Nursing Assessment: A. Learning Outcome and Indicators [PDF]

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Chapter 1 NURSING ASSESSMENT A. Learning Outcome and Indicators After teaching learning process in this chapter, the students are able to understand nursing assessment with the following indicators: Understanding vocabulary and useful expression related to nursing assessment. Asking personal data through interview. Getting subjective data through interview. Getting objective data and physical examination. Analyzing data. B. Language Competency Language function : Collecting subjective and objective data. Language focus : Expression asking subjective and objective data. Grammar focus : Question words, adjectives and adverbs. Related Nursing : Communication techniques on nursing Skill assessment. C. Materials 1.1 Getting Personal Data Reading



Source: writer’s doc. A nurse gets personal data when the nurse meets a patient for the first time. This data should include the patient’s full name, address and telephone number, date of birth, age, marital status and religion. A contact number of someone who can be called in an emergency should be included and this may be a next of kin or, if they live some distance away, it may be a partner or spouse. It is usual to find out who could be contacted at night, especially if the partner or spouse is elderly and infirm. Patients may be concerned about the implications of having to call someone in an emergency, and so it is wise to explain that it is usual practice to ensure all contact details are current and an emergency number is very rarely needed.



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Enquiring as to whether the patient practices his religion provides an opportunity for him to express whether he will want to follow particular religion, such as attending a service or saying prayers at particular times. There may be particular cultural practices that he would wish to fo llow during illness, and facilities should be made available for him to do so where possible. Further information about cultural awareness can be followed up in the recommended further. Activity 1- Individually Read these patient’s data and answer the questions. Title : Mr. First Name : Heru Surname : Mahardika Sex : Male Material Status : Married Religion : Christian DOB (Date of Birth) : 12.09.1982 Occupation : Construction Worker Address : Dhoho Street No.100 Telephone : (mobile) 081330726623 E-mail : [email protected] General Physician (GP) : dr. Fathony Next of Kin : Anasthasia Mahardika Relation to Patient : Wife Smoking Intake : 1 pack a day Allergies : Seafood Reason for admission : 7 times passing stool, diarrhea 1. 2. 3. 4. 5. 6.



Is the patient a man or a woman? A man When is the patient’s birthday? 12.09.1982 What is the patient’s job? Construction Worker Is the patient married? Yes Who is the patient’s family doctor? No Who is Anasthasia Mahardika? Next of Kin patient



Find the words in the admission form with these meanings. 1. family name 2. job 3. Mr / Mrs / Ms 4. family doctor 5. the name the patient wants the medical staff to use 6. closest relative 7. country where patient was born 8. male or female 9. married / single / divorced / widowed 10. why the patient is visiting hospital 11. date of birth 12. the amount of something you drink / eat, etc. regularly 13. a bad reaction to, for example, food or medicine 2



Listening - Speaking The following conversation, a nurse is going to check personal data. Nurse : I’d like to check your personal data, if that’s OK. Patient : Of course. Nurse : Can you give me your full name, please? Patient : Maria Fecylia. Nurse : Can you spell your last name, please? Patient : F-E-C-Y-L-I-A, Fecylia Nurse : And what would you like us to call you? Patient : Maria is fine Nurse : Where are you from? Patient : I’m originally from Surabaya, but I came here for my studies, got married and now we’re looking forward to our first child. I’ve been here for ten years already. Nurse : That’s lovely. And what is your date of birth Mrs. Maria? Patient : The 20th of the first, 81. Nurse : Is that the 20th of January 1981? Patient : That’s right. Nurse : And what is your job? Patient : Marketing manager for Mayapada. Nurse : Marketing manager of bank. OK. Now, I also need to ask, what’s your marital status and who is your next of kin, to contact in an emergency? Patient : I’m married and my husband, Daniel, is my next of kin. His mobile number is 081779 706 7517. Nurse : Thank you. Do you have any allergies? Patient : No. Nurse : Thank you for your information. Patient : You are welcome. Activity 2 - Individually Complete the nurse’s questions. 1 Can you give me your full name please? 2 Can you ….. that, please ? 3 What would you like us to call you? 4 What is your date of birth Mrs. Maria ? 5 What is your job ? 6 Do you have any allergies? Grammar Focus What, Where and Who - questions We can use questions with what, where and who to ask for patient information. The use what is when we want to What is the telephone number know about something. of your GP? The use where is to ask about places. Where does she live? The use who is to ask about a person Who is your GP? or people. Activity 3 - Work in Pairs. 3



Complete these questions with what, where or who. Then practice asking and answering the questions. 1. ’s your surname/first name/full name? 2. do you live? 3. ’s your address/email address/mobile phone number? 4. ’s your date of birth? 5. ’s your GP? 6. ’s your next of kin? 7. ’s his/her relationship to you? Useful Expressions Collecting Personal Data Explaining what you are going to do immediately.     



