Chapter 1

NURSING ASSESSMENT
A. Learning Outcome and Indicators
After teaching learning process in this chapter, the students are able to understand
nursing assessment with the following indicators:
Understanding vocabulary and useful expression related to nursing assessment.
Asking personal data through interview.
Getting subjective data through interview.
Getting objective data and physical examination.
Analyzing data.

B. Language Competency
Language function : Collecting subjective and objective data.
Language focus : Expression asking subjective and objective
data.
Grammar focus : Question words, adjectives and adverbs.
Related Nursing : Communication techniques on nursing
Skill assessment.

C. Materials
1.1 Getting Personal Data
Reading

Source: writer’s doc.

A nurse gets personal data when the nurse meets a patient for the first time. This
data should include the patient’s full name, address and telephone number, date of
birth, age, marital status and religion. A contact number of someone who can be called
in an emergency should be included and this may be a next of kin or, if they live some
distance away, it may be a partner or spouse. It is usual to find out who could be
contacted at night, especially if the partner or spouse is elderly and infirm. Patients may
be concerned about the implications of having to call someone in an emergency, and so
it is wise to explain that it is usual practice to ensure all contact details are current and
an emergency number is very rarely needed.

1
 Enquiring as to whether the patient practices his religion provides an
opportunity for him to express whether he will want to follow particular religion, such
as attending a service or saying prayers at particular times. There may be particular
cultural practices that he would wish to fo llow during illness, and facilities should be
made available for him to do so where possible. Further information about cultural
awareness can be followed up in the recommended further.

Activity 1- Individually
Read these patient’s data and answer the questions.
Title : Mr.
First Name : Heru
Surname : Mahardika
Sex : Male
Material Status : Married
Religion : Christian
DOB (Date of Birth) : 12.09.1982
Occupation : Construction Worker
Address : Dhoho Street No.100
Telephone : (mobile) 081330726623
E-mail : hmahardika@yahoo.co.id
General Physician (GP) : dr. Fathony
Next of Kin : Anasthasia Mahardika
Relation to Patient : Wife
Smoking Intake : 1 pack a day
Allergies : Seafood
Reason for admission : 7 times passing stool, diarrhea

1. Is the patient a man or a woman? A man

2. When is the patient’s birthday? 12.09.1982
3. What is the patient’s job? Construction Worker
4. Is the patient married? Yes
5. Who is the patient’s family doctor? No
6. Who is Anasthasia Mahardika? Next of Kin patient

Find the words in the admission form with these meanings.

1. family name
2. job
3. Mr / Mrs / Ms
4. family doctor
5. the name the patient wants the medical staff to use
6. closest relative
7. country where patient was born
8. male or female
9. married / single / divorced / widowed
10. why the patient is visiting hospital
11. date of birth
12. the amount of something you drink / eat, etc. regularly
13. a bad reaction to, for example, food or medicine

2
Listening - Speaking
The following conversation, a nurse is going to check personal data.
Nurse : I’d like to check your personal data, if that’s OK.
Patient : Of course.
Nurse : Can you give me your full name, please?
Patient : Maria Fecylia.
Nurse : Can you spell your last name, please?
Patient : F-E-C-Y-L-I-A, Fecylia
Nurse : And what would you like us to call you?
Patient : Maria is fine
Nurse : Where are you from?
Patient : I’m originally from Surabaya, but I came here for my studies, got married
and now we’re looking forward to our first child. I’ve been here for ten
years already.
Nurse : That’s lovely. And what is your date of birth Mrs. Maria?
Patient : The 20th of the first, 81.
Nurse : Is that the 20th of January 1981?
Patient : That’s right.
Nurse : And what is your job?
Patient : Marketing manager for Mayapada.
Nurse : Marketing manager of bank. OK. Now, I also need to ask, what’s your
marital status and who is your next of kin, to contact in an emergency?
Patient : I’m married and my husband, Daniel, is my next of kin. His mobile
number is 081779 706 7517.
Nurse : Thank you. Do you have any allergies?
Patient : No.
Nurse : Thank you for your information.
Patient : You are welcome.

Activity 2 - Individually
Complete the nurse’s questions.
1 Can you give me your full name please?
2 Can you ….. that, please ?
3 What would you like us to call you?
4 What is your date of birth Mrs. Maria ?
5 What is your job ?
6 Do you have any allergies?

Grammar Focus
What, Where and Who - questions
We can use questions with what, where and who to ask for patient information.
The use what is when we want to What is the telephone number
know about something. of your GP?
The use where is to ask about places. Where does she live?
The use who is to ask about a person Who is your GP?
or people.

Activity 3 - Work in Pairs.

3
Complete these questions with what, where or who. Then practice asking and answering
the questions.
1. ’s your surname/first name/full name?
2. do you live?
3. ’s your address/email address/mobile phone number?
4. ’s your date of birth?
5. ’s your GP?
6. ’s your next of kin?
7. ’s his/her relationship to you?

Useful Expressions
Collecting Personal Data
Explaining what you are going to do immediately.

 It is time for me to...

 I just want to... interview you
 I would like to... assess your personal data
 I am going to... assess your health condition
 I need to...

2. Questions to collect personal data element.

There are some personal data elements:

Name: What is your name?

What is your complete name?
What is your surname?
Ages: How old are You?
Address: What is your address?
Where do you live?
Phone: Your phone number please?
What is your phone number?
Do you have a Mobile Phone number?
Ethnic Origin: What is your ethnic origin?
Marital Status: Are you married?
Health Insurance: Do you have any health insurance?
Occupation & Title: What is your occupation?
Do you have any academic title
What is your title?
What do you do?
Next of Kin: Who is your next of kin?
Reason for Contact: What brings you in this hospital?
Who sends you to this hospital?
What makes you come to this hospital?

