LAPORAN SMALL GROUP DISCUSSION 1

BAHASA INGGRIS
(ASKKB3234)
“NURSING ASSESSMENT”

Fasilitator SGD :Ns. I Kadek Saputra, S.Kep., M.Erg

Kelompok SGD 3
Yohana Ventalia Ina 1802521007
Ni Putu Nanda Adi Putri 1802521008
I Putu Candra Mulyadinata 1802521021
I Putu Langgeng Sugih Tataraharja 1802521026
Ni Nyoman Parayoni Diastuti 1802521030
Laely Wahyunita Septianingrum 1802521032
Pande Luh Made Diah Kharisma Yanti 1802521042
Kadek Citra Mutiara 1802521047
Anak Agung Sagung Dhevie Jayanthi 1802521048
Dewik Prisilia Ariestini 1802521050

PROGRAM STUDI SARJANA ILMU KEPERAWATAN DAN PROFESI

NERS
FAKULTAS KEDOKTERAN
UNIVERSITAS UDAYANA
2021
 NURSING ASSESSMENT
Nurse : “Hello! Good Morning, I’m Yoni, one of Registered Nurses (RNs)
who will do the assessment to you.”
Patient : “Good Morning, oh sure! Glad to see you.”
Nurse : “Glad to see you too, Sir. May I know your name, Sir?”
Patient : “I’m Mr T.”
Nurse : “Okay Mr. T, that’s match with the data. So, how are you today? Are
you feel bad somewhere?”
Patient : “Just a little ache on my wound.”
Nurse : “How old are you, Sir?”
Patient : “I’m 40 years old.”
Nurse : “Is it true you had surgery?”
Patient : “Yes, it is.”
Nurse : “May I know when the operation was performed?”
Patient : “I performed the surgery on May 1st, 2020.”
Nurse : “Okay, then what time were you transferred to the surgical ward?”
Patient : “My family told me, I was transferred at 10 a.m.”
Nurse : “Okay. Now, I would like to check your vital signs. Is that okay?”
Patient : “Of course.”
Nurse : “I will check your temperature first. Excuse me, I will put the
thermometer on your armpit. Hold on for a moment, please.”
Patient : “Yes, of course.”
Nurse : “Okay, your temperature is 37 C, its normal. Now, I want to check
your blood pressure. Would you mind giving me your right arm,
please?”
Patient : “Sure. My blood pressure usually normal.”
(Nurse checking the blood pressure)
Nurse : “Okay, your blood pressure is 110/80 mmHg, its normal. Then I will
check your pulse and your oxygen saturation. I’m going to put the
saturation probe on your finger. Can you put out your finger for me?”
Patient : “Okay nurse.”
Nurse : “Your pulse is 90 beats per minute, and your oxygen saturations is
98%. Its good. I also counted your respirations. Your respiratory rate is
20. It’s better to check when the patient don’t know about it.”
Patient : “Oh, I see. No problem nurse. Does that mean my breath is good?”
Nurse : “Yes, it does. It’s normal.”
Patient : “Okay, thank you nurse.”
Nurse : “Now, I would like to check your level of consciousness. I will ask
you some questions, and I want you to answer it, Sir.”
Nurse : “Now, I want to check your level of consciousness and I want you to
answer

my questions Sir.”

(The nurse observetions the patient eyes response)

Patient : “Yes nurse.”

Nurse : “Do you know who is she?”

Patient : “Yes, I do. She is my friends.”

Nurse : “Do you know where you are?”

Patient : “Yes, I do. I’m in the hospital.”

Nurse : “Do you know what time is it?”

Patient : “Yes, I do. Now the time is about 11 AM.”

Nurse : “Now, please follow my further instruction Mr. T you raise up your

hand please?”

Patient : “Sure nurse.” (patient raise up his hand)

Nurse : “Very good, now can you lift up your leg please?”

Patient : “Yes, sure.” (patient lift up his leg)

Nurse : “Okay, thank you Mr. T.”

Nurse : “Do you feel a pain or discomfort, Sir?”

Patient : “Yes, i feel pain. And it’s very uncomfortable”

Nurse : “Where do you feel the pain?”

Patient : “I feel the pain in the wound area”

Nurse : “When you feel the pain?”

Patient : “Any time, since the surgery was over”

Nurse : “Is the pain felt in the other parts of your body?”

Patient : “No. It’s only in the wound area”

Nurse : “What does the pain look like? Can you explain?”

Patient : “I can’t explain it, I feel it’s very painfull”

Nurse : “On a scale of 0 to 10, with 10 the worst, how would you rate what
you feel right now?”

Patient : “The pain I feel right now on number 6”

Nurse : “What did you do to reduce the pain?”

Patient : “I consume painkillers that the doctor gave me and it’s quite helpful”

Nurse : “Good Sir. I hope you get better soon, Sir.”

Nurse : “I would like to do some examination about your fluid intake and
output Mr. T.”

Patient : “Ok, no problem.”

Nurse : “Alright then, Did you already urinate for today?”

Patient : “I already urinated 3 times for today”

Nurse : “Okay, Excuse me Mr. T. If I may know do you remember the color of
your urine and does it feel hurt when you urinated?”

Patient : “I guess its white and I don’t feel any pain nurse.”

Nurse : “Okay, next I want to check your IV line, may I see it mr?”
Patient : “Okay, sure.”

Nurse : “Seems your IV line in good condition, Did you feel any pain or
anything in your hand Mr. T?

Patient : “No nurse, I don’t feel any uncomfortable fellings.”