It is time for me to... I just want to... I would like to... I am going to... I need to...



interview you assess your personal data assess your health condition



2. Questions to collect personal data element. There are some personal data elements: Name:



Ages: Address: Phone:



Ethnic Origin: Marital Status: Health Insurance: Occupation & Title:



Next of Kin: Reason for Contact:



What is your name? What is your complete name? What is your surname? How old are You? What is your address? Where do you live? Your phone number please? What is your phone number? Do you have a Mobile Phone number? What is your ethnic origin? Are you married? Do you have any health insurance? What is your occupation? Do you have any academic title What is your title? What do you do? Who is your next of kin? What brings you in this hospital? Who sends you to this hospital? What makes you come to this hospital?



Activity 4 - Work in Pairs. Interview your partner with the questions listed above. Name : What is your name? siska What is your complete name? Irena siska manalu 4



What is your surname? Siska Ages Address



: How old are You? 21 years : What is your address? Sp 2 maboh permai kab.sekadau Where do you live? Kalimantan barat



Phone



: Your phone number please? 08354373628 What is your phone number?89237483 Do you have a Mobile Phone number? Yes



Ethnic Origin



is your ethnic : What Pontianak,Kalimantan Barat



Marital Status



: Are you married? single



Health Insurance Occupation & Title



: Do you have any health insurance? Yes : What is your occupation? College student Do you have any academic title What is your title? What do you do?-



Next of Kin



: Who is your next of kin? Bona gogo



Reason for Contact



: What brings you in this hospital? I’m sick Who sends you to this hospital? Big family What makes you come to this hospital? I’m sick



origin?



Activity 5 - Work in Pairs. Take turns playing the role of a patient and of the nurse who admits the patient to hospital. Invent an identity for your patient, including the details below. Copy a blank patient admission form like the one. Interview your patient and complete the details in the form. Full Name Address Family Next of Kin Date and Place of Birth Occupation Marital Status Smoking Intake Allergies Reason for Admission



1.2 Getting Subjective Data Reading Learn the acronym for collecting subjective data. 5



ACRONYM 1. P – provocative or palliative



EXPRESSIONS What helps or worsens the symptoms? Do certain situations such as stress or particular physical positions make a difference? What your symptom that really burden you? What your problem?



2. Q – quality 3. or quantity



What does the symptom look, feel or sound like? Is he experiencing it during the interview? How does it affect his normal activities? What is it like? Is it sharp? Dull, stabbing, aching? Do you feel…….?



4. R – region 5. or radiation



Where in the body does the symptom occur? Is anywhere else affected by it? Where do you feel it? Does it move around? Show me where.



S – severity



How severe is this symptom on a range of 1 to 10 (10 being most severe)? Is it getting better, worse or staying the same? On a scale of 0 to 10, with ten the worst, how would you rate what you feel right now? What is the worst has been? Does this problem burden your usual activities? In what ways?



T – timing



When did it begin? Did it start gradually or suddenly? How frequently does it happen? How long does it last? When did you first notice it? How long does it last? How often does it happen?



Additional information SETTING Does it occur in a particular place or under certain circumstances? AGGRAVATING FACTOR OR ALLEVIATING FACTORS



What makes it better? What makes it worse? When does it change? Have you noticed other changes associated with this?



Activity 6 - Work in Pairs:



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Learn and understand the way to collect chief complains. Interview your partner and make description of chief complains based on your partner’s symp toms.                      



Would you show me the location of your pain? Yes Can you point at the location of your pain? Knees down my feet Show me where the location of your pain is! Knee leg Where is the pain? knee Is it (your pain) in your leg (part of the body) Yes Do you feel pain in your ankle (part of the body) No Would you say that was moderate or severe? moderate Does the pain move at all? No How long did the pain last this time? Only a while Can you tell me how it started? When a walk How often do you have these pains? Just once in a while What seems to make the pain better? No Is there anything that makes it worse? walk How do you feel about your condition? apprehensive Can you describe your symptoms to me? yes What happens when you get pain? Just stay quiet When did you start feeling ill? 3 days ago Does it hurt when I press your abdomen just here? No How bad is the pain? Prickling a needle Tell me, what were you doing when the symptom appeared? Be quiet Were you taking your medication? No Etc.



Vocabulary Dull Stabbing Sharp Aching aggravating factors alleviating factors Pale Painful Sallow Suffocate dream day Rigid Moan Bouncy Contempt Bruise Tender Tense afraid of



: rasa tidak terlalu sakit, berlangsung terusmenerus. : sakit yang berdenyut, seperti pukulan : rasa sakit yang menusuk-nusuk : rasa sakit yang berlangsung terus-menerus : faktor-faktor yang memberatkan (penyakit) : faktor-faktor yang meringankan (penyakit) : Pucat : Tegang : muka yang pucat kekuning-kuningan : napas sesak seperti tercekik (suffocating) : Melamun : Kaku : mengerang, merintih : Bersemangat : rasa jijik : Memar : Perih : Tegang : ketakutan/takut 7



Papery Confuse Tired Gasp Groan Sigh Stiff Swallow Yellowish



: : : : : : : : :



kelihatan tipis dan kering Membingungkan Lelah terengah-engah terutama karena kesakitan mengerang, merintih Mendesah Kaku Bengkak kekuning-kuningan



