BASIC NURSING PAPERS

“PHYSICAL ASSESSMENT”

Study Program : Applied Undergraduate Program and Professional

Education Study Program
Placement : Semester 2 T.B 2022/2023
Subject : Basic Nursing
Class : 1RKI
Supporting Lecturer : Ratna Ningsih, S.Kp., M.Kep
Person Responsible : Ratna Ningsih, S.Kp., M.Kep
Arranged by Group 2 :
1. Evi innayah (P3.73.20.2.22.094)
2. Galih Fakhri Pratama (P3.73.20.2.22.095)
3. Hafizh Nasrulloh Al Adnan (P3.73.20.2.22.096)
4. Ihda Choirusyifa Annasri (P3.73.20.2.22.097)
5. Jessica Astuti Pereira (P3.73.20.2.22.098)
6. Jessica Sarah Blesta Nababan (P3.73.20.2.22.099)
7. Jihan Layla Putri (P3.73.20.2.22.100)
8. Keysha Aulia Ryzqita (P3.73.20.2.22.101)
9. Luxke Puji Darmawanti (P3.73.20.2.22.102)
10. Malika Zulfa Nurrunnisa (P3.73.20.2.22.103)
11. Nadya Amelia Putri (P3.73.20.2.22.104)
12. Naila Deviana Heryadi (P3.73.20.2.22.105)

GRADUATE PROGRAM OF APPLIED NURSING + PROFESSION

NURSING MAJOR
HEALTH POLYTECHNIC MINISTRY OF HEALTH JAKARTA III
2023
 FOREWORD

Praise we pray to God Almighty for bestowing his grace and guidance so that we can make a paper
entitled "physical assessment" in a timely manner.

In the process of compiling this assignment we express our thanks and appreciation to all related
parties who have assisted in the completion of this task.

We thank Ratna Ningsih, SKp.,M.Kep., as supervisors who have provided guidance, support and
direction to us so that this paper can be completed.

For that, we expect criticism and suggestions from all parties for this paper. Hopefully the guidance
and direction that has been given to us will get a reply from the Lord. We hope that this paper will
be useful especially for us and for the readers and others in general.

Bekasi, 27 April 2023

Drafting team

Group 2

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 TABLE OF CONTENTS

FOREWORD................................................................................................................................. 2

TABLE OF CONTENTS ............................................................................................................. 3

CHAPTER I .................................................................................................................................. 4

INTRODUCTION......................................................................................................................... 4

A. Background ........................................................................................................................ 4

B. Question of The Problems ................................................................................................. 4

C. Objectives............................................................................................................................ 5

CHAPTER II ................................................................................................................................. 6

THEORETICAL STUDY ............................................................................................................ 6

A. Preparing The Client ......................................................................................................... 6

B. Preparing The Environment ............................................................................................. 6

C. Positioning .......................................................................................................................... 7

D. Draping ............................................................................................................................. 12

E. Instrumentation................................................................................................................ 12

F. Methods Of Examining.................................................................................................... 12

CHAPTER III ............................................................................................................................. 17

CONCLUSION AND RECOMMENDATIONS ...................................................................... 17

A. Conclusion ........................................................................................................................ 17

B. Recommendations ............................................................................................................ 17

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 CHAPTER I

INTRODUCTION

A. Background
Health is the need of every human being in living his life. Health is also very
important because without good health, it will be difficult for every human being to carry
out daily activities. Health is a healthy state, both physically, mentally, spiritually and
socially which enables everyone to live a productive life.

Physical assessment is a process of a medical professional examining a patient's

body for clinical signs of disease. The results of the examination will be recorded in the
medical record. Medical records and physical examination will assist in the diagnosis and
treatment planning of patients. In clinical practice, there are several approaches to
completing a physical health assessment used by the interprofessional healthcare team. The
selected assessment approach guides the sequence of cues/data collection for the clinician;
examples include the head-to-toe assessment and the body systems approach. The head-to-
toe assessment commences at the head and proceeds in a systematic manner downward to
the toes.

Nurses are often the first to detect changes in a client's condition, regardless of
background. Therefore the ability to think and interpret critically about the meaning of
client behavior and the physical changes that are displayed is very important for nurses.
Assessment and physical examination skills are powerful tools for nurses to detect both
subtle and real changes that occur in a client's health. The physical assessment allows the
nurse to assess patterns that reflect health problems and evaluate the client's progress.

B. Question of The Problems

a. What is physical assessment ?
b. What are the methods for performing physical assessment ?
c. How to perform a physical assessment ?
d. Why is physical assessment a skill that nurses must have ?

