ELLA BIISNILLA

2011114359

Group 1 A 2020.2

Reporting Of Patients Health Problem

Situation (S)

Nurse : “Assalamualaikum, good afternoon Doctor, I'm nurse Ella in NusaIndah 2”

Doctor : “Waalaikumussalam nurse”

Nurse : “I want to report a new patient from the ER last night. Mrs. Tiara is 69 years old
in room 2, now complaining of right hip pain on a scale of 8. The right leg is also difficult to
move. She already got ketorolac injection yesterday at 6 am.”

Background (B)

Dokter : “What is the history, TTV results, laboratory and patient diagnosis nurse?”

Nurse : “The patient has a history of falling from the bathroom, has a history of long
strokes. A spalk on the right leg has been installed in the ER and an X-ray of the femur has been
performed but there are no readings, the laboratory has been taken but there are no results, vital
signs with blood pressure 140/90 mmHg, pulse 76 times/minute, RR 22 times/minute,
temperature 36 ,5 C.”

Assessment (A)

Nurse : “Provisional diagnosis is femoral fracture doc”

Recommendation (R)

Dokter : “Okay nurse, loosen the spalk if it's too tight and take a Pelvis photo”

Nurse : “Ok doc, is there any additional therapy to relieve the pain doc?”

Dokter : “Give extra ketoproten supp . therapy”

Nurse : “Ok doc, when will the doctor be able to come to the room to see the patient?”

Dokter : “Later I will come to the room at 10 am”

Nurse : “Ok, thank you, then I'll excuse myself, doc, assalamualaikum”

Dokter : “Waalaikumussalam nurse”