On Wednesday November 11th 2015 a nurse will carry out the assessment and

intervention to the patient named Aullia Niken Wulandari, 20 years old in long stay ward after
the client's family reported that their daughter had blown suddenly at the break.

Nurse : Good afternoon.

Patient : Good afternoon nurse.

Nurse : Excuse me, may I look your bracelet please?

Patient : Of course nurse, please check it.

Patient : Am I right this is with Miss Aullia Niken Wulandari 20 years old from
Boyolali?

Patient : You are right nurse. I am Aullia Niken W, 20 years old and I live in Boyolali.

Nurse : All right Miss, I am nurse Aisyah. Today I am nurse on duty this time to care
you so if you need helps you can call by press this switch. Okay?

Patient : So I have to press this switch if I have a problem or something nurse?

Nurse : Yes you are right. Okay at this moment I am going to do an assessment to you
because a few moment ago I get a report from your parent that you difficult to
breathe. It is right Miss?

Patient : Yes that is right nurse. I felt difficult to breathe.

Nurse : I need time for about 15 minutes to assess you at this place. Do you agree with
me?

Patient : Yes nurse, I agree with the thing but do not do it in a long time because I need
to take a rest, I tired nurse.

Nurse : Do not worry about that. It is just need not too long time. However before we
start it do you want to drink or go to toilet first?

Patient : All right nurse. I am feeling thirsty now, could you help me to take the water at
the table please?

Nurse : Ohhh of course. Here you are Miss.

Patient : Thanks you so much, nurse. You are so kind and I am feeling roomy now.
Please start the assessment right now please because I ready.

Nurse : Okay, I will do it now. What is your chief complaint today?

Patient : Well nurse, a few moment ago suddenly I felt difficult to breathe .

Nurse : When you feel a blown suddenly?

Patient : First, I felt cool and suddenly I felt the blown.

Nurse : Is the air to cool here Miss ?

Patient : Actually no nurse. However at first I felt hot with the air then I set the air
conditioner with this air conditioner remote. After I feel chilly I slumbered and a
few minutes later I awaken because of the blown. It is happened may be because I
set the degree of the air conditioner too cool nurse.

Nurse : What happening next after that ?

Patient : My parent, they take the remote near me soon and turn off the air conditioner.

Nurse : And then ?

Patient : My parent also try o make me calm down and warm.

Nurse : Do you have any breathing disease before likes asthma, bronchitis, or
emphysema?

Patient : Yes nurse. I have a bronchitis since I was in senior high school.

Nurse : What kind of activity or something may usually make you relapse?

Patient : When I felt cool I will feel difficult to breathe nurse.

Nurse : Is the blow very severe so that it may be can disturb your activity ?

Patient : Actually no nurse, I just felt the blown is not too severe not like usual.

Nurse : Do you use your shoulders when you breathe?

Patient : That is right nurse. I used them but now a can breathe without them.

Nurse : Therefore, are you feeling the blown now.

Patient : Yes. I am feeling it now but not too severe like I said before.

Nurse : Is any other thing do you feel beside the blow?

Patient : Sometime , I also felt I cough nurse.

Nurse : What the characteristic of the cough. Can you tell me please?
Patient : There is a bit of sputum nurse. When I am coughing I also put outside mucus.
However, I just complaint and feel disturb with the blown nurse right now not
other things.

Nurse : All right, based of the information from your report I will give you an
intervention. It is give you oxygen by canul . I will leave you for some minutes to
prepare it and I will be back again.

Patient : Okay nurse.

30 minutes later the nurseback with the oxygenation set likes oxygen tube, humidifier, canul, and
canul to give it to the patient.

Nurse : Assalamualaikum Miss, do yu still remember me?. I am nurse Aisyah.

Patient : Of course nurse. I remember you because you had here.

Nurse : All right, so this is right with Miss Aullia Niken Wulandari was born on
th
November 11 1995 ?

Patient : Yes you are right nurse.

Nurse : Based on our plan before, here I will give you oxygen with these canuls for
about 10 minutes. This is important for you because it will help you in breathing
so that you will not feel difficult to breathe again. Do you agree about that?

Patient : Yes nurse, please do it please.

Nurse : Well Miss I agreed about that. I will wash my hands first before I do it for
you.

Patient : Please nurse, no problem.

Nurse : In this procedure I will put in this canuls to your nostrils while the canuls will
connected with this oxygen tube. Then you will feel air flow to your nose.

Patient : Is the air in the tube safe for me nurse?

Nurse : Oh no, do not worry about that Miss. The oxygen before go into your nose will
mixed with the clean water in this little tube first so that it will make your airway
moist so it is safe for you. Besides of that the speeds of the flow will be set first as
your needed it is 1-6 L/minutes.

Patient : However the tube will go into my nostrils. Is it will make my nose graze or
no?
Nurse : No Miss. The tube made from plastic and the tube will go into your nostrils just
for about a millimeter so that is not too long.

Patient : Oh so just like that nurse. Okay now just do it right now nurse.

Nurse : Okay I will do it know. First I will help you to change your position to semi
fowler position. Are you ready?

Patient : Okay I am ready nurse.

Nurse : I will say 1-3 and then I will set your bed so do not be shocked.

Patient : Okay lets go.

Nurse : Great Miss. You can do it goodly. After that I will put in these canuls now but
first I will connected with this oxygen tube. Then I will open this valve so that the
air will flow and finally I will set the speeds of the flow.

Patient : How many the spedds nurse?

Nurse : It is about 3 L/minute Miss. Then I will check is the flow of the air is good or
not. You can see at this little water tube, if there is a air bubble in this tube it
show thai it has good function.

Patient : I understand what are you say and I am looking it nurse.

Nurse : After that I will give you these canuls into your nostrils.

Patient : Okay, and then?

Nurse : I will set the elastic tape under your chin so it will stable in your face. Now, do
you feel comfort?

Patient : I feel comfort nurse, there is no problem.

Nurse : Now, what is your feeling Miss after I give you this oxygen?

Patient : Hmmmm, it is good. I feel easier to breathe now. I feel fresh.

Nurse : It is great Miss. Okay Miss thank you for your cooperation. One hour later I
will backt again to check your condition. Furthermore, if you need my help do not
forget to press this switch. I will stay in nurse station. Okay?. Have a good break.

Patient : Waalaikumussalam