DOCUMENTATION OF PHYSICAL EXAMINATION AND

SUPPORTING EXAMINATION

ARRANGED BY :

 Abillah Almubaroqah P01720322051

 Irfan Fazrul Pratama P01720322076
 Mela Apriana Dewi P01720322080
 Pita Ayu Azhari P01720322086
 Riri Agustina P01720322088
 Tari Diaslara Putri P01720322039

SUBJECT : Nursing Documentation

Lecturer : Asmawati, S.Kp, M.Kep

HEALTH POLYTECHNIC, BENGKULU MINISTRY OF

HEALTH

BACHELOR OF APPLIED NURSING PROFESSION AND

PROFESSIONAL NERS CLASS OF RKI

2023/2024
 FOREWORD

Praise to the presence of Allah SWT, God Almighty for all His blessings so
that this paper with the title "Documentation of Nursing Care" can be compiled to
completion. We also do not forget to thank our Supervisor Mam Asmawati, S.Kp,
M.Kep for her guidance and direction in the process of preparing this paper.

The preparation of this paper aims to fulfill the value of assignments in the
Nursing Documentation course. In addition, the preparation of this paper also
aims to add knowledge and insight to the readers.

Due to limited knowledge and experience, we believe there are still many
shortcomings in this paper. Therefore, we really hope for constructive criticism
and suggestions from readers for the perfection of this paper.Akhir kata, semoga
makalah ini dapat berguna bagi para pembaca.

Bengkulu, 20 August 2023

Writer

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 LIST OF CONTENTS
FOREWORD.......................................................................................................................2
LIST OF CONTENTS.........................................................................................................3
BAB I INTRODUCTION....................................................................................................4
1.1. Background...............................................................................................................4
1.2. Formulation of the problem......................................................................................5
1.3. Objective...................................................................................................................5
BAB II DISCUSSION.........................................................................................................6
2.1 Physical Examination.................................................................................................6
A. Definition of Physical Examination.....................................................................6
B. Purpose of Physical Examination........................................................................7
C. Benefit of Physical Examination..........................................................................8
D. Indication.............................................................................................................8
E. Sample form of physical examination :.............................................................25
2.2. Supporting Examination.........................................................................................31
A. Definition of Supporting Examination...............................................................31
B. Function of supporting examination..................................................................31
C. Purpose of supporting examination....................................................................32
D. Types of supporting examination.......................................................................32
E. Preparation of supporting examination..............................................................34
F. Steps of supporting examination........................................................................34
F. The tools used for supporting examination........................................................34
G. An example of a supporting examination form :...............................................37
BAB III CLOSING............................................................................................................39
3.1. Conclusion..............................................................................................................39
3.2. Suggestion...............................................................................................................39
BIBLIOGRAPHY..............................................................................................................40

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 BAB I
INTRODUCTION

1.1. Background
The hospital as a health service facility that performs outpatient and
inpatient services is required to make medical records. Persons responsible for
filling out medical records are general practitioners, specialists, dentists and
specialists who serve patients in hospitals, visiting doctors, residents, nurses,
dentists, midwives, clinical laboratory personnel, nutritionists, anesthesiologists,
X-ray stylists, medical rehabilitation ( MOH RI, 2006).

The role of nurses as one of the health workers has a major contribution to
health services in efforts to improve the quality of health services. The nursing
profession is currently a profession that has legal risks, care errors that result in
disability or death for patients can drag nurses to court, therefore all activities
carried out on patients must be properly and clearly documented.

Effective and efficient documentation can improve the quality of nursing

services felt by clients. Documentation of nursing care must be complete and
according to standards because it is a link to find out the patient's health
development, therefore completing nursing care documentation is the duty of a
nurse.

As regulated in the Minister of Health of the Republic of Indonesia Number.

HK.02.02/Menkes/148/I/2010 regarding permits and implementation of nursing
practice and stipulated in SK Menkes No.436/Menkes/SK/VI/1993 concerning
hospital service standards.

Nursing documentation is any record, both written and electronic, that

describes nursing services provided to clients and can be used as evidence for
authorized personnel.

Implementation of the nursing process consists of assessment, diagnosis,

planning, implementation and evaluation. All of these actions must be

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 documented as evidence of the implementation of the nursing process. Therefore,
research was conducted on documentation based on the nursing process.

1.2. Formulation of the problem

1. What is a physical examination?
2. What is the purpose of the physical examination?
3. What are the benefits of doing a physical examination?
4. What are the indications for a physical examination?
5. What is the physical examination procedure?
6. What is meant by supporting examination?
7. What is the function of the supporting examination?
8. What is the purpose of carrying out a supporting examination?
9. What are the types of supporting examinations?
10. What should be prepared for a supporting examination?
11. What are the stages in the supporting examination?
12. What tools are used in supporting examinations?

1.3. Objective
1. To know the definition of a physical examination.
2. To find out the purpose of doing a physical examination.
3. To find out the benefits of doing a physical examination.
4. To find out what are the indications of a physical examination.
5. To know the physical examination procedure.
6. To know the definition of supporting examination.
7. To know the function of supporting examinations.
8. To find out the purpose of carrying out a supporting examination.
9. To find out what types of supporting examinations are.
10. To find out what should be prepared in a supporting examination.
11. To find out the stages in the supporting examination.
12. To find out what tools are used in supporting examinations.

