CASE STUDY

Ms. L (Lilian Harrow) is a 20 years old woman, she had been admitted to Health World Hospital accompanied by her mother, Mrs. Evelyne Harrow on May 12th 2011 with complaints of short breathing, ineffective cough, inability to remove airway secretions, chest pain, fever, anorexia and weakness. The patient is in Magnolia ward number 8. The medical diagnosis is Acute Bronchitis, with problems of ineffective airway clearance. Based on the vital sign examination, her blood pressure is 95/55 mmHg, her pulse is 60 beats/min, her respiratory rate is 25 times/min and her body temperature is 37,7 0C.

SCRIPT SCENARIO
In the Magnolia ward number 8, on 12th May 2011 at 09.00 am, nurse Anne Lorient meet the patient, Ms. Lilian to do an assessment. Ms. Lilian is lying on the bed accompanied by her mother. : Assalamualaikum. Good morning, Ms. And Mrs. Harrow. (Nurse greet Ms. And Mrs. Harrow within shake hand and smile friendly) Patient : Waalaikumussalam. Good morning, nurse. (answer the greeting weakly) Mrs. Harrow : Waalaikumussalam. Good morning, nurse. Nurse : You are Ms. Lilian Harrow, arent you? How are you today? Patient : Youre right, nurse. Im not quiet well. Nurse : Im Anne Lorient, nurse in charge here until 02.00 pm. You may call me Anne. Would you mind if I call you Lily? Patient : Never mind, nurse Anne. Nurse : Thanks Lily. Now, I would like to do an assessment to you. The purpose is to get and clarificare your information or your data that used for your appropriate nursing care. I will ask you some questions. I hope very much, you can answer my questions honestly. Dont be worry, Lily. I will keep your privacy and all secrets about you. Just relax. The contract time are about 10 minutes. Before we start, is there any question or any complaint? Patient : No, thanks nurse Anne. But may I sit while answering your questions? Nurse : Of course, let me help you. Patient : Thank you very much, nurse Anne. Lets start. Nurse : OK. Firstly, would you mind to let me know your full name? Patient : My full name is Lilian Elizabeth Harrow. Nurse : Now, would you mind to tell me about your self? Such as age, religion, education, occupation, and so on. Patient : Never mind, nurse. Im 20 years old, my religion is Islam. Now, Im a student of Arts in Cambridge University. Nurse : Wow, thats great. And then, would you mind to let me know where do you live? Patient : I live with my parents in Fleur Drive number 5, Wisteria Walk, Edensor, Herthfordshire. Nurse : Thats nice and beautiful place. Is your house clean and healthy? Patient : Yeah, Im very happy there. I think its quiet healthy, nurse Anne. Nurse : OK, good. Now, would you like to tell me about your illness, please Lily? Patient : Errsince two days ago, I got fever. I think its just an usual fever, but yesterday I was difficult to breath and cough. I had bleeding cough and pain when trying to breath. Its like pressure of heavy thing in my middle chest. It was so bad in night. So I came here soon. Nurse : Is there any complaint that make you feel bad, Lily? Patient : Untill now, I feel so weak, and I dont want to eat. Nurse

: Im so sorry to hear that. Had you ever felt the same complaint and suffer the same illness, Lily? Patient : Yes, I had nurse Anne. I ever suffered the same illness when I was still 19 years old. But, it was not too bad. Nurse : Is there any family who smoke in home and ever suffer the same illness, Lily? Patient : No, there isnt, nurse Anne. But my father is an active smoker. Nurse : Well. Is there anything I have to know, Lily? Patient : No thanks, I just feel like a stranger here, may be because I have to stay away from my lovely home. Nurse : Yeah, I hope youll be happy here, you just havent used to be here. Your mom and I will help you. Patient : Thanks, nurse Anne. Ill try. Mrs. Harrow : Yeah, we will. Nurse : OK. Thats very good, Lily. This assessment is finish. Thank you very much for your participation and your cooperation, you have answered all of my questions well. I will come here again about 1 hour later for other nursing care. I hope youll get better soon, amin. Keep spirit to be better! Good bye. Assalamualaikum (with shake hand and smile friendly again) Patient & Mrs. Harrow : Waalaikumussalam, nurse. Nurse Nurse Anne leave the Magnolia ward number 8.