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Patient Assessment for Annisa

1) Nurse Lina assessed patient Annisa who complained of a sore throat. She took Annisa's vitals and medical history. 2) Nurse Dila then examined Annisa's head, face, neck, eyes, nose, and mouth. 3) The nurses consulted with Doctor Dhea about Annisa's condition. The doctor examined her throat and wrote a prescription.

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0% found this document useful (0 votes)
22 views4 pages

Patient Assessment for Annisa

1) Nurse Lina assessed patient Annisa who complained of a sore throat. She took Annisa's vitals and medical history. 2) Nurse Dila then examined Annisa's head, face, neck, eyes, nose, and mouth. 3) The nurses consulted with Doctor Dhea about Annisa's condition. The doctor examined her throat and wrote a prescription.

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lina
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Nurse 1: Lina

Nurse 2: Dila
Nurse 3: Tri
Patient: Annisa
Doctor: Dhea
Narator: Elly
Patients Family1: Doni
Patients Family2: Retno
Patients Family3: Aqrom

In the morning at the hospital Jambi area, a nurse named is Lina will to assess patient named
Annisa
Nurse1: Good morning Miss (gereted with a friendly)
Patient : Good morning nurse.
Nurse1: Well Miss, I need to collect your personal data. Im going to ask you some question.
Petient : Certainly, nurse.
Nurse1 : Ok Miss, what is your name?
Patient : My name is Annisa.
Nurse1 : How old are you Miss Annisa?
Patient : Im 19 years old.
Nurse1 : Where do you live?
Patient : I live in Simpang Rimbo.
Nurse1 : Are you married?
Patient : No, Im single, nurse.
Nurse1 : Do you have any health Insurance?
Patient : Yes, I have health insurance.
Nurse1 : What is it?
Patient : My health insurance is ASKES, nurse.
Nurse1 : What is your occupation?
Patient : Im a student
Nurse1 : Dou you have a doctors referral?
Patient : No, I dont have. Because Iv never sick nurse, if I have pain usually I just eat
vitamins.
Nurse1 : Ok, first Im going to check your vital sign Miss Annisa.
Patient : Ok
Nurse1 : (Doing it) Sorry Miss what do you feel now?
Patient : My throat is very painful,nurse.
Nurse1 : Are you saying that your throat is painful Miss?
Patient : Yes nurse
Nurse1 : When did you first notice your pain?
Patient : I have this pain since 3 day ago, Is my condition very bad nurse? Im very afraid
Nurse1 : Dont be afraid Miss Annisa, you will be ok.
What is your pain like? Sharp, dull, stabbing, or acching?
Patient : Its like dull pain,nurse.
Nurse1 : Owh, on a scale of 1 to 10, with ten the worst, how would you rate what you feel right
now?
Patient : I think it is about 4.
Nurse1 : oke,, I have a finish to check your vital sign, your blood pressure is 100/80 mmHg,
your temperature 36,5C, your respirate is 21x/minute, and your heart rate is 86x/minute.
Patient : Is that normal nurse?
Nurse1 : yes Miss Annisa doesnt be afraid, this is never mind
Patient : oke nurse.
Nurse1: ok Miss, because My task is done, now I will back to nurse station, and my partner will
come in here to check and asses you again.
Patient: ok nurse. Thank you
Nurse: Your Welcome
(Narator: And Nurse1 is go back to the nurse stations, and no long of that nurse 2 came to
[Link] again and do some assesement again)
Nurse2 : Excuse me, ok.. . .Now I want to asses your head, face, and neck.
Patient : oke nurse
Nurse2 : Miss Annisa, Please do my intruction...ok??
Patient : okk
Nurse2 : Excuse me Miss,.. now I want to observe your haed and your hair..
Patient : Oke Nurse
Nurse2 : Would you rise your eyebrows?
Patient : yes