Grammar Focus Adjectives and Adverbs Sometimes in the written expression, adjectives are incorrectly used in place of adverbs, or adverbs are incorrectly used in place of adjectives. Adjectives and adverbs have very different uses in sentences. Adjectives have only one job, they describe nouns or pronouns. Examples: It is delicious meal (adj.) (noun) It is delicious (pron.) (adj.) In the first example, the adjective delicious describes the noun meal. In the second example, the adjective delicious describes the pronouns it. Adverbs have three different uses. They can describe verbs, adjectives, or other adverbs. Examples: He writes letters quickly (verb) (adv.) It is quickly written letter (adv.) (adj.) (noun) It is extremely quickly written letter (adv.) (adv.) (adj.) (noun) In the first example, the adverb quickly describes the verb writes. In the second example, the verb adverb quickly describes the adjective written (which describe the noun letter). In the third example, the adverb extremely describes the adverb quickly, which describes the adjective written (which describes the noun letter). The following are examples of incorrect sentences as they might appear. They were seated at a largely table (adv.) (noun) The child talked soft to her mother (verb) (adj.) We read an extreme long story (adj.) (adj.) She speaks unbelievable quickly (adj.) (adv.) In the first example, the adverb largely is incorrect because the adjective large is needed to describe the noun table. In the second example, the adjective soft is incorrect 8



because the adverb softly is needed to describe the verb talked. In the third example, the adjective extreme is incorrect because the adverb extremely is needed to describe the adjective long. In the last example, the adjective unbelievable is incorrect because the adverb unbelievably is needed to describe the adverb quickly. The following chart outlines the important information that you should remember about the use of adjectives and adverb. The use of adjective and adveb Adjectives Adjective is to describe nouns or pronouns Adverb Adverb is to describe verbs, adjectives, or other adverb Activity 7 - Individually Each of following sentences has at least one adjective or adverb. Circle the adjective and adverb, and label them. Draw arrows to the words they describe. Then, indicate if the sentences are correct (C) or incorrect (I). 1. Her hair was an unusually color of red. 2. The weather is really comfortable. 3. The nurse injected intravenous carefully. 4. We attended a poor planned conference. 5. He talked slowly and carefully. 6. The blood samples were automatically examined in laboratory 7. The composition was careful prepared. 8. She had an incredible story about her long trip 9. He sent me a quickly written note. 10. The cat meowed sad. 11. The children are hungry and tired. 12. The lecturer spoke extremely loud. Activity 8 - Individually Translate these into communicative English. 1. Maaf pak, sepertinya perut anda sakit. Sorry sir, it looks like your stomach hurts 2. Maaf pak, kelihatanya bapak mengalami gangguan pada dada bapak. Sorry sir, it looks like you have trouble with your chest 3. Sepertinya bapak merasa tidak nyaman ketika berjalan. It seems you feel uncome 4. Anda seperti kelelahan You are like exhausted 5. Jari tangan anda kelihatan bengkak. Your fingers look swollen. 6. Sepertinya anda takut dengan tindakan medis ini. It seems you are afraid of this medical action



.



Activity 9 - Individually Arrange these jumbled words into a sentence about patient’s complains. 1. look – scars – reddish – your 9



look reddish scars cell 2. seem – respiration – to have – you – with – problem – your. Seem you have to problem with your respiration 3. your – look – uncomfortable – turning – head – when – you. You uncomfortable when look your turning 4. skin – dry – your – looks. your looks skin dry 5. seem – with – uncomfortable – you – sling – that. seem you uncommfortable with that sling Activity 10 - Work in Pairs Instructions: 1 Observe your partner’s physical performance. 2 Focused your observation on health condition. 3 Share your observation to your partner. 4 Reserve the role. 5 Write your observation result. 6 Tell your result to your partner.



1.3 Patient’s Observation Reading



Source: Writer’s doc. Assessment of a patient’s vital signs includes observations of temperature, pulse, blood pressure, respiratory rate and oxygen saturation, blood glucose levels and level of consciousness. These observations provide an efficient and accurate method of monitoring a patient’s condition. They also enable evaluation of response to treatment and early detection of problems. Observations give vital information about a patient’s condition Before observations are taken, the patient should be made comfortable and be encouraged to relax. If the patient has taken even mild exercise he should be allowed to rest for a few minutes. To get an accurate assessment of a patient’s condition, pain should be relieved and every effort made to reduce anxiety as these factors may influence the vital signs. Body temperature, posture and certain drugs will also alter a patient’s observations. Learn the dialogue below. Mention 5 important things as observations. Nurse : Your skin looks reddish. Patient : It started yesterday after swimming in the beach; I didn’t apply any 10



Nurse Patient Nurse Patient



: : : :



lotion over my skin. My skin is very sensitive to sunshine. Would you tell me how you feel now? Yes, I feel hot and tender around my arm and my back. You seem to have sunburn. Let’s consult your doctor. Thank you.



