Assessing Patient’s Health

CHAPTER 7 Program

CHAPTER 7

MONITORING THE PATIENT

Nurses see the patients more often than other specialist and are in the best position to monitor them.
They look out for any problems and assess the patient’s progress and response to treatment. Basically,
by careful monitoring and recording, a nurse answer the question: what is happening to this patient?

Monitoring body functions by checking vital signs helps to answer this question. The vital signs are body
temperature, heart rate, blood pressure and respiratory rate. Changes or abnormalities in vital signs
indicate changes in the patient’s condition. However, they are not 100% reliable and stable vital signs do
not always mean that everything is okay.

Bodily fluids, including blood and urine, can be analyzed, usually in a laboratory. And it is now possible
to get images of what is going on inside the body using technological aids like X-rays and ultrasound
scans. For more detailed information, there are endoscopes which are used to look inside the body, and
biopsies where tissues is removed for examination.

Some patients with chronic illness like hearts diseases, diabetes and asthmas can self-monitor. They
communicate with doctors and nurses by phone and online. Patients can also be monitored from a
distance using satellite technology and the internet. This has major advantaged; the patient doesn’t
have to keep visiting a hospital and it saves a lot of money.

Perawat melihat pasien lebih sering daripada spesialis lain dan berada dalam posisi terbaik untuk
memantau mereka. Mereka mencari masalah dan menilai kemajuan pasien dan respon terhadap
pengobatan. Pada dasarnya, dengan pemantauan dan pencatatan yang cermat, seorang perawat
menjawab pertanyaan: apa yang terjadi pada pasien ini?

Pemantauan fungsi tubuh dengan memeriksa tanda-tanda vital membantu menjawab pertanyaan ini.
Tanda-tanda vital adalah suhu tubuh, denyut jantung, tekanan darah dan laju pernapasan. Perubahan
atau kelainan pada tanda vital menunjukkan perubahan kondisi pasien. Namun, mereka tidak 100%
handal dan stabil. Tanda-tanda vital tidak selalu berarti bahwa semuanya baik-baik saja.

Cairan tubuh, termasuk darah dan urin, dapat dianalisis, biasanya di laboratorium. Dan sekarang
mungkin untuk mendapatkan gambar dari apa yang terjadi di dalam tubuh menggunakan bantuan
teknologi seperti sinar-X dan scan ultrasound. Untuk informasi lebih rinci, ada endoskopi yang digunakan
untuk melihat ke dalam tubuh, dan biopsi di mana jaringan dikeluarkan untuk pemeriksaan.

Beberapa pasien dengan penyakit kronis seperti penyakit jantung, diabetes dan asthmas dapat
memonitor diri. Mereka berkomunikasi dengan dokter dan perawat melalui telepon dan online. Pasien
juga dapat dipantau dari jarak jauh menggunakan teknologi satelit dan internet. Ini memiliki keunggulan
utama; pasien tidak perlu mengunjungi rumah sakit dan menghemat banyak uang.
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CHAPTER 7 Program

1. Nurses are in a good position to… (Perawat berada dalam posisi yang baik untuk)
a. Monitoring patients (memantau pasien)
b. Specialize
c. Get to know their patients
1. ‘What is happening to this patient?’ Is a question which… ('Apa yang terjadi pada pasien ini?'
Adalah pertanyaan yang)
a. Only nurses can answer (hanya perawat uyang dapat menjawab)
b. Monitoring helps to answer
c. Nurses must ask
2. Stable vital signs mean… (Tanda-tanda vital yang stabil berarti)
a. everything is probably ok (semuanya mungkin baik)
b. A change in a patient’s condition
c. Something’s is definitely wrong
3. Technological aids give information about… (Teknologi membantu memberikan informasi
tentang)
a. Internal organs (organ internal)
b. Bodily fluids
c. Vital signs
4. An endoscopy gives… (endoskopi memberi)
a. Less information than an X-ray
b. More detail than a scan (lebih detail daripada scan)
c. Less information than a biopsy
5. Self-monitoring is…
a. Done by doctors and nurses
b. Done at a hospital
c. Cheap and convenient (murah dan nyaman)

PHYSICAL EXAMINATION SKILLS

There are some techniques that enable the nurse to collect a broad range of physical data about
their patients. Ada beberapa teknik yang memungkinkan perawat untuk mengumpulkan berbagai
data fisik tentang pasien mereka.

1. INSPECTION : The process of observation, a visual examination of the patient’s body

parts to detect normal characteristics or significant physical signs
INSPEKSI : Proses pengamatan, pemeriksaan visual dari bagian tubuh pasien untuk
mendeteksi karakteristik normal atau tanda-tanda fisik yang signifikan
2. PALPATION : Involves the use of the sense touch. Giving gentle pressure or deep
pressure using your hand is the main activity of palpation technique
Palpasi : Melibatkan penggunaan sentuhan indera. Memberi tekanan lembut atau tekanan
dalam menggunakan tangan Anda adalah kegiatan utama teknik palpasi
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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
Perkusi : Melibatkan mengetuk tubuh dengan ujung jari untuk mengevaluasi ukuran, batas,
dan konsistensi organ tubuh dan menemukan cairan dalam rongga tubuh
4. AUSCULTATION : Listening to sound produced by the body
Auskultasi : Mendengarkan suara yang dihasilkan oleh tubuh

Mention what activity you do for each case listed below. Is it an Inspection, Palpation,
Percussion or Auscultation? Sebutkan aktivitas apa yang Anda lakukan untuk setiap kasus yang
tercantum di bawah ini. Apakah itu Inspeksi, Palpasi, Perkusi atau Auskultasi?

