Nama : Karina Chania dan Amalia Lenanda

Kelas/Prodi : 2B/D3 Keperawatan

TOPIC 6

PATIENT ASSESSMENT (NOSE, SINUSES, MOUTH, AND PHARYNX)

Conversation

Nurse : Good Morning

Patient : Good Morning, nurse

Nurse : How are you?

Patient : I’m good

Nurse : Okay, I’m nurse Karina of Faletehan Serang, I will take care of you today.

Patient : Okay

Nurse : I am here to do an asssessment on your nose, mouth, and throat. Is that okay?

Patient: that’s sounds fine

Nurse : I am going to start with two questions. Any problem with your nose like frequent cold
and sinus infection?

Patient: No

Nurse : Any problem with your teeth or mouth that you’re aware of?

Patient: No

Nurse : So I’m just looking at your nose and I see that your nose is in the midline like it should
be and it’s symmetrical.

Patient: Ok

Nurse : I’m just going to touch your nose, now I’m just palpating for any pain or tenderness
here?

Patient: No

Nurse : I want you to put your finger on one of your sinuses then breathing. Tell me if you feel
any pain with this.

Patient: No
Nurse : Can you show me your teeth?

Patient: (doing the instruction)

Nurse : Can you open your mouth?

Patient: (doing the instruction)

Nurse : So I can see your teeth are wide and they’re in line and I also was looking at the gums
are pink and they’re nice and tight around the teeth, I don’t see any evidence of any
gum disease.

Nurse : Can you open your mouth again?

Patient: (doing the instruction)

Nurse : Could you stick out your tongue a little? All right. And lift your tongue up?

Patient: (doing the instruction)

Nurse : I was looking at is the dorsal surface of the tongue the top of the tongue is rough an
pink and then the ventral surface of the tongue is shiny and you see veins and then the
bottom of the mouth underneath the tongue that’s a place where cancers are likely to
start. So I didn’t it’s all pink and moist, I didn’t see any signs of any lesions in that area.

Patient: Ok

Nurse : And then can you open your mouth again?

Patient: (doing the instruction)

Nurse : I’m looking in the back up at the roof of the mouth there is the soft palate is pink,
uvulas pink in the midline.

Patient: Okay Thank you nurse

Nurse : Your welcome