Useful Expression It is important to help the patient to express the health problems. Below are techniques on helping patient identify and express feeling. uncomfortable You look… tense Your (part of the body) looks… stiff You seem ... happy sad, etc. Your ... looks ... skin sallow eyes reddish nail, etc yellowish, etc. You seem uncomfortable when… walking moving your hand/leg changing yours clothes, etc. You look uncomfortable with your... leg/position/stomach/chest/etc. You seem you have + (a problem with + a part of the body) (a health problem : such as a stomachache, chest pain, etc.) Would you show me the location of your pain? Can you point at me the location of your pain? Show me where the location of your pain is? Where is the pain? Is it (your pain) in your leg ( part of body) Do you feel pain in your ankle (part of body) Activity 11 – Work in Pair Translate these into communicative English. 1. Apakah anda pernah memperhatikan ada perubahan lain sehubungan dengan rasa sakit ini? Have you noticed any other changes associated whit this pain ? 2. Apa yang bisa mengurangi rasa sakit itu? What can reduce the pain? 3. Kapan rasa sakit itu berubah? When did the pain change? 4. Apakah rasa sakit itu terjadi di tempat tertentu atau dalam kondisi tertentu? Does the pain occur in a certain place or under certain conditions? 5. Berapa lama rasa sakit itu berlangsung? How long did the paint last For each number, arrange these jumbled words into a sentence about patient’s complaints. 1. ( vomiting – have – I – been ) 11



I have vomiting been 2. (short – lost – have – a lot of – I – weight – in – time ) i have short lost a lot of weight time 3. ( 3 days – more – pain – my – than – persists ) my pain more persists than 3 day 4. (pain – the – mainly – back – lower – in – is – part – the – my – of ) My pain is mainly in the part of my lover back 5. (pain – the – back – legs – shoots – the – my – down – of ) My Pain Of the back shoots the legs Reading Measles Sandra is five years old. Her GP phones the hospital to prepare for an admission and her parents accompany her in an ambulance. Her parent should bring her to hospital immediately. Sandra has been weepy for the past two days and sometimes crying inconsolably. Nothing has been making her comfortable to stop her from crying. She has been running a temperature of around 39.5 degree Celcius. She has a nasty-looking rash on her nose and throat and has difficulty breathing and sometimes has a dry cough. She has been developing those symptoms for two days. Her parents report no diarrhea though she vomited once an hour before seeing the doctor. A diagnosis is required and in the meantime the doctor recommends that she should be given as much fluid as possible to drink in order to avoid dehydration as a result of her fever (though no drinks containing caffeine). Also that she should be dressed lightly, with light bedclothes and she should be given a lukewarm sponge bath. On the day she is in hospital, her parents found that she has been developing tiny white spots, like grains of salt, appear inside the mouth. Her parents report this to the nurses in charge. The nurse, then, tells the pediatrician. On the fourth and fifth days, her temperature rises again and the characteristic measles skin rash appears. The doctor diagnoses that she has been suffering from measles. She has been complaining of headaches for the time she is in hospital. The doctor tells her parent that this is a contagious disease. But most children who contract measles, the disease disappears within 10 days and the only after-effect is lifelong immunity to another attack. Learn the case above and answer based on the following instructions: 1. Tell the result of anamneses and observation. 2. Add your assessment based other sources or references. 3. Determine nursing diagnosis based on the text. 4. Write and share your work to your partner. 5. Reserve the role. 6. Tell your result to your partners in group and in front of class. Useful expression Asking Health Problem 1. Nurse’s questions to check the patient’s complaint/condition: What’s your problem? How is your feeling today? What makes you call me? What’s your chief complaint? 12



What’s troubling you? What’s wrong with you? What’s the matter with you? What seems to be bothering you? Doctor: what are the symptoms? What is she/he complaint about? 2. Patient’s expressions about symptoms and physical problems: - I have (a part of the body + ache) a toothache a stomachache a backache a headache - I have ( a sore + parts of the body) a sore throat a sore arm a sore knee a sore foot - I have/get + kinds of physical problems the measles a bloody vomit and stool a bowel movement the flu a cold a bad cough - I feel + kinds of physical problems dizzy cold and clammy sick unwell fever - I experience + kinds of symptoms and physical problem lassitude difficulty in breathing low back pain cold and clammy - I suffer from + kinds of certain illness cancer constipation - I sprained my (possessive) + joints/bones problems. ankle hurt broke leg collarbone arm - I cut + my (possessive) + parts of the body (head, leg, hand, etc) - She has + V3 ……. - I have been …… - She/he has been + V(ing) ….. Vocabulary measles GP weepy mucus run a temperature lukewarm dehydration spot grain of salt nasty-looking break



: : : : : : : : : : :



campak General Practitioner/dokter umum/keluarga merengek lender kenaikan suhu hangat kuku kekurangan cairan bercak butiran garam nampak parah patah 13



bother



: mengganggu



bowel movement waterworks constipation lassitude in bad shape not in any shape clammy dribble waterworks



: : : : : : : :



buang air besar buang air kecil sembelit lemas/lesu kondisi tidak sehat tidak cukup sehat basah buang air kecil tidak lancar