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 BAB II
DISCUSSION

2.1 Physical Examination

A. Definition of Physical Examination
Physical examination is a process of a medical expert examining the
patient's body to find signs of disease on the patient's body. 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.
The physical examination is a head-to-toe review of each body system that
provides information about the client and allows the nurse to make clinical
judgments. The accuracy of the physical examination influences the choice of
therapy that the client receives and determines the response to the therapy (Potter
and Perry 2005).
Physical examination is an examination of the client's body as a whole or
only certain parts that are deemed necessary to obtain objective data to prove the
results of the anamnesis in determining the problem and planning appropriate
nursing actions for the client (Dewi Sartika 2010).
The physical examination techniques used are:
1) Inspection
Inspection is an examination carried out by looking at the part of the body
being examined through eye observation or a magnifying glass. General
inspection is carried out when you first meet a patient which is a picture or
general impression regarding the state of health that is formed. The focus of
inspection on each part of the body includes body size, color, shape, position,
symmetry, lesions, and protrusions/swellings. After inspection, it is necessary
to compare the normal and abnormal results of one body part with another.
2) Palpation
Palpation is an examination using the sense of touch by placing the hand
on a body part that can be reached by the hand. Palpation is an examination
technique that uses the sense of touch: hands and fingers to determine the

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characteristics of a tissue or organ. Things that are detected are temperature,
humidity, texture, movement, vibration of growth or mass crepitus edema and
sensation.
3) Percussion
Percussion is an examination that includes tapping on the surface of the
body to produce sounds that will assist in determining the location and position
of the underlying structures. Percussion is an examination by tapping certain
parts of the body surface to compare with other body parts, by producing
sound, which aims to identify the boundaries of tissue location and consistency
(Dewi Sartika 2010)
4) Auscultation
Auscultation is the act of listening to sounds produced by various organs
and tissues of the body. Auscultation Is a physical examination carried out by
listening to the sounds produced by the body. Usually using a tool called a
stethoscope. The things that are heard are heart sounds, breath sounds, and
bowel sounds (Dewi Sartika 2010).

In carrying out a physical examination there are principles that must be

considered, namely the following:

a. infection control
Includes washing hands, putting on sterile gloves, putting on masks and
helping clients put on clothes.
b. Environmental control
Namely ensuring the room is comfortable, warm and well lit to carry
out physical examinations for both the client and the examiner himself.
For example closing doors/windows or screens to maintain client
privacy.

B. Purpose of Physical Examination

In general, the physical examination carried out aims to:
1. Collect basic data about the client's health

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 2. Add, confirm or deny the data obtained in the nursing history
3. Confirm and identify nursing diagnoses
4. Make a clinical assessment of changes in the client's health status and
management
5. Evaluate the physiological outcomes of care
However, each examination also has a specific purpose which will be
explained later on each part of the body that will be physically examined.

C. Benefit of Physical Examination

Physical examination has many benefits both for the nurses themselves
and for other health professions including
1. As data to assist nurses in enforcing nursing diagnoses
2. Knowing the health problems experienced by clients
3. As a basis for selecting appropriate nursing interventions
4. As data to evaluate the results of nursing care

D. Indication
An absolute must for every client, especially for:
 Clients who have just entered a health care facility for treatment
 Routinely on clients who are being treated
 From time to time according to client needsProsedur pemeriksaan fisik
A. Persiapan
1) Alat
Meteran, Timbangan BB, Penlight, Steteskop, Tensimeter/spighnomanometer,
Thermometer, Arloji/stopwatch, Refleks Hammer, Otoskop, Handscoon bersih
(jika perlu), tissue, buku catatan perawat.
2) Lingkungan
Pastikan ruangan dalam keadaan nyaman, hangat, dan cukup penerangan.
Misalnya menutup pintu/jendala atau skerem untuk menjaga privacy klien.
3) Klien (fisik dan fisiologis)
Bantu klien mengenakan baju periksa jika ada dan anjurkan klien untuk rileks.

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 Prosedur Pemeriksaan
1. Cuci tangan
2. Jelaskan prosedur
3. Lakukan pemeriksaan dengan berdiri di sebelah kanan klien dan pasang
handscoen bila di perlukan

a) Pemeriksaan umum meliputi penampilan umum, status mental dan nutrisi

Posisi klien: duduk berbaring
Cara: inspeksi
 Kesadaran, tingkah laku, ekspresi wajah, mood. (Normal: Kesadaran
penuh, ekspresi sesuai, tidak ada menahan nyeri /sulit bernafas)
 Tanda-tanda stress/ kecemasan (Normal : relaks tidak ada tanda-tanda
cemas/takut)
 Jenis kelamin
 Usia dan Gender
 Tahapan perkembangan
 TB, BB (Normal : BMI dalam batas normal)
 Kebersihan Personal NormalBersih dan tidak bau)
 Cara berpakaian (Normal : Benar tidak terbalik)
 Postur dan cara berjalan
 Bentuk dan ukuran tubuh
 Cara bicara (Relaks, lancer, tidak gugup)
 Evaluasi dengan membandingkan dengan keadaan normal
 Dokumentasikan hasil pemeriksaan

b) Pengukuran Tanda Vital

Posisi klien : duduk berbaring
1. Suhu tubuh (Normal : 36,5-37,5)
2. Tekanan darah (Normal : 120/80 mmHg)
3. Nadi
a. Frekuensi

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 Normal : 60-100x/menit
Takikardia : >100/menit
Bradikardia : <60 menit
b. Keteraturan
Normal : teratur
c. Kekuatan
0 : Tidak ada denyutan
1+ : denyutan kurang teraba
2+ : Denyutan mudah terabatak mudah lenyap;
3+ : denyutan kuat dan mudah teraba
4. Pernafasan
1) Frekuensi
Normal : 15-20x/menit
Takipnea : >24x/menit
Bradipnea : <10 menit
2) Keteraturan
Normal : teratur
3) Kedalaman : dalam/dangkal
4) Penggunaan otot bantu pernafasan : Normal tidak ada

