Dialogue Physical Assessment

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The dialogue describes a nurse conducting a physical assessment and treatment of a patient named Zayn who is experiencing fever and dizziness.

Measuring vital signs helps determine the patient's current condition and assess the function of their body.

The nurse measures the patient's vital signs, examines their eyes, mouth, stomach and breathing.

DIALOGUE PHYSICAL ASSESSMENT

Nurse : Good Morning. What is your name?

( Selamat pagi, siapa nama anda)

Patient : Good Morning nurse. My name is Zayn.

(Selamat pagi sus, nama saya Zayn)

Nurse : Mr Zayn., my name is Nurse Ayu, I’m the nurse as a duty in this morning. How is
your condition today Mr zayn.?

( Tuan Zayn, nama saya suster ayu, saya perawat yang bertugas pagi ini.
Bagaimana kondisi anda hari ini?)

Patient : I am still feel the fever and dizzy nurse.

( Saya merasa demam dan pusing)

Nurse : Have you got your breakfast today?

( Apakah kamu sudah sarapan hari ini)

Patient : Yes nurse, I got my breakfast. I was ate a quarter plate of rice and side dishes. I was
drunk a glass of water before.

( Iya suster, saya sudah sarapan. Saya makan seperempat porsi nasi dan lauk. Saya
sudah minum segelas air sebelumnya)

Nurse : Mr zayn., now I will do physical examination to you and measure your vital sign.

(Tuan zayn, sekarang saya akan melakukan pemeriksaan fisik dan mengukur Tanda
tanda vital)

Patient : Yes, please nurse.

(Iya, silahkan sus)

Nurse : For the first, I will measure your vital sign. I will take this termometer in your armpit,
please clip this. And I will fold your sleeve to easy I take the manset of
sphygmomanometer in your arm. And I will check now.

( Pertama, saya akan mengukur tanda – tanda vital. Saya akan meletakan
thermometer di ketiak anda, tolong dijepit. Dan saya akan melipat lengan baju anda
agar memudahkan memasang manset di lengan anda. Dan saya akan memeriksa
sekarang)

Patient : Why is measure vital sign necessary nurse?

( Kenapa perlu mengukur tanda-tanda vital sus?)

Nurse : Yes, because by measuring the vital sign, we will know your condition and assess the
function of your body today.

(Iya, karena dari pemeriksaan tanda-tanda vital ,kita tau kondisi dan dapat menilai
fungsi tubuh kita)

Patient : How is the result nurse?

( Bagaimana hasilnya sus ?)

Nurse : Well, the result of your vital sign are your blood pressure is 120/80 mmHg, your pulse
82 bpm, and your temperature 38 degrees celcius.

(Jadi, hasil dari pemeriksaan tanda-tanda vital anda TD : 120/80mmHg, nadi


82x/menit, dan suhu anda 38oC)

Patient : That’s sound good nurse.

( Itu terdengar baik sus)

Nurse : Now, I will continued to do physical examination to you.

(Sekarang, saya akan melakukan pemeriksaan fisik pada anda)

Patient : Why you do physical assessment to me nurse? Is it a necessary?

(Kenapa anda melakukan pemeriksaan fisik? Apakah itu perlu?)

Nurse : Yes, of course Mr zayn.. Do the physical assessment is necessary. The purpose is to
find out how your current physical condition.

( Iya tentu saja tuan zayn, pemeriksaan fisik itu perlu. Yang bertujuan untuk
menemukan bagaimana kondisi anda saat ini)

Patient : Yes, please nurse.

(Iya, silahkan sus)


Nurse : For the first, I will check on your conjunctiva. Can I see your eye please ?

( Pertama, saya akan memeriksa konjungtiva anda, bolehkah saya melihat mata
anda?)

Patient : Yes, of course nurse.

( Iya, tentu saja)

Nurse : Could you open your mouth please! I will saw condition of your mouth. Your lips
mucosa look pale and dry. I suggest you drink a lot of water, because is also important
for you and for fluid balance your body.

( Bisakah anda membuka mulut anda?, saya akan melihat keadaan mulut anda.
Permukaan bibir anda tampak pucat dan kering. Saya menyarankan untuk minum
banyak air, karena ini sangat penting untuk anda dan untuk keseimbangan cairan
dalam tubuh anda )

Patient : Thank you for your suggest nurse.

( Terimakasih atas sarannya sus)

Nurse : You’re welcome Mr zayn.. Now I will palpate your stomach. Do you feel pain?

( Sama-sama tuan zayn. Sekarang saya akan mengetuk perut anda. Apakah anda
merasa nyeri?)

Patient : No nurse.

(Tidak sus)

Nurse : do you feel difficulty in breathing Mr zayn.?

(Apakah anda merasa kesulitan dalam bernapas tuan?)

Patient : Yes nurse, I feel little difficult when I breathing.

( Iya sus, saya merasa sedikit sulit saat bernapas)

Nurse : Okay, to make you easy to breathing I will change your position to semi fowler
position and set oxygen to your. do you feel more comfortable?

( Oke, untuk memudahkan anda bernapas saya akan merubah posisi anda menjadi
setengah duduk dan memasang oksigen untuk anda. Apakah anda sudah merasa
lebih nyaman?)
Patient : Yes, nurse I felt more comfortable and easy to breathing.

( Iya, saya sudah merasa lebih nyaman, dan mudah bernapas sus)

Nurse : Now I will give you a paracetamol, to help decrease your fever. We will monitor your
fluid balance and vital sign.

(Sekarang, saya akan memberikan anda paracetamol, untuk membantu menurunkan


demam anda. Kami akan memonitor keseimbangan cairan dan tanda-tanda vital
anda)

Patient : Thank you for your suggest nurse.

(Terimakasih atas saran anda sus)

Nurse : You’re welcome Mr zayn.. Now I will leave you, before I leave do you still have any
question or complaints?

(Sama-sama tuan zayn, sekarang saya akan meninggalkan anda. Sebelum saya
tinggal apakah ada pertanyaan atau keluhan?)

Patient : No nurse.

(Tidak sus)

Nurse : If you have a complaint, you can call me on nursing station and 30 minutes letter
doctor will come here to check your condition. I hope you get well son. Excuse me Mr
zayn.

(Jika anda ada keluhan, anda bisa memanggil saya di ruang perawat dan 30 menit
lagi dokter akan datang kesini untuk memeriksa keadaan anda. Semoga anda lekas
sembuh. Permisi tuan zayn)

Patient : Thank you nurse.

(Terimakasih sus)

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