Activity 4 - Work in Pairs.

Interview your partner with the questions listed above.
Name : What is your name? siska
What is your complete name? Irena siska
manalu

4
 What is your surname? Siska

Ages : How old are You? 21 years

Address : What is your address? Sp 2 maboh permai
kab.sekadau
Where do you live? Kalimantan barat

Phone : Your phone number please? 08354373628

What is your phone number?89237483
Do you have a Mobile Phone number? Yes

Ethnic Origin : What is your ethnic origin?

Pontianak,Kalimantan Barat

Marital Status : Are you married? single

Health Insurance : Do you have any health insurance? Yes

Occupation & Title : What is your occupation? College student
Do you have any academic title
What is your title? -
What do you do?-

Next of Kin : Who is your next of kin? Bona gogo

Reason for Contact : What brings you in this hospital? I’m sick
Who sends you to this hospital? Big family
What makes you come to this hospital? I’m
sick

Activity 5 - Work in Pairs.

Take turns playing the role of a patient and of the nurse who admits the patient to
hospital. Invent an identity for your patient, including the details below. Copy a blank
patient admission form like the one. Interview your patient and complete the details in
the form.
Full Name
Address
Family
Next of Kin
Date and Place of Birth
Occupation
Marital Status
Smoking Intake
Allergies
Reason for Admission

1.2 Getting Subjective Data

Reading

Learn the acronym for collecting subjective data.

5
 ACRONYM EXPRESSIONS
1. P – provocative What helps or worsens the symptoms?
or palliative Do certain situations such as stress or particular
physical positions make a difference?
What your symptom that really burden you?
What your problem?

2. Q – quality What does the symptom look, feel or sound like?

3. or quantity Is he experiencing it during the interview?
How does it affect his normal activities?
What is it like? Is it sharp? Dull, stabbing,
aching?
Do you feel…….?

4. R – region Where in the body does the symptom occur?

5. or radiation Is anywhere else affected by it?
Where do you feel it?
Does it move around?
Show me where.

S – severity How severe is this symptom on a range of 1 to

10 (10 being most severe)?
Is it getting better, worse or staying the same?
On a scale of 0 to 10, with ten the worst, how
would you rate what you feel right now?
What is the worst has been?
Does this problem burden your usual activities?
In what ways?

T – timing When did it begin?

Did it start gradually or suddenly? How
frequently does it happen?
How long does it last?
When did you first notice it?
How long does it last?
How often does it happen?

Additional information
SETTING Does it occur in a particular place or under
certain circumstances?
AGGRAVATING What makes it better?
FACTOR OR What makes it worse?
ALLEVIATING When does it change?
FACTORS Have you noticed other changes associated with
this?

Activity 6 - Work in Pairs:

6
Learn and understand the way to collect chief complains. Interview your partner and
make description of chief complains based on your partner’s symp toms.

 Would you show me the location of your pain? Yes

 Can you point at the location of your pain? Knees down my feet
 Show me where the location of your pain is! Knee leg
 Where is the pain? knee
 Is it (your pain) in your leg (part of the body) Yes
 Do you feel pain in your ankle (part of the body) No
 Would you say that was moderate or severe? moderate
 Does the pain move at all? No
 How long did the pain last this time? Only a while
 Can you tell me how it started? When a walk
 How often do you have these pains? Just once in a while
 What seems to make the pain better? No
 Is there anything that makes it worse? walk
 How do you feel about your condition? apprehensive
 Can you describe your symptoms to me? yes
 What happens when you get pain? Just stay quiet
 When did you start feeling ill? 3 days ago
 Does it hurt when I press your abdomen just here? No
 How bad is the pain? Prickling a needle
 Tell me, what were you doing when the symptom appeared? Be quiet
 Were you taking your medication? No
 Etc.

Vocabulary
Dull : rasa tidak terlalu sakit, berlangsung terus-
menerus.
Stabbing : sakit yang berdenyut, seperti pukulan
Sharp : rasa sakit yang menusuk-nusuk
Aching : rasa sakit yang berlangsung terus-menerus
aggravating factors : faktor-faktor yang memberatkan (penyakit)
alleviating factors : faktor-faktor yang meringankan (penyakit)
Pale : Pucat
Painful : Tegang
Sallow : muka yang pucat kekuning-kuningan
Suffocate : napas sesak seperti tercekik (suffocating)
dream day : Melamun
Rigid : Kaku
Moan : mengerang, merintih
Bouncy : Bersemangat
Contempt : rasa jijik
Bruise : Memar
Tender : Perih
Tense : Tegang
afraid of : ketakutan/takut

7
Papery : kelihatan tipis dan kering
Confuse : Membingungkan
Tired : Lelah
Gasp : terengah-engah terutama karena kesakitan
Groan : mengerang, merintih
Sigh : Mendesah
Stiff : Kaku
Swallow : Bengkak
Yellowish : kekuning-kuningan

Grammar Focus
Adjectives and Adverbs
Sometimes in the written expression, adjectives are incorrectly used in place of
adverbs, or adverbs are incorrectly used in place of adjectives. Adjectives and adverbs
have very different uses in sentences. Adjectives have only one job, they describe nouns
or pronouns. Examples:
It is delicious meal
(adj.) (noun)
It is delicious
(pron.) (adj.)