Setelah diadakan pemeriksaan tanda-tanda vital evaluasi hasil yang

didapat dengan membandikan dengan keadaan normal dan
dokumentasikan hasil pemeriksaan yang didapat

c) Pemeriksaan Kulit dan Kuku

Tujuan
1. Mengetahui kondisi kulit dan kuku
2. Mengetahui perubahan oksigenasi sirkulasikerusakan jaringan
setempat dan hidrasi

Persiapan
1. Posisi klien duduk/berbaring

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 2. Pencahayaan yang cukup lampu
3. Sarung tangan (untuk lesi, basah dan berair)

Prosedur Pelaksanaan
a. Pemeriksaan kulit
 Inspeksi : kebersihan, warna, pigmentasi, lesi/perlukaan, pucat,
sianosis, dan ikterik
Normal : kulit tidak ada ikterik/pucat/sianosis
 Palpasi: kelembapan, suhu permukaan kulit, tekstur, ketebalan,
turgor kulit, dan edema
Normal : lembab, turgor baik/elastic, tidak ada edema
Setelah diadakan pemeriksaan kulit, evaluasi hasil yang di dapat dengan
membandikan dengan keadaan normal dan dokumentasikan hasil
pemeriksaan yang didapat tersebut.

b. Pemeriksaan kuku
 Inspeksi: kebersihan, bentuk, dan warna kuku
Normal : bersih, bentuk normal, tidak ada tanda-tanda jari tabuh
(clubbing finger), tidak ikterik/sianosis
 Palpasi : ketebalan kuku dan capillary refile (pengisian kapiler)
Normal : aliran darah kuku akan kembali < 3 detik
Setelah diadakan pemeriksaan kuku evaluasi hasil yang di dapat dengan
membandikan dengan keadaan normal dan dokumentasikan hasil
pemeriksaan yang didapat tersebut.

d) Pemeriksaan kepala, wajah, mata, telinga, hidung, mulut dan leher

Posisi : klien duduk untuk pemeriksaan wajah sampai dengan leher dan
perawat berhadapan dengan klien

1. Pemeriksaan kepala
Tujuan
 Mengetahui bentuk dan fungsi kepala

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  Mengetahui kelainan yang terdapat di kepala
Persiapan alat
 Lampu
 Sarung tangan (jika di duga terdapat lesi atau luka)

Prosedur Pelaksanaan
 Inspeksi : ukuran lingkar kepala, bentuk, kesimetrisan, adanya
lesi atau tidak, kebersihan rambut dan kulit kepala, warna,
rambut, jumlah dan distribusi rambut
Normal: simetris, bersih, tidak ada lesi, tidak menunjukkan
tanda- tanda kekurangan gizi(rambut jagung dan kering).
 Palpasi: adanya pembengkakan/penonjolan dan tekstur rambut
Normal : tidak ada penonjolan /pembengkakan, rambut lebat
dan kuat tidak rapuh.

2. Pemeriksaan wajah
 Inspeksi: warna kulit, pigmentasi, bentuk dan kesimetrisan
Normal : warna sama dengan bagian tubuh laintidak
pucat/ikteriksimetris
 Palpasi: nyeri tekan dahidan edemapipidan rahang
Normal : tidak ada nyeri tekan dan edema

3. Pemeriksaan mata
Tujuan
a) Mengetahui bentuk dan fungsi mata
b) Mengetahui adanya kelainan pada mata

Persiapan alat:
a. Senter Kecil
b. Surat kabar atau majalah
c. Kartu Snellen
d. Penutup Mata

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e. Sarung tangan

Prosedur Pelaksanaan
 Inspeksi : bentuk, kesimestrisan alis mata, bulu mata, kelopak
mata, kesimestrisan bola mata, warna, konjunctiva dan selera
(anemis/ikterik), penggunaan kacamata lensa kontakdan respon
terhadap Cahaya
Normal : simetris mata kika, simetris bola mata kika, warna
konjungtiva pink dan selera berwarna putih
 Tes Ketajaman Penglihatan
Ketajaman penglihatan seseorang mungkin berbeda dengan
orang lain. Tajam penglihatan tersebut merupakan derajat
persepsi deteil dan contour. Beda Visus tersebut dibagi dua
yaitu

1. Visus sentralis

Visus sentralis ini dibagi dua yaitu visus sentralis jauh dan
visus sentralis dekat.
- Visus centralis jauh merupakan ketajaman penglihatan
untuk melihat benda benda yang letaknya jauh. Pada
keadaan ini mata tidak melakukan akomodasi
(EMSutrisna, dkkhal 21)
- Visus centralis dekat yang merupakan ketajaman
penglihatan untuk melihat benda benda dekat misalnya
membaca, menulis dan lain lain. Pada keadaan ini mata
harus akomodasi supaya bayangan benda tepat jatuh di
retina (EM. Sutrisna, dkkhal 21)

2. Visus perifer

Pada visus ini menggambarkan luasnya medan

penglihatan dan diperiksa dengan perimeter. Fungsi dari
visus perifer adalah untuk mengenal tempat suatu benda

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 terhadap sekitarnya dan pertahanan tubuh dengan reaksi
menghindar jika ada bahaya dari samping. Dalam klinis
visus sentralis jauh tersebut diukur dengan menggunakan
grafik huruf Snellen yang dilihat pada jarak 20 feet atau
sekitar 6 meter.