Class Activity 12 (Group or Pair – Orally) 1) Have you ever been sick? 2) Mention what you complaint based on your sickness? 3) What do you call kind of your complaints? Class Activity 13 (Group or Pair – Orally) 1) Make a conversation between a nurse and a patient. 2) Case is based on your sickness. 3) Conversation : Nurse : “ Good morning, how are you today ?” Patient “ I alredy feel good Nurse” Nurse : “ Alright, according ro thr doctror’s advise today you may gp home” Patient : “ What should I do before going home?” Nurse :” First yu have to finish the administrasion First, can you oerder your family to take care of it” Patient : “ Alright Nurse” Nurse : “ So before you go home, there are a few thing I have to explain, first you have to take the medicine according to the prescption given by the doctor, secondly, you have to comply whit the schecdule for a health check in the Outpatient Installation, the third you have to apply a diet low- ceab and lowsugar diets that have been taught, do you understand?” Patient: “ Why should I go on a low-carb and low-sugardiet?” Nurse : “ studies prove that diabetics on a low-crab and Low-carbohydrate diet have lower blood sugar levels compred to diabetics who eat as usual.in addition ,a low –carbohdyrate diet also helps diabetics to lose weight.Do you understand?” Patient:”I understand Nurse” Nurse:”Alright,after your family finishes administration we will give you medicine that you can use at home,you can go home “ Patient:”Thank you Nurse” Nurse:”You’re welcome ,stay healthy” 1.4 Physical Examination Skills



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Inspection, palpation, percussion and auscultation are examination techniques that enable the nurse to collect a broad range of physical data about patients. (l) Inspection: the process of observation, a visual examination of the patient's body parts to detect normal characteristic or significant physical signs. (2) Palpation: involves the use of the sense of touch. Giving gentle pressure or deep pressure using your hand is the main activity of palpation. (3) Percussion: involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and discover fluids in body cavities, and (4) Auscultation: listening to sounds produced by the body.



Patient’s physical examination: Head, Face and Neck Vocabulary toupee/wig : hairpiece : clench : frown



:



puff



:



shrug



:



cartilage



:



anterior posterior lateral node sternum tenderness



: : : : : :



rambut palsu rambut palsu untuk memperpanjang rambut pegangan, genggaman, cengkeraman, kepalan, mengepalkan kerut (dahi), mengerutkan dahi, memberengut, to f. on tidak setuju/menyukai tiupan (of air, wind), isapan, embusan (of smoke), gumpal, mengepul (of smoke), terengah – engah angkatan (bahu), mengangkat (bahu). to s. off menganggap enteng, tidak mcnghiraukun tulang rawan/muda cricoid (also cricoid cartilage): bagian dari "larynx" yang berhentuk cincin bagian depan bagian belakang bagian samping benjolan tulang dada rasa sakit, perih



Useful Expression Study and practice these useful expressions: Question to ask: Do you have any cold recently? Do you have any infection recently? Did you have any thyroid problem? Did you have neck pain? Did you note any enlargement on the parts of your head? Explaining what you are going to do immediately • Now I am going to .... • It's time for me to .... • Now I want to .... Pres your + (parts of the body) gently Examine your + (parts of the body) gently - Artery - Cheeks - Neck Instructions: • Would you? 15



• Now I want you to?  Remove you wig  Put off your hairpieces/ toupees  Clench your teeth  Rise your eyebrows  Please close your eyes tightly  frown your forehead  smile  show your teeth  puff out cheeks (menggelembungkan pipi)  shrug your shoulder (mengangkat bahu)  flex your neck with chin toward (your chest / ceiling)  bend your neck, with ear toward shoulder  take a sip of water from this glass Activity 14 - Work in Pairs 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 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 fingers remaining off 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 air through the lungs. 7. Testing deep tendon reflexes using hammer. 8. Checking the tender areas with her hand. 9. Pressing abdomen deeply to check the condition of underlying organ. 10. Preparing a good lighting, then he observes the body parts. Activity 15 - Individually Write a sentence using the words given. 1. (want – puff – cheeks – you ) 2. (clench – fist) 3. (you – tenderness – feel) 4. (sip – water – spoon ) 5. (have-a node-neck) Activity 16 - Work in Pairs  Make a short conversation explaining the procedure as shown in useful expression.  Make a complete conversation on the acts of assessing head, face and neck.  Use the expressions above. Activity 17 - Work in Pairs Making Nursing Documentation  Study the nursing documentation below.  Assess your partner’s condition. 16



  



Use a complete communication. Write the report and use your own sentences. Reverse your roles.



Nursing Documentation: A sample of head and neck assessment Example: expected hair distribution, soft and curly in appearance. Scalp clean. Rounded skull with no masses or tenderness. Symmetrical face. Trachea midline. No lymphadenopathy. Thyroid palpable with no masses or enlargement. Carotid arteries plus two bilaterally. No venous distention. Patient’s Physical Examination: Eyes and Ears Vocabulary diplopia : blur : discharge : spotters : floater : acuity : bridge :



bayangan dobel kabur kotoran (berupa cairan / kental) titik - titik dalam penglihatan mata titik - titik halus yang bergerak dalam penglihatan ketajaman (penglihatan) pikiran atau pendengaran anatomy. berhuhungan dengan bagian yang keras hidung



Useful Expression Eye Assessment Study and practice these useful expressions. Questions to ask: Have you ever had eye disease? Have you ever had eye trauma? Have you ever had eye itching? Have you ever had eye discharge? Do you use glasses? Do you use contact lens? Other questions: Do you have diabetes? Do you take any medication recently, for instance antibiotics or large dosage of aspirin? Instructions Just, follow my instructions Please .... Now, I want you to .... Study and Practice these useful expressions. Explaining what you are going to do immediately. It is time for me to examine your eyes I just want to... (one of the expressions) I would like to... (one of the expressions) I am going to... (one of the expressions) I need to... (one of the expressions) Read this newspaper while wearing glasses. Read this letter (written on the snellen eye chart) 17