Nurse : “Okay thanks for the response Mr. T, based on records of nursing
documentation regarding fluid intake and fluid output. the result is
nothing abnormal about your condition Mr. T.”

Patient : “Okay Nurse, thanks for the information.”

Nurse : “Your welcome Mr. T.”

Nurse : Ok Mr T, May I Continue the assessment?

Ptient : Yes, Of course nurse

Nurse : Ok, Now I would like to check your drainage tubesir, the purpose of
the assessment is to know the drainage tube condition, are you ready for
it?

Ptient :Yes Nurse

Nurse : Ok excuse me sir, I would like to check the drainage tube, there is no
leak in the drainage tube, the drainage tube is good condition

Ptient : Ok nurse, but I am very discomfort with this drainage tube nurse

Nurse : well then later I will collaborate with other medical teams for the next
plan that will be given to help your discomfort

Ptient : Yes, thank you nurse

Nurse : You are welcome sir

Ptient : Ok, Now I would like to assess your checking wounds and dressings.

Nurse : okay Sir, now I would like to check the wound section of the surgery.

Patient : oh okay nurse

Nurse : What do you feel in the area of the surgery, Sir?

Patient : I feels pain, nurse.

Nurse : Oh, the pain is an inflammatory response to prepare for wound

healing, sir.

Patient : is it good, nurse?

Nurse : Okay, I would like to check first, before that I will prepare the tools,
wash my hands and wear gloves to make it clean

Nurse : Your dressing has a little blood on it, moist but it's not too wet. Now
I’m going to open the dressing to see the condition of the wound. If you
have any pain or discomfort, please tell me, okay?

Patient : Yes. of course, nurse

Nurse : Oke Sir, the dressing is open, your wound tissue is pink, there is a little
blood, no pus or other foreign object. Which is good.

Patient : what does it mean if the wound is pink, nurse?

Nurse : it means the tissue is in good condition, there is no infection that hinders
the wound healing process. If it is yellow, slightly greenish, or black
then it could indicate an infection.

Patient : OK nurse, I feel calm

Nurse : Yes Sir, now I’m going to clean the wound first before dressing it
again.

Patient : aww aww

Nurse : feel pain sir?

Patient : just a little bit hehe

Nurse : Okay Sir, it is clean, now I would replace it with a new dressing.
Finally, done.

Patient : Thank you nurse. You are very skilled.

Nurse : you're welcome sir. So don't press on the wound, don't put it in the
water, and don't open it, Sir. Anyway, if the dressing is wet, dirty,
exposed, or has severe pain, please contact me or another nurse
immediately to check the wound and this dressing again, sir.

Patient : Of couse, nurse.

Nurse : Ok sir, now I’ll continue to assess you urinary status

Patient : Sure, Nurse

Nurse : Did you urinate this morning Sir?

Patient : Yes,Nurse

Nurse : How many times did you urinate this morning?

Patient : I think two times this morning

Nurse : And then could you estimate how much is your urine output today in
ml or cc?

Patient : Maybe 500 ml

Nurse : Did you have difficulties when you urinating?

Patient : No, I don’t have, nurse

Nurse : Ok, so what’s the color of your urinate?

Patient : The color is light yellow, nurse

Nurse : Ok sir, do you have any pain while urinating?

Patient : No, nurse

Nurse : Ok that’s good, your urinary status is good. Thank you for your
information. Hope you can recovery soon.

Patient : Ok, thank you nurse

Nurse : Good morning sir, how are you feeling now?

Patient : I am good Nurse.

Nurse : Yes,goodmis. I come here to give youassess patient psychological
status, but let me check your identity and medical record first. Excuse
me Miss, what is your complete name?

Patient : Mr. T

Nurse : Age?

Patient : 40 years old.

Nurse : Okay, thank you. I am going to prepare the instruments and wash my
hands first.

Patient : Please.

First, I will examine how patients behave when communicating,and gestures of

the patient,

Nurse : Give me 15 minutes to ask your psychological status, if you have any
questions beforehand

Patient : I think nope.

Nurse : Very good. well, I will do my goal earlier, did you previously
experience hallucinations during illness?

Patient : never.

Nurse : did you feel a bad day? or a bad mood?

Patient : no, I feeling okay

Nurse : whether today you can remember the events of today, and before?

Patient : Yes.I still remember where before I performed the surgery

Nurse : Is there anything you are worried about now?

Patient : I'm just worried about my illness,

Nurse : Well,well I understand your problem, after this, I hope you don't have
any worries about health services, that's all I can ask you
Patient : thanks nurse

Nurse : Yes Miss!Thanks a lot.for your time, before I’m leaving do you have
any question ?

Patient : nothing nurse

Nurse : Have you ever fallen, Sir?”

Patient : Yes, I have ever fell once form the bed.”

Nurse : When did it happen?”

Patient : Last week.”

Nurse : Why did you fall, Sir? Do you have another disease?”

Patient : No, I dont. That’s because I had a bad dream.”

Nurse : I'm sorry to hear that, thank you for your information.”

Nurse : Okay, now I will check your nutrition Sir.”

Patient : Yes Nurse.”

Nurs : How is it sir? Have you eaten the right portion?”

Patient : Yes. I spend eating portions.”

Nurse : What about your throat, do you feel disturbed by a catheter ?”

Patient : Yes, I feel annoyed because I am not free to eat.”

Nurse : Well then later I will collaborate with other medical teams for the next
plan that will be given.”

Patient : Yes nurse, thank you.”