4. Pemeriksaan telinga
Tujuan:
Mengetahui keadaan telinga luar, saluran telinga, gendang telinga,
dan fungsi pendengaran

Persiapan Alat:
a) Arloji berjarum detik
b) Garpu tala
c) Speculum telinga
d) Lampu kepala

Prosedur Pelaksanaan
 Inspeksi : bentuk dan ukuran telinga, kesimetrisan, integritas,
posisi telinga,warna liang telinga (cerumen tanda-tanda
infeksi), alat bantu dengar
Normal : bentuk dan posisi simetris kika, integritas kulit bagus,
warna sama dengan kulit lain, tidak ada tanda-tanda infeksi
dan alat bantu dengar
 Palpasi: nyeri tekan aurikuler, mastoiddan tragus
Normal : tidak ada nyeri tekan

Pemeriksaan Telinga Dengan Menggunakan Garpu Tala

a. Pemeriksaan Rinne
 Pegang agrpu tala pada tangkainya dan pukulkan ke
telapak atau buku jari tangan yang berlawanan

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  Letakkan tangkai garpu tala pada prosesus mastoideus
klien
 Anjurkan klien untuk memberi tahu pemeriksa jika ia
tidak merasakan getaran lagi
 Angkat garpu tala dan dengan cepat tempatkan di depan
lubang telinga klien 1-2 cm dengan posisi garpu tala
parallel terhadap lubang telinga luar klien
 Instruksikan klien untuk memberi tahu apakah ia masih
mendengarkan suara atau tidak
 Catat hasil pemeriksaan pendengaran tersebut

b. Pemeriksaan Webber
 Pegang garpu tala pada tangkainya dan pukulkan ke
telapak atau buku jari yang berlawanan.
 Letakkan tangkai garpu tala di tengah puncak kepala klien
 Tanyakan pada klien apakah bunyi terdengar sama jelas
pada kedua telinga atau lebih jelas pada salah satu telinga
 Catat hasil pemeriksaan dengan pendengaran tersebut

5. Pemeriksan hidung dan sinus

Tujuan:
a. Mengetahui bentuk dan fungsi hidung
b. Menentukan kesimetrisan struktur dan adanya inflamasi atau
infeksi

Persiapan Alat:
a. Spekulum hidung
b. Senter kecil
c. Lampu penerang
d. Sarung tangan (jika perlu)

Prosedur Pelaksanaan:

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  Inspeksi: hidung eksternal (bentuk, ukuran, wama,
kesimetrisan), rongga hidung (lesisekret, sumbatan,
pendarahan), hidung internal (kemerahan, lesi, tanda infeksi)
Normal : simetris kika, warna sama dengan warna kulit lain,
tidak ada lesi, tidak ada sumbatan, perdarahan dan tanda-tanda
infeksi
 Palpasi dan Perkusi frontalis dan maksilaris (bengkak nyeridan
septum deviasi)
Normal : tidak ada bengkak dan nyeri tekan

6. Pemeriksaan mulut dan bibir

Tujuan: Mengetahui bentuk kelainan mulut

Persiapan Alat:
a. Senter kecil
b. Sudip lidah
c. Sarung tangan bersih
d. Kasa

Prosedur Pelaksanaan:
 Inspeksi dan palpasi struktur luar: warna mukosa mulut dan
bibirtekstur, lesidan stomatitis
Normal : warna mukosa mulut dan bibir pink, lembab, tidak
ada lesi dan stomatitis
 Inspeksi dan palpasi strukur dalam gigi lengkap/penggunaan
gigi palsu, perdarahan/ radang gusi, kesimetrisan, warna, posisi
lidah, dan keadaan langit2
Normal : gigi lengkap, tidak ada tanda-tanda gigi berlobang
atau kerusakan gigi ,tidak ada perdarahan atau radang gusi,
lidah simetris, warna pink, langit2 utuh dan tidak ada tanda
infeksi.

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 Gigi lengkap pada orang dewasa berjumlah 36 buahyang
terdiri dari 16 buah di rahang atas dan 16 buah di rahang
bawahPada anak-anak gigi sudah mulai tumbuh pada usia
enam bulanGigi pertama tumbuh dinamakan gigi susu di ikuti
tumbuhnya gigi lain yang disebut gigi sulungAkhirnya pada
usia enam tahun hingga empat belas tahungigi tersebut mulai
tanggal dan dig anti gigi tetap. Pada usia 6 bulan gigi
berjumlah 2 buah (dirahang bawah)usia 7-8 bulan berjumlah 7
buah(2 dirahang atas dan 4 dirahang bawah)usia 9. 11 bulan
berjumlah 8 buah(4 dirahang atas dan 4 dirahang bawah)usia
12-15 bulan gigi berjumlah 12 buah (6 dirahang atas dan 6
dirahang. bawah)usia 16-19 bulan berjumlah 16 buah (8
dirahang atas dan 8 dirahang bawah)dan pada usia 20-30 bulan
berjumlah 20 buah (10 dirahang atas dan 10 dirahang bawah)

7. Pemeriksaan leher
Tujuan:
a. Menentukan struktur integritas leher
b. Mengetahui bentuk leher serta organ yang berkaitan
c. Memeriksa system limfatik