In the first example, the adjective delicious describes the noun meal. In the second
example, the adjective delicious describes the pronouns it.
Adverbs have three different uses. They can describe verbs, adjectives, or other adverbs.
Examples:
He writes letters quickly
(verb) (adv.)
It is quickly written letter
(adv.) (adj.) (noun)
It is extremely quickly written letter
(adv.) (adv.) (adj.) (noun)

In the first example, the adverb quickly describes the verb writes. In the second
example, the verb adverb quickly describes the adjective written (which describe the
noun letter). In the third example, the adverb extremely describes the adverb quickly,
which describes the adjective written (which describes the noun letter). The following
are examples of incorrect sentences as they might appear.

They were seated at a largely table

(adv.) (noun)
The child talked soft to her mother
(verb) (adj.)
We read an extreme long story
(adj.) (adj.)
She speaks unbelievable quickly
(adj.) (adv.)

In the first example, the adverb largely is incorrect because the adjective large is
needed to describe the noun table. In the second example, the adjective soft is incorrect

8
because the adverb softly is needed to describe the verb talked. In the third example,
the adjective extreme is incorrect because the adverb extremely is needed to describe
the adjective long. In the last example, the adjective unbelievable is incorrect because
the adverb unbelievably is needed to describe the adverb quickly.
The following chart outlines the important information that you should remember
about the use of adjectives and adverb.

The use of adjective and adveb

Adjectives Adjective is to describe nouns or pronouns
Adverb Adverb is to describe verbs, adjectives, or other adverb

Activity 7 - Individually
Each of following sentences has at least one adjective or adverb. Circle the adjective and
adverb, and label them. Draw arrows to the words they describe. Then, indicate if the
sentences are correct (C) or incorrect (I).
1. Her hair was an unusually color of red.
2. The weather is really comfortable.
3. The nurse injected intravenous carefully.
4. We attended a poor planned conference.
5. He talked slowly and carefully.
6. The blood samples were automatically examined in laboratory
7. The composition was careful prepared.
8. She had an incredible story about her long trip
9. He sent me a quickly written note.
10. The cat meowed sad.
11. The children are hungry and tired.
12. The lecturer spoke extremely loud.

Activity 8 - Individually
Translate these into communicative English.

1. Maaf pak, sepertinya perut anda sakit.

Sorry sir, it looks like your stomach hurts
2. Maaf pak, kelihatanya bapak mengalami gangguan pada dada bapak.
Sorry sir, it looks like you have trouble with your chest
3. Sepertinya bapak merasa tidak nyaman ketika berjalan.
It seems you feel uncome
4. Anda seperti kelelahan
You are like exhausted
5. Jari tangan anda kelihatan bengkak.
Your fingers look swollen.
6. Sepertinya anda takut dengan tindakan medis ini.
It seems you are afraid of this medical action .
Activity 9 - Individually
Arrange these jumbled words into a sentence about patient’s complains.

1. look – scars – reddish – your

9
 look reddish scars cell
2. seem – respiration – to have – you – with – problem – your.
Seem you have to problem with your respiration
3. your – look – uncomfortable – turning – head – when – you.
You uncomfortable when look your turning
4. skin – dry – your – looks.
your looks skin dry
5. seem – with – uncomfortable – you – sling – that.
seem you uncommfortable with that sling
Activity 10 - Work in Pairs
Instructions:
1 Observe your partner’s physical performance.
2 Focused your observation on health condition.
3 Share your observation to your partner.
4 Reserve the role.
5 Write your observation result.
6 Tell your result to your partner.

1.3 Patient’s Observation

Reading

Source: Writer’s doc.

Assessment of a patient’s vital signs includes observations of temperature, pulse,

blood pressure, respiratory rate and oxygen saturation, blood glucose levels and level of
consciousness. These observations provide an efficient and accurate method of
monitoring a patient’s condition. They also enable evaluation of response to treatment
and early detection of problems. Observations give vital information about a patient’s
condition
Before observations are taken, the patient should be made comfortable and be
encouraged to relax. If the patient has taken even mild exercise he should be allowed to
rest for a few minutes. To get an accurate assessment of a patient’s condition, pain
should be relieved and every effort made to reduce anxiety as these factors may
influence the vital signs. Body temperature, posture and certain drugs will also alter a
patient’s observations.
Learn the dialogue below. Mention 5 important things as observations.
Nurse : Your skin looks reddish.
Patient : It started yesterday after swimming in the beach; I didn’t apply any

10
 lotion over my skin. My skin is very sensitive to sunshine.
Nurse : Would you tell me how you feel now?
Patient : Yes, I feel hot and tender around my arm and my back.
Nurse : You seem to have sunburn. Let’s consult your doctor.
Patient : Thank you.

Useful Expression
It is important to help the patient to express the health problems.
Below are techniques on helping patient identify and express feeling.
uncomfortable
You look… tense
Your (part of the body) looks… stiff
You seem ... happy
sad, etc.
Your ... looks ...
skin sallow
eyes reddish
nail, etc yellowish, etc.
You seem uncomfortable when… walking
moving your hand/leg
changing yours clothes, etc.
You look uncomfortable with your... leg/position/stomach/chest/etc.
You seem you have + (a problem with + a part of the body)
(a health problem : such as a stomachache, chest pain, etc.)
Would you show me the location of your pain?
Can you point at me the location of your pain?
Show me where the location of your pain is?
Where is the pain?
Is it (your pain) in your leg ( part of body)
Do you feel pain in your ankle (part of body)

Activity 11 – Work in Pair

Translate these into communicative English.
1. Apakah anda pernah memperhatikan ada perubahan lain sehubungan dengan rasa
sakit ini?
Have you noticed any other changes associated whit this pain ?
2. Apa yang bisa mengurangi rasa sakit itu?
What can reduce the pain?
3. Kapan rasa sakit itu berubah?
When did the pain change?
4. Apakah rasa sakit itu terjadi di tempat tertentu atau dalam kondisi tertentu?
Does the pain occur in a certain place or under certain conditions?
5. Berapa lama rasa sakit itu berlangsung?
How long did the paint last
For each number, arrange these jumbled words into a sentence about patient’s
complaints.