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C. Objectives
a. Knowing and understand about physical assessment
b. Knowing and understand about methods for performing the physical assessments
c. Knowing and mastering how to perform physical assessment
d. Knowing and understand the skill nurse must have in physical assessment

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 CHAPTER II

THEORETICAL STUDY

A. Preparing The Client

Most people need an explanation of the physical examination. Often clients are
anxious about what the nurse will find. They can be reassured during the examination by
explanations at each step. The nurse should explain when and where the examination will
take place, why it is important, and what will happen. Instruct the client that all information
gathered and documented during the assessment is kept confidential in accordance with the
Health Insurance Portability and Accountability Act (HIPAA). This means that only those
health care providers who have a legitimate need to know the client’s information will have
access to it.

Health examinations are usually painless; however, it is important to determine in

advance any positions that are contraindicated for a particular client. The nurse assists the
client as needed to undress and put on a gown. Clients should empty their bladders before
the examination. Doing so helps them feel more relaxed and facilitates palpation of the
abdomen and pubic area. If a urinalysis is required, the urine should be collected in a
container for that purpose.

When assessing adults it is important to recognize that people of the same age differ
markedly. Box 30–3 provides special considerations for assessing adults, especially older
adults. The sequence of the assessment differs with children and adults. With children,
always proceed from the least invasive or uncomfortable aspect of the exam to the more
invasive. Examination of the head and neck, heart and lungs, and range of motion can be
done early in the process, with the ears, mouth, abdomen, and genitals being left for the
end of the exam.

B. Preparing The Environment

It is important to prepare the environment before starting the assessment. The time
for the physical assessment should be convenient to both the client and the nurse. The
environment needs to be well lighted and the equipment should be organized for efficient
use. A client who is physically relaxed will usually experience little discomfort. The room

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 should be warm enough to be comfortable for the client. Providing privacy is important.
Most people are embarrassed if their bodies are exposed or if others can overhear or view
them during the assessment. Culture, age, and gender of both the client and the nurse
influence how comfortable the client will be and what special arrangements might be
needed. For example, if the client and nurse are of different genders, the nurse should ask
if it is acceptable to perform the physical examination. Family and friends should not be
present unless the client asks for someone.

C. Positioning
Several positions are frequently required during the physical assessment. It is
important to consider the client’s ability to assume a position. The client’s physical
condition, energy level, and age should also be taken into consideration. Some positions
are embarrassing and uncomfortable and therefore should not be maintained for long. The
assessment is organized so that several body areas can be assessed in one position.

1. Dorsal Recumbent
Dorsal Recumbent is a Back-lying position with knees flexed and hips
externally rotated; small pillow under the head; soles of feet on the surface. areas
assessed are female genitals, rectum, and female reproductive tract. for patient
comfort and back strain

2. Supine
supine position is a back lying position with legs extended: with or without
pillow under the head . Variation in position. In supine position, legs may be
extended or slightly bent with arms up or down. It provides comfort in general for
patients under recovery after some type of surgery

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3. Lateral
In lateral or side-lying position, the patient lies on one side of the body with
the top leg in front of the bottom leg and the hip and knee flexed. Flexing the top
hip and knee and placing this leg in front of the body creates a wider, triangular
base of support and achieves greater stability. An increase in flexion of the top hip
and knee provides greater stability and balance. This flexion reduces lordosis and
promotes good back alignment.to help relieve the sacrum and heels especially in
people who are seated or limited to resting in a supine position

4. Trendelenburg
Trendelenburg’s position involves lowering the head of the bed and raising
the foot of the bed of the patient. The patient’s arms should be tucked at their sides.
to improve blood circulation to the brain. Patients with hypotension are often placed
in this position because the stronger venous return can increase blood pressure

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5. Sims
Sims position is Side-lying position with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow. areas
assessed theyv are Rectum and vagina. Prevents aspiration of fluids. Sims’ may be
used for unconscious clients because it facilitates drainage from the mouth and
prevents aspiration of fluids.