Nurse2 : Please close your eyes tighly Miss
Patient : (close my eyes)
Nurse2 : now, I want to observe you eyes colour.
Patient : oke nurse
Nurse2 : its time for me to check check your nose
Patient : yes nurse
Nurse2 : Im going to press you on the spot (frontal sinus), if you fell painful, please talk to
me...
Patient : oke
Nurse2 : Miss Annisa please breathe with your other nostril, And I will press the other one
Patient : oke nurse
Nurse2 : do you have difficultly breathing throught the nose?
Patient : no
Nurse2 : Will you do the same the opposite part?
Patient : yes ..of course
Nurse 2 Do you have nasal discharge?
Patient : no,
Nurse2 : have you experienced any injury to your nose?
Patient : no, Nurse
Nurse2 : have you ever head bleeding from your nose Miss Annisa?
Patient : no, nurse
Nurse2 : oke, next... I would like to examine your mouth, Are you ready Miss?
Patient : oke, I ready
Nurse2 : Miss Please smile
Patient2 : (doing the instruction)
Nurse2 : Would you show your teeth?
Patient2 : (doing the instruction)
Nurse2 :Do you brush your teeth every day?
Patient : yes...of course
Nurse2 : How many time in the day?
Patient2 : 3 x nurse
Nurs2e : its good..can you open your mouth?
Patient : yes...AAAAAAA
Nurse2 : now, I want to check your reflexplease say AAAHHH
Patient2 : AH
Nurse : Please, put of your cheeks
Patient :upppsss
Nurse : Please shurg your shoulders
Patient : eehhhhmmmm
Nurse : Would you flex your neck with ear toward your left and right shoulder?
Patient : oke
Nurse : oke Miss I have finish to asses your personal data and assesment your head,face, and
neck. Now, I will consultation with the doctor about your condition,
Patient : thanks you very much nurse
Nurse :youre welcome
([Link] come to the nurse room, He want to consult with nurse about a patient in the
room..)
Doctor : assalamualaikum
Nurse3 : waalaikum salam
Doctor : What happen with a new patient Nurse?
Nurse3 : At the seven oclock Nurse Lina and Nurse Dila did the anamnesa and phisical
assesment to Miss ANNISA.
Doctor : What Is Miss Annisa feel nurse?
Nurse3: Miss Annisa say that her throat is very painful
Doctor : owh. Okeh nurse. Thanks you.. now I will go to patient room for check general
condition of patient
(Doctor and Nurse go to patient room for check the general conditions of patient.)
Doctor : Assalamualaikum
Patient : Waalaikumsallam
Doctor : Are you Miss Annisa?
Patient : yes, Doctor Im Annisa
Doctor :what do you feel now Miss Annisa?
Patient :my trhoat is very painfull,doc
Doctor : oke.. I want to check your throat [Link] open your mouth Miss Annisa?
Patient : How is it Doc ?
Doctor : Dont be afraid Miss Annisa. You will be fine, now i want to write prescription for you.
Please Nure give me his medical record.
Nurse : Oke dok.
(Nurse Retno give medical record to doctor, and doctor Dhea write prescription for Patient)
Patient : oke thanks you very much Doctor and Nurse.
Doctor : Youre welcome.
Nurse : youre welcome Miss Annisa, we are permission, later If you need something you can
call me in nurse room.
{Narator: Theres no long from that, some people come to the nurse station and ask about
[Link] Room)
Patients Family1: Hello nurse..
Nurse3: Yes..Sir.. can I help You?
Patients Family1: Im looking for the patient named [Link]
Nurse3: Oh.. Miss Annisa is in the Mawar room sir..
Patient Family2: where is the mawar room nurse?
Nurse3: mawars room is front of the nurse station sir.. there..
Patient Family3: oh.. this way..?
Nurse3: yes sir..
PatientsFamily: thank you nurse
Nurse3: Your Welcome sir.
(Narator: and Patients Family go to the mawar room to see the patient)

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