Nursing Assessment Scenario

Name : Intan Okta Kusuma as a Patient

Raheme Zam Zam Sheira Banu as a Nurse

Class : Sarjana Terapan Keperawatan

1 Orientation

In the morning at Emergency Unit

Raheme : Good morning Maam.

Intan : Good Morning.

Raheme : Let me introduce myself. My name is Raheme and I’am your Nurse now. From
now until next shift I will responsible for your lamentation.

Intan : Okay Nurse.

Raheme : So, what is your lemantation?

Intan : I got a stomachache like someone squeeze mine and I got it since 3 days ago.

Raheme : Have you taken any pain killers?

Intan : Yes. I already took asam mefenamat pills.

Raheme : Okay. I will put you on the line. But, first you have to register since you are
new patient in our hospital. Aside that I will do the physical examination to
check your body condition. It will takes about 30 minutes. Is it okay for you
maam?

Intan : Sure. No problem.

Raheme : Okay. What is your name?

2 Work

Intan : My name is Intan Okta Kusuma

Raheme : What is your nickname?

Intan : My family and friends usually calls me Intan.

Raheme : Are you single / merried?

Intan : I’m still single.

Raheme : What is your birth day?

Intan : I born in Oktober 31th 1997.

Raheme : Do you have private health insurance?

Intan : No

Raheme : Who is person that responsible to you?

Intan : I have my mom.

Raheme : What is her name?

Intan : Kusuma Hati

Raheme : So, do you live with her?

Intan : Yes. I live at Talang Sari road.

Raheme : What is her phone number?

Intan : 085388xxxxxx

Raheme : Ok maam. I got your personal details. Now I want to check your vital signs.

Intan : Of course
Raheme : Let me check your blood pressure. Would you mind pulling your sleeve up and
make your arm straight, please? Yeah that’s right.

Intan : How is the result?

Raheme : Usually how high is your blood pressure?

Intan : About 120/70 mmhg.

Raheme : Your blood pressure is 130/90 and it’s still normal also your temperature is
36.50 c.

Intan : Thanks

Raheme : Now, I will examine you. Please sit well. Where is the pain location? Could
you show me?

Intan : It’s here Nurse. Exactly right here. I can’t finish my job because this pain. It’s
so disturbing.

Raheme : Is it still painful? On the score between 1 – 10, how pain is it?

Intan : I think it’s about 5 maybe?

Raheme : Do you have any problem with your digestion?

Intan : I think so, because I am on diet now.

Raheme : Since when you diet?

Intan : About 1 month ago.

Raheme : Have you ever got emesis?

Intan : Yes. 3 days ago and it feels like poignant.

Raheme : Would you mind if I touching your stomachache?

Intan : Sure.
 Raheme : If I touch this area, do you feel pain?

Intan : Yes I do

Raheme : How about this?

Intan : It’s getting worse.

Raheme : Okay. Thank you. How about your bowel movement?

Intan : It’s seems normal but the tecsture is like a liquid.

Raheme : What color of your feces?

Intan : I don’t know. It’s like black, darker then my usually feces and I think there is
blood in my feces.

Raheme : Okay. So, your feces is like liquid and darker also there is blood in yours?

Intan : Yes. Is it normal?

Raheme : I don’t think so maam. I think you got Gasthritis. But, we have to do more
examination like endoscopy and laboratory examination. How do you feel now?

Intan : I feel anxious especially because I can not finish a lot of my job.

3 Termination

Raheme : Okay. I will call doctor to meet you so you can get next treatment. Please stay
here untill he comes. If you need anything, you can ask me.

Intan : Okay Nurse. Thank you.

Raheme : It’s my pleasure maam.