Persiapan Alat: Stetoskop

Prosedur Pelaksanaan:
 Inspeksi leher: warna, integritas, bentuk simetris
Normal: warna sama dengan kulit lain, integritas kulit baik,
bentuk simetris, tidak ada pembesaran kelenjer gondok
 Inspeksi dan auskultasi arteri karotis: lokasi pulsasi
Normal: arteri karotis terdengar
 Inspeksi dan palpasi : kelenjer tiroid (nodus/difus,
pembesaran,batas konsistensi nyeri, gerakan/perlengketan pada

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 kulit), kelenjer limfe (letak, konsistensi
nyeripembesaran)kelenjer parotis (letak,terlihat/ teraba)
Normal : tidak teraba pembesaran kel.gondok, tidak ada nyeri,
tidak ada pembesaran kel.limfe, tidak ada nyeri
 Auskultasi : bising pembuluh darah

e) Pemeriksaan dada( dada dan punggung)

Posisi klien berdiri, duduk dan berbaring

Cara/prosedur:
a. System pernafasan
Tujuan:
 Mengetahui bentuk, kesimetrisan, sekspansi, keadaan kulit,
dan dinding dada
 Mengetahui frekuensi, sifat irama pernafasan
 Mengetahui adanya nyeri tekan, masa peradangan, traktil
premitus

Persiapan alat :
a) Stetoskop
b) Penggaris centimeter
c) Pensil penada

Prosedur pelaksanaan
 Inspeksi : kesimetrisan, bentuk/postur dada, gerakan nafas
(frekuensi, irama, kedalaman dan upaya pernafasan
/penggunaan otot-otot bantu pernafasan) warna kulitlesi,
edema, pembengkakan/ penonjolan
Normal : simetris bentuk dan postur normal, tidak ada
tanda-tanda distress pernapasan, warna kulit sama dengan
warna kulit lain tidak ikterik/sianosis tidak ada
pembengkakan/penonjolan/edema

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  Palpasi : Simetris, pergerakan dada, massa dan lesi, nyeri,
tractile fremitus (perawat berdiri di belakang pasien,
instruksikan pasien untuk mengucapkan angka tujuh-tujuh"
atau "enam-enam" sambil melakukan perabaan dengan
kedua telapak tangan pada punggung pasien)
Normal : integritas kulit baik, tidak ada nyeri tekan/massa
tanda-tanda peradangan, ekspansi simetris, taktil vremitus
cendrung sebelah kanan lebih teraba jelas
 Perkusi : paru eksrusi diafragma konsistensi dan
bandingkan satu sisi dengan satu sisi lain pada tinggi yang
sama dengan pola berjenjang sisi ke sisi) Normal : resonan
(dug dug dug") jika bagian padat lebih daripada bagian
udara pekak ("bleg bleg bleg") jika bagian udara lebih besar
dari bagian padat-hiperesonan (deng deng deng") batas
jantung-bunyi rensonan-hilang>>redup
 Auskultasi : suara nafas trachea bronchus paru (dengarkan
dengan. menggunakan stetoskop di lapang paru kika di RIC
dan 2 (di atas manubrium dan di atas trachea)
Normal : bunyi napas vesikuler, broncho vesikuler brochial,
tracheal

b. System kardiovaskuler
Tujuan:
 Mengetahui ketifdak normalan denyut jantung
 Mengetahui ukuran dan bentuk jantug secara kasar
 Mengetahui bunyi jantung normal dan abnormal
 Mendeteksi gangguan kardiovaskuler

Persiapan alat:
 Stetoskop
 Senter kecil

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 Prosedur pelaksanaan:
 Inspeksi : Muka bibir konjungtiva, vena jugularis, arteri
karotis
 Palpasi : denyutan
 Normal untuk inspeksi dan palpasi denyutan aorta teraba
Perkusi : ukuran, bentuk dan batas jantung (lakukan dari
arah samping ke tengah dada, dan dari atas ke bawah
sampai bunyi redup)
Normal : batas jantung tidak lebih dari 4,7,10 cm ke arah
kiri dari garis mid sterna pada RIC 4,5,dan 8.
 Auskultasi : bunyi jantung arteri karotis (gunakan bagian
diafragma dan bell dari stetoskop untuk mendengarkan
bunyi jantung
Normal terdengar bunyi jantung I/S1 (lub) dan bunyi
jantung II/S2 (dub) tidak ada bunyi jantung tambahan (S3
atau S4)

f) Dada dan aksila

Tujuan:
a. Mengetahui adanya masa atau ketidak teraturan dalam jaringan
payudara
b. Mendeteksi awal adanya kanker payudara

Persiapan alat:
Sarung tangan sekali pakai (jika diperlukan)

Prosedur pelaksanaan:
 Inspeksi : payudara, Integritas kulit
 Palpasi : payudara, Bentuk, simetris, ukuran acrola putting dan
penyebaran vena
 Inspeksi dan palpasi : aksila nyeri, perbesaran nodus limfe,
konsistensi

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g) Pemeriksaan Abdomen Perut)
Posisi : klien berbaring

Tujuan:
a. Mengetahui bentuk dan gerakan-gerakan perut
b. Mendengarkan suara peristaltic usus
c. Meneliti tempat nyeri tekanorgan-organ dalam rongga perut
benjolan dalam perut

Persiapan alat :
a) Stetoskop
b) Penggaris kecil
c) Pensil gambar
d) Bantal kecil
e) Pita pengukur

