PADJADJARAN UNIVERSITY

MEDICAL SCHOOL

CLINICAL SKILLS PROGRAM

RESPIRATORY SYSTEM

Syllabus and learning guide

Respiratory System 2006-2007

Clinical Skills Schedule

Time : 09.30 - 12.00
Venue : Skills Lab Room (A.5.1.1)

Week GROUP A Topic GROUP B

Date
Tuesday Trainer(s) Saturday
05 Sep 06 09 Sep 06
Pediatric Pediatric
RP : Oma,dr RP : Oma,dr
Melinda,dr Melinda,dr
Sri
Sri Sudarwati,dr
Sudarwati,dr
ENT ENT
RP : Wijana,dr RP : Wijana,dr
Arief,dr Arief,dr
Dennis,dr Dennis,dr
Yussi,dr Yussi,dr
Radiology Radiology
RP : Rista,dr RP : Rista,dr
Soehartinah,dr
Soehartinah,dr
Irma,dr Irma,dr
Sylvana,dr Sylvana,dr
Interne Interne
RP : Prof Zul
Prof Zul Dahlan
Dahlan
Yana,dr Yana,dr
Emmy,dr Emmy,dr
Arto, dr dr. Arto
Interne Interne
RP : Arto,dr RP : Arto,dr
Yana,dr Yana,dr
Oma,dr Oma,dr
Heda,dr Heda,dr
Interne Interne
Prof Zul Dahlan Prof Zul Dahlan
Yana,dr Yana,dr
Emmy,dr Emmy,dr
dr. Arto dr Arto
Pediatric Pediatric
RP : Oma,dr RP : Oma,dr
Heda,dr Heda,dr
Sri S,dr Sri S,dr
Iesje,dr Iesje,dr
 MODULE OF SKILL LABORATORIUM PRACTICE

BLOCK : RESPIRATORY SYSTEM

TOPIC : PEDIATRIC HISTORY TAKING AND EXAMINATION

I. GENERAL OBJECTIVE
After finishing skill practice, the students will able to perform clinical examination (history
taking and physical diagnostic) of pediatric respiratory system problems in order to make a
differential and proper diagnosis.

II. SPECIFIC OBJECTIVE

At the end of this skill practice, the students will be able to understand the
systematic information gathering from pediatric history taking and physical
diagnosis about respiratory diseases.

III. SYLLABUS DESCRIPTION

3.1 Sub Model Objective
After finishing these skill practices, the students will able to perform history taking
and physical examination of pediatric respiratory diseases.

3.2 Expected Competencies

a. Students will be able to demonstrate procedure of pediatric history taking,
especially about respiratory diseases.
b. Students will be able to demonstrate procedure of pediatric physical
examination about respiratory system.

3.3 Methods
a. Presentation
b. Demonstration
c. Training
d. Self practices

3.4 Laboratory Facilities

a. Skills Laboratory
b. Trainers
c. Standardized patient
d. Students Learning guide
e. Trainer’s guide
f. References

3.5 Venue
Skills Laboratory

3.6 Evaluation
a. Point nodal evaluation
b. OSCE
IV. LEARNING GUIDE OF CLINICAL EXAMINATION

Procedure for Clinical Examination

No Procedure Performance Comment

scale

0 1 2
History Taking

1 Preparation
a. Should be taken in an environment with comfort for all,
may be some toys for younger children.
b. Privacy has to be ensured, without the usual
interruption by phone call and other distraction.
c. Make some notes while taking the history, but this
writing should not interrupt the flow of the interview.
d. Data should be recorded at the beginning include the
patient’s name and address, the patient’s or guardian
home and phone numbers, the name of referring
physician, information on the kindergarten or school.

2 Structure of history taking (auto/ alloanamnesis)

a. The source of and the reason for referral should be
noted.
b. The chief complaint should be identified (Cough and
sputum production, Noisy breathing, Wheezing,
Cyanosis, Digital clubbing, cardiovascular signs, Chest
pain):
 The onset and duration
 The environment and circumstances under which it
developed.
 Its manifestations and their treatments.
 Symptoms should be defined by their qualitative and
quantitative characteris- tics (timing, location,
aggravating and alleviating factors associated
manifes- tations).
 The relation between respiratory symptom and daily
activities, diurnal variation, food intake.
 To know whether other family members also
affected.
c. The Birth history should be reviewed including prenatal,
natal and neonatal.
d. Feeding history (the amount, type and schedule food
intake).
e. Physical development may retarded in children with
 chronic respiratory diseases.
f. Psychosocial development may be affected.
g. Many diseases of the respiratory tract in children have a
genetic component.
h. A detailed report of prior tests and immunizations
should be obtained.
i. The patient’s current medication and their efficacy
should be documented.
j. Previous hospital admissions and their indication should
be listed.
k. A review of other organ systems is usually the last part
of the history taking.
l. Common signs and symptoms of pediatric respiratory
disease:

 COUGH & SPUTUM PRODUCTION

o Define the nature of the cough
o Whether it is dry, hacking or brassy or productive
o Define the colour, odor, presence of blood
o Define the timing of cough

 NOISY BREATHING
 Describe their own perception of
noise: Does it occur during inspiration, expiration or
both? Does it have musical qualities? Did an episode
of choking precede the onset of noisy breathing? Is it
prominent during certain activities? At what times of
day or night? In which positions is it most noticeable?