6. Lithotomy
Lithotomy’s position is Back-lying position with feet supported in stirrups;
the hips should be in line with the edge of the table. area assessed is Female genitals,
rectum, and female reproductive tract. Lithotomy position is commonly used for
vaginal examinations and childbirth. There are several types of lithotomy positions
: Low Lithotomy Position (bed surface is 40 degrees to 60 degrees), Standard
Lithotomy Position (bed surface is 80 degrees to 100 degrees), Hemilithotomy
Position: The patient’s non-operative leg is positioned in standard lithotomy, High
Lithotomy Position: (bed surface is 110 degrees to 120 degrees) The patient’s lower
legs are flexed, Exaggerated Lithotomy Position (bed surface is 130 degrees to 150
degrees)

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7. Genu Pectoral
Genu pectoral position is A position with the patient on the knees, thighs
upright, the head and upper part of the chest resting on the table, arms crossed above
the head. It is employed in displacement of a prolapsed fundus, dislodgement of the
impacted head of a fetus, management of transverse presentation, replacement of a
retroverted uterus or displaced ovary, or flushing of the intestinal canal.

8. Prone
Prone position is Lies on abdomen with head turned to the side, with or
without a small pillow. areas assessed are Posterior thorax, hip joint movement.
Extension of hips and knee joints. Prone position is the only bed position that allows
full extension of the hip and knee joints. It also helps to prevent flexion contractures
of the hips and knees.

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9. Fowler
Fowler’s position, also known as semi-sitting position, is a bed position
wherein the head of the bed is elevated 45 to 60 degrees. Variations of Fowler’s
position include low Fowler’s (15 to 30 degrees), semi-Fowler’s (30 to 45 degrees),
and high Fowler’s (nearly vertical). Promotes lung expansion. Fowler’s position is
used for patients who have difficulty breathing because, in this position, gravity
pulls the diaphragm downward, allowing greater chest and lung expansion.

10. Orthopneic
Orthopneic or tripod position places the patient in a sitting position or on
the side of the bed with an overbed table in front to lean on and several pillows on
the table to rest on. Maximum lung expansion. Patients with difficulty of breathing
are often placed in this position because it allows maximum chest expansion. Helps
in exhaling. Orthopneic position is particularly helpful to patients who have
problems exhaling because they can press the lower part of the chest against the
edge of the overbed table.

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D. Draping
Drapes should be arranged so that the area to be assessed is exposed and other body areas
are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide
not only a degree of privacy but also warmth. Drapes are made of paper, cloth, or bed linen.

E. Instrumentation
All equipment required for the health assessment should be clean, in good working order
and readily accessible. The equipment used will depend on the purpose of the physical
examination. Equipment is frequently set up on trays, ready for use.

The equipment and equipment used for medical examination are as follows:

1) Vaginal speculum; to open the cervix and the vagina.

2) Cotton applicators; to obtain specimens.
3) Gloves; to protect the nurse and patient from infection.
4) Lubricant; to ease insertion of instruments (e.g. vaginal speculum).
5) Tongue blades; to depress the tongue during assessment of the mouth and pharynx.
6) Flashlight or penlight; to assist viewing of the pharynx or to determine the reactions
of the pupils of the eye.
7) Ophthalmoscope; to visualize the interior of the eye.
8) Otoscope; to visualize the eardrum and external auditory canal.
9) Percussion hammer; to test reflexes.
10) Tuning fork; to test hearing acuity and vibratory sense.

F. Methods Of Examining
Four primary techniques are used in the physical examination: inspection, palpation,
percussion, and auscultation. These techniques are discussed throughout this chapter as
they apply to each body system.

a. Inspection
Inspection is the visual examination, which is assessing by using the sense of sight.
It should be deliberate, purposeful, and systematic. The nurse inspects with the
naked eye and with a lighted instrument such as an otoscope (used to view the ear).
In addition to visual observations, olfactory (smell) and auditory (hearing) cues are

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 noted. Nurses frequently use visual inspection to assess moisture, color, and texture
of body surfaces, as well as shape, position, size, color, and symmetry of the body.
Lighting must be sufficient for the nurse to see clearly; either natural or artificial
light can be used. When using the auditory senses, it is important to have a quiet
environment for accurate hearing. Inspection can be combined with the other
assessment techniques.

b. Palpation
Palpation is the examination of the body using the sense of touch. The pads of the
fingers are used because their concentration of nerve endings makes them highly
sensitive to tactile discrimination. Palpation is used to determine (a) texture (e.g.,
of the hair); (b) temperature (e.g., of a skin area); (c) vibration (e.g., of a joint); (d)
position, size, consistency, and mobility of organs or masses; (e) distention (e.g.,
of the urinary bladder); (f) pulsation; and (g) tenderness or pain.

