ASSESSMENT : PHYSICAL EXAMINATION

BAHASA INGGRIS II
MODUL PRAKTIKA
ASSESMENT
Penulis
Indriana Rakhmawati SKp., MSi., MTD (HE)
PENDIDIKAN JARAK JAUH PENDIDIKAN TINGGI KESEHATAN
Pusdiklatnakes, Badan PPSDM Kesehatan
Kementerian Kesehatan Republik Indonesia
Hak cipta @ Pusdiklatnakes, Badan PPSDM Kesehatan, Kemkes RI,
2013

Tujuan Pembelajaran Umum
Tujuan Pembelajaran Khusus
Kegiatan Belajar
1
Pendahuluan Uraian Materi Rangkuman Tugas Mandiri
II
Setelah menyelesaikan kegiatan belajar ini Anda
diharapkan mampu melakukan pemeriksaan fisik
(physical examination) menggunakan bahasa Inggris.
TUJUANPembelajaran Umum
TUJUANPembelajaran Khusus
khususnya memperlihatkan kemampuan :
1.1. Melakukan pemeriksaan tanda vital
1.2. Melakukan pemeriksaan fisik head to toe
Melakukan Assesment : Physical Examination
POKOKMateri
2.1. Melakukan pemeriksaan tanda vital

Modul Pendidikan Jarak Jauh, Pendidikan Tinggi Kesehatan Prodi Keperawatan
2
Uraian Materi
1.1. Melakukan pemeriksaan tanda – tanda vital
Vital sign menggambarkan fungsi dasar tubuh secara umum karena itu
dalam pengkajian pemeriksaan vital sign merupakan bagian penting
dalam pengkajian untuk mengetahui fungsi dasar tubuh pasien. Tujuan dari
pengukuran tAnda vital adalah untuk memperoleh data dasar pada saat
mendaftar ke pelayanan kesehatan.
Lingkup pemeriksaan tAnda vital adalah
1. Body temperature (Temp)
2. Pulse/heart rate (P)
3. Respiration (R)
4. Blood pressure (BP)
Untuk dapat memperoleh ke-4 data di atas Anda memerlukan alat bantu
berikut :
Pic 1. Alat yang digunakan saat pemeriksaan fisik
Sesuai dengan tujuan pembelajaran maka dalam modul ini akan diuraikan
hal – hal penting yang harus Anda perhatikan dan lakukan untuk dapat
melakukan pengukuran tAnda vital dalam bahasa Inggris. Apakah Anda masih
ingat prosedur pengukuran tAnda vital yang telah Anda pelajari pada modul

3
sebelumnya ? Pasti Anda masih ingat tahapan prosedurnya secara garis besar.
Berikut ini adalah tahapan tersebut dalam bahasa Inggris.
Orientasi 1. Greet the patient and introduce yourself.
2. Explain the purpose : to gain the data that represent the basic of
physical condition. Explain to the patient that measuring blood
pressure may normally cause a little numbing and tingling in
the arm when the cuff is inflated.
3. Ask him/her to arrange the comfort position: lay down or sit
down.
4. Check that in the last 30 minutes prior to the procedure, the
patient has not consumed any hot or cold fluids, exercised, or
experience any emotional situation.
Kerja 1. Sanitize your hands, and assemble the equipment.
2. Remove clothing from the patient’s shoulder and arm. Ensure
that the axilla is dry. If it is wet, pat it dry with a paper towel or
a gauze pad.
3. Take the patient’s temperature by placing the thermometer in
the center of the patient’s axilla. Instruct the patient to hold the
arm close to the body.
4. Take the thermometer from the patient’s axilla. Wipe it with
clean gauze or paper and read the scale.
5. Chart the results.

