Anamnese cardiovascular examination

wash your hands and wear PPE if necessary

introduce yourself to the patient including your name and role.

Asalamualaikum sir, good morning, I'm a galih nurse. May I know your name sir ?

How old are you?

And what are you complained about your chest, why you come to here?

What is prior history of suffering chest , may be due to conflict or accidents and previous disease ?

What pain in your chest do you feel during even your activity, sir?

How does your chest feel, can you explain is there a problem? Or is the pain like a heavi load?

So, what if you take a break for a few minutes , after resting the pain goes away?

Are you have a history of hipertension, diabetes or smoking?

If you have a history of hypertension, did you use blood pressure drugs,regularly?

And smoking habits how many packs a day?

THERE ARE 4 THINGS TO BE DONE IN EXAMINATION, PALPATION, PERCUSION AND AUSCULTATION.

THIS PROCEDURE YOU WILL TAKE OFF THE CLOTHES AND SLEEP iN THE BED, AND I WILL CLOSE THE
CURTAIN TO KEEP THE PRIVACY. AND IF YOU DON'T FEEL IT COMFORTABLE, OR PAIN PLEASE SAY TO
ME OR YOU CAN DEEP BREATH TO REDUCE TENSION. DO YOU WANT?

PRE INTERAKSI

PREPARE TOOLS 1. STETOSCOP , 2. 2 RULER TO DO MEASUREMENT ON JUGULAR VENA, MEDICAL

GLOVES IF THE PATIENT HAS A HISTORY OF INFECTIOUS DISEASE, HAND SANITIZER, AND DONT
FORGET TO READ PATIENT'S MEDICAL AND NURSING RECORDS

AND EXPLAIN THE PURPOSE OF THE EXAMINATION. SO THE PURPOSE OF THIS EXAMINATION IS AN
EARLY DETECTED CONDITION OF YOUR HEART SYSTEM, MAYBE IT WILL BE A LITTLE
UNCOMFORTABLE, I WILL OPEN your CLOTHES, AND WILL TAP YOUR CHEST, THEN I WILL LISTEN TO
YOUR HEART TO KNOW THE SOUND. WILL YOU MISTER?

OK I will close the curtains for your privacy and to make you stay comfort during this inspection
MISTER.

ORIENTASI

OK, I'M GOING TO CHECK YOUR CHEST, I WANT TO CHECK AND PLEASE TAKE OFF your top shirt?
Okay, lay down FOR A WHILE, then I'll wash my hands first.
I wash my hands for a while sir (practice washing hands with 6 steps)

(Physical examination of the heart includes examination, palpation, percussion and auscultation. The
nurse begins the physical examination) with an examination including an eye exam. TO KNOW THE
CONJUNTIVA AND SCLERA

action: so I started checking sir? Sir, LOOK AT MY HANDS! (Is there conjunctival anemia, or icteric
sclera)

Action: look at my finger.

While being demonstrated, step 2

then examination in the lip area to assess cyanosis, examination in the chest area to assess the type
of chest shape, is the chest shape normal? Or there are abnormalities such as [pectus carinatum,
pectus excavatum, or barrel chest] in the chest wall. The nurse identifies the location of the ictus
cordis (AFTER SHOWED) and other pulses in the area around the chest wall

Then the nurse performs an examination of the extremities to assess the pulse ( indicates the
presence or absence of cyanosis, clubbing, and capillary crt. (SHOWED) and checks the OEDEM ON
STEPS.

The next examination is palpation examination, including palpation examination Palpation of the
ictus cordis (shown), a touch is performed to assess the location of the lift strength and the extent of
the ictus cordis AND PULSATION IN OTHER AREAS.

The next examination is jugular vein pressure (jvp) jvp, which is an assessment of the height of the
internal jugular vein filling in the neck, identification of the internal jugular vein based on its location
in the medial clavicle head, cledomastodios muscle shorthand. Identification is also based on the
filling of the skull (pressure on the practitioner) and can be increased by emphasis on hepatic or
hepato jugular reflexes (in practice). The method of examination is to raise the head above the bed,
then the patient turns to the left (while practicing). The height of the internal jugular vein is
measured percenticularly from the sternal amulus using a ruler (practiced). The jugular venous
pressure expressed as 5cm measured from the atrium sticulus sterni plus the height of the internal
jugular vein filling the normal value of jvp is 5 plus minus 2cm

The next examination is a percussion examination to determine the boundaries of the heart. The
heart weight assessed is the right heart limit, left and lower heart limit, waist heart limit, and upper
heart limit (while showing)

Sir, I will knock on YOUR wall CHEST, it might feel a little uncomfortable. IF YOU DON'T FEEL
COMFORTABLE PLEASE TAKE A Deep BREATH

EXAMINATION IS CONTINUED WITH AUSCULTATION OF THE HEART USING STETOSCOPE

IN AUSCULTATIon EXAMINATION USING STETOSCOPE DIAFRAGM MEMBRANE, EXAMINATION OF

HEART BEEPS ON PROJECTION TO FOUR HEART VALVES, namely MITRAL VALVES ics 5 apex cordis,
TRICUSPIDALIS VALVES stemalis dextra ics 5, PULMONALIS VALVES ics 2 sinistra linea stenal, AND
AORTA VALVES ics 2 dextra linea sternal.
By using a stethoscope listen for heart dub sounds 1 and 2 and whether any auditions are found or
additional sounds such as MURMUR HEART, AND GALLOP

terminasi

Sir, thank you for your cooperation, we have finished the inspection, we invite you to wear clothes.
Wash hands in 6 steps . SO FROM THE RESULTS OF THE EXAMINATION OF GOD'S CHEST IS GOOD
AND NORMAL. HOW DO YOU FEEL NOW? AFTER THE EXAMINATION? Is there anything you want to
say or complain about? SO IN THE NEXT 2 DAYS FROM NOW, IF you STILL FEELS LESS, PLEASE
CONTACT US. THANK YOU VERI MUCH.

dokumentasi

DOCUMENTED FROM THE OBTAINED RESULTS AND NURSE'S DATE, HOUR, DAY AND SIGNATURE.