fungsi motorik seperti : genggaman tangan! kekuatan otot! pergerakan dan postur +. #a"i adanya ke"ang atau tremor ,. #a"i catatan penggunaan o'at dan diagnostik tes yang mempengarui --P.
<!!i# support9ists$!!%b. <!!endi#$!!% Sistem Kardiovaskular
1. #a"i nadi : frekuensi! irama! kualitas (keras dan lema) serta tanda penurunan kekuatanpulse deficit 2. Periksa tekanan dara : kesamaan antara tangan kanan dan kiri atau postural ipotensi 3. Inspeksi vena "ugular seperti distensi! dengan mem'uat posisi semi fowlers
. &ek suu tu'u dengan metode yang tepat! atau palpasi kulit. *. Palpasi dada untuk menentukan lokasi titik maksimal denyut "antung +. uskultasi 'unyi "antung -1/ -2 di titik terse'ut! adanya 'unyi "antung tam'aan! murmur dan 'ising. ,. Inspeksi mem'ran mukosa dan warna kulit! liat tanda sianosis (pucat) atau kemeraan 0. Palpasi adanya edema di ekstremitas dan wa"a . Periksa adanya "ari/"ari ta'u dan pemeriksaan pengisian kapiler di kuku 1.#a"i adanya tanda/tanda perdaraan (epistaksis! perdaraan saluran cerna! ple'itis! kemeraan di mata atau kulit. 11.#a"i o'at/o'atan yang mempengarui sistem kardiovaskular dan test diagnostik.
c. Sistem Respirasi (Pernapasan)
1. Kaji keadaan umum dan pemenuhan ke(utuhan respirasi 2. Kaji respirator' rate, irama dan kualitasn'a . *nspeksi #ungsi otot (antu napas, ukuran rongga dada, termasuk diameter anterior dan posterior thora, dan adan'a gangguan spinal ;. Palpasi posisi trakea dan adan'a su(kutan emph'sema . /uskultasi seluruh area paru dan kaji suara paru normal 06esikular, (ronko6esikular, atau (ronkial dan kaji juga adan'a (un'i paru patologis 0whee=ing, cracles atau ronkhi
>. Kaji adan'a keluhan (atuk, durasi, #rekuensi dan adan'a sputum3dahak, cek warna, konsistensi dan jumlahn'a dan apakah disertai darah ?. Kaji adan'a keluhan &84 0 shortness of breath3sesak napas, d'spnea dan orthopnea. @. *nspeksi mem(ran mukosa dan warna kulit A. entukan posisi 'ang tepat dan n'aman untuk meningkatkan #ungsi pernapasan pasien 1B. Kaji apakah klien memiliki riwa'at merokok 0jumlah per hari dan (erapa lama telah merokok 11. Kaji catatan o(at terkait dengan sistem pernapasan dan test diagnostik
d. Sistem Pencernaan
1. *nspeksi keadaan umum a(domen : ukuran, kontur, warna kulit dan pola pem(uluh 6ena 06enous pattern 2. /uskultasi a(domen untuk mendengarkan (ising usus . Palpasi a(domen untuk menentukan : lemah, keras atau distensi, adan'a n'eri tekan, adan'a massa atau asites ;. Kaji adan'a nausea dan 6omitus . Kaji tipe diet, jumlah, pem(atasan diet dan toleransi terhadap diet >. Kaji adan'a peru(ahan selera makan, dan kemampuan klien untuk menelan ?. Kaji adan'a peru(ahan (erat (adan @. Kaji pola eliminasi : 4/4 dan adan'a #latus A. *nspeksi adan'a ileostom' atau kolostomi, 'ang nantin'a dikaitkan dengan #ungsi 0permanen atau temporal, kondisi stoma dan kulit disekitarn'a, dan kesediaan alat 1B. Kaji kem(ali o(at dan pengkajian diagnostik 'ang pasien miliki terkait sistem C* e. Sistem Perkemihan
1. Kaji ke(iasaan pola 4/K, output3jumlah urine 2; jam, warna, kekeruhan dan ada3tidakn'a sedimen 2. Kaji keluhan gangguan #rekuensi 4/K, adan'a d'suria dan hematuria, serta riwa'at in#eksi saluran kemih
. Palpasi adan'a distesi (ladder 0kandung kemih ;. *nspeksi penggunaan condom catheter, #olle's catheter, silikon kateter atau urostom' atau supra pu(ik kateter . Kaji kem(ali riwa'at pengo(atan dan pengkajian diagnostik 'ang terkait dengan sistem perkemihan f. Sistem Integumen