Can you see the print clearly? Mention what letter it is? Visual fields: Sit in front of me Look at my eye Close one eye with your palm hand. Look at movement of my finger/this object, State when you first notice it. Extra ocular movement test: Look straight toward me Keep your head motionless/keep your head steady Follow movement of my finger with your eyes, keep your head still. Accommodation test Just stay here, look at the wall in this distance. (I want to move my finger toward your nose) look at my finger. (I want to move my finger toward your nasal bridge) look at my finger. External eye assessment (I need to check your lid position) Now close both eyes. (I want to move my finger toward your nasal bridge) look at my finger. External eye assessment (I need to check your lid position) Now close both eyes. (I need to check upper eye lid) Now, raise your eyebrows. (I need to press here gently) (I need to check your cornea) Now, Look up (I'm going to shine your eye with this light). Ear assessment Useful Expression Study and practice these useful expressions. Questions to ask Have you ever had ear disease? Have you ever had ear itching? Have you ever had ear discharge? Ringing of the ears (tinnitus) Do you use hearing aids? What do you say when you are going to insert the tip of an otoscope into the ear canal? Study and practice these useful expressions. Explaining what you are going to do immediately. I just want to ... check your ears I would like to... I am going to ... I need to... Now, let me ... Instructions. Just, follow my instructions Please, .... 18



Now, I want you to + (The expression below) Would you .... Hearing Acuity Test Put off your hearing aids. Close your eyes. (Now I want to whisper "nine four") repeat what I mentioned. If you suspect a loss of hearing, perform a tuning fork test Webber's test, (Now I put this in the middle of your forehead) Can you listen the sound equally in both ears? Do you listen the sound better in one ear? Rinne test (listening to the length of the vibration of the tuning fork), Listen to this...Tell me when sound is no longer heard. Activity 18 - Work in Pairs Make a short conversation explaining the procedure as shown in useful expression.  Make a complete conversation on the acts of assessing head, face and neck.  Use the expressions above. Activity 19 - Work in Pairs Making Nursing Documentation  Study the nursing documentation below  Assess your partner’s condition.  Use a complete communication.  Write the report and use your own sentences.  Reverse your roles. Nursing Documentation Ear condition Example: Whisper test response positive bilaterally. Voice perceived from 15 feet. Pinna is smooth with no tenderness over mastoid. Ear canals clear with no drainage. Tympanic membranes pearl gray, intact; light reflexes present in both ears. No bulging noted. Patient’s Physical Examination: Nose, Sinuses, Mouth and Pharynx Nose, Sinuses, Mouth and Pharynx Assessment The condition of the oral cavity can reveal significant information about a patient's health, such as state of hydration, nutritional status, hygiene practices and specific pathological conditions. The procedure is to be done thoroughly so as not to miss a lesion or local area of inflammation under or around the tongue and along the mucosal surface. Useful Expression Questions to ask: Do you snore at night? Do you smoke? Do you use any nasal sprays or drops? Do you drink alcohol? Do you use dentures? Do you feel any pain when you brush your teeth? 19



Do you feel any tenderness? Do you brush your teeth everyday (how many times a day?) Do you have difficulty breathing through the nose? Do you have nasal discharge? Do you have any problem with your appetite recently? Do you have any problem with your dentures? Have you experienced any injury to your nose or mouth? Have you ever had bleeding from your nose? Explaining what you are going to do immediately It is time for me to examine your nose / mouth I just want to press you on this sport (frontal sinus) I would like to close one of your nostrils I am going to ... I need to... Instructions Will you open your mouth? Would you tip your head back slightly say "ah" Please, breathe with your other nostril. I will press the other one do the same with the opposite part. Now, I want you to... Vocabulary extremities



epistaxis nares uvula mucous pharynx bilateral buccal denture



: (n) [pl.] (formal) tangan dan kaki example: cold extremities and hot head are the first signs of the fever : (n) (medicine) mimisan (keluar darah dari hidung) : (sing. naris) anatomy. lubang hidung : (n) (plural uvulae (anatomy): kh. anak lidah / tekak : (adj) mukosa ks. membrane selaput lender : (n) pharynges, tekak, hulu kerongkongan : (adj) dua belah pihak, timbal balik : (adj) (ks. berhuhungan dengan pipi dan mulut) : (n) gigi palsu



Useful Expression Assessment Study and practice these useful expressions. Question to ask: Do you…………….? Snore at night Smoke Use any nasal sprays or drops Drink alcohol Use dentures Feel any pain when you brush your teeth Feel any tenderness? Brush your teeth everyday (How mwny times a day?) Questions to ask: 20



