ENGLISH (COMMUNICATION)

FORM SYMPTOM ASSESMENT

Group 14:
I Wayan Dedy Gunawan (203213233)
Ni Made Udiyani Lestari (203213234)
I Putu Agus Artawan (203213235)

NURSING SCIENCE STUDY PROGRAM

WIRA MEDIKA BALI HIGH SCHOOL OF HEALTH SCIENCES
DENPASAR 2021
 CONVERSATION

Nurse: good morning, is it true with Mrs. Udi?

Patient: yes that's right
Nurse: Introduce me nurse Agus who is on duty today, first I will ask you a few questions, may I?
Patient: yes you can
Nurse: ok, before you go to the hospital, why if I may know?
Patient: I feel pain in my stomach
Nurse: how long have you been sick mrs?
Patient: about 5 minutes
Nurse: what makes you feel sick to your stomach?
Patient: I think it's because I often eat spicy food
Nurse: how do you feel now about your illness?
Patient: my stomach feels like it's suffocating
Nurse: Is the pain spreading?
patient: not spread only in the right abdomen only
Nurse: on a scale of 0-10 what is the pain scale, mrs?
Patient: scale 5
Nurse: If the scale is 5, is it difficult for you to carry out daily activities?
patient: yes it is difficult nurse
Nurse: when did you feel pain in your stomach?
Patient: every minute nurse
Nurse: What do you know about the cause of your stomach pain?
Patient: I think it's because I don't control my diet
Nurse: ok for the medicine I will call the doctor to give the medicine mrs
Patient: yes ok
Doctor: morning, mrs. udi, I'm doctor Dedy, earlier, nurse Agus explained some things to me. This is a pain
reliever, please, madam, drink it after lunch
Patient: ok doc thank you
Doctor: yes you're welcome
 Name patient Ni Made Udiyani Lestari
Symptom Date of Birth 11,October-2002
Asesssment No Medical Record 11102002
Sex Woman
Address Jln. Nagasari. No 3. Ds. Jagapati
Phone Number 08977440851

Symptom: Pain in right side of stomach

Palliative Performance Scale%: Stabl Slow decline Rapid decline Unknown
e

Onset The patient said that the right side of the stomach hurts and feels pain, the pain is
When did it begin? How long does it last?
O How often does it occur? felt for about 5 minutes

Provoking/palliating the patient says stomach pain from eating spicy food
What brings it on? What
P makes it better? What
makes it worse?
Quality he patient said his stomach pain was like choking
What does it feel like?
Q Can you describe it
(patient's own words)
Region/radiation The patient said that the abdominal pain did not spread only to the right side
R Where is it?
Does it spread? of the abdomen
Severity
How severe is this symptom? he patient said the pain scale was 5 and the patient had difficulty doing
What would you rate it on a scale 0-10 (0 being
none and 10 being the worst possible)? activitie
S Right now? At worst? On average?
How bothered are you by this symptom?
Are there any other symptom(s) that accompany this
symptom?
Treatment
What medications and treatments are you
The patient is given painkillers by the doctor
currently using?
Are you using any non-prescription treatments,
herbal remedies, or traditional healing practices?
T How effective are these?
Do you have any side effects from the
medications and treatments?
What have you tried in the past?
Do you have concerns about side effects or cost of
treatments?
Understanding The patient said that the cause of his stomach pain was because the patient
What do you believe is causing this symptom?
U How is it affecting you and/or your family? did not control his diet
What is most concerning to you?
Values the patient's pain scale is 5, the patient is difficult to carry out activities,
What overall goals do we need to keep in mind as
we manage this symptom? some activities are assisted by the family
What is your acceptable level for this symptom (0-
10)?
V Are there any beliefs, views or feelings about this
symptom that are important to you and your family?
What are you having trouble doing because of this
symptom that you would like to do?

Describe likely etiology of the symptom: the possibility of the patient experiencing symptoms of appendicitis
Physical findings/comments:……………………………………………………………………………………………………

Name of Physician/ Signature Date of Data Collected

Nurse agus and Doctor dedy November 18, 2021