Nama : Karina Chania dan Amalia Lenanda

Kelas/Prodi : 2B/D3 Keperawata

NURSING DOCUMENTATION

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

NURSING DOCUMENTATION

I. Patient’s identity
Name : Amalia Lenanda Address : Serang at Kampung Baru

Sex : female
Age : 20 years old Phone number :
Assessment Results
1. Nose No Lumps/bumps
 Nostrils (nares)
 Sinuses No Lesions

Her nose of Symmetrical

No Breathing

No Infection
No Tenderness

Mouth :
 Teeth No Lessions
 Gum
Colour is pink
 Tongue
 Soft palate Moisture -> moist
Symmetrical
In the midline

pharynx :
 Uvula Color is pink
No Lesions
Uvula is Symmetrical
In the midline

Day, Date, Time : Monday, 12 March 2021, at 02:00 pm

Assessor : Nurse Karina Chania