PORTOFOLIO MATA KULIAH

BAHASA INGGRIS DALAM

KEPERAWATAN II
KODE MATA KULIAH: BAE 112

PENULIS:
NAMA : DIAH AYU MUSTIKA
NIM: 131511133080

FAKULTAS KEPERAWATAN UNIVERSITAS

AIRLANGGA SURABAYA
2016
Format sampul tugas resume dan tugas lain.

Nama : Diah Ayu Mustika

NIM : 131511133080
Mata Kuliah : English In Nursing 2
Judul Tugas : Resume Assessmment 2
Pertemuan Ke :2
Tanggal : 3 Oktober 2016
mengumpulkan

Dengan ini saya menyatakan bahwa tugas berikut adalah hasil karya saya
sendiri. Apabila dengan sengaja terdapat kesamaan (plagiarisme) dalam
pengerjaannya. Saya bersedia untuk mengulang pengerjaan portofolio
sebagaimana ditetapkan bersama dengan PJMK BAE 112.

Surabaya, 3 Oktober 2016

(Diah Ayu Mustika)

NIM: 131511133080

Tugas terlampir telah direview dan ditelaah

Nama Dosen :
Pengampu
NIP/NIK :

Hasil Review :

Nilai Tugas (0100) :

 Tanda Tangan Dosen

ASSESSMENT 2

Nursing assessment is gathering information about the health status of

a person and identify concerns and needs that can be treated or managed by
nursing care. How to make an assessment of nursing is to see look, listen,
touch, to make an informed decision about care. Types of assessment is initial,
focused, ongoing, shift assessment, and emergency.
Health history health encompass reason for admission/chief complaint,
demographic information, history of present illness, family history, other
history such as medical and surgical history. Physical exam encompass usually
follows history, head to toe approach, includes (as needed) such as
inspection, palpation, auscultation, and percussion.
General survey is like how do they look overall?, what can you discern
just by looking at and talking with them?, are they oriented?, what is their
mood?, how about nutritional status?, vital signs?. General survey is as you
introduce yourself and establish trust with the patient your are beginning the
general survey
The definition of HEENT is head, eyes, ears, nose, throat. The example of
HEENT assessment is look at distribution of hair. Are there any lumps on the head?
Discolorations?, is head normal size? Upright? Are the facial structures symmetrical
in shape?, basically a cranial nerve assessment, you do not need to check each
cranial nerve at this point, but be aware of what they are and how to assess them,
does the mouth droop?, talk to the patient. Do all the facial muscles move together?,
can the person see and hear well?, pupils equal, round and reactive to light and
accommodation, what does this mean?, check the eye muscle function. Have the
patient follow your finger to all eight positions, inspect the ear and assess hearing by
talking to the patient, check the nose for abnormalities, if warranted, palpate the
sinuses for tenderness, look at mouth and neck. Take a look at the tongue. Are there
white patches? Red patches?, check range of motion for the neck (gently!), look at
the neck for jugular vein distention. This could indicate a heart problem, where are
these structures? Lymph nodes, jugular veins, carotid arteries, trachea, trapezius and
sternocleidomastoid, to assess the lymph nodes, place both hands on the neck at the
same time and palpate using the pads of your fingers, normal: not palpable or
smooth, firm, less than 1 cm, mobile, and nontender