1. ( vomiting – have – I – been )

11
I have vomiting been
2. (short – lost – have – a lot of – I – weight – in – time )
i have short lost a lot of weight time
3. ( 3 days – more – pain – my – than – persists )
my pain more persists than 3 day
4. (pain – the – mainly – back – lower – in – is – part – the – my – of )
My pain is mainly in the part of my lover back
5. (pain – the – back – legs – shoots – the – my – down – of )
My Pain Of the back shoots the legs

Reading
Measles
Sandra is five years old. Her GP phones the hospital to prepare for an admission and
her parents accompany her in an ambulance. Her parent should bring her to hospital
immediately. Sandra has been weepy for the past two days and sometimes crying
inconsolably. Nothing has been making her comfortable to stop her from crying. She has
been running a temperature of around 39.5 degree Celcius. She has a nasty-looking rash
on her nose and throat and has difficulty breathing and sometimes has a dry cough. She
has been developing those symptoms for two days. Her parents report no diarrhea
though she vomited once an hour before seeing the doctor.
A diagnosis is required and in the meantime the doctor recommends that she should
be given as much fluid as possible to drink in order to avoid dehydration as a result of
her fever (though no drinks containing caffeine). Also that she should be dressed lightly,
with light bedclothes and she should be given a lukewarm sponge bath.
On the day she is in hospital, her parents found that she has been developing tiny
white spots, like grains of salt, appear inside the mouth. Her parents report this to the
nurses in charge. The nurse, then, tells the pediatrician.
On the fourth and fifth days, her temperature rises again and the characteristic
measles skin rash appears. The doctor diagnoses that she has been suffering from
measles. She has been complaining of headaches for the time she is in hospital.
The doctor tells her parent that this is a contagious disease. But most children who
contract measles, the disease disappears within 10 days and the only after-effect is
lifelong immunity to another attack.

Learn the case above and answer based on the following instructions:
1. Tell the result of anamneses and observation.
2. Add your assessment based other sources or references.
3. Determine nursing diagnosis based on the text.
4. Write and share your work to your partner.
5. Reserve the role.
6. Tell your result to your partners in group and in front of class.

Useful expression
Asking Health Problem
1. Nurse’s questions to check the patient’s complaint/condition:
What’s your problem?
How is your feeling today?
What makes you call me?
What’s your chief complaint?

12
 What’s troubling you?
What’s wrong with you?
What’s the matter with you?
What seems to be bothering you?
Doctor: what are the symptoms? What is she/he complaint about?

2. Patient’s expressions about symptoms and physical problems:

- I have (a part of the body + ache)
a toothache a stomachache
a backache a headache

- I have ( a sore + parts of the body)

a sore throat a sore arm
a sore knee a sore foot
- I have/get + kinds of physical problems
the measles a bloody vomit and stool
a bowel movement the flu
a cold a bad cough
- I feel + kinds of physical problems
dizzy cold and clammy
sick unwell
fever
- I experience + kinds of symptoms and physical problem
lassitude difficulty in breathing
low back pain cold and clammy
- I suffer from + kinds of certain illness
cancer
constipation
- I sprained my (possessive) + joints/bones problems.
ankle hurt
broke leg
collarbone arm
- I cut + my (possessive) + parts of the body (head, leg, hand, etc)
- She has + V3 …….
- I have been ……
- She/he has been + V(ing) …..

Vocabulary
measles : campak
GP : General Practitioner/dokter umum/keluarga
weepy : merengek
mucus : lender
run a temperature : kenaikan suhu
lukewarm : hangat kuku
dehydration : kekurangan cairan
spot : bercak
grain of salt : butiran garam
nasty-looking : nampak parah
break : patah

13
bother : mengganggu

bowel movement : buang air besar

waterworks : buang air kecil
constipation : sembelit
lassitude : lemas/lesu
in bad shape : kondisi tidak sehat
not in any shape : tidak cukup sehat
clammy : basah
dribble : buang air kecil tidak lancar
waterworks

Class Activity 12 (Group or Pair – Orally)

1) Have you ever been sick?
2) Mention what you complaint based on your
sickness?
3) What do you call kind of your complaints?