1. Kaji integritas kulit dan mem(rane mukosa, turgor, dan keadaan umum kulit 0jaundice, kering 2. Kaji warna kulit, pruritus, kering, odor . Kaji adan'a luka, (ekas operasi3skar, drain, deku(itus, ds( ;. Kaji resiko terjadin'a luka tekan dan ulkus . Palpasi adan'a n'eri, edema, dan penurunan suhu >. Kaji riwa'at pengo(atan dan test diagnostik terkait sistem integument
g. Sistem muskuloskeletal
1. Kaji adan'a n'eri otot, kram atau spasme 2. Kaji adan'a kekakuan sendi dan n'eri sendi . Kaji pergerakan ekstremitas tangan dan kaki, D8+ 0range of motion, kekuatan otot ;. Kaji kemampuan pasien duduk, (erjalan, (erdiri, cek postur tu(uh . Kaji adan'a tanda!tanda #raktur atau dislokasi >. Kaji ulang pengo(atan dan test diagnostik 'ang terkait sistem musculoskeletal <!!i# support9ists$!!%i. <!!endi#$!!% Sistem Physikososial 1. <!!endi#$!!%Kaji perasaan pasien tentang kondisin'a dan pen'akitn'a 2. <!!endi#$!!%Kaji tingkat kecemasan, mood klien dan tanda depresi . <!!endi#$!!%Kaji pemenuhan support sistem ;. <!!endi#$!!%Kaji pola dan ga'a hidup klien 'ang mempengaruhi status kesehatan . <!!endi#$!!%Kaji riwa'at pen'alah gunaan o(at, narko(a, alkohol, seksual a(use, emosional dan koping mekanisme >. <!!endi#$!!%Kaji ke(utuhan pem(elajaran dan pen'uluhan kesehatan
. !okumentasi
&emua in#ormasi 'ang dieproleh dari hasil wawancara dan pemeriksaan #isik harus didokumentasikan dalam catatan pengkajian keperawatan klien. al ini nantin'a mendukung pencatatan data o(jekti# dan data su(jekti#, 'ang mengarahkan diagnsa keperawatan 'ang akan ditegakkan. Dencana dan tujuan nursing care plan 0EP 'ang akan di(uat sesuai #ormat PGD 0Pro(lem 5 Gtiologi dan Despon akan (erguna untuk perawat, pasien dan tenaga kesehatan lainn'a
E)ui!*ent Needed
/n 8toscope ongue 4lades otton ipped /pplicators 9ate Clo6es
Gene"al +onside"ations he head and neck eam is not a single, #ied seHuence. -i##erent portions are included depending on the eaminer and the situation.
Head 1. 9ook #or scars, lumps, rashes, hair loss, or other lesions. 1$ 2. 9ook #or #acial as'mmetr', in6oluntar' mo6ements, or edema. . Palpate to identi#' an' areas o# tenderness or de#ormit'.
Ea"s 1. *nspect the auricles and mo6e them around gentl'. /sk the patient i# this is pain#ul. 2. Palpate the mastoid process #or tenderness or de#ormit'. . old the otoscope with 'our thum( and #ingers so that the ulnar aspect o# 'our hand makes contact with the patient. ;. Pull the ear upwards and (ackwards to straighten the canal. . *nsert the otoscope to a point just (e'ond the protecti6e hairs in the ear canal. 7se the largest speculum that will #it com#orta(l'. 2$ >. *nspect the ear canal and middle ear structures noting an' redness, drainage, or de#ormit'.
?. *nsu##late the ear and watch #or mo6ement o# the t'mpanic mem(rane. $ II ;$ @. Depeat #or the other ear.
Nose *t is o#ten con6enient to eamine the nose immediatel' a#ter the ears using the same speculum. 1. ilt the patientJs head (ack slightl'. /sk them to hold their (reath #or the net #ew seconds. 2. *nsert the otoscope into the nostril, a6oiding contact with the septum. . *nspect the 6isi(le nasal structures and note an' swelling, redness, drainage, or de#ormit'. ;. Depeat #or the other side.
