Muhammad Ghazy Setyaputra (180103063)

NURSING ASSESSMENT
Assessment Data Assessment Interview and Physical Examination (Nurse – Patient Dialogue)
Case 2
Mr. G, aged 73, was hospitalized due to a medical diagnosis of Nurse : Good morning, how are you?
Pulmonary TB. The client complained of shortness of breath. Mr. G : Good morning, nurse. I’m fine
The client said that he was coughing up blood for an hour ± 5 Nurse : My name is Ghazy, I’m nurse in charge this shift. I’d like to check your
tbsp. The client was frightened of the expelled blood while condition today
coughing. He also suffered from chest pain with scale 5 out of Mr. G : Sure, nurse
10 to cough up with sputum. The results of his physical Nurse : I just want to take a look at your ID bracelet, please give me your hand
examination were BP 140/90 mmHg, P : 120 bpm, T : 36.8 ‘C, Mr. G : Here it is
RR : 30 breaths/ minute, and ronchi breathing. The client’s face Nurse : How old are you ?
lookes tense and nervous. The patient said that he has never Mr. G : 73 YO, nurse
had this condition before. Nurse : Ok, thanks. Are you comfortable with your position now? Is there anything i
Subjective Data Objective Data can do for you?
Mr. G : I’m okay nurse, thanks
Nurse : Before I start the assessment, I will close the curtain for your privacy and
1. The client complained of 1. The client’s face lookes wash my hands
shortness of breath tense and nervous Mr. G : Okay
2. The client said that he was 2. Blood Pressure : 140/90 Nurse : Now, I’d like to ask some questions about your condition, it will be about 15
coughing up blood for an mmHg minutes, is that okay?
hour ± 5 tbsp 3. Pulse : 120 bpm Mr. G : Yeah, sure
3. The patient said that he 4. Temperature : 36.8 °C Nurse : So, How is your feeling today?
has never had this 5. Respiration : 30 breaths/ Mr. G : I feel so frightened because expelled blood while coughing and my breathing
condition before minute is shortness
6. Ronchi (+) Nurse : How long has it been?
Mr. G : I was coughing up blood for an hour ± 5 tbsp
Nurse : : On a scale 1 to 10, how would you rate your pain ?
Mr. G : I think it’s around 5
Nurse : Anyway, Have you ever had medical problem or physical injury?
Mr. G : No, never had this condition before
Nurse : Now, I’d like to check your vital signs. Could you please unbutton your shirt?
Im going to put this thermometer into your armpit
Mr. G : Sure, nurse
Nurse : And let me check your pulse. Please, give me your other hand
Mr. G : This is it.
Nurse : : Now I need to check your blood pressure. Would you please roll your sleeve
up?
Mr. G : OK
Nurse : Excuse me, I just need to put this cuff around your arm. It will
be a bit tightening
Mr. G : Okay, nurse
Nurse : I’m done. I will take the thermometer from your armpit and note this. Your
temperature was 36,8°C, your pulse was 120 BPM, your respiration was 30/minute,
and your blood pressure was 140/90 mmHg and I found ronchi breathing
Mr. G : Is that normal?
Nurse : You have got abnormal respiration, I will give you some medication and by
drinking a lot it will be better soon
Mr. G : Ok thanks you, nurse
Nurse : Thank you. I have got all I need. Now, I will reopen the curtain. Is there
anything I can help before I leave?
Mr. G : No, thanks
Nurse : Ok, your call button is here. If you need anything, just let me know. Get well
soon, see you
Mr. G : Thank you, nurse. See you too