Class Activity 13 (Group or Pair – Orally)

1) Make a conversation between a nurse and a patient.
2) Case is based on your sickness.
3) Conversation :
Nurse : “ Good morning, how are you today ?”
Patient “ I alredy feel good Nurse”
Nurse : “ Alright, according ro thr doctror’s advise today you may gp home”
Patient : “ What should I do before going home?”
Nurse :” First yu have to finish the administrasion First, can you oerder your
family to take care of it”
Patient : “ Alright Nurse”
Nurse : “ So before you go home, there are a few thing I have to explain, first you
have to take the medicine according to the prescption given by the doctor,
secondly, you have to comply whit the schecdule for a health check in the
Outpatient Installation, the third you have to apply a diet low- ceab and low-
sugar diets that have been taught, do you understand?”
Patient: “ Why should I go on a low-carb and low-sugardiet?”
Nurse : “ studies prove that diabetics on a low-crab and Low-carbohydrate diet
have lower blood sugar levels compred to diabetics who eat as usual.in
addition ,a low –carbohdyrate diet also helps diabetics to lose weight.Do you
understand?”
Patient:”I understand Nurse”
Nurse:”Alright,after your family finishes administration we will give you
medicine that you can use at home,you can go home “
Patient:”Thank you Nurse”
Nurse:”You’re welcome ,stay healthy”

1.4 Physical Examination Skills

14
 Inspection, palpation, percussion and auscultation are examination techniques
that enable the nurse to collect a broad range of physical data about patients. (l)
Inspection: the process of observation, a visual examination of the patient's body parts
to detect normal characteristic or significant physical signs. (2) Palpation: involves the
use of the sense of touch. Giving gentle pressure or deep pressure using your hand is the
main activity of palpation. (3) Percussion: involves tapping the body with the fingertips
to evaluate the size, borders, and consistency of body organs and discover fluids in body
cavities, and (4) Auscultation: listening to sounds produced by the body.

Patient’s physical examination: Head, Face and Neck

Vocabulary
toupee/wig : rambut palsu
hairpiece : rambut palsu untuk memperpanjang rambut
clench : pegangan, genggaman, cengkeraman, kepalan,
mengepalkan
frown : kerut (dahi), mengerutkan dahi, memberengut, to f. on
tidak setuju/menyukai
puff : tiupan (of air, wind), isapan, embusan (of smoke),
gumpal, mengepul (of smoke), terengah – engah
shrug : angkatan (bahu), mengangkat (bahu). to s. off
menganggap enteng, tidak mcnghiraukun
cartilage : tulang rawan/muda cricoid (also cricoid cartilage):
bagian dari "larynx" yang berhentuk cincin
anterior : bagian depan
posterior : bagian belakang
lateral : bagian samping
node : benjolan
sternum : tulang dada
tenderness : rasa sakit, perih

Useful Expression
Study and practice these useful expressions:
Question to ask:
Do you have any cold recently?
Do you have any infection recently?
Did you have any thyroid problem?
Did you have neck pain?
Did you note any enlargement on the parts of your head?
Explaining what you are going to do immediately
• Now I am going to ....
• It's time for me to ....
• Now I want to ....
Pres your + (parts of the body) gently
Examine your + (parts of the body) gently
- Artery - Cheeks - Neck
Instructions:
• Would you?

15
 • Now I want you to?
 Remove you wig
 Put off your hairpieces/ toupees
 Clench your teeth
 Rise your eyebrows
 Please close your eyes tightly
 frown your forehead
 smile
 show your teeth
 puff out cheeks (menggelembungkan pipi)
 shrug your shoulder (mengangkat bahu)
 flex your neck with chin toward (your chest / ceiling)
 bend your neck, with ear toward shoulder
 take a sip of water from this glass

Activity 14 - Work in Pairs

Mention what activity you do for each case listed below.
(inspection, palpation, percussion or auscultation)
1. Examining patient’s respiratory.
2. Inspecting the mouth and throat.
3. Asking patient to stand up to find whether there is scoliosis or not.
4. Pressing her middle finger of non-dominant hand firmly against the patient’s back.
With palm and fingers remaining off the skin, the tip of the middle finger of the
dominant hand strikes the other, using quick, sharp stroke.
5. Observing the color of the eyes
6. Observing the movement of air through the lungs.
7. Testing deep tendon reflexes using hammer.
8. Checking the tender areas with her hand.
9. Pressing abdomen deeply to check the condition of underlying organ.
10. Preparing a good lighting, then he observes the body parts.

Activity 15 - Individually
Write a sentence using the words given.
1. (want – puff – cheeks – you )
2. (clench – fist)
3. (you – tenderness – feel)
4. (sip – water – spoon )
5. (have-a node-neck)
Activity 16 - Work in Pairs
 Make a short conversation explaining the procedure as shown in useful
expression.
 Make a complete conversation on the acts of assessing head, face and neck.
 Use the expressions above.

Activity 17 - Work in Pairs

Making Nursing Documentation
 Study the nursing documentation below.
 Assess your partner’s condition.

16
  Use a complete communication.
 Write the report and use your own sentences.
 Reverse your roles.

Nursing Documentation:
A sample of head and neck assessment
Example: expected hair distribution, soft and curly in appearance. Scalp clean. Rounded
skull with no masses or tenderness. Symmetrical face. Trachea midline. No
lymphadenopathy. Thyroid palpable with no masses or enlargement. Carotid arteries
plus two bilaterally. No venous distention.