Do you have……………..? Difficulty breathing through yhe nose Nasal discharge Any problem with your appetite recently Any problem with your dentures Have you…………………? Experienced any injury to your nose or mouth Ever had bleeding from your nose Implementation Steps Study and practice these useful expressions Explaining what you are going to do immediately. It is time for me to……….. I just want to……………… I would like to…………………. I am going to…………………… I need to………………………… Examine your nose / mouth Press you on this spot. (frontal sinus) Close one of your nostrils. Instructions Will you……………? Would you………….? Please,……………….. Now, I want you to………… Open your mouth Tip your head back slightly. Say “ah”. Breathe with your other nostril. I will press the other one. Do the same with the opposite part. Activity 20 - Work in Pairs Giving instruction.  Practice the instructions below.  Listen to teacher’s instruction, act out them.  Then, practice these in pairs.  Open your mouth, please.  Tip your head back slightly. I need to check your nostrils.  Say ”ah”  Now I want to press one of your nostrils. Breathe with the nostril, while I press the other one. Activity 21 - Work in Pairs Making nursing documentation.  Study the nursing documentation below.  Assess your partner’s condition.  Use a complete communication.  Write the report and use your own sentences.  Reverse your role.



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Nursing Documentation A sample of nose, sinuses, mouth and pharynx Assessment Report Example: Nose - Nares patent bilaterally. No tenderness over sinuses, no drainage. Buccal mucosa, gums and pharynx pink and smooth with no inflammation or lesions. Uvula in midline and rises on phonation. Teeth in adequate repair, no mouth and pharynx extractions. Reading Tonsilitis and Pharyngitis in Children The two tonsils at the back of the throat are part of the ring of limph glands that guard the entrance to the respiratory and digestive system. Very small at birth, they enlarge gradually, reaching maximum size at age 6 or 7 years. Thereafter, they shrink but do not disappear, as adenoids do. The tonsils are relatively large at early school age, when the respiratory tract begins to be attacked by a variety of new microbes; the tonsils are thought to act to keep the microbes away from the lower respiratory tract. Both tonsilitis and pharyngitis are bacterial or viral infections of the back of the throat that cause soreness, and they are often associated particularly in children. Sore throat may also be part of a more generalized respiratory infection, such as influenza. What are the symptoms? Tonsilitis starts suddenly with sore throat and difficulty in swallowing; within a few hours, the child becomes feverish and may seem quite ill. The painful irritation in the throat makes some children vomit or cough. In a very few cases, the child has a febrile convulsion (see convulsions in children). Young children often complain of stomach pain. Glands on either side of the neck and in the angle the jaw may swell and become tender. They can be felt as small, knob-like protuberances. Sometimes, the swellings persist for several weeks after the main symptoms have subsided. How common is the problem? Virtually every child has one or more attacks of tonsilitis, which is very contagious. Frequent attacks usually lessen after the age of 7 years as resistance develops. What are the risks? Before the advent of antibiotics, tonsilitis could lead to rheumatic fever or some form of glomerulonephritis, but such complications are rare today. What should be done? Try the self-help measures recommended in the next paragraph. If the child is clearly uncomfortable, consult your doctor, who will examine the child’s tonsils and determine and whether the condition is present. What is the treatment? Self –help the child should be kept indoors (but not in bed, unless he or she requests otherwise) in a warm – not overheated- room. Symptoms can usually be relieved by giving paracetamol and plenty of fluids, which should be sipped regularly. Do not force the child to eat or drink. If he or she asks for cold desserts to cool the throat, there is no harm in giving these. Frequent sponging of the face with tepid water may 22



comfort the child. In most cases, children with tonsilitis respond swiftly to these measures. Professional helps? The doctor will probably prescribe an antibiotic drug; ensure your child takes the full course as instructed. The tonsillitis should clear up in a few days. If attacks of tonsillitis are so severe and frequent that they affect general health, then surgical removal of the tonsils may be the only answer. This operation was performed frequently in the past but most doctors today recommend it only as a last resort. Severe sore throats with similar symptoms when the tonsils have already been removed can clearly not be tonsilitis, and are more likely to be pharyngitis. Vocabulary 1. Guard (agains) : melindungi terhadap, melawan. Guard : pelindung (mouth guard : pelindung mulut) You can do nothing once you have stroke. But you can guard yourself against stroke or prevent recurrence. 2. Birth (n) : kelahiran DOB : (date of birth) : tanggal kelahiran Give birth to : melahirkan Mr. Johnson, your baby weighs three kilos at birth. 3. shrink : mengecil, kempis Your tumor shrinks to nthe size of pea. 4. track : saluran ………………… + track urinary track : saluran kencing digestive track : saluran pencernaan 5. Soreness (n) : rasa nyeri Sore (adj) : keadaan/mengalami nyeri Sore + ………………… (part of the body) I have a sore throat. Nurse, my feet are still sore after walk. 6. difficulty in……………(adj) : kesulitan difficulty in speaking : kesulitan bicara difficulty (in) breathing : susah bernafas difficulty (n) : kesulitan Doctor, the patient has difficulty in speaking. 7. Fever (n) : demam She has high fever. Feverish (adj) : terasa demam Nurse, my child feels aching an feverish. 8. Irritate (v) : menyebabkan radang Irritation (n) : iritasi ………………..+ irritation irritant : penyebab iritasi irritable : dapat ter-iritasi The symptoms indicate that you have irritable colon. 9. vomit (n) : muntahan vomit (v) : muntah 23