 WHEEZING, STRIDOR
 Asthma ?
 Congenital malformation? (vascular ring, web,
hemangioma, cyst, malacia, stenosis)
 Inflammation (tracheitis, bronchitis, bronchiolitis,
bronchiectasis, cystic fibrosis)
 Extrinsic compression (Esophageal foreign body,
malignancy, lymphadenopathy)
 Intrinsic compression (endobronchial foreign body)
 Extrathoracic disease (laryngitis, epiglottitis, vocal
cord paralysis, retropharyngeal abcess, peritonsillair
abcess, laryngomalacia, polyp, adenoid)
 Other (metabolic, psychosomatic)

 CHEST PAIN
 How the parents know that the child is in pain.
 Whether sleep is affected?
 Define duration of symptoms, localized, sharp and
superficial pains.
3 Physical Examination

The general appearance

Well/moderately or seriously ill? ,try to determine the
system involved (flaring of the nares indicate a problem in
the respiratory or cardiac system), Note the nature of the
cry of the child, Comfortable/uncomfortable, Breathing?,
Physical/emotional, Alert/lethargic, Clean/dirty,
Cooperative / belligerent, gross abnormalities/anomalies? ,
Fat/thin, tall/short, malnourished? ,apprehensive?

Inspection
a. The pattern of breathing should be observed
(respiratory rate, rhythm and effort).
b. Indrawing of supraclavicular, intercostal and
epigastric should be noted.
c. Flaring of the nares is sensitive sign of respiratory
distress.
d. The normal movement of chest and abdominal walls
should be evaluated.
e. The symmetry of respiratory chest excursions should
be examined.
f. The dimensions of the chest should be measured
(chest size and shape).
g. The Oropharynx should be inspected for its size and
signs of malformations (such as cleft palate, signs of
obstruction by enlarged tonsils).
h. Evidence of chronic ear infections should be
documented.
i. Inspection of the skin may reveal atopy.
j. The finding of BCG scar may be relevant.
k. Common physical findings such as cyanosis (look at
the tongue for evaluating the central cyanosis),
clubbing should be noted.

Palpation
a. To confirm observed abnormalities, to identify areas
of tenderness or lymph nodal enlargement, to
document the position of the trachea, to assess
respiratory excursion, and to detect changes in the
transmission of voice sounds through the chest
b. Placing the hands on both sides of the lateral rib
cage, the students should feel for symmetry of chest
expansion.
c. Voice generated vibration should be felt with the
palm over corresponding sites on the right and left
hemithorax.
 d. Subcutaneous emphysema is felt as a crackling or
crepitant sensation under the skin. It is most
commonly associated with pneumothorax or
pneumomediastinum, and also palpated over a bone
fracture.

Auscultation
a. Ideally should be performed in the quiet room.
b. The patient should be in a straight position, in young
patients beginning on the back.
c. The students should make note of the lung sound
intensity over different areas.
d. Respiratory sounds should be documented according
to their location and character include the intensity
and frequency :
 Wheezes
 Crackles
 Stridor
 Grunting
 Pleural rub

Percussion
a. In children is performed by light tapping with the
index or middle finger on the terminal phalanx.
b. Symmetric sites over the anterior, lateral and
posterior should be compared.
c. Subjective assessment should be evaluated
 Tympanic
 Dullness
 SKILL LABORATORY MODULE

BLOCK : RESPIRATORY SYSTEM

TOPIC : ANTERIOR NASAL PACKING PROCEDURE

I. GENERAL OBJECTIVE
After completing skill practice of anterior nasal packing, the student will be able to
perform anterior nasal packing procedure with appropriate technique.

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to perform anterior nasal packing,
which includes :
1. Describe the principle of the procedures.
2. Describe the equipments needs for the procedures.
3. Demonstrate the procedure properly.

III. SYLLABUS DESCRIPTION

3.1 Expected Competencies

a. Students describe the principles of the procedures.
b. Students describe the equipments needs for the procedures.
c. Students demonstrate the procedure properly.

3.2 Methods
a. Presentation.
b. Demonstration.
c. Coaching.
d. Self practice on artificial models.

3.3 Laboratory Facilities

a. Skill Labolatory.
b. Traines.
c. Students learning guide.
d. Trainer’s guide.
e. References.

3.4 Venue
Skill Laboratory.
 3.5 Evaluation
a. Skill demonstration.
b. point nodal evaluation.
c. OSCE.

IV. EQUIPMENT
1. Presentation :
Audiovisual : Slides presentations on LCD projector.
2. Demonstration and coaching :
a. Head lamp.
b. Nasal speculum.
c. tongue blade.
d. Pinset.
e. Petrolatum or Vaseline gauze coated with an antibacterial ointment.
V. LEARNING GUIDE
LEARNING GUIDE: ANTERIOR NASAL PACKING PROCEDURE

Performance Scale
No Procedures
0 1 2 3
Preparation
1 Wash your hands first with antiseptic soap and dry it
with paper tissues
2 Self protection: put on the mask hand gloves
3 Put on the head lamp
Procedures
4 Hold the nasal speculum with one hand and then put in
on the left or right nostril
5 Holt it with the thumb on the joint, the index finger free
to steady it on the patient’s nose and the rest of the
fingers on the stem proper to hold the speculum
6 Always try to open the stem or times in an upward
action and not down into the floor or the nose. The
good view of the nose anteriorly can be obtained
simply by pressing on the tip of the nose
7 Topical anesthesia can be administered in order to
decreasing discomfort, the risk of apnea, bradycardia,
and hypotension by blocking the nasal-vagal reflex. A
pledget or cotton swab soaked in 1 % pantocaine or
lidocaine solution (with or without containing 1-2
drops of an epinephrine solution dilutes 1:1,000) is
placed in the nose for 3-5 minutes
8 The traditional anterior pack petrolatum gauze (0.5 x
72 inch) coated with an antibacterial ointment is firmly
packed into the nasal cavity
9 The packing is placed in a methodical (layering)
fashion toward the posterior choana, starting at the
nasal floor and packing up to about the level middle
turbinate. It is possible to put a large amount into each
side
10 Great care must be taken that :
- The pack does not rub on the columella, which is
easily traumatized
- The free and of the packing should not be visible in
the oropharynx behind the soft palate as this can lead
to irritation, and also a danger that this portion might
slip deeper into the aerodigestive tract and cause
complication
11 Once the gauze is firmly packed properly into the nasal
cavity:
 - The patient should be admitted and kept under
careful observation
- Give the patient humidifies oxygen and sedate with
caution and only with reversible agents
- As the pack will be left in for at least 48 hours, put
the patient on a board-spectrum antibiotic
- Establish an intravenous line, and cross-match the
blood

