PEMERIKSAAN FISIK PARU

By : Iis Fatimawati,S.Kep,Ns.M.Kes

Ideally the patient should be sitting on the end of an exam

table.

The examination room must be quiet to perform adequate

percussion and auscultation.

Observe the patient for general signs of respiratory disease

(finger clubbing, cyanosis, air hunger, etc.).

FOUR METHODS OF CHEST EXAMINATION

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

A. INSPEKSI

Tulang rusuk, sternum, clavicula

1. Postur

Postur tubuh bervariasi, misal pada klien dg masalah kronis sehingga

klavikula menjadi elevasi.

Bentuk Dada bayi dan dewasa berbeda.

Bayi perbandingan diameter anteroposterior = tranversal

Dewasa perbandingan diameter anteroposterior = tranversal= 1:2

Observe the rate, rhythm, depth, and effort of breathing. Note
whether the expiratory phase is prolonged
Observe for retractions and Use of accessory muscles of respiration:
sternomastoids, abdominals
2. Bentuk / Shape of chest
a. Normal chest (ellips) transverse > AP
b. Pectus excavatum (funnel chest) sternum bertakuk masuk
c. pectus carinatum (pigeon chest) sternum menonjol keluar
d. Increased anteroposterior (AP) diameter (barrel chest) dada
seperti tong
 3.
Simetris

4. Kulit

Mungkin ada crepitasi, hematom.

B. PALPASI

1. Identify any areas of tenderness or deformity by palpating the ribs and

sternum Daerah nyeri tekan

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 breath
deeply.

Kesimetrisan pergerakan dada

Vokal Fremitus dan Fremitus taktil

 tactile fremitus: Chest wall vibrations from speech (patient says "ninety-
nine").

Compare sides. Fremitus should be symmetric - the same on both sides.

Abnormal fremitus can help you diagnose several lung abnormalities:

Decreased fremitus occurs if something gets between the lung and chest
wall:

Air in the pleural space ( pneumothorax or "collapsed lung")

Fluid in the pleural space ( pleural effusion )

Scarred, thickened pleura

Increased fremitus:

In pneumonia, thick pus in the airways and alveoli increases vibration

transmission (like wobbling jello). Patients with pneumonia may have
increased fremitus on that side

C. PERCUSION

Proper Technique

1. Hyperextend the middle finger of one hand and place the distal
interphalangeal joint firmly against the patient's chest.

2. With the end (not the pad) of the opposite middle finger, use a
quick flick of the wrist to strike first finger.

3. Categorize what you hear as normal, dull, or hyperresonant.

 4. Practice your technique until you can consistantly produce a
"normal" percussion note on your (presumably normal) partner
before you work with patients.

B. 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.

2. Compare one side to the other looking for asymmetry.

3. Note the location and quality of the percussion sounds you

hear.

4. Find the level of the diaphragmatic dullness on both sides

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

Percussion Notes and Their Meaning

Flat or Dullness liquid or solid
1. Pleural Effusion
2. Lobar Pneumonia
lung area full of pus

Normal Healthy Lung or Bronchitis

Hyperresonant Emphysema or Pneumothorax
AUSCULTATION

TUJUAN : mendengarkan suara nafas

Breath sounds are produced by turbulent air flow

A. 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.

2. Compare one side to the other looking for asymmetry.

3. Note the location and quality of the sounds you hear.

B. Anterior Chest

1. Auscultate 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 sounds you hear

Suara Nafas Normal

1. Trakeal : bunyi yang terdengar kasar, keras, dan dengan tinggi nada tinggi
pada bagian trakea ekstratoraks

2. Bronkial : bunyi yang dengan tinggi nada tinggi, seperti udara mengalir
melalui pipa didengar di atas manubrium sternal

3. Vesikular : bunyi yang terdengar lemah dengan tinggi nada rendah seluruh
lapang paru

4. Bronkovesikular : campuran bunyi bronkial dan bunyi vesikular hanya

terdengar pada ICS I dan II

Suara nafas tambahan (Adventitious (Extra) Lung Sounds)

Crackles/ Rales : These are high pitched, discontinuous sounds similar to

the sound produced by rubbing your hair between your fingers. signs of
water in the alveoli (heart failure), pus in the alveoli (pneumonia), or scarring
(pulmonary fibrosis)

Wheezes/Wheezing: These are generally high pitched and "musical" in

quality. Stridor is an inspiratory wheeze associated with upper airway
obstruction (croup). sign of asthma or, if localized, of a tumor or foreign
body
 Rhonchi : These often have a "snoring" or "gurgling" quality. Any extra sound
that is not a crackle or a wheeze is probably a rhonchi. originate in larger
airways than wheezes and are a sign of bronchitis

Friction rub is a dry, leathery sound heard in inspiration and expiration. It is

a sign of inflammation of the pleura.

Gambar pola nafas

SUARA UCAPAN

1. Bronchophony is increased clarity of words, e.g. in area of pneumonia

2. Whispered pectoriloquy -- even a whisper is clear to the stethoscope - is

an extreme form of bronchophony (Suara terdengar jauh dan tidak jelas)

3. Egophony: patient says EE and stethoscope hears A - is similar to increased

tactile fremitus. Egophony may be the only physical examination abnormality
in early pneumonia