PATIENT ASSESSMENT EFN

ASTRI MUTIAR, MSN

TODAY'S TOPIC

PATIENT’S ASSESSMENT
A nursing assessment is a process where a nurse
gathers, sorts, and analyzes a patient’s health
information using evidence-informed tools to
learn more about a patient’s overall health,
symptoms, and concerns. 
NURSING NOTES
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 characteristics 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 fingertips to evaluate the size, borders, and consistency of body organs and discover fluids in body
cavities.

Auscultation
Listening to sounds produced by the body.
ACTIVITY
Mention what activity you do for each case listed below.

Activity Technique
Examining patient’s respiratory
Inspecting the mouth and throat
Asking patient to stand up to find whether there is scoliosis or not
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
Observing the color of the eyes
Observing the movement of air through the lungs
Testing deep tendon reflexes using hammer
Checking the tender areas with her hand
Pressing abdomen deeply to check the condition of underlying organ
Preparing a good lighting, then he observes the body parts
LET'S DISCUSS

What kind of examination

technique?
VOCABULARY
Pulse Rate Rhythm or regularly Tension Beats per minute
Indonesian: Indonesian: Indonesian: Indonesian:

Patient’s chart Bradycardia Tachycardia Reflexes

Indonesian: Indonesian: Indonesian: Indonesian:

Bounding Weak Suffocate Daydream

Indonesian: Indonesian: Indonesian: Indonesian:
VOCABULARY
USEFUL EXPRESSION
Implementation step

Now I am going to…. Press your…….

It’s time for me to…. Examine your…..
Now I want to….

Hi Mark. Welcome to the ward. My name is Sandy, I will be working with you
today. I am going to do physical assessment, first I would like to examine your
eyes…..
USEFUL EXPRESSION
Instruction

Would you…?
Now I want you to….?
Remove your upper clothes
Put off your hairpieces

Please +

Flex your neck with your chin toward

Bend your neck, with ear toward shoulder
Take a sip of water from this glass
ACTIVITY Reading!

Sign and symptoms are the tools for making a diagnosis, but what is the difference between them?
The signs of an illness are the things that nurses can see and measure. Signs are the things like spot
and bleeding. Meanwhile, symptoms are the things which a patients experiences, but others can’t
always see. Nausea and thirsty are examples of symptoms.

The symptoms which make a patient seek medical help in the first place are called the presenting
symptoms. Symptoms can be categorized by strong, mild or weak. Sometimes the symptoms of
serious illnesses like cancer and diabetes are weak. Then will remain weak along with undiagnosed
illnesses.

Nurse will ask patients about the onset of the symptoms, what they feel like, what relieves them and
what makes them worse. The more detail they have, the faster they can make a diagnosis.
QUESTIONS

Question 1 Question 2 Question 3 Question 4

You need sign and Too much information slow Nurses will only ask about
You can't see sign
symptoms for diagnosis up the diagnosis the onset and the kind of
symptoms

Question 5
The symptoms always stay
weak before diagnosed
Question 6
Nurses will ask the patient
about their sign of illness
TRY AND LEARN
ACTIVITY
• Make into groups consisting of 10 participants
• Make a complete conversation on acts of assessing head,
face, eyes, ears, mouth, and nose.
• Use the expression above
• You are having 20 minutes to discuss.
• After that, present on class.
• Good luck!
THANK
YOU

FOR A LOVELY SESSION