VI. SCHEDULE

ALLOCATED
NO SUBJECT TUTOR
TIME

1 Presentation
30’ 4 persons

2 Demonstration & coaching

30’ 4 persons

3 Self practice on artificial models

90’ 4 persons

VII. CRITERIA OF PERSONAL PERFORMANCE EVALUATION

NO. PERFORMANCE ACHIEVEMENT COMMENT

1 If student are doing the sleep less then 35% of the Low
whole step precisely

2 If student are doing the step less then 35%-50% of Mild

the whole step precisely

3 If student are doing the step less then 50%-75% of Moderate

the whole step precisely

4 If student are doing the step more then 80% of the Excellent
whole step precisely
 MODULE OF SKILL LABORATORIUM PRACTICE

FOR KPBI PROGRAM

BLOCK : RESPIRATORY SYSTEM

TOPIC : DEMONSTRATE KNOWLEDGE INTERPRETING NORMAL
PARANASAL SINUSES RADIOGRAPH

DEPARTMENT OF RADIOLOGY

MEDICAL SCHOOL PADJADJARAN UNIVERSITY

MODULE OF SKILL LABORATORIUM PRACTICE

BLOCK : RESPIRATORY SYSTEM
TOPIC : DEMONSTRATE KNOWLEDGE INTERPRETING NORMAL
PARANASAL SINUSES RADIOGRAPH

I. GENERAL OBJECTIVE
After finishing skill practice of interpreting normal paranasal sinuses radiograph,
the student will be able to interpret normal paranasal sinuses radiograph.

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to:
a. Demonstrate knowledge radiopositioning of the paranasal sinuses.
b. Demonstrate knowledge radioanatomy of the paranasal sinuses.
b. Demonstrate knowledge radiological appearances of normal paranasal sinuses.

III. SYLABUS DESCRIPTION

3.1. Sub Model Objective

After finishing skill practice of interpreting normal paranasal sinuses radiograph,
student will be able to interpret normal paranasal sinuses radiograph.

3.2. Expected Competencies

a. Student demonstrate knowledge radiopositioning of the paranasal sinuses.
b. Student demonstrate knowledge radioanatomy of the paranasal sinuses.
c. Student demonstrate knowledge radiological appearances of normal paranasal
sinuses

3.3. Topics
a. Radiopositioning of the paranasal sinuses.
b. Radioanatomy of the paranasal sinuses.
c. Radiological appearances of normal paranasal sinuses.

3.4. Methods
a. Presentation
b. Demonstration
c. Coaching
d. Self practices on normal paranasal sinuses radiograph

3.5. Laboratory Facilities

a. Skill Laboratory
b. Trainers
c. Paranasal sinuses radiograph
d. Student learning guide
e. Trainer’s guide
f. References
 g. Light case

3.6. Venue
Skills Laboratory

3.7. Organizer
Block of respiratory system of clinical skills program, Medical School
Padjadjaran University, Hasan Sadikin Hospital.

3.8. Evaluation
a. Skill demonstration on normal paranasal sinuses radiograph
b. Point nodal evaluation.
c. OSCE

IV. LEARNING GUIDE OF DEMONSTRATING KNOWLEDGE INTER-

PRETING NORMAL PARANASAL SINUSES RADIOGRAPH

V. CRITERIA OF PERSONAL PERFORMANCE EVALUATION

VI. SKILL LABORATORIUM PRACTICE ARRANGEMENT
References for paranasal sinuses in radiology :
1. Allison D, Grainger RG. Grainger & Allison’s diagnostic radiology: a textbook of
medical imaging, vol.1.3rd ed. New York: Churchill Livingstone; 1997.p.313-9.
2. Dennis CA, Eisenberg RL, May CR. Radiographic positioning pocket manual. 1st ed.
Philadelphia: WB Saunders; 1993.p. 22-33, 304-10.
3. Moeller TB. Normal findings in radiography. Rome: CIC Edizioni Internazionali;
2000.p. 8-9.
4. Sutton D, editor. Textbook of radiology and umaging. 7th ed. Philadelphia: Churchill
Livingstone; 2003.p. 1519-23.

Correction for CSG:

CT Scan and MRI are not included in CSG.

MODULE OF SKILL LABORATORIUM PRACTICE

 FOR KPBI PROGRAM

BLOCK : RESPIRATORY SYSTEM

TOPIC : DEMONSTRATE KNOWLEDGE INTERPRETING NORMAL

PLAIN CHEST RADIOGRAPH

DEPARTMENT OF RADIOLOGY

MEDICAL SCHOOL PADJADJARAN UNIVERSITY

MODULE OF SKILL LABORATORIUM PRACTICE

BLOCK : RESPIRATORY SYSTEM
TOPIC : DEMONSTRATE KNOWLEDGE INTERPRETING NORMAL PLAIN
CHEST RADIOGRAPH

I. GENERAL OBJECTIVE
After finishing skill practice of interpreting normal plain chest radiograph,
the student will be able to interpret normal plain chest radiograph.

