Course Title : English for the Professional Nurses 1 (EPN 1)

Lecturer : Ollyvia Freeska Dwi Marta, S.Kep., Ns., M.Sc.

UNIT 9 TAKING & RECORDING PATIENT OBSERVATION

1. Patient Assessment
Subjective data : what the patient tells the nurse, it is the patient’s perception. (i.e.
description of pain, perceptions, feelings or experiences).
Objective data : the nurse’s observations that are measurable and verifiable. observations
such as vital signs, odors, redness of a wound, hostile behavior, and laboratory and medical
imaging findings
Correlation of subjective and objective data: e.g. is shortness of breath supported by decreased
breath sounds on auscultation or dullness to percussion?
Subjective Objective
“I feel dizzy” BP 90/60 mmHg, pulse 100
“My bladder never seems empty” Voids 100-150mls/void q 1-2 h.
“I am too fat” 14 yr. old ♀ 150 cm (5’2”) 36 Kg (80 lbs)

1. Inspection
When you are using inspection, you are looking for things you can observe with your eyes, ears
or nose. Examples of things you may inspect are skin color, location of lesions, bruises or rash,
symmetry, size of body parts and abnormal findings, sounds, and odors.
2. Palpation
Involve the use of the sense of touch. Giving gentle pressure or deep pressure using your hand
is the main activity of palpation. Palpation allows you to assess for texture, tenderness,
temperature, moisture, pulsations, masses and internal organs.
3. Percussion
Involve tapping the body with fingertips to evaluate the size, borders and consistency of body
organs and discover fluids in body cavities.
4. Auscultation
Listening to sounds produced by the body
Mention what activity do you for each case listed below
No Activity Technique
Press the distal part of the middle finger of your non-dominant hand firmly on
1
the body part
2 Asking patient to stand up to find whether there is scoliosis or not
3 Testing deep tendon reflexes using hammer
4 Enlargement may indicate a mass
5 Preparing a good lighting, then he observes the body parts
6 Systemic color changes
To know over the aortic, pulmonic, mitral, and tricuspid valves and over Erb’s
7
point
8 Lightly then deeply noting any muscle guarding, rigidity, masses or tenderness
9 Examining patient’s respiratory
10 Looking for the condition of mouth and throat

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Course Title : English for the Professional Nurses 1 (EPN 1)
Lecturer : Ollyvia Freeska Dwi Marta, S.Kep., Ns., M.Sc.

Pressing her middle finger of non-dominant hand firmly against the patients back.
11 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
12 Observing the color of the eye
13 Observing the movement of air through the lungs
14 Checking the tender areas with her hand
15 Pressing abdomen deeply to check the condition of underlying organ

2. What kind of examination technique?

………………………………………………… ………………………………………………….

……………………………………………… …………………………………………………

Language Spot
Will + infinitive for future
➢ we will use will + infinitive to make predictions for the future and to talk about
decisions.
➢ For example: Prediction: You will feel better soon

Decision: I will take your temperature now

3. Complete these sentence by using will and the verbs in the box.
Be clip hurt put take write

1) I _________ my fingers on your wrist.

2) I _________ a second reading.
3) I _________ just _________ this little meter to your finger.
4) ___________ it __________ ?

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Course Title : English for the Professional Nurses 1 (EPN 1)
Lecturer : Ollyvia Freeska Dwi Marta, S.Kep., Ns., M.Sc.

5) No, it __________. It ____________ very quick, I promise.