Patient’s Physical Examination: Eyes and Ears

Vocabulary
diplopia : bayangan dobel
blur : kabur
discharge : kotoran (berupa cairan / kental)
spotters : titik - titik dalam penglihatan mata
floater : titik - titik halus yang bergerak dalam penglihatan
acuity : ketajaman (penglihatan) pikiran atau pendengaran
bridge : anatomy. berhuhungan dengan bagian yang keras hidung

Useful Expression
Eye Assessment
Study and practice these useful expressions.
Questions to ask:
Have you ever had eye disease?
Have you ever had eye trauma?
Have you ever had eye itching?
Have you ever had eye discharge?
Do you use glasses?
Do you use contact lens?
Other questions:
Do you have diabetes?
Do you take any medication recently, for instance antibiotics or large dosage of
aspirin?
Instructions
Just, follow my instructions
Please ....
Now, I want you to ....
Study and Practice these useful expressions.
Explaining what you are going to do immediately.
It is time for me to examine your eyes
I just want to... (one of the expressions)
I would like to... (one of the expressions)
I am going to... (one of the expressions)
I need to... (one of the expressions)
Read this newspaper while wearing glasses.
Read this letter (written on the snellen eye chart)

17
 Can you see the print clearly?
Mention what letter it is?
Visual fields:
Sit in front of me
Look at my eye
Close one eye with your palm hand.
Look at movement of my finger/this object,
State when you first notice it.
Extra ocular movement test:
Look straight toward me
Keep your head motionless/keep your head steady
Follow movement of my finger with your eyes, keep your head still.
Accommodation test
Just stay here, look at the wall in this distance.
(I want to move my finger toward your nose) look at my finger.
(I want to move my finger toward your nasal bridge) look at my finger.
External eye assessment
(I need to check your lid position) Now close both eyes.
(I want to move my finger toward your nasal bridge)
look at my finger.
External eye assessment
(I need to check your lid position) Now close both eyes.
(I need to check upper eye lid) Now, raise your eyebrows.
(I need to press here gently)
(I need to check your cornea) Now, Look up
(I'm going to shine your eye with this light).

Ear assessment
Useful Expression
Study and practice these useful expressions.
Questions to ask
Have you ever had ear disease?
Have you ever had ear itching?
Have you ever had ear discharge?
Ringing of the ears (tinnitus)
Do you use hearing aids?
What do you say when you are going to insert the tip of an otoscope into the ear
canal?

Study and practice these useful expressions.

Explaining what you are going to do immediately.
I just want to ... check your ears
I would like to...
I am going to ...
I need to...
Now, let me ...
Instructions.
Just, follow my instructions
Please, ....

18
 Now, I want you to + (The expression below)
Would you ....
Hearing Acuity Test
Put off your hearing aids. Close your eyes.
(Now I want to whisper "nine four") repeat what I mentioned.
If you suspect a loss of hearing, perform a tuning fork test Webber's test, (Now I
put this in the middle of your forehead)
Can you listen the sound equally in both ears?
Do you listen the sound better in one ear?
Rinne test (listening to the length of the vibration of the tuning fork), Listen to
this...Tell me when sound is no longer heard.

Activity 18 - Work in Pairs

Make a short conversation explaining the procedure as shown in useful expression.
 Make a complete conversation on the acts of assessing head, face and neck.
 Use the expressions above.

Activity 19 - Work in Pairs

Making Nursing Documentation
 Study the nursing documentation below
 Assess your partner’s condition.
 Use a complete communication.
 Write the report and use your own sentences.
 Reverse your roles.

Nursing Documentation
Ear condition
Example: Whisper test response positive bilaterally. Voice perceived from 15 feet. Pinna
is smooth with no tenderness over mastoid. Ear canals clear with no drainage.
Tympanic membranes pearl gray, intact; light reflexes present in both ears. No bulging
noted.

Patient’s Physical Examination: Nose, Sinuses, Mouth and Pharynx

Nose, Sinuses, Mouth and Pharynx Assessment

The condition of the oral cavity can reveal significant information about a patient's
health, such as state of hydration, nutritional status, hygiene practices and specific
pathological conditions. The procedure is to be done thoroughly so as not to miss a
lesion or local area of inflammation under or around the tongue and along the mucosal
surface.

Useful Expression
Questions to ask:
Do you snore at night?
Do you smoke?
Do you use any nasal sprays or drops?
Do you drink alcohol?
Do you use dentures?
Do you feel any pain when you brush your teeth?

19
 Do you feel any tenderness?
Do you brush your teeth everyday (how many times a day?)
Do you have difficulty breathing through the nose?
Do you have nasal discharge?
Do you have any problem with your appetite recently?
Do you have any problem with your dentures?
Have you experienced any injury to your nose or mouth?
Have you ever had bleeding from your nose?
Explaining what you are going to do immediately
It is time for me to examine your nose / mouth
I just want to press you on this sport (frontal sinus)
I would like to close one of your nostrils
I am going to ...
I need to...
Instructions
Will you open your mouth?
Would you tip your head back slightly say "ah"
Please, breathe with your other nostril. I will press the other one do the same
with the opposite part.
Now, I want you to...

Vocabulary
extremities : (n) [pl.] (formal) tangan dan kaki
example: cold extremities and hot head are the first
signs of the fever
epistaxis : (n) (medicine) mimisan (keluar darah dari hidung)
nares : (sing. naris) anatomy. lubang hidung
uvula : (n) (plural uvulae (anatomy): kh. anak lidah / tekak
mucous : (adj) mukosa ks. membrane selaput lender
pharynx : (n) pharynges, tekak, hulu kerongkongan
bilateral : (adj) dua belah pihak, timbal balik
buccal : (adj) (ks. berhuhungan dengan pipi dan mulut)
denture : (n) gigi palsu

Useful Expression
Assessment
Study and practice these useful expressions.
Question to ask:
Do you…………….?
Snore at night
Smoke
Use any nasal sprays or drops
Drink alcohol
Use dentures
Feel any pain when you brush your teeth
Feel any tenderness?
Brush your teeth everyday (How mwny times a day?)
Questions to ask:

20
 Do you have……………..?
Difficulty breathing through yhe nose
Nasal discharge
Any problem with your appetite recently
Any problem with your dentures
Have you…………………?
Experienced any injury to your nose or mouth
Ever had bleeding from your nose
Implementation Steps
Study and practice these useful expressions
Explaining what you are going to do immediately.
It is time for me to………..
I just want to………………
I would like to………………….
I am going to……………………
I need to…………………………
Examine your nose / mouth
Press you on this spot. (frontal sinus)
Close one of your nostrils.
Instructions
Will you……………?
Would you………….?
Please,………………..
Now, I want you to…………
Open your mouth
Tip your head back slightly.
Say “ah”.
Breathe with your other nostril. I will press the other one.
Do the same with the opposite part.