4
1. Ask the patient to sit down. Position the patient’s arm in a
comfortable position.
2. Place your three middle fingertips over the radial pulse site.
Apply moderate, gentle pressure directly over the site until you
feel the pulse. If you cannot feel the pulse ask someone else to
do it.
3. Count the pulse for 30 seconds. Note the rhythm and volume of
the pulse. If abnormalities occur in the rhythm or volume, count
the pulse for 1 full minute.
4. After taking the pulse, measure the respirations. This helps to
ensure that the patient is unaware that respirations are being
monitored. Observe the rise and fall of the patient’s chest as the
patient inhales and exhales.
5. Count the number of respirations for 30 seconds and; note the
rhythm and depth of the respirations. Also observe the patient’s
color. If abnormalities occur in rhythm or depth, count the
respiratory rate for 1 full minute.
1. The patient should relax in a sitting position for at least 5 minutes
before measuring his or her blood pressure. Roll up the patient’s
sleeve approximately 5 inches above the elbow. If the sleeve does
not roll up or is too tight after being rolled up, remove the arm
from the sleeve.
2. Locate the brachial pulse with the fingertips. Center the inner
bladder over the brachial pulse site. (Note: Place the cuff on the
patient’s arm so that the lower edge of the cuff is approximately
1 to 2 inches above the bend in the elbow.)
3. Release the pressure at a moderately steady rate of 2 to 3 mm
Hg/sec by slowly turning the thumbscrew counterclockwise (to
the left) with the thumb and forefinger. This opens the valve and
allows the air in the cuff to escape slowly. Listen for the first clear
tapping sound (phase I of the Korotkoff sounds).

5
4. Quickly and completely deflate the cuff to zero. Remove the
earpieces of the stethoscope from your ears, and carefully remove
the cuff from the patient’s arm.
5. Sanitize your hands, and chart the results. Include the date, the
time, and the blood pressure reading. Blood pressure is recorded
using even numbers. Make a notation in the patient’s chart if the
lying or standing position was used to take blood pressure.
6. Clean the earpieces and the chest piece of the stethoscope with
an antiseptic wipe, and replace the equipment properly.
Terminasi 1. Perform subjective and objective evaluation : inform the result,
how they feel about it, is there another complain.
2. Greet the patient and explain what they should do.
Tugas Anda adalah memilih kata – kata apa yang sesuai dengan tahapan
prosedur dan susun menjadi scenario seperti contoh berikut.

6
1. Greet the patient and introduce
yourself.
2. Explain the purpose : to gain the data
that represent the basic of physical
condition. Explain to the patient
that measuring blood pressure may
normally cause a little numbing and
tingling in the arm when the cuff is
inflated.
3. Ask him/her to arrange the comfort
position: lay down or sit down.
4. Check that in the last 30 minutes
prior to the procedure, the patient
has not consumed any hot or cold
fluids, exercised, or experience any
emotional situation.
• “Good afternoon Miss ….., How
are you? I’m indri, I;m the nurse in
charge this afternoon”.
• “Please sit down and make your
self in you comfort position. I will
measure your vital sign to know
you physical condition. Hopefully it
doesn’t too long.”
• “Have you eat or drink anything
before come here? What have you
been done..?”
• ….etc..
5. Count the pulse for 30 seconds. Note
the rhythm and volume of the pulse.
If abnormalities occur in the rhythm
or volume, count the pulse for 1 full
minute.
6. After taking the pulse, measure the
respirations. This helps to ensure
that the patient is unaware that
respirations are being monitored.
Observe the rise and fall of the
patient’s chest as the patient inhales
and exhales.
• “Your hand please, I will check you
pulse and then your respiration.
Do you have any complain..?”
• “Please lay down and breath
normally..”
• …etc
7. Perform subjective and objective
evaluation : inform the result, how
they feel about it, is there another
complain
“ Ok. Mrs/Mr.. I have done.. I think
your condition is good. The BP is….,
your pulse …. Etc.