6) I _______ just _______ this down.
4. Complete what the nurse says to Ana as she takes her blood pressure. Use will and
the correct form of the verbs in the box.
Be eat feel hold put roll see take wrap

I (1) ________ just __________ your sleeve up a little. That’s good. We (2) _____ a
pillow on your lap. Can you (3) ______ your arm out straight for me? You can rest it
on the pillow. I (4) _______ the cuff round your arm. Just relax, that’s right.
You (5) ______ any pain; it (6) ______ just (7) _____ a bit tight around your arm. OK?
That’s 130/85. I (8) ______ just _____ the cuff off now and then you can (9) _____
your breakfast in peace! I will (10) _____ you later.
5. Read the article and decide if sentences are True (T) or False (F)
The Nursing Profession
One hundred and fifty years ago, nurses
were unpaid, untrained, and unpopular, but then
Florence Nightingale made nursing into a profession.
The methods she introduces in the 1850s were
copied all over the world and now nursing is a career
with three or four-year training, qualifications,
grades, unions and pensions.
In Britain, every nurse is on a grade. The
grade depends on experience and skills, and each
grade has different responsibilities and pay. On the
bottom grades are unqualified auxiliary nurses who do the routine work on hospital wards. On the
top grades are nursing officers, who are usually administrators.
Auxiliary nurses are on the bottom grades, but student nurses get the lowest pay.
However, students don’t say at the bottom of the pay scale forever. When they qualify, they start
working on a middle grade. As they get experience, they can get promotion a move up the ranks to
become staff nurse, then sister (charge nurse if a man) and perhaps eventually nursing officer.
Many nurses work shifts, and often they work overtime to earn more money. After basic
training, many nurses choose to do further study and become specialist. Nurses can specialize in
many different fields - there are triage nurses working in casualty, and psychiatric nurses who treat
the mentally ill. There is health’s visitor who visit patients in their own homes, practice nurses
working in GP’s surgeries and midwives who deliver babies.
Many of them say they do not get enough pay and respect for they work they do. They
say that the works is physically mentally hard, that they work long hours and get very tired, but
they also say that there are many great rewards, which have nothing to do with money.

Read the article and decide if sentences are True (T) or False (F)
1. The more responsibility you have, the higher you grade _____
2. Nursing officers are the same as auxiliary nurses ______
3. Student are paid less than auxiliary nurses _____
4. A charge nurse is a man _____
5. There are not many opportunities for British nurses to specialize _____
6. Many nurses say that the job is rewarding, but the pay is low _____

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Course Title : English for the Professional Nurses 1 (EPN 1)
Lecturer : Ollyvia Freeska Dwi Marta, S.Kep., Ns., M.Sc.

6. Patient Record
PATIENT RECORD

Surname : Grady First name : Jim

DOB : 2.3.50 Gender : M
Occupation : Retired
Marital Status : Widowed
Place of birth : Miami
Next of kin : Son
Contact no. : 07765 432178
Smoking intake : n/a
Alcohol intake : 30 units per week
Reason for admission : Snake bite
Medical history : High blood pressure
Allergies : None
GP : Dr. Parkinson, Central Surgery

Find words and abbreviations in the patient record with these meanings.

1. Job occupation
2. Bad reaction, for example to certain medications _______________
3. Family doctor _______________
4. Closest relative _______________
5. The amount of something you eat, drink, etc. regularly _______________
6. Date of birth _______________
7. Male/female _______________
8. Past illnesses and injuries _______________
9. Married/single/divorced/widowed _______________
10. Not applicable (not question for this patient) _______________
11. In each (day, week, etc.) _______________
8. Look at the following examples of written and spoken abbreviations. In pairs,
practice saying the spoken abbreviations.
Written Spoken

T 365 Temp thirty-six five

P 78 Pulse seventy-eight

BP 125/85 BP one twenty-five over eighty-five

RR 18 Resps 18

02 SATS 97% Sats ninety-seven percent

9. Listen to some more patient observation and circle the readings you hear.
1) Her temp’s up today. It’s 362 or 373
2) He has a slow pulse. It’s 46 or 56
3) Her BP’s 95/60 or 95/16

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Course Title : English for the Professional Nurses 1 (EPN 1)
Lecturer : Ollyvia Freeska Dwi Marta, S.Kep., Ns., M.Sc.

4) His temp’s normal, 376 or 367

5) Her resps are slow at 15 or 14 breaths per minute
6) She has a pulse 72 or 62 and a BP of 119/70 or 118/70