Dien’s

MODULE 3
For Nursing Students

CONSULTATION
OBJECTIVES
1. Students will be able to
conduct a nurse-patient
consultation.
2. Students will be able to make a
brief report about a patient’s
health condition after
consultation.
 VOCABULARY
 Consult (v)  Mengkonsultasikan
 Consultation (n)  Konsultasi
 Interview (n), (v)  Wawancara; Mewawancarai
 Sign (n)  Tanda
 Symptom (n)  Gejala
 Disease / illness (n)  Penyakit
 Conduct (v)  Melakukan
 Prevent (v)  Mencegah
 Promote (v)  Meningkatkan
 Family history (n)  Riwayat keluarga
 Operation/surgery (n)  Operasi
 Physical examination (n)  Pemeriksaan fisik
 Suffer from (v)  Menderita penyakit
 VOCABULAR
 Cough (n)  Batuk Y
 Hiccup  Ingus/hidung berair
 Snore
 Sneeze
 Kepucatan
 Fart  Sakit kepala/pening
 yawn  Pusing
 Runny nose (n)  Sakit mata
 Pallor (n)
 Headache (n)
 Sakit/nyeri punggung
 Dizziness (n)  Narkoba
 Sore eyes (n)  Sakit gigi
 Backache (n)  Peradangan
 (illicit) Drugs (n)
 Toothache (n)
 Demam
 Inflammation (n)  Sakit maag
 Fever (n)  Gatal-gatal
 Gastritis (n)  Flu
 Itchiness (n)
 Influenza / Flu (n)
 Napsu makan
 Appetite (n)  ISPA
 URTI (Upper Respiratory Tract Infection (n)
 Cold  Pilek
 chill
 menggigil
 VOCABULARY
 Kidney stone (n)  Batu ginjal
 Hypertension (n)  Hipertensi
 Prevent (v)  Mencegah
 Cause (n, v)  Penyebab, menyebabkan
 Determine (v)  Menentukan
 Measure (v)  Mengukur
 Prescribe (v)  Meresepkan
 Prescription (n)  Resep (obat)
 Diabetes Mellitus (n)  Diabates Mellitus
 Indigestion (n)  Kesulitan dlm mencerna
 Anxious (adj.)  Gelisah
 Pale (adj.)  Pucat
 Fluttering (adj.)  Berdebar-debar
 Tightness (n)  Sesak napas
 Melena (n)  Feces mengandung darah
 Body reaction (n)  Reaksi tubuh
 STEPS of CONSULTATION
1. Greeting
2. Pt’s personal identity (name, address, age, DOB, POB,
occupation, etc)
3. Patient’s health condition
- What is your complaint?
- How is your condition?
- What makes you come here?
4. Patient’s signs and symptoms of disease
- Do you feel any signs / symptoms of disease?
5. Time length of having the problem
- How long have you got (had) this problem?
6. Time of occurrence
- When does the problem occur?
7. Alleviating and aggravating factors
- Is there any alleviating / aggravating factor?
 PT’s PERSONAL IDENTIFICATION
NAME
 What’s your complete name?
 What’s your first name?
 What’s your middle name?
 What’s your last name (surname)?
ADDRESS
 What’s your address?
 Where do you live?
AGE
 How old are you?
DOB
 When were you born?
POB
 Where were you born?
 HISTORY TAKING:
A GENERAL GUIDE

• History taking is fundamental and essential.

GOALS
• The primary goal:

• to help the doctor in establishing a diagnosis (or

certainly a list of diagnostic possibilities).
• Other goals:

• to develop a relationship the patient

• to highlight important physical signs that need
to be sought on physical examination.
1
 PAST MEDICAL HISTORY
 Past Illness. This part of the history should
include any previous illnesses or operations.
– Tell me about your past illness (disease).
– Tell me about your past operation (surgery)
 Depending on the presenting compliant, who
may what to specifically ask about certain
conditions – for example if a patient presents
with central chest pain – who may want to know
if the patient has a history of angina,
hypertension, diabetes etc.
– Do you have any history of hypertension?
– Did you suffer from diabetes in the past?