Th"oat *t is o#ten con6enient to eamine the throat using the otoscope with the speculum remo6ed. 1. /sk the patient to open their mouth. 2. 7sing a wooden tongue (lade and a good light source, inspect the inside o# the patients mouth including the (uccal #olds and under the tougue. Eote an' ulcers, white patches 0leucoplakia, or other lesions. . *# a(normalities are disco6ered, use a glo6ed #inger to palpate the anterior structures and #loor o# the mouth. II ;. *nspect the posterior orophar'n (' depressing the tongue and asking the patient to sa' "/h." Eote an' tonsilar enlargement, redness, or discharge.
Ne, 1. *nspect the neck #or as'mmetr', scars, or other lesions. 2. Palpate the neck to detect areas o# tenderness, de#ormit', or masses. . he musculoskeletal eam o# the neck is co6ered elsewhere...
-.*!h Nodes 1. &'stematicall' palpate with the pads o# 'our inde and middle #ingers #or the 6arious l'mph node groups. 1. Preauricular ! *n #ront o# the ear 2. Postauricular ! 4ehind the ear . 8ccipital ! /t the (ase o# the skull ;. onsillar ! /t the angle o# the jaw
. &u(mandi(ular ! 7nder the jaw on the side >. &u(mental ! 7nder the jaw in the midline ?. &uper#icial 0/nterior er6ical ! 86er and in #ront o# the sternomastoid muscle @. &upracla6icular ! *n the angle o# the sternomastoid and the cla6icle 2. he dee! e"'ial chain o# l'mph nodes lies (elow the sternomastoid and cannot (e palpated without getting underneath the muscle: 1. *n#orm the patient that this procedure will cause some discom#ort. 2. ook 'our #ingers under the anterior edge o# the sternomastoid muscle. . /sk the patient to (end their neck to#a"d the side 'ou are eamining. ;. +o6e the muscle (ackward and palpate #or the deep nodes underneath. . Eote the si=e and location o# an' palpa(le nodes and whether the' were so#t or hard, non!tender or tender, and mo(ile or #ied.
Th."oid Gland 1. *nspect the neck looking #or the th'roid gland. Eote whether it is 6isi(le and s'mmetrical. / 6isi(l' enlarged th'roid gland is called a goite". 2. +o6e to a position (ehind the patient. . *denti#' the "ioid a"tilage with the #ingers o# (oth hands. ;. +o6e downward two or three tracheal rings while palpating #or the isthmus. . +o6e laterall' #rom the midline while palpating #or the lo(es o# the th'roid. >. Eote the si=e, s'mmetr', and position o# the lo(es, as well as the presence o# an' nodules. he normal gland is o#ten not palpa(le.
S!eial Tests Faial Tende"ness 1. /sk the patient to tell 'ou i# these maneu6ers causes ecessi6e discom#ort or pain. II 2. Press upward under (oth e'e(rows with 'our thum(s. . Press upward under (oth mailla with 'our thum(s. ;. Gcessi6e discom#ort on one side or signi#icant pain suggests sinusitis.
Sinus T"ansillu*ination 1. -arken the room as much as possi(le. II 2. Place a (right otoscope or other point light source on the mailla.
. /sk the patient to open their mouth and look #or an orange glow on the hard palate. ;. / decreased or a(sent glow suggests that the sinus is #illed with something other than air.
Te*!o"o*andi/ula" Joint 1. Place the tips o# 'our inde #ingers directl' in #ront o# the tragus o# each ear. II 2. /sk the patient to open and close their mouth. . Eote an' decreased range o# motion, tenderness, or swelling.
Notes 1. Page num(ers re#er to 4ar(ara 4atesJ A Guide to Physical Examination and History Taking, Sixth Edition , pu(lished (' 9ippincott in 1AA. 2. he line o# hairs in the eternal ear is a good approimation o# where the (on' canal (egins. *nserting the speculum (e'ond this point can (e 6er' pain#ul. . *nsu##lation means to change the pressure in the outer ear. he t'mpanic mem(rane normall' mo6es easil' in response to this pressure change. 9ack o# mo6ement is a sign o# negati6e pressure or #luid in the middle ear. 4ates re#ers to this procedure as pneumatic otoscop'. ;. /dditional esting ! ests marked with 0II ma' (e skipped unless an a(normalit' is suspected
E)ui!*ent Needed
/ &tethoscope
Gene"al +onside"ations
he patient should ha6e an e*!t. /ladde". he patient should (e l'ing supine on the eam ta(le and appropriatel' draped. he eamination room *ust (e Huiet to per#orm adeHuate auscultation and percussion. Wath the !atient0s 1ae #or signs o# discom#ort during the eamination. 7se the appropriate terminolog' to locate 'our #indings: Dight 7pper uadrant 0D7 o Dight 9ower uadrant 0D9 o 9e#t 7pper uadrant 097 o 9e#t 9ower uadrant 099 o +idline: o Gpigastric Perium(ilical &uprapu(ic -isorders in the chest will o#ten mani#est with a(dominal s'mptoms. *t is alwa's wise to eamine the chest when e6aluating an a(dominal complaint. onsider the inguinal3rectal eamination in males. onsider the pel6ic3rectal eamination in #emales.
