Jumat, 16 Desember 2011

NURSING ASSESSMENT AND PROCEDURE


Miss. Fenny Firdaus, 22 years old, Indonesian, female, was administered to Padang Hospital in female internist ward at 08:30 a.m. with complained of dizziness and headache. She said that she has been insomnia for 3 days. The nurse who received her will make a nursing process for her and check her vital sign.

Nurse       : Good morning, Miss. Are you Miss. Feni Firdaus?
Patient      : Yes, I am. Just call me Fe, please.
Nurse       : All right Fe, I’m nurse Nola Asril. You can call me Ola, it’s sound more friendly. I’m the nurse who responsible to care you during your hospital stay. It pleasure to meet you.
Patient      : Nice to meet you too, Ola.
Nurse       : Bye the way, how are you today, Fe? It’s better than before?
Patient      : Well, I’ve got a little bit dizzy.
Nurse       :  I see. Your doctor give you a reffere letter and send you here because you got high blood pressure. So, I want to check your vital sign, Fe. It’s used to notice your health status, beside it’s my routine job.
If  there any changes or abnormal record, I’ll inform the doctor during ward round.
Do you agree and understand, Fe?
Patient      : Yes, I agree with it. What time the doctor  will come?
Nurse       : At 10:00 a.m. Lie down over here and could you please place this termometer on your armpit for 5 minutes, Fe. Now, give me your right hand and roll your sleeve up, I’ll take your blood pressure.
Patient      :  Is everything OK, Ola?
Nurse       :  I haven’t finish yet. Now, give me your right hand, I’ll take your pulse and respiration. Well, it’s done.
Patient      :  How is my vital sign, Ola?
Nurse       :  Well, your blood pressure and pulse is slightly higher than normal, it’s 140/100 mmHg. Did you take or consume anything this morning?
Patient      : As far as I remember there is nothing, Ola.
Nurse       :  Fine, there is nothing to worry about. I’ll inform them to your doctor immediately. He will be here in 1 hour.
                   Do you mind if I ask you few question to complete your registration form?
Patient      : No. I don’t mind. Please go a head.
Nurse       :  Your name is written here Miss. Feni Firdaus. Let me  check the list. How do you spell your complete name, Fe?
Patient      : Sure. My name is Fenny  Firdaus.                                                         F-E-N-N-Y F-I-R-D-A-U-S
Nurse       : OK, Fe. What’s your religion?
Patient      : My religion is Moslem
Nurse       : Where do you live?
Patient      : I live at Jl. Irigasi No. 11c
Nurse       : Tell me your civil state, are you married?
Patient      : No, I’m single
Nurse       : How old are you?
Patient      : I’m 22nd years old
Nurse       : What is your occupation?
Patient      : I’m a student at Andalas University
Nurse       : When were you born?
Patient      : I was born on 17th of August 1989
Nurse       : Your place of birth, please?
Patient      : I was born in Sawahlunto
Nurse       : Do you have health insurance, Fe?
Patient      : Yes, I have. ASKES
Nurse       : What is your phone number?
Patient      : 085365665665
Nurse       : Who is your next of kin’s name?
Patient      : Firdaus, my father
Nurse       : Where does he live?
Patient      : He live in Sawahlunto
Nurse       : Have you ever been hospitalized before?
Patient      : Yes, 3 years ago with fever and 5 years ago with tonsil operation.
Nurse       : Do you have any allergic?
Patient      : No, I don’t.
Nurse       : What is your current height and weight?
Patient      : My height is 150cm and my weight is 45kg.
Nurse       : Tell me about your typical day’s menu, please.
Patient      : Dendeng, cornet, pindang fish, sardenes, cheese, butter, bread
Nurse       : Do you have any problems with hearing? Vision?
Patient      : No, I don’t
Nurse       : Do you feel well rested after sleep?
Patient      : Yes, I do. But I’ve got insomnia for 3 days.
Nurse       : What do you do when you are under stress?
Patient      : I’ll meals.
Nurse       : Well, for this time, it’s done.
                   If you have any complain or need something, please press the bell.
Patient      : OK, Ola. I’ll call you latter.
Nurse       : Thank you for your good cooperation Fe.
                   Have a nice day.
Patient      : Welcome, Ola. Have a nice day too.



















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