II. SPECIFIC OBJECTIVE

At the end of skill practice of interpreting plain chest radiograph, the student will
be able to:
a. Demonstrate knowledge conditions of a good radiograph of the chest.
b. Demonstrate knowledge radiopositioning of the chest.
b. Demonstrate knowledge structure of the chest radiographically.

III. SYLABUS DESCRIPTION

3.1. Sub Model Objective

After finishing skill practice of interpreting normal plain chest radiograph, student
will be able to interpret normal plain chest radiograph.

3.2. Expected Competencies

a. Student demonstrate knowledge conditions of a good radiograph of the chest.
b. Student demonstrate knowledge radiopositioning of the chest.
c. Student demonstrate knowledge structure of the chest radiographically.

3.3. Topics
a. Conditions of a good radiograph of the chest.
b. Radiopositioning of the chest.
c. Structure of the chest radiographically.

3.4. Methods
a. Presentation
b. Demonstration
c. Coaching
d. Self practices on normal chest X-ray

3.5. Laboratory Facilities

a. Skill Laboratory
b. Trainers
c. Normal chest X-ray
 d. Student learning guide
e. Trainer’s guide
f. References
g. Light case

3.6. Venue
Skills Laboratory

3.7. Organizer
Block of respiratory system of clinical skills program, Medical School
Padjadjaran University, Hasan Sadikin Hospital.

3.8. Evaluation
a. Skill demonstration on normal chest X-ray
b. MDE.
c. OSCE

IV. LEARNING GUIDE OF DEMONSTRATING KNOWLEDGE

INTERPRETING PLAIN CHEST RADIOGRAPH
V. CRITERIA OF PERSONAL PERFORMANCE EVALUATION

VI. SKILL LABORATORIUM PRACTICE ARRANGEMENT

References for paranasal sinuses in radiology :
5. Allison D, Grainger RG. Grainger & Allison’s diagnostic radiology: a textbook of
medical imaging, vol.1.3rd ed. New York: Churchill Livingstone; 1997.p.313-9.
6. Dennis CA, Eisenberg RL, May CR. Radiographic positioning pocket manual. 1st ed.
Philadelphia: WB Saunders; 1993.p. 22-33, 304-10.
7. Moeller TB. Normal findings in radiography. Rome: CIC Edizioni Internazionali;
2000.p. 150-7.
8. Sutton D, editor. Textbook of radiology and imaging. 7th ed. Philadelphia: Churchill
Livingstone; 2003.p. 1-13, 47-54, 57-60.

Correction for CSG:

CT Scan and MRI are not included in CSG.

Skill Laboratory Module

BLOCK : Respiratory system
TOPIC : Respiratory history taking and physical examination in adults

I. GENERAL OBJECTIVE
After completing skill practice, the student will be able to perform respiratory history
taking and physical examination.

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to perform the procedure of
respiratory physical examination systematically including:
 History taking
 Systematic physical examination of respiratory system by performing
inspection, palpation, percussion and auscultation

III. SYLLABUS DESCRIPTION

3.1 Sub Module Objective
After finishing skill practice of clinical examination, the student will be able to
perform history taking and physical examination of respiratory disorders

3.2 Expected competencies

Student will be able to demonstrate the procedure of history taking of respiratory
disorders
Student will be able to demonstrate the procedure of physical examination of:
 Locating Cervical lymph node
 Tracheal position
 Locating imaginary lines around the chest
 Shape and movement of the chest
 Tactile fremitus
 Chest Percussion
 Normal breath sounds
 Presence and absent of adventitious sounds
 Presence and absent of transmitted voice sounds (bronchophony, egophony
and whispered pectoriloquy)

3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role-play

3.4 Laboratory facilities

a. Skills laboratory: table, chairs, and examination couch
 b. Trainers
c. Patient: Standardized patient
d. Student learning guide
e. Trainer’s guide
f. References

IV. LEARNING GUIDE FOR PHYSICAL EXAMINATION OF ADULT

RESPIRATORY PATIENT

Procedure for clinical examination

No Steps/ Task 1 2 3 4 5

A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. Introduce yourself
3. The patient should be given adequate explanation about
history taking and the goal or expected result of history
taking
4. Identifying patient’s data ( described elsewhere)

B. HISTORY TAKING
1 Identifying the chief complain (s) of respiratory disease
- Cough and expectoration
- Dyspnea
- Hemoptysis
- Chest pain
2. Symptoms
1. Cough and expectoration
Question should be asked concerning
a. Its time course
- Acute
- Chronic
b. Character of cough
- Hacking, short, dry frequents repeated
cough (post nasal drip)
- Deep, loose cough (bronchi and lung
parenchyma)
- Brassy cough (tracheal lesions)
- Bovine sound (laryngeal paralysis)
- Darth vader quality or stridorous in
narrowing in the upper airway
c. Character and quality of expectorated
material
- Color : whitish, yellow, greenish, blood
streaked
 - Consistency : mucoid, thick, purulent
- Other : foul odor, rusty
d. Time of occurrence
- Lying down at night
- Arising in the morning
- Shortly after ingestion
2. Dyspnea
a. Onset : sudden or gradual
b. What time of the day dyspnea particularly
obvious
c. Severity : occur during walking slowly or
running up stair
d. Relationship with wxertion
e. Relationship with position
f. Accompanying symptoms : wheeze, stridor
3. Hemoptysis
a. Make sure that it is coughing not spitting or
vomiting
b. Color : bright red mixed with frothy sputum
or dark
c. Amount in each cough and per day
4. Chest pain
a. When did it begin?
b. Is it associated with movement, deep
breath or cough?
c. How about the intensity, location, duration
and radiation
d. Accompanying symptoms : coughing,
sneezing shortness of breath