Activity 20 - Work in Pairs

Giving instruction.
 Practice the instructions below.
 Listen to teacher’s instruction, act out them.
 Then, practice these in pairs.
 Open your mouth, please.
 Tip your head back slightly. I need to check your nostrils.
 Say ”ah”
 Now I want to press one of your nostrils. Breathe with the nostril, while I press
the other one.

Activity 21 - Work in Pairs

Making nursing documentation.
 Study the nursing documentation below.
 Assess your partner’s condition.
 Use a complete communication.
 Write the report and use your own sentences.
 Reverse your role.

21
Nursing Documentation
A sample of nose, sinuses, mouth and pharynx Assessment Report
Example: Nose - Nares patent bilaterally. No tenderness over sinuses, no drainage.
Buccal mucosa, gums and pharynx pink and smooth with no inflammation or
lesions. Uvula in midline and rises on phonation. Teeth in adequate repair, no mouth
and pharynx extractions.

Reading
Tonsilitis and Pharyngitis in Children

The two tonsils at the back of the throat are part of the ring of limph glands that
guard the entrance to the respiratory and digestive system. Very small at birth, they
enlarge gradually, reaching maximum size at age 6 or 7 years. Thereafter, they shrink
but do not disappear, as adenoids do. The tonsils are relatively large at early school
age, when the respiratory tract begins to be attacked by a variety of new microbes; the
tonsils are thought to act to keep the microbes away from the lower respiratory tract.
Both tonsilitis and pharyngitis are bacterial or viral infections of the back of the throat
that cause soreness, and they are often associated particularly in children. Sore throat
may also be part of a more generalized respiratory infection, such as influenza.

What are the symptoms?

Tonsilitis starts suddenly with sore throat and difficulty in swallowing; within a
few hours, the child becomes feverish and may seem quite ill. The painful irritation in
the throat makes some children vomit or cough. In a very few cases, the child has a
febrile convulsion (see convulsions in children). Young children often complain of
stomach pain. Glands on either side of the neck and in the angle the jaw may swell and
become tender. They can be felt as small, knob-like protuberances. Sometimes, the
swellings persist for several weeks after the main symptoms have subsided.

How common is the problem?

Virtually every child has one or more attacks of tonsilitis, which is very
contagious. Frequent attacks usually lessen after the age of 7 years as resistance
develops.

What are the risks?

Before the advent of antibiotics, tonsilitis could lead to rheumatic fever or
some form of glomerulonephritis, but such complications are rare today.

What should be done?

Try the self-help measures recommended in the next paragraph. If the child is
clearly uncomfortable, consult your doctor, who will examine the child’s tonsils and
determine and whether the condition is present.

What is the treatment?

Self –help the child should be kept indoors (but not in bed, unless he or she
requests otherwise) in a warm – not overheated- room. Symptoms can usually be
relieved by giving paracetamol and plenty of fluids, which should be sipped regularly. Do
not force the child to eat or drink. If he or she asks for cold desserts to cool the throat,
there is no harm in giving these. Frequent sponging of the face with tepid water may

22
comfort the child. In most cases, children with tonsilitis respond swiftly to these
measures.

Professional helps?
The doctor will probably prescribe an antibiotic drug; ensure your child takes
the full course as instructed. The tonsillitis should clear up in a few days. If attacks of
tonsillitis are so severe and frequent that they affect general health, then surgical
removal of the tonsils may be the only answer. This operation was performed
frequently in the past but most doctors today recommend it only as a last resort. Severe
sore throats with similar symptoms when the tonsils have already been removed can
clearly not be tonsilitis, and are more likely to be pharyngitis.

Vocabulary
1. Guard (agains) : melindungi terhadap, melawan.
Guard : pelindung (mouth guard : pelindung mulut)
You can do nothing once you have stroke. But you can guard yourself against stroke
or prevent recurrence.
2. Birth (n) : kelahiran
DOB : (date of birth) : tanggal kelahiran
Give birth to : melahirkan
Mr. Johnson, your baby weighs three kilos at birth.
3. shrink : mengecil, kempis
Your tumor shrinks to nthe size of pea.
4. track : saluran
………………… + track
urinary track : saluran kencing
digestive track : saluran pencernaan
5. Soreness (n) : rasa nyeri
Sore (adj) : keadaan/mengalami nyeri
Sore + ………………… (part of the body)
I have a sore throat.
Nurse, my feet are still sore after walk.
6. difficulty in……………(adj) : kesulitan
difficulty in speaking : kesulitan bicara
difficulty (in) breathing : susah bernafas
difficulty (n) : kesulitan
Doctor, the patient has difficulty in speaking.
7. Fever (n) : demam
She has high fever.
Feverish (adj) : terasa demam
Nurse, my child feels aching an feverish.
8. Irritate (v) : menyebabkan radang
Irritation (n) : iritasi
………………..+ irritation
irritant : penyebab iritasi
irritable : dapat ter-iritasi
The symptoms indicate that you have irritable colon.
9. vomit (n) : muntahan
vomit (v) : muntah