Prosedur pelaksanaan:
 Inspeksi: kuadran dan simetris, contour, warna kulit, lesi
scarostomy distensi, tonjolan, pelebaran vena, kelainan
umbilicus dan Gerakan dinding perut
 Normal : simetris kika, warna dengan warna kulit lain tidak
ikterik tidak terdapat ostomy distensi, tonjolan, pelebaran vena,
kelainan umbilicus
 Auskultasi: suara peristaltik (bising usus) di semua kuadran
(bagian diafragma dari stetoskop) dan suara pembuluh darah
dan friction rub aortaa.renalis ailliaka (bagian bell)
 Normal : suara peristaltic terdengar setiap 5-20x/dtk, terdengar
denyutan arteri renalis arteri iliaka dan aorta
 Perkusi : semua kuadran mulai dari kuadran kanan atas
bergerak searah jarum jam, perhatikan jika klien merasa nyeri
dan bagaiman kualitas bunyinya

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  Perkusi batas hepar
 Perkusi Limfa: ukuran dan batas
 Normal: timpani, bila hepar dan limfa membesar-redup dan
apabila banyak cairan, hipertimpani
 Perkusi ginjal : nyeri
 Palpasi semua kuadran (hepar, limfa, ginjal kiri dan kanan):
massa, karakteristik organ, adanya asistes, nyeri irregular,
lokasi, dan nyeri. dengan cara perawat menghangatkan tangan
terlebih dahulu
Normal: tidak teraba penonjolan tidak ada nyeri tekan tidak
ada massa dan penumpukan cairan

h) Pemeriksaan ekstermitas atas bahu, siku, tangan)

Tujuan:
a) Memperoleh data dasar tetang otot, tulang dan persendian
b) Mengetahui adanya mobilitaskekuatan atau adanya gangguan
pada bagian-bagian tertentu

Alat: Meteran
Posisi klien: BerdiriDuduk

Prosedur pelaksanaan
 Inspeksi struktur muskuloskletal simetris dan pergerakan,
Integritas, ROM, kekuatan dan tonus otot
Normal : simetris kika, integritas kulit baik, ROM aktif,
kekuatan otot penuh.
 Palpasi denyutan abrachialis dan aradialis
Normal : teraba jelas
 Tes reflex tendon trisep, bisep dan brachioradialis
Normal : reflek bisep dan trisep positif

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i) Pemeriksaan ekstermitas bawah (panggul, lutut, pergelangan kaki
dan telapak kaki)
 Inspeksi struktur muskuloskletal simetris dan pergerakan
integritas kulit, posisi dan letak, ROM, kekuatan dan tonus otot
Normal: simetris kika, integritas kulit baik, ROM aktif,
kekuatan otot penuh
 Palpasi: a. femoralisa. popliteaadorsalis pedisdenyutan
Normal: teraba jelas
 Tes reflex tendon patella dan archilles
Normal: reflex patella dan archiles positif

j) Pemeriksaan genitalia (alat genital anus rectum)

Posisi : Klien Pria berdiri dan wanita litotomy.

Tujuan
a) Melihat dan mengetahui organ-organ yang termasuk dalam
genetalia.
b) Mengetahui adanya abnormalitas pada genetalia, misalnya
varises, edema, tumor benjolan, infeksi, luka atau iritasi,
pengeluaran cairan atau darah
c) Melakukan perawatan genetalia
d) Mengetahui kemajuan proses persalinan pada ibu hamil atau
persalinan

Alat:
a. Lampu yang dapat diatur pencahayaannya
b. Sarung tangan

Pemeriksaan rectum :
Tujuan:
 Mengetahui kondisi anus dan rectum

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 Menentukan adanya masa atau bentuk tidak teratur dari
dinding rektal
 Mengetahui intregritas spingter anal eksternal
 Memeriksa kangker rectal dil

Alat:
a) Sarung tangan sekali pakai
b) Zat pelumas
c) Penetangan untuk pemeriksaan

Prosedur Pelaksanaan:

a. Wanita
 Inspeksi genitalia eksternal: mukosa kulit integritas, kulit
contour, simetris, edema, pengeluaran
Normal : bersih, mukosa lembab, integritas kulit baik,
semetris tidak ada edema dan tanda-tanda infeksi
(pengeluaran pus/bau)
 Inspeksi vagina dan servik : integritas kulit, massa
pengeluaran
 Palpasi vagina, uterus dan ovarium, letak ukuran,
konsistensi dan massa
 Pemeriksaan anus dan rectum : feses, nyeri, massa, edema,
haemoroid, fistula ani, pengeluaran dan perdarahan
Normal : tidak ada nyeri, tidak terdapat edema hemoroid/
polip/tanda-tanda infeksi dan pendarahan

b. Pria:
 Inspeksi dan palpasi penis : Integritas kulit, massa dan
pengeluaran
Normal : integritas kulit baik, tidak ada massa atau
pembengkakan, tidak ada pengeluaran pus atau darah

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  Inspeksi dan palpassi skrotum : integritas kulit, ukuran dan
bentuk, turunan testis dan mobilitas, massa nyeri dan
tonjolan
 Pemeriksaan anus dan rectum : feses, nyeri, massa,
edema, hemoroidfistula ani, pengeluaran dan perdarahan
Normal : tidak ada nyeri, tidak terdapat edema/ hemoroid/
polip/ tanda-tanda infeksi dan pendarahan.

E. Sample form of physical examination :

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2.2. Supporting Examination
A. Definition of Supporting Examination
Supporting examinations are medical examinations carried out for certain
indications in order to obtain more complete information. Supporting examinations
that can be carried out are therapeutic, diagnostic, laboratory, etc. Investigation is
also an applied science that is useful for assisting health workers in diagnosing and
treating patients (Basariyadi, 2016).