There are two types of palpation: light and deep. Light (superficial) palpation
should always precede deep palpation because heavy pressure on the fingertips can
dull the sense of touch. For light palpation, the nurse extends the dominant hand’s
fingers parallel to the skin surface and presses gently while moving the hand in a
circle. With light palpation, the skin is slightly depressed. If it is necessary to
determine the details of a mass, the nurse presses lightly several times rather than
holding the pressure.

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 Deep palpation is done with two hands (bimanually) or one hand. In deep bimanual
palpation, the nurse extends the dominant hand as for light palpation, then places
the finger pads of the nondominant hand on the dorsal surface of the distal
interphalangeal joint of the middle three fingers of the dominant hand. The top hand
applies pressure while the lower hand remains relaxed to perceive the tactile
sensations. For deep palpation using one hand, the finger pads of the dominant hand
press over the area to be palpated. Often the other hand is used to support from
below

c. Percussion
Percussion is the act of striking the body surface to elicit sounds that can be heard
or vibrations that can be felt. There are two types of percussion: direct and indirect.
In direct percussion, the nurse strikes the area to be percussed directly with the pads
of two, three, or four fingers or with the pad of the middle finger. The strikes are
rapid, and the movement is from the wrist. This technique is not generally used to
percuss the thorax but is useful in percussing an adult’s sinuses.

Indirect percussion is the striking of an object (e.g., a finger) held against the body
area to be examined. In this technique, the middle finger of the nondominant hand,
referred to as the pleximeter, is placed firmly on the client’s skin. Only the distal
phalanx and joint of this finger should be in contact with the skin. Using the tip of
the flexed middle finger of the other hand, called the plexor, the nurse strikes the
pleximeter, usually at the distal interphalangeal joint or a point between the distal
and proximal joints

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 Percussion is used to determine the size and shape of internal organs by establishing
their borders. It indicates whether tissue is fluid filled, air filled, or solid. Percussion
elicits five types of sound: flatness (is an extremely dull sound produced by very
dense tissue, such as muscle or bone), dullness (is a thudlike sound produced by
dense tissue such as the liver, spleen, or heart), resonance ( is a hollow sound such
as that produced by lungs filled with air), hyperresonance ( is not produced in the
normal body. It is described as booming and can be heard over an emphysematous
lung.), and tympany ( is a musical or drumlike sound produced from an air-filled
stomach).

d. Auscultation
Auscultation is the process of listening to sounds produced within the body.
Auscultation may be direct or indirect. Direct auscultation is performed using the
unaided ear, for example, to listen to a respiratory wheeze or the grating of a moving
joint. Indirect auscultation is performed using a stethoscope, which transmits
sounds to the nurse’s ears. A stethoscope is used primarily to listen to sounds from
within the body, such as bowel sounds or valve sounds of the heart and blood
pressure.

Auscultated sounds are described according to their pitch, intensity, duration, and
quality. The pitch is the frequency of the vibrations (the number of vibrations per
second). Low-pitched sounds, such as some heart sounds, have fewer vibrations per
second than high-pitched sounds, such as bronchial sounds. The intensity
(amplitude) refers to the loudness or softness of a sound. Somebody sounds are
loud, for example, bronchial sounds heard from the trachea; others are soft, for
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example, normal breath sounds heard in the lungs. The duration of a sound is its
length (long or short). The quality of sound is a subjective description of a sound,
for example, whistling, gurgling, or snapping

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 CHAPTER III

CONCLUSION AND RECOMMENDATIONS

A. Conclusion
Physical examination is an examination of the client's body as a whole or only certain parts
that are deemed necessary, to obtain systematic and comprehensive data, ensure/prove the
results of anamnesis, determine problems and plan appropriate nursing actions for clients.

Absolute physical examination is carried out for every client, especially for clients who
have just entered a health service to be treated, routinely for clients who are being treated,
at any time according to the client's needs. So this physical examination is very important
and must be carried out in these conditions, both the client is conscious and unconscious.

Physical examination is very important because it is very useful, both for establishing
nursing diagnoses, choosing the right intervention for the nursing process, and for
evaluating the results of nursing care.

B. Recommendations
This is what we can discuss in writing this group, even though this writing is far from
perfect, at least we can implement this writing. It is our hope that carrying out a correct
physical examination can provide benefits in making nursing diagnoses, choosing
interventions for the nursing process, and evaluating the results of nursing care. Apart from
that, we also hope that this correct physical examination can provide comfort to the patient.

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 BIBLIOGRAPHY

Berman, Audrey., Shirlee J. Synder., Geralyn Frandsen. 2016. Kozier & Erb's Fundamentals of

Nursing : concepts, process and practice 10th Edition. Pearson

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