Ins!etion 1. 9ook #or scars, striae, hernias, 6ascular changes, lesions, or rashes. 1$ 2. 9ook #or mo6ement associated with peristalsis or pulsations. . Eote the a(dominal contour. *s it #lat, scaphoid, or protu(erantL
Ausultation 1. Place the diaphragm o# 'our stethoscope lightl' on the a(domen. 2$ 2. 9isten #or (owel sounds. /re the' normal, increased, decreased, or a(sentL . 9isten #or (ruits o6er the renal arteries, iliac arteries, and aorta.
Pe"ussion 1. Percuss in all #our Huadrants using proper techniHue.
2. ategori=e what 'ou hear as t'mpanitic or dull. 'mpan' is normall' present o6er most o# the a(domen in the supine position. 7nusual dullness ma' (e a clue to an underl'ing a(dominal mass.
-i'e" S!an 1. Percuss do#n#a"d #rom the chest in the "ight *idla'iula" line until 'ou detect the top edge o# li6er dullness. 2. Percuss u!#a"d #rom the a(domen in the same line until 'ou detect the (ottom edge o# li6er dullness. . +easure the li6er span (etween these two points. his measurement should (e >!12 cm in a normal adult.
S!leni Dullness 1. Percuss the lowest costal interspace in the le1t ante"io" a2illa". line . his area is normall' t'mpanitic. 2. /sk the patient to take a deep (reath and percuss this area again. -ullness in this area is a sign o# splenic enlargement.
Pal!ation Gene"al Pal!ation 1. 4egin with light !al!ation. /t this point 'ou are mostl' looking #or areas o# tenderness. he most sensiti6e indicator o# tenderness is the patientJs #acial epression 0so watch the patientJs #ace, not 'our hands. Moluntar' or in6oluntar' guarding ma' also (e present. 2. Proceed to dee! !al!ation a#ter sur6e'ing the a(domen lightl'. r' to identi#' a(dominal masses or areas o# deep tenderness.
Pal!ation o1 the -i'e"
Standa"d Method 1. Place 'our #ingers just (elow the right costal margin and press #irml'. 2. /sk the patient to take a deep (reath. . Nou ma' #eel the edge o# the li6er press against 'our #ingers. 8r it ma' slide under 'our hand as the patient ehales. / normal li6er is not tender.
Alte"nate Method his method is use#ul when the patient is o(ese or when the eaminer is small compared to the patient. 1. 2. . ;.
&tand (' the patientJs chest. "ook" 'our #ingers just (elow the costal margin and press #irml'. /sk the patient to take a deep (reath. Nou ma' #eel the edge o# the li6er press against 'our #ingers.
Pal!ation o1 the Ao"ta 1. Press down deepl' in the midline a(o6e the um(ilicus. II 2. he aortic pulsation is easil' #elt on most indi6iduals. . / well de#ined, pulsatile mass, greater than cm across, suggests an aortic aneur'sm.
Pal!ation o1 the S!leen 1. 2. . ;.
7se 'our le#t hand to li#t the lower ri( cage and #lank. II Press down just (elow the le#t costal margin with 'our right hand. /sk the patient to take a deep (reath. he spleen is not normall' palpa(le on most indi6iduals.
S!eial Tests Re/ound Tende"ness his is a test #or peritoneal irritation. II 1. 2. . ;.
Warn the patient what 'ou are a(out to do. Press deepl' on the a(domen with 'our hand. /#ter a moment, Huickl' release pressure. *# it hurts more when 'ou release, the patient has re(ound tenderness. ;$
+osto'e"te/"al Tende"ness M/ tenderness is o#ten associated with renal disease. II 1. Warn the patient what 'ou are a(out to do. 2. a6e the patient sit up on the eam ta(le. . 7se the heel o# 'our closed #ist to strike the patient #irml' o6er the costo6erte(ral angles. ;. ompare the le#t and right sides.