B. Function of supporting examination

1. Screening or screening test for the presence of subclinical disease, with the
aim of determining the risk of a disease and early detection of disease,
especially for high-risk individuals (even if there are no symptoms or
complaints)
2. Confirmation of a definite diagnosis, namely to ascertain the disease that a
person is suffering from, related to the treatment that will be given by the
doctor and closely related to complications that might occur

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 3. Finding diagnostic possibilities that can disguise clinical symptoms
4. Help monitor treatment
5. Provide information on the prognosis or course of the disease, namely to
predict the course of the disease and is related to the therapy and
subsequent management of the patient.
6. Monitor the progress of the disease, namely to monitor the progress of the
disease and monitor the effectiveness of the therapy carried out in order to
minimize complications that can occur. This monitoring should be done
regularly.
7. Determine whether there are abnormalities or diseases that are often found
and potentially harmful. Give peace to both patients and clinicians because
no disease is found

C. Purpose of supporting examination

1. Therapeutic
Namely for treatment or treatment that is appropriate for patients with
certain disease conditions.
2. Diagnostik
That is to help establish a certain diagnosis

D. Types of supporting examination

1. Laboratory Examination
1) Complete Blood Count
Complete blood count (CBC) is a type of screening examination to
support the diagnosis of a disease and see how the body responds to a
disease. Besides that, this examination is often carried out to see the
progress or response to therapy in patients suffering from an infectious
disease. The blood that is examined includes the number of red blood
cells, white blood cells, leukocytes, platelets and others. The cell count is
counted to find out whether the patient also suffers from anemia (a type
of iron deficiency disease in the blood), while leukocytes is to see the

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patient's immune system. If the leukocyte level is above normal, it means
that an infectious disease is attacking the patient.
A complete blood count is usually recommended for every patient
who comes to a hospital accompanied by a clinical symptom, and if
results are obtained that are outside the normal value, a follow-up
examination that is more specific for the disorder is usually carried out so
that the correct diagnosis and treatment can be done immediately.

2) Liquor Cerebro Spinalis

Examination of the Brain Fluid (Liquor Cerebro Spinalis - LCS) is the
fluid that covers the central nervous system. Its function is to protect the
brain and spine. In addition, it also functions as a regulator of excitability
by regulating ionic composition, removing metabolites (because the brain
does not have lymph vessels) and providing protection against pressure.
This liquid has almost the same composition as blood plasma, namely
Sodium, Potassium, Urea, Lactic Acid and Sulfonamides, as well as 12
other substances whose composition is different from blood plasma.
Examination of the CSF is aimed at detecting abnormalities in the
brain and bone marrow, meningitis, tumors, abscess echephilitis and viral
infections in the area. Examination of the protein in the cerebrospinal
fluid is the most important. Under normal circumstances the protein
contained in the cerebrospinal fluid is very small. so, the purpose of this
examination is to find out the amount can be done qualitatively and
quantitatively.
3) Urine Examination
A urine test (urinalysis) is a method of examination that uses urine as
a detector for disturbances in the body. A urine sample test is usually
performed to diagnose diseases related to the urinary tract. For example,
urinary tract infections, kidney disease, and diabetes. Urinalysis generally
checks the color, concentration, composition, and smell of urine.
Urinalysis results that indicate abnormalities often require further
examination to uncover the cause.

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E. Preparation of supporting examination
1. Ensure Patient Identity
2. Selection of the location for taking the specimen
3. Time of specimen collection
4. Technique or method of specimen collection
5. How to accommodate the specimen in the container
6. Granting of Identity
7. Delivery of specimens to the laboratory
8. Specimen handling and specimen storage

F. Steps of supporting examination

The stages of supporting examination include:
1. Tool preparation
In preparing the tools to be used, one must always pay attention to the
doctor's instructions so that there are no wrong preparations and give the
impression of being professional at work
2. Patient preparation
Patient preparations that need to be considered are releasing all electronic
devices and metal objects attached to the body which can affect the
examination, fasting, drugs taken by the patient while undergoing
treatment, time of taking and position of sampling

F. The tools used for supporting examination

1. EMG (Electro Myo Grafi)
EMG examination is usually performed to determine the electrical potential
of the muscle. EMG helps to diagnose the presence of damage to the
neuromuscular, LMN (Lowe Motor Neuron) and peripheral nerves. The
client needs to be informed that this examination can cause discomfort due
to the electrode needle entering the muscle. After the examination, the nurse
helps to deal with discomfort and observes whether there is a hematoma at
the needle puncture site so that cold compresses can be given
2. EKG (Electro Cardiograph)

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 EKG is a measuring tool used to measure or detect heart conditions by
monitoring the rhythm and frequency of heartbeats. To measure the heart
rate the electrodes of the electrocardiograph are placed onto the patient's
chest. The electrodes detect the fluctuations in the heart's electrical current
and send them to an electrocardiograph which records the changes as
waveforms on a moving roll of paper.
3. EEG (Electro Encephalograph)
Electro Encephalograph (EEG) is a tool that studies images from recordings
of electrical activity in the brain including EEG recording techniques and
their interpretation. The neurons in the cortex of the brain emit electrical
waves with a very small voltage (mV) which are then streamed to the EEG
machine to be amplified so that an electroencephalogram is recorded that is
of sufficient size to be captured by the eye of an EEG reader as deltaalpha,
beta, thetagamma waves, etc. The purpose of the EEG examination is to
diagnose diseases related to brain and psychiatric disorders. EEG
indications and uses in patients who have seizures or are suspected of
having seizures, evaluating the cerebral effects of various diseases, systemic
(eg metabolic encephalopathy due to diabetes, kidney failure) conducting
studies to determine sleep disorders (sleep disorder) or narcolepsy to help
establish the diagnosis of coma to localize Changes in the brain's electrical
potential caused by trauma, tumors, vascular disorders (vascular) and
degenerative diseases, help look for various cerebral disorders that can
cause headaches, behavioral disorders and intellectual decline.
4. MRI (Magnetic Resonance Imaging)
Used to diagnose parts of the structure of the human body with
electromagnetic waves that do not give the effect of radiation such as X-
rays. This tool is very useful for examining nerves, muscle tissue, heart and
blood vessels and tumors. The greater the tesla or magnetic strength the
better the image quality. MRI can examine the brain and spinal cord,
ligaments, tumor tears.
5. Audiometry