7
Setelah Anda selesai latihan mengukur tAnda vital,
berikutnya adalah melakukan pemeriksaan fisik
menggunakan bahasa Inggris. Coba periksa apakah di
format pengkajian yang Anda gunakan ada bagian
tentang pemeriksaan fisik? Bila ya, susunlah scenario
sebagai pedoman Anda melakukan latihan pemeriksaan
fisik.
Masih ingatkah Anda bagaimana melakukan
pemeriksaan fisik? Pada Mata Kuliah Kebutuhan Dasar
Manusia, ada modul yang mempelajari tentang pemeriksaan fisik; pelajarilah
kembali modul tersebut.
Dalam melakukan physical examination, secara keseluruhan ada 4 metode yang
digunakan; inspection, palpation, percussion dan auscultation. Jadi scenario yang
Andasusunsebaiknyamemenuhikeempatmetodetersebut.Lingkuppemeriksaan
sesuai dengan format pengkajian yang digunakan dan harus di peroleh seluruh
datanya. Untuk memperoleh data Anda dapat melakukanya secara berurutan
sesuai format tetapi Anda juga dapat melakukan pemeriksaan fisik pada
komponen yang saling berkaitan lebih dahulu misalnya pemeriksaan jantung dan
pernapasan/paru-paru dilakukan secara berurutan meskipun penempatan data
di format pengkajian berbeda. Dalam melakukan pemeriksaan fisik ada beberapa
kalimat yang lazim digunakan seperti “roll up your sleeve, please open wide and
say ‘ah’, blood work, to hold one’s breath, to pull on one’s shirt, to breathe deeply,
to look ship shape, physical examination/exam, follow the light, look straight, etc.
Pastikan bahwa di scenario Anda istilah yang digunakan sudah tepat.
Perlu Anda ingat bahwa pemeriksaan fisik ini adalah bagian dari pengkajian
sehingga dapat dilakukan mix dengan interview atau dilakukan tersendiri setelah
interview.
Dibawah ini adalah lingkup pemeriksaan fisik pada bagian dada dan scenario
yang dapat Anda pelajari dan praktekkan.

8
Preparation Prepare the Equipment Needed
• Stethoscope
• Peak Flow Meter
Consider these to inform to your patient (General Considerations).
1. The patient must be properly undressed and gowned for this
examination.
2. Ideally the patient should be sitting on the end of an exam
table.
3. The examination room must be quiet to perform adequate
percussion and auscultation.
4. Observe the patient for general signs of respiratory disease
(finger clubbing, cyanosis, air hunger, etc.).
Inspection 1. Observe the rate, rhythm, depth, and effort of breathing; note
whether the expiratory phase is prolonged.
2. Listen for obvious abnormal sounds with breathing such as
wheezes.
3. Observe for retractions between clavicle or abdominal muscle.
4. Observe the chest for asymmetry, deformity, or increased
anterior-posterior (A-P) diameter.
A-P (anterior-posterior) diameter vs. transverse diameter
• A-P should be less than Transverse in adults; 1:2 – 5:7
• Elevated A-P size = barrel chest, may be COPD in adult;
normal in children

9
Palpation 1. Identify any areas of tenderness or deformity by palpating the
ribs and sternum.
2. Assess expansion and symmetry of the chest by placing your
hands on the patient’s back, thumbs together at the midline,
and ask them to breathe deeply.
3. Check for tactile fremitus.

10
Percussion Diaphragmatic Excursion
1. Find the level of the diaphragmatic dullness on both sides.
2. Ask the patient to inspire deeply.
3. The level of dullness (diaphragmatic excursion) should go down
3-5 m symmetrically.
Anterior Chest
1. Percuss from side to side and top to bottom using the pattern
shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you
hear.
Posterior Chest
1. Percuss from side to side and top to bottom using the pattern
shown in the illustration. Omit the areas covered by the
scapulae.
3. Note the location and quality of the percussion sounds you
hear.
4. Find the level of the diaphragmatic dullness on both sides.
Interpretation
Flat or Dull : Pleural Effusion or Lobar Pneumonia
Normal : Healthy Lung or Bronchitis