1. Examining patient’s respiratory (__________)

Memeriksa pernafasan pasien
2. Inspecting the mouth and throat (__________)
Memeriksa mulut dan tenggorokan
3. Asking the patient to stand up to find whether there is scoliosis or not (__________)
Meminta pasien untuk berdiri untuk menemukan apakah ada skoliosis atau tidak
4. Pressing her middle finger of non-dominant hand firmly against
the patient’s back with palm and finger remaining off the skin,
the tip of the middle finger of the dominant hand strikes the other,
using quick and sharp stroke (__________)
Menekan jari tengah tangannya yang tidak dominan dengan kuat di punggung pasien dengan
telapak tangan dan jari yang tersisa dari kulit, ujung jari tengah tangan dominan menyerang
yang lain,menggunakan stroke cepat dan tajam
5. Observing the color of the eyes (__________)
Mengamati warna mata
6. Observing the movement of air through the lungs (__________)
Mengamati pergerakan udara melalui paru-paru
7. Testing deep tendon reflexes using hammer (__________)
Menguji refleks tendon dalam menggunakan palu
8. Checking the tender areas with her hand (__________)
Memeriksa area tender dengan tangannya
9. Pressing abdomen deeply to check the condition of underlying organ (__________)
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CHAPTER 7 Program

10. Preparing a good lighting, then he observes the body parts (__________)
Mempersiapkan pencahayaan yang baik, kemudian dia mengamati bagian-bagian tubuh

SPEAKING SKILL
Explaining what you are going to do immediately
• Now I am going to …

• It’s time for me to…

• Now I want to… press your… + (parts of the body e.g. artery
cheeks
neck) gently
examine your…+ (parts of the body) gently

Question to Ask When Assessing:

You look so… (tense / stiff / painful)
Your… (Skin, eyes, nail, etc) looks…
(sallow, reddish, yellowish, etc)
You seem uncomfortable when…
(walking, moving your hand, bend
your knee, etc)
 Do you have any… (cold, infection,
etc) recently?
 Did you have any… (thyroid problem,
neck pain, etc)
 Did you note any enlargement on the
parts of your… (parts of the body)?
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CHAPTER 7 Program

Instruction
Head, face, and neck nose, sinuses, Eyes and ears
assessment mouth and assessment
pharynx
assessment

 Will you…? e.g. frown your e.g. open your e.g. puff off
 Would you…? forehead, mouth, your hearing
aids,
 Please, can you… puff out cheeks, tip your head back
 Now, I want you flex your neck with slightly, close your eyes,

to… chin forward, say ‘ah’, repeat what I

 Just follow my shrug your shoulder, mentioned.
breathe with your
instruction other nostril and I
bend your neck
will press the other
one.

ROLE PLAY
Make a group of 2 students (one student as the nurse and the other as the patient)
and then make a conversation explaining about the procedure of:
 Assessing head, face, and neck
 Assessing nose, sinuses, mouth and pharynx
 Assessing eyes and ears

SIGNS AND SYMPTOMS

A sign of disease is something that a nurse can see or feel for herself. She can observe it
through the patient’s complaint. Example of signs: bruising, rash, swelling, loss.
A symptom of disease is something that only the patient knows about what they feel. The
patient tells the nurse about it. Example of symptoms: nausea, insomnia, all kinds of pain.
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CHAPTER 7 Program

Look at these common complaints below. Some of it are signs and some are symptoms.
Decide whether it is signs or symptoms of the disease and put on the table.

 Irregular Pulse Haematemesis Jaundice

 Dull pain Hungry Thirst
 Stomachache Pallor Dyspnea
 Dizziness Diarrhea Constipation

 Headache Inflammation Backache

 Cyanosis Shallow Pulse
 Anorexia Weigh gain
 Laceration Shallow respiration

Signs Symptoms
 
 
 
 
 
 
 
 
 
 

Common Complaints:
 Bruising/bruise : an injury which makes a mark on the skin (blue or black
colored) but doesn’t break the skin.
 Rash : red spots on the skin. A signs of certain illness such as Measles.
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 Swelling : a part of the body which has become enlarged by disease or

injury such as sprained ankle.
 Nausea : feeling sick or wanting to vomit
 Insomnia : inability to sleep
 Irregular pulse or respiration : the pulse or respiration rate varies from
fast to slow
 Dizziness : the feeling that everything is turning around you, and that you
will lose your balance
 Haematemesis : blood in the vomit
 Pallor/pale : lack of color in the skin
 Diarrhea : frequent loose stools, passes through the bowels
 Jaundice : the skin and eyes of a patient with jaundice look yellow
 Dyspnoea : having difficulty in breathing
 Constipation : when a patient cannot open his bowels or having
difficulty to do it
 Cyanosis : blue skin caused by insufficient oxygen in the blood
 Anorexia : lack of appetite
 Laceration : a cut with broken edges
 Abrasion : rubbed or torn skin
 Inflammation : a red, hot, swollen, painful place on the skin
 Shallow pulse or respiration: a light or faint pulse
 Respiration : breathing
 Oedema : swelling caused by excessive fluid in the tissue

WRITING
Study these instructions for taking a patient’s pulse and write similar instructions for how to
measure: Temperature
Blood pressure
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Example:
Taking Patient’s Pulse
First wash your hands. Support the patient’s arm with the palm of the hand downwards.
Press three fingers against the radius bone until you feel the place where the artery expands
and contracts with the heartbeat. Do not use your thumb because it has its own pulse.
Count the beats for 30 seconds and multiply the number by two to get the heart rate for

one minute.