Shi1ting Dullness his is a test #or peritoneal #luid 0ascites. II 1. Percuss the patientJs a(domen to outline areas o# dullness and t'mpan'. 2. a6e the patient roll awa' #rom 'ou. . Percuss and again outline areas o# dullness and t'mpan'. *# the dullness has shi#ted to areas o# prior t'mpan', the patient ma' ha6e ecess peritoneal #luid. $
Psoas Sign his is a test #or appendicitis. II 1. Place 'our hand a(o6e the patientJs right knee. 2. /sk the patient to #le the right hip against resistance. . *ncreased a(dominal pain indicates a positi6e psoas sign.
O/tu"ato" Sign his is a test #or appendicitis. II 1. Daise the patientJs right leg with the knee #leed. 2. Dotate the leg internall' at the hip. . *ncreased a(dominal pain indicates a positi6e o(turator sign.
Notes 1. For more in#ormation re#er to A Guide to Physical Examination and History Taking, Sixth Edition (' 4ar(ara 4ates, pu(lished (' 9ippincott in 1AA. 2. /uscultation should (e done !"io" to percussion and palpation since (owel sounds ma' change with manipulation. &ince (owel sounds are transmitted widel' in the a(domen, auscultation o# more than one Huadrant is not usuall' necessar'. *# 'ou hear them, the' are present, period. . /dditional esting ! ests marked with 0II ma' (e skipped unless an a(normalit' is suspected. ;. enderness #elt in the D9 when palpation is per#ormed on the le#t is called Do6singJs &ign and suggests appendicitis. De(ound tenderness re#erred #rom the le#t to the D9 also suggests this disorder. . &mall amounts o# peritoneal #luid are not usuall' detecta(le on ph'sical eam.
E)ui!*ent Needed
/ &nellen G'e hart or Pocket Mision ard /n 8phthalmoscope
3isual Auit. *n cases o# e'e pain, injur', or 6isual loss, alwa's check 6isual acuit' /e1o"e (e#ore proceeding with the rest o# the eem or putting medications in 'our patients e'es. 1. /llow the patient to use their glasses or contact lens i# a6aila(le. Nou are interested in the patientJs (est o""eted 6ision. 2. Position the patient 2B #eet in #ront o# the &nellen e'e chart 0or hold a Dosen(aum pocket card at a 1; inch "reading" distance. . a6e the patient co6er one e'e at a time with a card. ;. /sk the patient to read progressi6el' smaller letters until the' can go no #urther. . Decord the smallest line the patient read success#ull' 02B32B, 2B3B, etc. 1$ >. Depeat with the other e'e. ?. 7nepected3uneplained loss o# acuit' is a sign o# serious ocular patholog'.
Ins!etion 1. 8(ser6e the patient #or ptosis, eophthalmos, lesions, de#ormities, or as'mmetr'. 2. /sk the patient to look up and pull down (oth lower e'elids to inspect the conjunti6a and sclera. . Eet spread each e'e open with 'our thum( and inde #inger. /sk the patient to look to each side and downward to epose the entire (ul(ar sur#ace. ;. Eote an' discoloration, redness, discharge, or lesions. Eote an' de#ormit' o# the iris or lesion cornea. . *# 'ou suspect the patient has conjunti6itis, (e sure to #ash .ou" hands immediatel'. Miral conjunti6itis is highl' contagious ! protect 'oursel#
3isual Fields &creen Misual Fields (' on#rontation 2$
1. 2. . ;. . >.
&tand two #eet in #ront o# the patient and ha6e them look into 'our e'es. old 'our hands to the side hal# wa' (etween 'ou and the patient. Wiggle the #ingers on one hand. $ /sk the patient to indicate which side the' see 'our #ingers mo6e. Depeat two or three times to test (oth temporal #ields. *# an a(normalit' is suspected, test the #our Huadrants o# each e'e while asking the patient to co6er the opposite e'e with a card. II ;$
E2t"aoula" Musles +o"neal Re1letions 1. &hine a light #rom directl' in #ront o# the patient. 2. he corneal re#lections should (e centered o6er the pupils. . /s'mmetr' suggests etraocular muscle patholog'.
E2t"aoula" Mo'e*ent 1. &tand or sit to > #eet in #ront o# the patient. 2. /sk the patient to #ollow 'our #inger with their e'es without mo6ing their head. . heck ga=e in the si cardinal directions using a cross or "" pattern. ;. heck con6ergence (' mo6ing 'our #inger toward the (ridge o# the patientJs nose.
