Goodmorning Ma’am, I am nurse Jessa your nurse for today, how would you like me to address you po?

Gharyz na lang

Okay Ms. Ghrayz

I am going to conduct an interview with you to better help you assess your health status, you have to
communicate with me, you have to tell me honestly what you feel, rest assured that the information will
be safe and confidential and it will be used for your medication purposes only, also I’m going to
document your information so that I will be able to create an individualized nursing care plan? Is it okay
with you? Do you mind if I take a seat?

Yes sure

I have here your biographical data, let me just confirm it to you, okay ma’am?

Okay

You are Ghrayz Manalo, Born on May 13, 2005 18 years old, from Del Pillar San Pascual Batangas, is that
correct ma’am?

Yes

What is your goal attaintment?

College

Ma’am Ghrayz what language do you prefer?

English

Do you have any difficulties in hearing or in speaking?

None

Is my voice clear to you?

Yes

Do you understand me well?

Yes

Before we proceed, do you need anthing? Do you want to attend your personal needs? Like you can go
to CR, do you want someone with you?

No thank you

Are you comfortable with your seat?

Yes

Do you want me to change the room temperature?

No need, I’m fine

Let’s begin Ma’am Ghrayz, what brought you here to the clinic, what is your major health concern?

I experience LBM

C – Can u describe the feeling, are you in pain?

I feel like my skin is dry, I am always thirst and I have a headache

O – When did the it start?

3 days ago

L – Where does it hurt the most?

My head

D – How long does it last? (LBM)

I have loose watery stool 6 times in 24 hours for 3 days

S- How bad your headache? can you rate on scale of 1 – 10, 10 being the highest

P- Are there any treatment you’ve tried to relive the pain?

I take biogesic

A – Do you have any other problems that seem related it?

Abdominal pain

Upon answering all of my questions, you stated that 3 days ago, you loose watery stool 6 times
in 24 hours in 3 days, You feel abdominal pain, thirsty, headache and you feel that your skin is dry . You
rate the pain 8 out of 10, You take biogesic is that correct ma’am?

Yes

Do you want to add something?

I feel like I have a fever right now, my body feel so tired and I am dizzy

All right ma’am can I check your temperature?

Ma’am your temperature is 38.5

upon checking all of these you need to be admitted because you are experiencing dehydration, are you
willing to admitted?

Yes

Ma’am here are the papers that you need to sign for the hospital policy, this is your consent for your
admission.
 Working Phase

Hi Ms. Ghrayz, I am Jessa your attending nurse for 3 pm until 11 pm, how are you?

Hello, I’m good

Is it better than yesterday?

Yes po

Good!

Did you eat po already?

Yes

Okay great! I’ll get your medicine

Are you comfortable with your bed?

Yes

Do you need anything?

None

How’s your sleep last night?

Ahhhmmm, to be honest I don’t have enough sleep

Do you have any difficulties in sleeping?

I think I overthink to my situation and I worry because I have many things to do in school

Hmm, that why you seem worried today, would you mind if I seat here and talk with you?

Yes sure

Okay ma’am ghrayz if you want to share something, I will listen to you and you are free to share your
feelings

Actually I feel tired lately because of schoolwork I feel pressured, before I confined here the results of
our exam was posted to our portal and I feel so sad to the results, I remember the sleepless nights and
hardwork but in the end I failed.

You are not satisfied for the results it must be frustrating and you feel pressured but I believe that you
can overcome the situation because I’ve seen your courage and determination don’t push yourself to
limit because our top priority is our health

Thank you, so much appreciated

So let’s check your temperature, it is 36.6

Do you feel any pain?

No po

Aside having from difficult in sleeping, do you need anything else?

None po

So ma’am ghrayz you told me earlier that you don’t have enough sleep last night, in that case maybe we
should try to off the light during the bed or change your room temperature or anything that makes you
comfortable, just tell me po, okay?

Yes po, thank you

So let me summarize your data, You were admitted here yesterday due to dehydration your
temperature is 38.5 but it lower to 36.6, you were prescribed oresol and paracetamol is that correct
ma’am?

Yes po

Ahhh ma’am can you repeat what I said po?

(inulit)

So ma’am ghrayz if you have clarifications, you can tell me okay po?

Aahhmmm can I ask when I will be discharged?

Actually your doctor says that you have to rest and you have to stay and tomorrow you can go home but
still you have to rest at home and there will be medicine that you need to take and, always drink plenty
of water, okay?

Okay po, thank you

Do you have any more question?

None po

In that I case I am going for you to rest and I will report your situation to your attending physician, and I
will be back at 6 okay?

Okay po

And when you need anything just press the nurse call button and I will be here right away, have a good
day Ma’am ghrayz