Things that need to be considered in conducting observations:
1. Not always are we going to do the examination described in detail to the client (although the therapeutic communication remains to be done), because sometimes this can increase the client's anxiety or obscure the data (the data obtained becomes impure). For example: "Sir, I will count the breaths you in a minute" data obtained most likely become invalid, because it is likely the client will attempt to regulate his breathing.
2. Concerning aspects of physical, mental, social and spiritual clients.
3. The results were recorded in nursing notes, so it can be read and understood by other nurses.
Examples of such observations: visible physical abnormalities, bleeding, there are parts of the body burned, the smell of alcohol, urine, feces, blood pressure, heart rate, coughing, crying, pain expression, and others. PHYSICAL EXAMINATION
The third stage in data collection is the physical examination. Physical examination in nursing is used to obtain objective data from the client's nursing history. Physical examination should be performed in conjunction with the interview. The focus of nursing physical assessment is the client's functional ability. For example, a client experiencing musculoskeletal system disorders, the nurse examines whether the disorder affects the client in carrying out daily activities or not.
The purpose of physical examination in nursing is to determine the client's health status, identify problems and take client data base to determine the plan of nursing actions.
There are four techniques in the physical examination are:
1. Inspection
Examination is performed by looking at parts of the body being examined through observation. Adequate light is needed for nurses to distinguish color, shape and cleanliness of the client's body. Focus inspections on every part of the body include: body size, color, shape, position, symmetrical. And compared the results to normal and abnormal body parts with each other body parts. Example: yellow eyes (jaundice), there is a goitre in the neck, bluish skin (cyanosis), and others.
2. Palpation
Palpation is a technique that uses the sense of touch. Hands and fingers are sensitive instruments used to collect data, for example about: temperature, turgor, shape, moisture, vibration, size.
The steps that need to be considered during palpation:
· Create a comfortable and relaxing environment.
· Nurses must be in good hands warm and dry
· Nurses Fingernails should be cut short.
• All parts of the palpable pain at the end.
Ie, the presence of tumor, edema, crepitus (bone fracture), and others.
3. Percussion
Percussion is the examination by tapping certain parts of the body surface to compare with other body parts (left and right) with the goal of producing sound.
Percussion aims to identify the location, size, shape and consistency of the network. Nurses use both hands as a tool to produce sound.
The sounds found on percussion are:
Sonor: percussive sound normal tissue.
Dim: percussive sound that is more dense tissue, eg in areas of lung in pneumonia.
Deaf: a dense network of percussive sounds such as the heart on percussion, percussion liver area.
Hipersonor / tympanic: percussion sound more hollow in the empty areas, such as lung caverna area, on the client with chronic asthma.
4. Auscultation
Physical examination is performed by listening to the sound produced by the body. Typically use a device called a stethoscope. Things that are heard are: heart sounds, breath sounds, and bowel sounds.
The sound is not normal that can be auscultated in the breath are:
* Rales: the sound produced from the sticky exudate when the channels of smooth breathing expands on inspiration (rales fine, medium, coarse). For instance on the client pneumonia, tuberculosis.
* Ronchi: a low pitch and very rough sounding either during inspiration or during expiration. Ronchi characteristic is lost when the client coughs. For example in pulmonary edema.
* Wheezing: the sound is heard "ngiii .... K". can be found in the phase of inspiration and expiration. For example in acute bronchitis, asthma.
* Pleural Friction Rub; noise that sounded "dry" sound like rubbing sandpaper on wood. For instance on the client with pleural inflammation.
Physical assessment approach can be used:
1. Head to toe (head to toe)
This approach is done starting from the head and in sequence to the foot. Starting from: general condition, vital signs, head, face, eyes, ears, nose, mouth and throat, neck, chest, lung, heart, abdomen, kidneys, back, genetalia, rectum, ektremitas.
2. ROS (Review of System / body system)
Studies made by covering the entire body system, ie: general condition, vital signs, respiratory system, cardiovascular system, persyarafan system, urinary system, digestive system, musculoskeletal system and the integument, reproductive system. The information obtained helps nurses to determine which body systems need special attention.
3. The pattern of health functions Gordon, 1982
Nurses collect data systematically by evaluating patterns of health functions and physical assessment focuses on specific issues include: health perception-health management, nutritional-metabolic patterns, elimination patterns, sleep-rest patterns, cognitive-perceptual patterns, role-related patterns, activity- exercise patterns, sexuality, reproductive patterns, coping-stress tolerance pattern, value-belief pattern.
4. Doengoes (1993)
Includes: activity / rest, circulation, ego integrity, elimination, food and liquids, hygiene, Neurosensori, pain / discomfort, respiratory, safety, sexuality, social interaction, education / learning.
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