C PHYSICAL EXAMINATION
I PREPARATION
1 Tell the patient what is going to be done
2 Help the patient on to the examination table
3 Wash hands thoroughly with soap and water and dry
with a clean dry cloth or air drier
4 The examiner should stand at the patient’s right side
II EXAMINATION TECHNIQUE
A GENERAL PHYSICAL EXAMINATION (described
elsewhere)

B LOCATING CERVICAL LYMPH NODES

1. Make the patient comfortable and relax

 2. Flexed the neck slightly forward, and if
needed slightly toward the examination
3. Palpate using the pads of your index and
middle fingers
4. Move the skin over the underling tissue in
each area

Describe location, quantity, size (diameter), consistency,

movability, presence specific formation (package).
Findings :
1 Preauricular – in front of the ear
2 Posterior auricular – superficial to mastoid
process
3 Occipital – at the base of the skull posteriorly
4 Tonsilar – at the angle of mandible
5 Submandibular – midway between the angle
and the tip of the mandible. These nodes are
usually smaller and smoother than lobulated
submandibular gland against which they lie
6 Submental – in the midline a few cm behind the
tip of mandible
7 Superficial cervical – superficial to
sternomastoid
8 Posterior cervical – along the anterior edge of
trapezius
9 Deep cervical chain – deep to the sternomastoid
and often inaccessible to examination. Hook
your thumb and fingers around either side of the
sternomastoid muscle to find them
10 Supraclavicular – deep in the angle formed by
the clavicle and the sternomastoid

C TRACHEA

1. Inspect trachea for any deviation from its midline

position.
2. Place the finger along one side of the trachea and
note the space between trachea and the
sternomastoid.
3. Compare it with the other side. Normally the space
should be symmetrical.

D LOCATING IMAGINARY LINES AROUND THE CHEST

1. midsternal and vertebral are lines drops

vertically mid sternal and midvertebral
 2. identify both end of the clavicle and the
midclavicular line drops vertically from the mid
point of clavicle.
3. Anterior and posterior axillary lines drop
vertically from the anterior and posterior axillary
folds
4. The midaxillary line drops from the apex of the
axilla
5. scapular line drops from the inferior angle of the
scapula

E TECHNIQUES OF CHEST EXAMINATION

Inspection
1. place the patient in supine position
2. your position is in the midline position in
front of the patient
3. inspect the shape of the chest and the
movement of chest wall

findings : deformities or asymmetry, abnormal

retraction of interspace during inspiration,impairment
of respiratory movement on one or both side or a
unilateral lag (delay) in the movement.

Palpation
Test respiratory expansion
4. place your thumb along each costal
margin, your hands along the lateral rib
cage.
5. As you position your hands, slide them
medially a bit to raise loose skin folds
between your thumbs.
6. ask the patient to inhale deeply
7. observe how far your thumb diverge as
the thorax expands and feel for the extent
and symmetry of respiratory movement.

Tactile fremitus
8. use either the ball (the bony part of the
palm at the base of the fingers) or the ulnar
surface of your hand and place it in both
side of the chest symmetrically
9. ask the patients to repeat the words “ninety
nine” or “one – one – one”
10. repeat this examinations in other areas of
 the chest symmetrically
fremitus is usually decreased or absent over the
precordium. When examining a woman gently
displaced breast as necessary

Percussion
11. hyperextend the middle finger of your left
hand (the pleximeter finger)
12. press its distal interphalangeal joint firmly
on the surface to be percussed.
13. AVOID contact by any other part of the
hand
14. Position your right forearm quite close to
the surface with the hand cocked upward.
The right middle finger should be partially
flexed, relaxed, and poised to strike
15. Strike the pleximeter finger with the right
middle finger (the plexor), with a quick,
sharp but relaxed wrist motion
16. Aim the strike at your distal interphalangeal
joint.
Learn to identify five percussion notes which can be
distinguished by differences in their basic qualities of
sound : intensity, pitch and duration.

Auscultation

17. instruct the patients to breath deeply

through an open mouth
18. listen to breath sound with the diaphragm
of your stethoscope
19. move your stethoscope from one side to
the other and comparing symmetrical
areas of the lung

pattern of breath sound identified by their intensity,

pitch, and relative duration of their inspiratory and
expiratory phases
the normal breath sounds are : vesicular,
bronchovesicular and bronchial

20. listen for any added or adventitious sound

that are superimposed on the usual breath
sound. Adventitious sounds are crackles
(rales), wheezes and rhonchi
 if you hear crackles, listen for the following
 characteristics
- loudness, pitch and duration (summarized
as fine or coarse crackles)
- number (few to many)
- timing in respiratory cycle
- location on the chest wall
- persistence of their pattern from breath to
breath
- any change after a cough or a change in
the patients position
 if you hear wheeze or rhonchi , note their timing
and location and do they change with deep
breathing or coughing
 if you hear abnormally located bronchovesicular
or bronchial breath sound, continue on to asses
transmitted voice sound. With stethoscope, listen
in symmetrical areas over the chest, as you :
- ask the patient to say “ninety nine”.
Normally the sound transmitted through
the chest wall are muffled and indistinct.
Louder and clearer voice sounds are called
bronchophony
- ask the patient to sal “ee” you will normally
hear a muffled long E sound. When “ee” is
heard as “ay”. An E to A change
(egophony) is present.
- Ask the patient to whisper “ninety nine” or
“one – two – three “. The whispered voice
is normally heard faintly and indistinctly.
Louder, clearer whispered sounds are
called whispered pectoriloquy
 SKILL LABORATORY MODULE

- Block : Respiratory system

-Topic : Oxygen therapy

I. General Objective
After completing skill practice, the student will be able to perform oxygen therapy.

II. Specific Objective

At the end of skill practice, the student will be able to perform the procedure of
oxygen therapy, indications for oxygen therapy, and goal of oxygen therapy.