2
 DRUG/MEDICATION HISTORY
 Ask the patient if they are taking any prescription
medication (in the form of tablets, injections, inhalers etc).
– Are you taking medicines?
– What kind of medicine you are taking?
 Ask whether the patients are taking
alternative/complementary treatment.
– Are you taking an alternative treatment?
 Ask if the patient has any allergies to medication or other
substances. If they state they have an allergy - ask them to
describe what reaction that occurred.
– Do you have any allergies?
– Describe your body reaction after you have ..…(certain
food)..…
– Tell me about your body reaction after you take …..
(certain medicine)…. 3
 FAMILY HISTORY OF ILLNESS
 Ask about the patient’s family medical history.
This can give you clues to possible conditions
that they may be predisposed to. If the patient
has any conditions in their family (particularly
first degree relatives i.e. children, siblings,
parents) ask about the age of onset or age of
death. Depending on the history you may want
to ask if any specific conditions run in their
family
 If the patient presents with angina type pain:
– Is there any history of heart disease or high
cholesterol in your family?
4
– Marital status
SOCIAL HISTORY
 Are you married/single?
– Children
 Do you have any children?)
– Occupation
 What’s your occupation
– Pets
 Do you have any pets
– Smoking:
 Do you smoke?
 How many cigarettes do you smoke a day?
 How long do you have this bad habit?
– Drinking alcohol?
 Do you drink (alcohol/liquor)?
 How many glasses do you drink alcohol a day?
 How long do you have this bad habit?
– Illicit drugs usage:
 Do you use drugs?
– Problem affecting the lifestyle:
 Does the problem affect your activities?
5
 PREGNANCY
 When did you get your last (menstrual) period? or Tell me
about your LMP?
 Do you have period?
 Is this your first/second pregnancy?
 Is there any problems during pregnancy?
 Do you have any problems during pregnancy?
 What contraceptive device did you use before getting
pregnant?
 Tell me about the contraceptive device you used before
getting pregnant?
 Have you ever had (got) Cesarean Section before?
 When did you examine your pregnancy at the last time?
 Tell me about the history of your previous pregnancies?
 Did you have complications in the last pregnancy?
 Can you feel the baby move?
 How about your sleep and rest?
 Can you sleep well (tight) at night?
 Do you have nausea and vomiting in the
morning (morning sickness)?
 Do you have oedema (swelling)?
 Procedure
 SUMMARY
Now summarize your findings to the
patient.
 This gives the patient an opportunity to
clarify any issues and to confirm that the
history you have taken is correct.
 Now progress on to physical examination.

6
HISTORY TAKING
1. Full name
2. DOB and POB
3. Marital status / civil state
4. Occupation
5. Family and parents
6. Family history of diabetes or hypertension
7. Operation
8. Past health problems
9. Allergy
10. Childhood diseases
11. Heart problem (such as palpitation)
12. Blood pressure
13. Body weight and height
14. Menstrual period
15. Pregnancy
 Useful Expressions
 What is your full name?
 Are you married/single?
 Have you got any children?
 Did you have any problems with your …..?
 Are you allergic to certain medicines or food?
 Have you had all the children diseases?
 Is there any history of …….?
 Is there any family history of …….?
 Have you had any operation?
 Do you suffer from …….?
 What is your appetite like?
 Is there any other problems with your health in
the past?
During The setting:
You and the patient should be comfortably seated at the
consulta same level in a way that allows you to face and observe
tion one another. Make sure the door is closed to ensure
privacy.

Introduction:
Always introduce yourself, ask the patient's identity and
seek their permission to take a history.

Non verbal communication:

Patients expect doctors/nurse to be professional at all
times. Make sure you are neatly dressed and if you are
wearing a white coat make sure it is clean. Be aware of
your posture and gestures throughout the consultation. Try
not to have a table as a barrier between yourself & the
patient. A smile and a handshake can often set a patient at
ease.
During Questioning:
consulta In your questioning make sure you use open
questions e.g. “Tell me about your problems”
tion
Later on in your questioning you may use more
closed questions to obtain a clear and precise
history. Closed questions can clarify what the
patient has said or to obtain pieces of factual
information that the patient did not volunteer.
Give the patient every opportunity to clarify your
questions and try not to use medical terms, e.g.
“Do you have melena?” instead “Have you
noticed any black motions?”
THANKS

for your attention