The sufferer of scarlet fever may vomit. 10. swell (v) : membengkak swell (n) : pembengkakan Bacteria can cause your gum to swell. Swelling (n) : bengkak Swollen (adj) : bengkak, mis : swollen joints : sendi-sendi yang membengkak 11. persist (v) : berlangsung terus The cough persist at nights Persistent (adj) : cenderung berlangsung terus Doctor, the patient has persistent cough Persistence (n) : keberlangsungan 12. subside (v) : mereda (bedakan dengan subsidize : memberi subsidi) I took an aspirin and the pain gradually subsides. 13. attack : serangan ……………attack. Heart attack : serangan jantung This symptoms suggest that your husband has got a heart attack. 14. resistance (n) : daya tahan resist (v) : menolak resistant (adj) The pneumonia that is caused by bacteria resistant to antibiotics is difficult to cure. 15. contagious (adj) : menular Nurse, this patient suffers from contagious disease. He must be isolated. Contagion (n) : penularan Communicable (adj) : dapat menular 16. sip (v) : meneguk sip (n) : cairan sedikit dalam mulut If you have passed win, you may have a sip of water. 17. perform (v) : menjalankan tugas, melaksanakan, melakukan. If your dental decay, the dentist will perform root canal treatment. Activity 22 - Individually Translate this into communicative English. Refer your translation to the reading passage above. 1. Amandel melindungi saluran pernapasan dan saluran system pencernaan. ........................................................................................................................................... 2. Setelah mencapai umur 6 sampai 7 tahun, amandel mengecil tetapi tidak hilang sama sekali. ........................................................................................................................................... 3. Amandel sangat kecil saat kelahiran. Tetapi kemudian membesar secara bertahap. ........................................................................................................................................... 4. Infeksi virus pada bagian belakang tenggorokan menyebabkan nyeri. ........................................................................................................................................... 5. Radang amandel mulai dengan sakit tenggorokan dan kesulitan menelan. ........................................................................................................................................... Activity 23 - Individually 24



Fill in the blanks with the suitable word.  Sore ● to shrink ● swollen ● to swell ● resists ● persist ● subside ● difficulty ● to perform ● persistent 1. This is a corticosteroid nasal spray. Your nasal polyps are not too large. This may enough……….them. 2. Do you false teeth fit to you? Or do they make you feel……. 3. Do you still have…………..in moving your foot? 4. A bee stung my child on her lower arm. Now you see, her arm begins………….. 5. Your child has the symptoms of mumps. You can see here some………..glands, in front of the ear, the salivary glands, the parotid gland under the ear. 6. It’s enough with drug treatment. Your breathlessness should improve, and swellings…………. 7. The doctor gives you symptomatic drugs. If the symptoms…………….consult your doctor. 8. This……………pain annoys me. 9. Your surgeon will take only 15…………sterilization operation. 10. After the first attack of TB, your body will………..the bacteria by means of natural defenses.



1.5 Key Points of Nursing Assessment The vital first phase in nursing process, assessment consists of the patient history, the physical examination, and laboratory studies. The other nursing process phases – nursing diagnosis formation, outcome identification, care planning, implementation, and evaluation – depan on the quality of the assessment data for their effectiveness. A properly recorded initial assessment provides: a way to communicate patient information to other caregivers. a method of documenting initial baseline data. a foundation on which to build an effective plan of care. Your initial patient assessment begins with the collection of data (patient history, physical examination findings, laboratory data) and ends with a statement of the patient’s actual or potential problem – the nursing diagnosis. Building a data base – To limit your data base appropriately, ask yourself these questions: what data do I want to collect? how should I collect the information? how should i organize it to make care planning desicions? Your answers will help you to be selective in collecting meaningful data during patient assessment. The well-defined data base for a patient may begin with admission signs and symptoms, chief complaint, or medical diagnosis. Subjective and objective data – The assessment data you collect and analyze fall into two important categories, subjective and objective. The patient’s history, embodying a personal perspective of problems, provides subjective data. It is your most important assessment data source of patient information, it must be interpreted carefully. In the physical examination of a patient – involving inspection, palpation, percussion and auscultation – you collect objective data about patient’s health status or about the pathologic processes that may be related to his illness or injury. The most 25



objective form of assessment data, laboratory test results provides another source for interpreting your history and physical examination findings. You need booth subjective and objective data for comprehensive patient assessment. They validate each other and together provide more data that either could provide alone. D. Closing Class Activities → SGD, Discover learning, Role play & Presentation. Students make a summary and perform/role plays to present their papers that have been made with the topic: Nursing Assessment. 1. Work in Group (5 Groups) 2. Make a paper on the concept that determined according to nursing assessment. 3. Finding material through books and internet with illustration. 4. The group is randomly selected for the presentation. 5. The group delivers to role play. 6. The result of the revised product is collected as portfolio. The explanation should describe: Some concepts of nursing assessment are based on appropriate references from up-todate books and internet with illustration. How to work: Every group makes a paper in 5-8 pages. Computer type: Times New Roman (12) with 1.5 spacing on A4 paper. Provided Power Point for presentation, it can be included for illustration/case. The paper is collected in the form of files both MS-Word and Power Point to the lecturer 2 days before performance. The result of the revised products is collected as portfolio.



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