III. Syllabus Description

3.1. Sub Module Objective
After finishing skill practice of oxygen therapy, the student will be able to perform
oxygen therapy

3.2. Expected competencies

Student will be able to demonstrate the procedure of oxygen therapy, indications
and goal of oxygen therapy.

3.3.Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play

3.4. Laboratory facilities

a Skills laboratory : table,chairs, examination couch, nasal cannula, simple
oxygen masks, partial non-rebreathing mask, and true nonrebreathing mask.
b Trainers
c Patient
d Student learning guide
e Trainer’s guidef.
f References

3.5. Venue
Skills laboratory

3.6. Evaluation
a. Point Nodal Evaluation
b. OSCE

3.7. Sub Module Objective

 After finishing skill practice of oxygen therapy, the student will be able to
perform oxygen therapy.

3.8. Expected competencies

Student will be able to demonstrate the procedure of oxygen therapy, correct
documented or suspected acute hypoxemia, decrease the symptoms
associated with chronic hypoxemia, and decrease the work load hypoxemia
imposes on the cardiopulmonary system.

3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice

3.10. Laboratory facilities

a. Skills laboratory
b. Trainers
c. Patient and model
d. Student learning guide
e. Trainer’s guide
f. References

IV. Learning Guide for Oxygen therapy in adults

No Steps/Task 1 2 3 4 Comment
A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. The patient should be given adequate explanation about
oxygen therapy and the goal or expected result oxygen
therapy
B. PROCEDURE FOR OXYGEN THERAPY
B.1. This is basic steps when setting up oxygen
equipment:
1 Wash your hands before (and after) initiating oxygen
therapy to guard against transmitting nosocomial
2 When using a wall unit, connect the adapter to the unit
and check for leaks; reinsert, if necessary. Attach the
flowmeter and turn on the control switch to ensure that
the flowmeter is working, then shut it off again.
3 If you’re using an oxygen cylinder turn on the cylinder.
Check the cylinder gauge to ensure an adequate oxygen
supply
4 If you’re providing humidification, fill the humidifier bottle
or reservoir two-thirds full the sterile distilled water
5 Connect the humidifier bottle to the tubing and the
 flowmeter. Set the flowmeter as ordered, making sure
the center of the ball is on the line indicating the
prescribed liters per minute.
6 Now begin giving oxygen.
B.2.Setting up with nasal cannula
To start therapy with a nasal cannula, follow these steps:
1 Inspect each nostril using a flashlight. Check for patency,
polyps, edema, and deviated septum or other
obstruction. If both nostrils are obstructed, you’ll need to
deliver the oxygen via a mask.
2 Check whether the nasal prongs are straight, smooth,or
curved. Also check whether one side is smoother or
flatter than the other. If the prongs are straight, and if
both sides are the same, place them in the patient’s
nostrils with either side up. If they ‘re straight, but the
sides are different, place the smoother or flatter side
against the patient’s skin because it will produce less
friction. Place curved prongs with the curve facing
toward the nostrils’ floor. This position helps prevent
obstruction of the cannula lumen by the nasal mucosa,
which can decrease oxygen flow.

3 Now hook the cannula tubing behind the patient’s ears

and under his chin. Then slide the adjuster upward to
hold the cannula in place. When using an elastic strap to
hold the cannula in place, position the strap over the
patient’s head above his ears.
B.3. Setting up with Oxygen Masks
1. select the size mask that offers the most comfortable fit
and best airtight seal for your patient.
2. Connect the tubing, mask, and humidification device to
the flowmeter. Set the flowmeter to the correct setting to
deliver the prescribed oxygen concentration.
3. For a simple face mask, set the flowmeter to supply the
prescribed oxygen rate.
4. For a nonrebreathing or partial rebreather mask, set the
flowmeter to the ordered setting, usually between 6 and
15 liters/minute, depending on the oxygen concentration
the patient requires.
5. Observe the reservoir bag for initial inflation. If using a
nonrebreather mask, ensure that one-way flaps operate
properly.
6. As the patient breathes, observe the reservoir bag; it
should deflate slightly on inspiration.
LEARNING GUIDE OXYGEN THERAPY IN PEDIATRIC

PerformanceScale
No PROCEDURE (STEP/TASK) Comment
1 2 3 4

1 Preparations
1. Greet client/parents respectfully
and with kindness.
2. Tell client/parents what is going to
be done and encourage them to
ask some questions.
3. Provide information about oxygen
therapy, indication and its goals.
The indications are central
cyanosis, inability to drink, severe
chest indrawing, over 70
breaths/minute, grunting,
restlessness

2 The Oxygen Delivery

1. Check the cylinder is written
“OXYGEN”.
2. Prepare the equipment for the
administration of oxygen
 Oxygen cylinder
 Regulator with the gauge to
reduce the high pressure of gas
to a constant lower working
pressure (a full oxygen cylinder
has a pressure around 2000
p.s.i / 13,400 kPa / 132
atmospheres or bars, if less
than 120 p.s.i / 800 kPa / 8
atmospheres or bars it means
nearly empty).
 Flow control device must be
attached downstream from the
regulator (Flow-meter with a
range of 0.5-15 l/min, 0.5-2
l/min for pediatric patient,
sometimes up to 5 l/min if
 desirable)
 Humidifier filled up with clean
water has been boiled and
cooled up to water level
(periodically washed and dried)
 A 2-metre length of plastic tube
oxygen delivery.
 Prongs or cannula (can be
replaced by nasogastric tube).

