Capter 1

(General Assessment)

Vani Rosalina As Nurse

Elmi Khairani As Patient

Part 1 (Collecting Demographic Data Elements)

N : “Good Morning Miss”

P : “Good Morning Nurse”

N : “It’s Time To Me Interview You Assess Your Health Condition”

P : “Ok Nurse”

N : “What Is Your Name?”

P : “My Name Is Elmi Khairani”

N : “How Old Are You?”

P : “ I Am 18 Years Old”

N : “What Is Your Address?”

P : “ My Address Is In Street Kanangan No.22”

N : “What Is Your Phone Number?”

P : “ My Phone Number Is 088 000 888 000”

N : “Are You Married?”

P : “No, I Am Not”

N : “Do You Have Any Health Insurane?”

P : “ No, I Dont Have”

N : “What Is Your Occupation?”

P : “ My Occupation Is Student”

N : “What Brings You In This Hospital?”

P : “I Have Diarrhea”

N : “Who Send You To This Hospital?”

P : “My Mother”

N : “What Makes You Come To Hospital?”

P : “ I Did Not Stop Diarrhea In 3 Days”

Part 2 (Curren-Health And Illness Status)

N : “Would You Tell Me About Your Health Condition Recently?”

P : “ I’m Usually Health Have Usual Weak And Always Bowel Movement”

N : “ How Many Time A Day Do You Do Your Bowel Movement?”

P : “ 5 Times A Day”

N : “Is The Stool Formed Or Loosed?”

P : “ The Stool Is Loosed”

Part 3 (History Of Past Health And Illnesses)

N : “Have You Ever Had Communicable Disease?”

P : “ No, I Haven’t ”

N : “Are You Allergic To Antibiotic Or Certain Food?”

P : “ I Have Allergic Spicy Food ”

N : “Have You Ever Been Immunised Against Fever?”

P : “ Yes, I Have”
 Capter 2

(Dimension Of Symptops)

N : “Where Do You Feel It?”

P : “ I Feel Pain Around My Stomach”
N : “Does It Move Around?”
P : “ No doesn’t ”
N : “Show Me Where.”

P : “ Around Here (In The Lower Right Spot Of My Stomach)”

N : “What Is It Like? Is It Sharp, Dull, Stabbing, Aching?”

P : “ I Feel Stabbing Pain”
N : “Do You Feel Nusea?”
P : “ No, I Dont”
N : “What Does The Pain Look Like?”
P : “ I Feel Abdomen Cramps,Fetique And Dehydration”
N : “When Did It Last?”
P : “ The Last Time My Stomach Pain When I Wake Up This Morning”
N : “On A Scale Of 0 To 10, With Ten The Worst, How Would You Rate What You Feel
Right Now?”
P : “On A Scale Of 0 To 10,I Think 8”
N : “What Was The Worst It Has Been?”
P : “I Lose My Appetite, I Don’t Want To Have A Lot Of Meal”
N : “Does This Interfere Your Usual Activities? In What Ways?”
P : “It Becomes More Painful If I Am Working”
N : “When Did You First Notice It?”
P : “3 Day Ago When I Had Finished Lunch”
N : “How Long Does It Last?”
P : “3 Day Ago When I Had Finished Lunch”
N : “How Often Does It Happen?”
P : “It’s As Much As 8 Times A Day”
N : “Does It Occur In A Particular Place Or Under Certain Circumstances?”
P : “I Have Recurrent Paint In My Lower Part Of My Stomach”
N : “Have You Taken Anything For It?”
P : “I Taken Diapet”
N : “Does It Appear In Particular Time?”
P : “I Always Stomach Cramps And Dehydration After Works”

Chapter 3
(Patient Assessment)

N : “Now I Want To Exmine Your Abdoment”

P : “ OK Nurse”
N : “Would You Remove Your T-Shirt”
P : “Yes”
First Nurse Start To Check Patient Abdomen With Inspection Technique To Observe,
A Visual Examination Of The Patient’s Body Parts To Detect Normal Characteristic Or
Significant Physical Signs

Then Nurse Perform Palpation Technicque Nurse Give Deep Presure to Patient’s
Abdomen Using Her Hand To Check Patient Abdomen

N : “Does This Hurt?”

P : “Yes,it does”

Next Nurse Perform Auscultation Technicque Use Stethosope To Listen Sounds

Produced By The Colon,And Counting Sound Bowel Movement.
And Nurse Perform Percussion Involves Tapping The Abdomen With Fingertips To
Evaluate The Size, Borders, And Consistency Of Body Organs And Discover Fluids In Body
Cavities.

N ; “Ok Now I Want To Exmine Your Eye”

P :”Ok Nurse”
N : “Would You Look Up”
P :”Yes Nurse”

Nurse Perform Inspection Technicque To Check Patient Eye And Observation

Conjungtiva Appear Anemi Or Not.
 CHAPTER 4
(CHECKING VITAL SIGN)

N : “Ok Miss It’s Time For Me To Measure Your Blood Pressure,Would You Lie Down On
The Bed?”

P : “Ok Nurse,”(The Patient Is Lying On The Bed)

N : “Now I Want You To Roll Your Sleeve Up”

P (The Patient Roll Up His Sleeve)

N (The Nurse Starts Checking The Patient’s Blood Presure Using The Tension)

N : “Ok Now I Am Going To Count Your Pulse Would You Mind Give Me Your Right Or
Left Hand?”

P : “Ok Nurse,”(The Patient Give Her Right Had)

N(The Nurse Start’s Looking For The Pulse Of The Patient And Counting The Patient Pulse)

N : OK Fine,

N : “Ok Now I Would Like To Check Your Respiration,Now I Want You To Take A Deep
Breath ”

P (The Patient Take A Deep Breath)

N : Ok Good

N : “Now I Just Want To Measure Your Temperature,Would You Raise Your Arm? ”

P : “Ok Nurse,”(The Patient Raise Arm)

N (Nurse Check Patient Temperature Use Thermometric)

N : “Ok All Is Done”

 Chapter 5

Discharge Instruction

N : “Ok Miss,I Suggest You To Drink 8 Glassess Of Water A Day And You Should Have
Rest A Lot

P : “Ok Nurse”

N : “Then You’d Better Take You Medicine Regularly And You Must To Keep Your Food
Clean”

P : “Yes Nurse”

N : “Ok I Have Prohibition For You First You Should Avoid Eating Spicy Food And You
Should Not Be Too Tired Or Stresses Out”

P : “Ok Nurse”