English for Nursing 2

Topic 9

GENERAL ASSESSMENT

Instructional objective
The students are expected to be able:

 to pronounce well some vocabularies relating to general assessment,

 to act out a conversation and practice of collecting patient’s demographic data,
current health and illness, and history of past health and illness, and
 to write a nursing documentation of general assessment result.

General assessment is a part of comprehensive assesssment in nursing process . In this

assessment, a nurse attempts to collect patient’s demographic data, current health
status, and past-health history. The questions asked need to be specific, such as chief
complaint or reason for the visit.
A complete past family and/or social history should also be obtained on the first
encounter with a patient, regardless of setting and by a registered nurse. The history
should be age and sex appropriate and include all the necessary questions to enable an
adequate delivery of services according to prevention guidelines, scope of practice,
patient need, visit requirement, and/or request. Usually, completing a provider based
Health History and Physical Examination Form will assist in the assessment of the
patient’s past and current health and behavior risk status.
Glossaries
Demographic data (np) : patient’s data including name, age, place and date of birth,
sex, religion, ethnic group, occupation, marital status, next
of kin, contact number, referral, and health insurance.
Health history (np) : a holistic assessment of all factors affecting a patient’s
health status, including information about social, culture,
family, economy and life-style.

Related Vocabularies
Direction. Study the following vocabularies related to general assessment. Find out how to pronounce
them.
Demographic Data
 First name /................................/ (np) : nama pertama
 Surname /.........................../ (n) : nama belakang
 Next of kin /................................../ (np) : wali
 Marital status /………………………/ (np) : status pernikahan
 Married /……………………/ (adj.) : menikah

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  Single /……………………/ (adj.) : jomblo
 Divorced /…………………………/ (adj.) : bercerai
 Health insurance /………………………./ (np) : asuransi kesehatan
 National Health Insurance
/…………………………………………./ (np) : Jaminan Kesehatan Nasional (JKN)

Health History
 Communicable disease : penyakit menular
/……………………………………/ (np)
 Immunization /.................................../ (n) : imunisasi
 Allergy /............................./ (n) : alergi
 Bowel motion /…………………………./ (np) : BAB
 Waterworks /…………………………/ (np) : BAK

Useful Expressions
Direction. Study the procedure and the useful expressions when implementing a general assessment.
A. Greeting
 Hi, Mr. Stanford. How are you?
 Good morning, Sir.

B. Self-Introduction
 My name is Nancy.
 I am Nurse Shanti. I will take care of you today.

C. Explaining what you are going to do

 I am here to ....
 I am going to ....
 It is time for me to ....  Ask you some couples of question.
 I need to ....
 I want to ....

D. Asking patient’s demographic data

 Name  What is your name?
 What is your complete name?
 What is your surname?
 Age  How old are you?
 Address  What is your address?
 Where do you live?
 Phone  Your phone number, please.
 What is your phone number?
 Any mobile phone number?
 Marital status
 Are you married?
 Health insurance
 Do you have any health
 Occupation and title
insurance?
 Next of kin  What is your occupation?
 Reason for contact or visit  What is your title?

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E. Asking about patient’s current health status
 Current health condition
 Elimination pattern
F. Asking about patient’s health history
 Asking about communicable
disease
 Asking about immunizations
 Asking about allergy
 Asking about family health history
 Asking about life-style
G. Closing
 Ok, fine. That’s it.
 Well, let’s proceed to your physical examination.
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 Who is your next of kin?
 Why do you come to this hospital?
 What is your complaint?
 Would you tell me about your
condition?
 Do you have any problem with
your bowel motion?
 Do you have any problem with
your waterworks?
 How many times a day do you do
your bowel motion?
 Is the stool formed or loose?
 Is your waterworks sluggish?
 Have you ever had measles?
 Have you ever had rubella?
 How old were you when you got
it?
 Have you ever been immunized
against polio?
 Have you ever got diphteria
immunizations?
 Are you allergic to seafood?
 Are you allergic to peanut?
 Is there any of your family
member who had heart disease?
 Did your parent have diabetes
mellitus?
 Do you smoke?
 Do you drink alcohol?
Integrated Listening and Speaking Exercise
Direction. Fill in the blanks with personal data (demographic data) according to the listening resource
(audio file).

Name : Barbara Johnson

Age : 45 y.o
Sex : female
Address :
City, State :
Phone :
Ethnic origin : African American
Religion :
Marital status : Divorced
Health insurance :
Occupation and title :
Next of kin : her mother
Reason for contact :
Date, time of contact :

Communication Exercise
Direction. Choose a pair and write a complete conversation on the topic of general assessment. You
can use the useful expressions above. Then, practice and present your communication practice without
looking at the text you have written.

Nursing Documentation
Direction. Work in pair to write a nursing documentation of your general assessment practice. The data
you must gather are mentioned on the useful expressions section. You can use the following form to jot
down the general assessment result.

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 FALETEHAN HOSPITAL
Cilegon Street KM. 06, Pelamunan, Kramatwatu, Serang, Banten
Phone/Fax: 0254 232729/230054
Patient’s identity Immunization History
Name : Vaccine Yes No Not sure When
Age : Polio
Address : DPT
Occupation : Measles
Phone number : Rubella
Marital status : Covid-19 step 1
Ethnic origin : Covid-19 step 2
Religion : History of communicable disease:
Health insurance :
Next of kin : Allergy:
Doctor’s referral : Family health history:
Reason for contact :
Current Health Status
Elimination pattern:

Assessor :
Day, date, time :