11
Auscultation
( B r e a t h
sound)
Use the
diaphragm
of the
stethoscope.
Posterior Chest
1. Auscultate from side to side and top to bottom using the
pattern shown in the illustration. Omit the areas covered by
the scapulae.
3. Note the location and quality of the sounds you hear.
Anterior Chest
1. Auscultate from side to side and top to bottom using the
pattern shown in the illustration.
3. Note the location and quality of the sounds you hear.
The general rule is, the larger the airway, the louder and higher
pitched the sound.
• Vesicular breath sounds are low pitched and normally heard
over most lung fields.
• Tracheal breath sounds are heard over the trachea.
• Bronchovesicular and bronchial sounds are heard in between.
• Inspiration is normally longer than expiration (I > E).

12
Adventitious (Extra) Breath Sounds
• Crackles : These are high pitched, discontinuous sounds similar
to the sound produced by rubbing your hair between
your fingers. (Also known as Rales)
• Wheezes :These are generally high pitched and “musical” in
quality. Stridor is an inspiratory wheeze associated
with upper airway obstruction (croup).
• Rhonchi : These often have a “snoring” or “gurgling” quality.
Any extra sound that is not a crackle or a wheeze is
probably rhonchi. Low pitched.
Interpretation
1. Breath sounds are decreased when normal lung is displaced by air (emphysema or
pneumothorax) or fluid (pleural effusion).
2. Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (pneumonia).
3. Extra sounds that originate in the lungs and airways are referred to as "adventitious" and are
always abnormal (but not always significant).
Source ; The NLN Assessment Exam for Credit by Exam Test Out http://nursing.
wright.edu/sites/default/files/page/attachements/Physical%20Assessment%20
Exam%20Study%20Guide.pdf
Seperti juga pada pada pengukuran tAnda vital, pada pemeriksaan fisik inipun
Anda melakukan tahapan yang sama hanya saja menggunakan pendekatan system
tubuh atau region tubuh. Berikut adalah contoh percakapan saat pemeriksaan
fisik dada.

13
Tabel. 4
Contoh dialog dalam pemeriksaan fisik
Orientation • “Good morning mam/sir,.. I’m nurse….. (your
name) and I will examine your body to get the
recent data about your health condition.” This will
last about 30 minutes.
• “I will ask you to do few things to get the precise
condition.”
• “Please let me know if you feel uncomfortable.”
Inspection • First I want to check your head, please sit in the
side of the bed, look straight ahead and stand still.
Do as I told you.”
• “Please uncover you shirt, I will examine your
chest”. Let me know if you have complain about
your breath or pain around the chest”
• “show me your hand, (check the fingers, nails and
lips)
• “ please breath normally, I will check the size of our
chest.” (compare the A-P and transverse diameter,
check for deformity, asymmetri).
Palpation • “Now I will palpable your chest, please let me know
if you feel pain when I touch it (palpating the ribs
and sternum)”.
• (rubbing our palm then placing them on the
patient’s back, thumbs together at the midline)”
Please take a deep breath mam/sir..” again…
again..
• “Now say “ninety nine or one two three for 3 x. ok.
enough.”

14
Percussion • “Please take a deep breath,,, I will check this side
(percuss the diapraghma level between abdomen
and chest)”.
• “Let me know if you feel pain when I’m percuss in
any region (note if there’s any).”
• (Record if there’s any abnormal finding and the
location of it).
Anterior Chest
Posterior Chest

15
Auscultation Posterior Chest
“Keep breath deeply mam/sir…… I will hear the
sound from your chest, please keep calm and quiet
otherwise I can not hera the voices”
[Rub the stethoscope diagframa and put in area of
scapulae, all surface of anterior chest, midline (along
trachea), between sternum] record if there’sa snoring,
rales, wheez.
The general rule is, the larger the airway, the
louder and higher pitched the sound.
Termination “Ok. Mam/sir…. I had done with your assessment,
and I will report it to doctor and maybe he will some
diagnostic test to find your health problem precisely..
Hoppefully it’s nothng serious…”
“Please wait until we know what ou should do. Good
day mam/sir…”