3 Administration of Oxygen
Using nasal prongs
1. Gently suck all the mucus from the
child’s nose and pharynx.
2. Open the flow-meter and check
effectiveness of the flow, if the child
less than 2 months old, give 0.5 l/m,
if more than 2 months give 1 l/m (will
deliver about 30-35% of oxygen if
child’s nose is not blocked and the
child is not breathing through the
mouth).
3. Enter the nasal infant or pediatric
prongs to the child’s nostrils.
4. Tape the prongs to the child’s face
just inside the nostrils.

4 Warnings on the use of Oxygen

1. Oxygen can cause a fire to spread
rapidly.
2. Make sure that no body is
smoking.
3. Keep anything that might create a
spark or flame.
4. In case of fire, switch off the flow
immediately.
 SKILL LABORATORY MODULE

- Block : Respiratory system

-Topic : Needle thoracostomy

I. General Objective
After completing skill practice, the student will be able to perform needle thoracostomy .

II. Specific Objective

At the end of skill practice, the student will be able to perform the procedure of needle
thoracostomy, indications for needle thoracostomy, and goal of needle thoracostomy .

III. Syllabus Description

3.1. Sub Module Objective
After finishing skill practice of needle thoracotomy , the student will be able to perform
needle thoracotomy .

3.2. Expected competencies

Student will be able to demonstrate the procedure of needle thoracotomy , indications
and goal of needle thoracotomy.

3.3.Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play

3.4. Laboratory facilities

a. Skills laboratory : table,chairs, examination couch, povidone-iodine solution, a sterile
16 G or larger needle, and a sterile glove
b. Trainers
c. Patient
d. Student learning guide
e. Trainer’s guide
f. References

3.5. Venue
Skills laboratory

3.6. Evaluation
a. Point Nodal Evaluation
b. OSCE

3.7. Sub Module Objective

After finishing skill practice of needle thoracotomy, the student will be able to perform
needle thoracotomy.
3.8. Expected competencies
Student will be able to demonstrate the procedure of needle thoracotomy, correct tension
pneumothorax for life-threatening until a doctor can insert a chest tube.

3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice

3.10. Laboratory facilities

a. Skills laboratory
b. Trainers
c. Patient and model
d. Student learning guide
e. Trainer’s guide
f. References

IV. Learning Guide for needle thoracotomy

No. Steps/Task 1 2 3 4 Comment
A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. The patient should be given adequate
explanation about needle thoracotomy and the
goal or expected result needle thoracotomy
(Briefly)
B. PERFORMING NEEDLE THORACOTOMY
1. Clean the skin around the second intercostals
space at the midclavicular line, using povidone
–iodine solution. Use a circular motion, starting
at the center and working outward.
2. Full fill the syringe with 2cc sterile normal saline
3. Insert a sterile 16G or larger needle with
attached syringe immediately over the superior
portion of the rib and through the tissue
covering the pleural cavity while aspirating.
4. When air is aspirated, advance cathether
completely, and withdraw syringe. Withdraw
syringe following connect the inserted needle
with tubing immediately and place the other end
of tubing in a measuring glass filled with water.
5. Leave the needle in place until a chest tube can
be inserted.
 SKILL LABORATORY MODULE

Block : Respiratory system

Topic : Heimlich’ Manuver

I. General Objective
After completing skill practice, the student will be able to perform Heimlich’ manuver.

II. Specific Objective

At the end of skill practice, the student will be able to perform the procedure of
Heimlich’ manuver indications for needle thoracotomy , and goal of Heimlich’
manuver.

III. Syllabus Description

3.1. Sub Module Objective

After finishing skill practice of Heimlich’ manuver, the student will be able to perform
Heimlich’ manuver.

3.2. Expected competencies

Student will be able to demonstrate the procedure of Heimlich’ manuver, indications
and goal of Heimlich’ manuver.

3.3.Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play
3.4. Laboratory facilities
a. Skills laboratory : table,chairs, examination couch,
b. Trainers
c. Patient
d. Student learning guide
e. Trainer’s guide
f. References

3.5. Venue
Skills laboratory

3.6. Evaluation
a. Point Nodal Evaluation
b. OSCE

3.7. Sub Module Objective

After finishing skill practice of Heimlich’ manuver, the student will be able to perform
Heimlich’ manuver.

3.8. Expected competencies

Student will be able to demonstrate the procedure of Heimlich’ manuver,

3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice

3.10. Laboratory facilities

a. Skills laboratory
b. Trainers
c. Patient and model
d. Student learning guide
e. Trainer’s guide
f. References

IV. Learning Guide for Heimlich Manuver

No. STEPS/TASK 1 2 3 4 COMMENT
A. CLIENT ASSESSMENT
1. Greet client respectfully and with
kindness
2 The patient should be given
adequate explanation about
Heimlich manuver and the goal or
expected result Heimlich manuver
B. PERFORMING ABDOMINAL THRUSTS (HEIMLICH’ MANUVER)
1. Standing behind the patient, wrap
both arms around his waist.
2. Place your fist int the center of his
abdomen, midway between the
umbilicus and the xiphoid process.
Rest the thumb side of your fist
aginst his epigastrium and then
grasp your fist with your other
hand.
3. Using a quick motion, thrust your
fists inward and upward four times
4. Repeat the process until the
obstruction is removed.

