Provision of nursing care is a therapeutic process that involves cooperation relationships with clients, families or communities to achieve optimal health level (Canpernito, 2000.2).
Nurses need a scientific method in the therapeutic process is the nursing process. The nursing process is used to assist nurses in nursing practice systematically in troubleshooting existing nursing, where the four components influence each other, namely: assessment, planning, implementation and evaluation. (Budianna Keliat, 1994.2).
Pleural Effusion Physical Examination
1. General health status
The level of consciousness of patients needs to be studied, how the general appearance of the patient, the patient's facial expression during conducted diagnose, attitudes and behavior of patients towards the officer, how the mood of patients to determine the patient's level of anxiety and tension. There should also be height weight measurements of patients.
2. Respiratory System
Inspection in patients with pleural effusion; diseased hemithorax convex shape, horizontal ribs, widened space between the ribs, decreased respiratory movement. Encouragement of the mediastinum towards the contra lateral hemithorax known from the position of the trachea and ictus cordis. Respiration tends to increase and the patient is usually dyspnea.
Vocal fremitus decreased mainly for pleural effusion fluid amount is more than 250 cc. Besides, it is also found on palpation of the chest wall movement on the left chest pain.
Sensitive to percussion sound dim depending on the amount of fluid. If the liquid does not fill the pleural cavity, there will be an upper limit to the liquid in the form of a curved line above the lateral end to medical patients in a sitting position. This line is called Ellis-Damoiseau-line. The most obvious line at the front of the chest, in the back is less clear.
Auscultation of breath sounds decreased until it disappears. In a sitting position to a more fluid upper thinner, and behind it there is compression atelectasis of the lung parenchyma, may be found auscultation signs of compression atelectasis around the upper limit of the liquid. Coupled with a sign i - e does it mean when people are asked to say the words i will e nasal voice, called egophony (Alsagaf H, Ida Bagus, Widjaya Adjis, Abdol Mukty, 1994.79)
3. Cardiovascular system
On inspection to note the location of ictus cordis, normally located on ICS - 5 at the left midclavicular linea with a width of 1 cm. This examination aims to determine whether there is cardiac enlargement. Palpation to calculate heart rate and be aware of the depth and the absence of a regular heart rate, should also check for vibrations that thrill ictus cordis. Percussion to determine the limits of the heart where the heart area sounded dull. It aims to determine is there any heart or left ventricular enlargement. Auscultation to determine the first and second heart sound gallop and is there a single or a third heart sound that is a symptom of heart trouble and is there a murmur which showed an increase in blood flow turbulence.
4. Digestive System
On inspection note, if abdominal bulge or flat, protruding belly edge or not, prominent umbilicus or not, but it is also necessary in inspection presence or absence of nodules or masses.
Auscultation to listen to sound normal intestinal peristalsis where the value 5-35 times per minute. On palpation should also be noted, is there any abdominal tenderness, is there a mass (tumor, stool), abdominal skin turgor to determine the degree of hydration of the patient, whether palpable liver, the spleen is also palpable. Tympanik normal abdominal percussion, a mass of solid or liquid will cause a dull sound (liver, ascites, urinarta bladder, tumors).
5. Neurological System
On inspection of the level of awareness needs to be studied as well, GCS examination is required. Is there composmentis or somnolence or comma. Pathological reflexes, and how the physiological reflex. Additionally sensory functions also need to be assessed as hearing, sight, smell, touch and taste.
6. Musculoskeletal System
On inspection to note is there pretibial edema, palpation at both extremities to determine the level of peripheral perfusion as well as the examination capillary refil time. By inspection and palpation examination of muscle strength were compared between the left and right.
7. Integumentary System
Inspection of the general condition of skin hygiene, the presence or absence of color in the skin lesions, in patients with pleural effusion, usually will appear cyanosis due to failure of the O2 transport system. On palpation need to be checked on the warmth of the skin (cold, warm, fever). Then the skin texture (smooth-soft-rough) as well as skin turgor to determine the degree of hydration of a person.