16
Nurse : When did you last come in for a physical exam?
Patient : I had my last physical two years ago.
Nurse: : Have you had any other exams recently? Blood work, an EKG or an
ultra-sound?
Patient : Well, I had a few X-rays at the dentist’s.
Nurse : How have you been feeling in general?
Patient : Pretty well. No complaints, really.
Nurse : Could you roll up your left sleeve? I’d like to take your blood
pressure.
Patient : Certainly.
Nurse : 120 over 80. That’s fine. You don’t seem to be overweight, that’s
good. Do you exercise regularly?
Patient : No, not really. If I run up a flight of stairs, it takes me a while to get
my breath back. I need to get out more.
Nurse : That would be a good idea. How about your diet?
Patient : I think I eat a pretty balanced diet. You know, I’ll have a hamburger
from time to time, but generally I have well-balanced meals.

17
Nurse : That’s good. Now, I’m going to listen to your heart.
Patient : Ooh, that’s cold!
Nurse : Don’t worry it’s just my stethoscope. Now, breathe in and hold your
breath. Please pull up your shirt, and breathe deeply...Everything
sounds good. Let’s take a look at your throat. Please open wide and
say ‘ah’.
Patient : ‘ah’
Nurse : OK. Everything looks ship shape. I’m going to order some blood
work and that’s about it. Take this slip to the front desk and they’ll
arrange an appointment for the tests.
Patient : Thank you nurse. Have a nice day.
Untuk lebih memudahkan gunakan alat–alat pemeriksaan fisik yang Anda
perlukan saat melakukan role play seperti stethoscope, sphygmomanometer,
thermometer, reflex hammer, pen light, turning fork, dll. Sebaiknya lakukan
latihan beberapa kali; lakukan evaluasi diri dan penilaian oleh teman kelompok
menggunakan format evaluasi yang sama dengan pengkajian (tabel 3) karena
pada pemeriksaan fisik dan wawancara ketrampilan yang dievaluasi/nilai
adalah speaking.

18
Pengkajian merupakan tahap dawal dari dari proses keperawatan yang
cukup banyak menggunakan komunikasi dengan pasien sehingga tahap ini
merupakan bagian yang tepat untuk melatih kemampuan berbahasa Inggris
Anda. Dua metode utama yang dilakukan saat mengkaji adalah wawancara
(interview) dan pemeriksaan fisik (physical examination). Pemeriksaan tAnda
vital (vital sign) adalah hal yang penting dalam pengkajian karena tAnda
vital merupakan gambaran kondisi dasar seseorang yang di pengaruhi oleh
berbagai organ vital seperti jangtung, paru-paru, persarafan dan hormonal.
Sebagai dasar dari pelayanan keperawatan yang diberikan maka dalam
mengkaji istilah atau terminology yang digunakan haruslah dipahami;
khususnya bila mengunakan terminology asing. Memahami bahasa Inggris
merupakan salah satu kemampuan yang perlu dimiliki oleh perawat karena
kemampuan berbahasa internasional merupakan salah satu ciri professional
perawat.
Rangkuman

19
Untuk memperkuat kemampuan Anda dalam melakukan interview dan
physical examination, berikut ini beberapa kegiatan perlu Anda lakukan
secara mandiri :
1. Pilihlah salah satu system organ atau region tubuh dan pahami cara
memeriksanya
2. Buatlah scenario pemeriksaan fisik sesuai soal no 1.
3. Memahami terminology dan singkatan asing yang sering digunakan
dalam bidang kesehatan
4. Melatih kemampuan speaking Anda dengan mengunduh situs internet
berikut :
http://www.youtube.com/watch?v=vCmkMFzVXyY
http://www.youtube.com/watch?v=ymMl28FZQLQ
http://www.youtube.com/watch?v=L1sL9sazFek
http://www.youtube.com/watch?v=JLLUkiZZfBo
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