MODULE OF SKILL LABORATORIUM PRACTICE

BLOCK: RESPIRATORY SYSTEM
TOPIC: TUBERCULIN SKIN TESTING (MANTOUX TEST=PPD TEST)

I. GENERAL OBJECTIVE
After finishing this skill practice, the students will be able to perform Mantoux test/PPD
test and reading and recording its result 48-72 hours afterward.

II. SPECIFIC OBJECTIVE

At the end of this skill practice, the students will be able to perform and reading and
recording the result of Mantoux test/PPD test for diagnosis of tuberculosis in children.

III. SYLLABUS DESCRIPTION

a. Methods
a. Presentation
b. Demonstration (by movie)
c. Training

b. Laboratory facilities
a. Skills laboratory
b. Trainers
c. Anatomic models
d. PPD RT-23 2 TU solution
e. Disposable tuberculin syringe
f. Alcohol 70%
g. Cotton
h. Transparant millimeter ruler
i. Plastic container
j. Students learning guide
k. Trainers guide
l. References

c. Venue
Skills laboratory

d. Evaluation
a. Point nodal evaluation
b. OSCE

LEARNING GUIDE
TUBERCULIN SKIN TESTING (MANTOUX TEST or PURIFIED PROTEIN
DERIVATIVE=PPD TEST)

Performance Scale
No PROCEDURE (STEP/TASK) Comment
1 2 3 4

1 Preparations
1. Greet client/parents respect-fully and with
kindness.
2. Obtain biographic information (name, birth
date, address or phone number).
3. Ask about the complaints that relate to
suspicion of tuberculosis (history of contact
with adult tuberculosis, HIV infection,
corticosteroid therapy, retarded of
increasing body weight or decreasing body
weight, often low-grade fever due to
unclear etiologies, coughing more than 3
weeks).
4. Provide information about the purpose of
procedure. Mantoux test is a useful
diagnostic tool of tuberculous infection. A
positive reaction have a great value in the
diagnosis. But, further evaluation including
physical examination, radiographic and
laboratory studies must be performed to
determine the presence of disease.
5. Tell client/parents what is going to be
done and encourage them to ask
questions.
6. Help client to get a comfortable position.

2 Check the material of procedure, include:

1. Cotton ball
2. Alcohol 70%
3. PPD RT 23 – 2 TU solution
4. Disposable tuberculin syringe
5. Ballpoint/pen
6. Transparant millimeter ruler
7. Leakproof container (plastic bag)
8. Plastic bottled

3 The Implementation of procedure

1. Wash hands with soap and water flow and
dry with clean cloth or air.
2. Put 0.1 ml PPD RT-23 2 TU solution into
the disposable tuberculin syringe.
3. Apply antiseptic solution (alcohol 70%) on
 the injection area and dried with a cotton
ball.
4. Hold the skin of the forearm taut
5. Inject 0.1 ml PPD solution into the skin
intracutaneously on the volar surface of
the forearm with the bevel of syringe face
up.
6. If injected appropriately, a 6-10 mm wheal
will be formed.
7. Remove your syringe.
8. Dispose of waste materials by placing in
leakproof container or plastic bag, and the
used syringe in the plastic bottled.
9. Sign the injected area by pen.
10. Wash hands with soap and water flow and
dry with clean cloth or air.
11. Counseled the parent that the procedure
must be evaluated in the 48-72 hours after
injection.

4 Readings results of procedure

1. Measure only the induration. The erythema
has no diagnostic value.
2. Palpate the margin of induration by touch
and mark the edge of the induration using
ballpoint pen from both lateral margins to
edge. Pen stops at induration (Ballpoint
pen method of Sokal).
3. Measured the diameter of induration
transversely to the long axis of the arm by
transparent ruler.
4. Sometimes, the result showed vesiculation
(vesicle).
5. Complete the client record.
6. Counseled the parents that a false negatif
reaction may result

5 Readings results
1. Measure all measurements in mm
of induration, not + or –
2. If there is no induration the
measurement is 0 (0 mm)

6 Interpretation
Induration  10 mm  PPD positive
(Pediatric Indonesian Concensus)

Laboratory facilities: Clinical Skills Program Respiratory System

  Patient : real patient and model
 Oxygen therapy equipment: cylinders of oxygen, flow control
device,humidifier, non crush plastic oxygen delivery, catheter or
prongs (nasal cannula), simple oxygen masks, partial non-
rebreathing, and true nonrebreathing
 Table, chairs, examination couch,povidone-iodine solution, a
sterile 16 G or larger needle, and a sterile 16G or larger needle,
and a sterile glove
 Cotton, alcohol 70%, PPD solution RT 23-2 TU, tuberculin syringe,
surgical gloves, ballpoint, and ruler
 Head lamp, nasal speculum, tongue blade, pinset, and petrolatum
or vaseline gauze coated with an antibacterial ointment
 Roentgen exposed film and viewing box

CRITERIA OF PERSONAL PERFORMANCE EVALUATION

No. Performance Achievement Comment

1 If student are doing the sleep less then 35% Low

of the whole step precisely
2 If student are doing the step less then 35%- Mild
50% of the whole step precisely
3 If student are doing the step less then 50%- Moderate
75% of the whole step precisely
4 If student are doing the step more then 80% Excellent
of the whole step precisely

SCHEDULE

Subject Allocated Time Tutor

Presentation

Demonstration & Coaching

Self practice on artificial models