BAHASA

INGGRIS III
Lectured by:
Mrs. Nita Yuanita, S.Pd., M.Si.
Mrs. Lusiana Lesari, S.S., M.M.

2. PATIENTS
ASSESSMENT
Prodi S1 Keperawatan, Tk. 3/ Sem. VI
STIKes Karsa Husada Garut, Tahun Akademik 2019/ 2020
A nurse can understand the patient’s condition by
doing the first step of the nursing process
i.e. assessment.
Assessment consists of:
1. Assessing Nursing/ Illness History: Patient’s Identity; Chief
Complaint; HPI (History of Present Illness); PNH (Past
Nursing History); Family History.
2. Observation Vital Sign: T-P-R-BP (Temperature-Pulse-
Respiration-Blood Pressure) and General Appearance.
3. PE (Physical Examination through Approach of IPPA
(Inspection; Palpation; Percussion; Auscultation)
4. Result of Diagnostic Test: Blood; Urine; Stool; X-ray;
CTSCAN; etc
During the assessment stage, it is enough for the nurse
just to ask the patient:

“How are you?” or “How do you feel today?”

The answer you get from the patient won’t always the
answer the objective of the assessment stage.

In this stage, the nurse not just listens to the words the
patient uses, but she should observe the reactions and
the body language which may tell you more than words.

So, the nurse should look for SIGN and SYMPTOMS

of pain, discomfort, and illness.
 SIGN

Sign are what the nurse can observe, what a

nurse can see (of feel) for herself.

The nurse can observe: changes in recorded

observation such as blood pressure,
temperature, pulse and respirations.
In the assessment step are also known as
findings.
The nurse can see the SIGN such as:
 A bruise (memar) or bruising that is hematoma or not.
 A rash: an area of red lumps or pimples on the skin, which can
be an erythema or urticarial (allergy rash). Some rashes are
very itchy so the patient wants to scratch it
 Sign of weight loss or weight gain
 Changes in color of the skin as the symptoms of a certain
disease
=> White- pale: anemic- looking (tampak anemia)
=> Blue- color : cyanosis
=> `Yellow color: jaundice (penyakit kuning)
 Inflammation (peradangan): redness
 Swelling of puffiness (pembengkakan, bengkak): i.e. extra fluid
in the tissues under the skin.
 Cuts, wound or lacerations (laserasi): breaks the skin (usually
caused by an accident)
 SYMPTOMS
Symptoms are something that only the
patient feels and knows about and tells
the nurse about it.

Symptoms are known as complaints. In

the assessment steps, symptoms are
considered as a subjective data.
The patient may say (The Symptoms):
 I feel like vomiting; or I feel sick in the stomach; or
I am nauseated (mual)
 I have pain in my chest
 I cannot sleep well; or I suffer from insomnia
 I have diarrhea; or I have frequent bowel actions (sering
BAB)
 I feel dizzy; or I have vertigo; or I feel headache
 I am very thirsty; or I am dehydrated
 I feel numbness (loss of sensation or changed sensation); or
I have tingling (geli)
EXERCISE 1.
Now look at these common complaints! Some are Signs and
some are Symptoms. Make two lists to differentiate “sign
and symptom” based on the list below:
Irregular pulse; dull pain; stomachaches; dizziness; pale;
diarrhea; jaundice; thirst; dyspnea (sulit bernafas);
constipation; headache; cyanosis; anorexia (kurang
nafsu makan); laceration; abrasion (luka lecet); weight
gain; backache; inflammation (peradangan) ; shallow
respiration (shallow: dangkal)
 
SIGNS SYMPTOMS
1. … 1. …
PHYSICAL EXAMINATION SKILLS
Inspection, Palpation, Percussion and Auscultation are
examination techniques that enable the nurse to collect a broad
range of physical data about patients.
 Inspection : The process of observation, a visual
examination of the patient’s body parts to detect normal
characteristic or significant physical signs.
 Palpation : Involves the use of the sense of touch.
Giving gentle pressure or deep pressure using your hand is
the main activity of palpation.
 Percussion : Involves tapping the body with the
fingertips to evaluate the size, borders and consistency of
body organs and discover fluids in the body cavities.
 Auscultation: Listening the sounds produced by the body.
EXERCISE 2.
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 the 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 finger remaining of 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 the air through the lungs
7) Testing deep tendon reflexes using hammer
8) Checking the tender area with her hand
9) Pressing abdomen deeply to check the condition of underlying organ
10) Preparing a good lighting, then he observe the body part.
EXERCISE 3.
What kind of examination techniques shows in each picture?
EXERCISE 4.

Mention any other kind of physical assessment to

the patient & what examination skills used on
the assessment techniques!
 END SECTION
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THANK
YOU