23
 The sufferer of scarlet fever may vomit.
10. swell (v) : membengkak
swell (n) : pembengkakan
Bacteria can cause your gum to swell.
Swelling (n) : bengkak
Swollen (adj) : bengkak, mis : swollen joints : sendi-sendi yang membengkak
11. persist (v) : berlangsung terus
The cough persist at nights
Persistent (adj) : cenderung berlangsung terus
Doctor, the patient has persistent cough
Persistence (n) : keberlangsungan
12. subside (v) : mereda (bedakan dengan subsidize : memberi
subsidi)
I took an aspirin and the pain gradually subsides.
13. attack : serangan
……………attack.
Heart attack : serangan jantung
This symptoms suggest that your husband has got a heart attack.
14. resistance (n) : daya tahan
resist (v) : menolak
resistant (adj)
The pneumonia that is caused by bacteria resistant to antibiotics is difficult to cure.
15. contagious (adj) : menular
Nurse, this patient suffers from contagious disease. He must be isolated.
Contagion (n) : penularan
Communicable (adj) : dapat menular
16. sip (v) : meneguk
sip (n) : cairan sedikit dalam mulut
If you have passed win, you may have a sip of water.
17. perform (v) : menjalankan tugas, melaksanakan, melakukan.
If your dental decay, the dentist will perform root canal treatment.

Activity 22 - Individually
Translate this into communicative English. Refer your translation to the reading
passage above.
1. Amandel melindungi saluran pernapasan dan saluran system pencernaan.
...........................................................................................................................................
2. Setelah mencapai umur 6 sampai 7 tahun, amandel mengecil tetapi tidak hilang
sama sekali.
...........................................................................................................................................
3. Amandel sangat kecil saat kelahiran. Tetapi kemudian membesar secara
bertahap.
...........................................................................................................................................
4. Infeksi virus pada bagian belakang tenggorokan menyebabkan nyeri.
...........................................................................................................................................
5. Radang amandel mulai dengan sakit tenggorokan dan kesulitan menelan.
...........................................................................................................................................

Activity 23 - Individually

24
Fill in the blanks with the suitable word.

 Sore ● to shrink ● swollen ● to swell ● resists ● persist

● subside ● difficulty ● to perform ● persistent

1. This is a corticosteroid nasal spray. Your nasal polyps are not too large. This may
enough……….them.
2. Do you false teeth fit to you? Or do they make you feel…….
3. Do you still have…………..in moving your foot?
4. A bee stung my child on her lower arm. Now you see, her arm begins…………..
5. Your child has the symptoms of mumps. You can see here some………..glands, in front
of the ear, the salivary glands, the parotid gland under the ear.
6. It’s enough with drug treatment. Your breathlessness should improve, and
swellings………….
7. The doctor gives you symptomatic drugs. If the symptoms…………….consult your
doctor.
8. This……………pain annoys me.
9. Your surgeon will take only 15…………sterilization operation.
10. After the first attack of TB, your body will………..the bacteria by means of natural
defenses.

1.5 Key Points of Nursing Assessment

The vital first phase in nursing process, assessment consists of the patient
history, the physical examination, and laboratory studies. The other nursing process
phases – nursing diagnosis formation, outcome identification, care planning,
implementation, and evaluation – depan on the quality of the assessment data for their
effectiveness.
A properly recorded initial assessment provides:
a way to communicate patient information to other caregivers.
a method of documenting initial baseline data.
a foundation on which to build an effective plan of care.
Your initial patient assessment begins with the collection of data (patient history,
physical examination findings, laboratory data) and ends with a statement of the
patient’s actual or potential problem – the nursing diagnosis.
Building a data base – To limit your data base appropriately, ask yourself these
questions: what data do I want to collect? how should I collect the information? how
should i organize it to make care planning desicions? Your answers will help you to be
selective in collecting meaningful data during patient assessment. The well-defined data
base for a patient may begin with admission signs and symptoms, chief complaint, or
medical diagnosis.
Subjective and objective data – The assessment data you collect and analyze fall
into two important categories, subjective and objective. The patient’s history,
embodying a personal perspective of problems, provides subjective data. It is your most
important assessment data source of patient information, it must be interpreted
carefully. In the physical examination of a patient – involving inspection, palpation,
percussion and auscultation – you collect objective data about patient’s health status or
about the pathologic processes that may be related to his illness or injury. The most

25
objective form of assessment data, laboratory test results provides another source for
interpreting your history and physical examination findings.
You need booth subjective and objective data for comprehensive patient
assessment. They validate each other and together provide more data that either could
provide alone.

D. Closing

Class Activities → SGD, Discover learning, Role play & Presentation.

Students make a summary and perform/role plays to present their papers that have
been made with the topic: Nursing Assessment.
1. Work in Group (5 Groups)
2. Make a paper on the concept that determined according to nursing assessment.
3. Finding material through books and internet with illustration.
4. The group is randomly selected for the presentation.
5. The group delivers to role play.
6. The result of the revised product is collected as portfolio.

The explanation should describe:

Some concepts of nursing assessment are based on appropriate references from up-to-
date books and internet with illustration.

How to work:
Every group makes a paper in 5-8 pages. Computer type: Times New Roman (12) with
1.5 spacing on A4 paper. Provided Power Point for presentation, it can be included for
illustration/case. The paper is collected in the form of files both MS-Word and Power
Point to the lecturer 2 days before performance. The result of the revised products is
collected as portfolio.

26