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 Audiometry is a tool used to determine a person's hearing level. With the
help of a tool called audiometry, the degree of a person's hearing acuity can
be assessed. An audiometric test is needed for someone who feels they have
hearing loss or someone who will work in a field that requires hearing
acuity.
6. Ultrasound (Ultrasound)
Ultrasound or better known as ultrasound is a non-invasive examination that
utilizes sound waves that are channeled through instruments into the body
and then reflected and the results can be seen on a monitor screen.
Ultrasound (ultrasonography) is very popularly used to monitor the
condition of the fetus, the development of pregnancy, preparation for
childbirth, and other problems. This technique is also used to determine the
location of tumors, cardiovascular disorders, and eye defects.
7. X-rays
X-rays, also known as x-rays, are examinations that utilize the role of x-rays
to screen and detect abnormalities in various organs including the heart,
abdomen, kidneys, ureters, bladder, throat and skeleton.
8. Mammography
Mammography is a radiographic examination of the mammary (breast)
using x-rays to create images that can distinguish between healthy cells and
malignant cells, and the aid of positive contrast media or not to make a
diagnosis.
9. CT scan
A computerized tomography scan, or more commonly called a CT scan, is a
special x-ray technique that produces more detailed pictures of internal
organs than conventional x-rays. Conventional x-rays produce two-
dimensional images of body parts. A CT scan on the other hand uses a
device that rotates around the body scattering x-rays and a rotating x-ray
tube. These images are then processed by a computer, thus producing a
cross-sectional image of the inside of the body. Example: organs in the skull
and organs in the abdomen.
10. Endoscopy

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 Endoscopy is a way of examining the inside of the body using an instrument
called an endoscope that is inserted into the body. An endoscope is a long,
thin, flexible tube with a flashlight and camera attached to the end. The state
of the inside of the body will be shown on the television screen. An
endoscope can be inserted into an opening in the body, such as the mouth or
anus. The endoscope instrument may also be inserted through a small
incision made in the skin, for example in the knee or abdomen. After
endoscopy, patients are usually advised to rest for at least 1 hour until the
side effects of the anesthetic wear off. Examples of endoscopy examinations
can be seen in patients with gastrointestinal disorders, including gastric
ulcers, difficulty swallowing, acid reflux disease (GERD), inflammatory
bowel disease, inflammation of the pancreas, gallstones, chronic
constipation, and gastrointestinal bleeding. Disorders of the airways,
including coughing up blood, chronic coughing, airway obstruction,
shortness of breath, lung tumors, and foreign bodies in the airways.
Disorders of the urinary tract, including urinary tract or bladder stones,
bladder tumors, bloody urine, urinary incontinence, and injuries or injuries
to the urinary tract. Disorders of the reproductive organs include vaginal
bleeding, pelvic inflammation, frequent miscarriages, infertility, uterine
fibroids and cysts, uterine cancer, and uterine deformities.

G. An example of a supporting examination form :

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38
 BAB III
CLOSING

3.1. Conclusion
Physical examination and supporting examination is a process of a medical
expert in examining and finding abnormalities in the patient's body, which then
the results of the examination will be recorded in the medical record. The purpose
of this physical examination is to be able to find out basic data regarding the
patient's health and make clinical judgments about changes in the client's health
status and its management. Physical examination techniques include inspection,
percussion, palpation, and auscultation. In practice, the nurse must know the
procedure to be carried out, so that problems do not occur during the examination
process.

3.2. Suggestion
It is expected that nurses can carry out physical examinations and supporting
examinations, in accordance with the preparations, techniques and procedures that
have been established.

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 BIBLIOGRAPHY

Olfah, Y. 2016. Modul Bahan Ajar Cetak Keperawatan : Dokumentasi

Keperawatan. Jakarta : Pusdik SDM Kesehatan.

Handayaningsih, Isti. (2009) Dokumentasi Keperawatan (panduan, konsep dan

aplikasi), Mitra Cendikia Press, Yogyakarta.

Iyer. P.W and Camp.N.H, (2005). Dokumentasi Keperawatan Suatu

Pendekatan Proses Keperawatan. Edisi 3. Jakarta : EGC.

Nursalam. (2009). Proses Dan Dokumentasi Keperawatan. Jakarta: Salemba

Medika.

Setiadi. (2012). Konsep dan Penulisan Dokumentasi Asuhan Keperawatan

(teori dan praktik). Graha Ilmu, Yogyakarta.

Koerniawan, D., Daeli, N. E., Srimayati. 2020. Aplikasi Standar Proses

Keperawatan : Diagnosis, Outcome, Dan Intervensi Pada Asuhan Keperawatan.
Jurnal Keperawatan Silampari, 3 (2), 739-751.

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