BAHASA

INGGRIS 2
Lectured by:
Mrs Nita Yuanita, S.Pd., M.Si.
Mr. Irsyad Nurgraha, M.Pd.

2
PATIENT ASSESSMENT &
PHYSICAL EXAMINATION
SKILLS
INDIKATOR:

1. Memahami berbagai ungkapan pada

tahapan penilaian yang berkaitan
dengan tanda dan gejala yang
dtunjukan pasien
2. Mengenal 4 keterampilan pemeriksaan
fisik pada pasien: inspection,
palpation, percussion and
auscultation.
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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
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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 objective
answer
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

 2ND MEETING

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

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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)
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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.
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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)
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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. …
2. … 2. …
3. … 3. …
… …
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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
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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.
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EXERCISE 3
What kind of examination techniques shows in each
picture?
End Session
Thank you