Pu!illa". Reations -ight 1. 2. . ;. .
-im the room lights as necessar'. /sk the patient to look into the distance. &hine a (right light o(liHuel' into each pupil in turn. 9ook #or (oth the direct 0same e'e and consensual 0other e'e reactions. Decord pupil si=e in mm and an' as'mmetr' or irregularit'.
Ao**odation *# the pupillar' reactions to light are diminished or a(sent, check the reaction to accommodation 0near reaction: $ II 1. old 'our #inger a(out 1Bcm #rom the patientJs nose.
2. /sk them to alternate looking into the distance and at 'our #inger. . 8(ser6e the pupillar' response in each e'e.
O!hthal*oso!i E2a* 1. -arken the room as much as possi(le. II 2. /djust the ophthalmoscope so that the light is no /"ighte" than neessa". . /djust the aperture to a plain white circle. &et the diopter dial to =ero unless 'ou ha6e determined a (etter setting #or 'our e'es. >$ . 7se 'our le1t hand and le1t e'e to eamine the patientJs le1t e'e. 7se 'our "ight hand and "ight e'e to eamine the patientJs "ight e'e. Place 'our #ree hand on the patientJs shoulder #or (etter control. ;. /sk the patient to stare at a point on the wall or corner o# the room. . 9ook through the ophthalmoscope and shine the light into the patientJs e'e #rom a(out two #eet awa'. Nou should see the retina as a "red re#le." Follow the red color to mo6e within a #ew inches o# the patientJs e'e. >. /djust the diopter dial to (ring the retina into #ocus. Find a (lood 6essel and #ollow it to the optic disk. 7se this as a point o# re#erence. ?. *nspect outward #rom the optic disk in at least #our Huadrants and note an' a(normalities. pictures on p2B@$ @. +o6e nasall' #rom the disk to o(ser6e the macula. A. Depeat #or the other e'e.
S!eial Tests U!!e" E.elid E'e"sion his procedure is per#ormed when a #oreign (od' is suspected. II 1. /sk the patient to loo, do#n. 2. Gentl. grasp the patientJs upper e'elashes and pull them out and down. . Place the sha#t o# an applicator or tongue (lade a(out 1 cm #rom the lid margin. ;. Pull the lid upward using the applicator as a #ulcrum to turn the lid "inside out." Do not !"ess do#n on the e.e itsel1% . Pin the e'elid in this position (' pressing the lashes against the e'e(row while 'ou eamine the palpe(ral conjunti6a. >. /sk the patient to (link se6eral times to return the lid to normal.
Notes 1. Misual acuit' is reported as a pair o# num(ers 02B32B where the #irst num(er is how #ar the patient is #rom the chart and the second num(er is the distance #rom which the "normal" e'e can read a line o# letters. For eample, 2B3;B means that at 2B #eet the patient can onl' read letters a "normal" person can read #rom twice that distance. 2. For more in#ormation re#er to A Guide to Physical Examination and History Taking, Sixth Edition (' 4ar(ara 4ates, pu(lished (' 9ippincott in 1AA. . Nou ma', instead o# wiggling a #inger, raise one or two #ingers 0unialterall' or (ilaterall' and ha6e the patient state how man' #ingers 0total, (oth sides the' see. o test #or neglet, on some trials wiggle 'our right and le#t #ingers simultaneousl'. he patient should see mo6ement in (oth hands. ;. /dditional esting ! ests marked with 0II ma' (e skipped unless an a(normalit' is suspected. . PGDD9/ is a common a((re6iation that stands #or "Pupils GHual Dound Deacti6e to 9ight and /ccommodation." he use o# this ter m is so routine that it is o#ten used incorrectl'. *# 'ou did not speci#icall' check the accommodation reaction use the term PGDD9. Pupils with a diminished response to light (ut a normal response to accommodation 0/rg'll! Do(ertson Pupils are a sign o# neuros'philis. >. -iopters are used to measure the power o# a lens. he ophthalmoscope actuall' has a series o# small lens o# di##erent strengths on a wheel 0positi6e diopters are la(eled in green, negati6e in red. When 'ou #ocus on the retina 'ou "dial!in" the correct num(er o# diopters to compensate #or /oth the patientJs and 'our own 6ision. For eample, i# (oth 'ou and 'our patient wear glasses with !2 diopter correction 'ou should epect to set the dial to !2 with 'our glasses on or !; with 'our glasses o##.
