NURSING ASSESMENT INUZUL QURANIATI

nuzul-q-a@fkp.unair.ac.id

TOPICS:

1. Introduction to health assessment

2.The assessment interview and healthhistory

3. Physical assessment technique

4. Diagnostic test

Health assesment: a proces by which you, the nurse analyze and synthesize (collected data information) judgment about health status or determine patients need NURSING CARE.

Assessment allows the Nurse to:

1. Determine strength promote health behaviours and wellness.

2. Identify needs, clinical problems or nursing diagnosis form the basis of nursing care.

1. Introduction to Health Assesment

Data CollectionPrimary data source: patient

Secondary data source: Family members, medicalrecords, other health

Various tools and technique can be used. E.g:interviewing, observing, listening, physical examination,reviewing records or results of diagnostic

Data is classified into (1) subjective data and (2)objective data.

Principles of Data CollectionLegal

Complete

Accurate

Relevance

New

2. The Assessment Interview and Health HistoryA clinical data base consists of two main components (1) the healthhistory and (2) the record of physical examination.

The purpose of the assessment interview: collect data (judgment about apersons health status), helping relationship between the nurse and client(with criteria: trust, a feeling care and concern).

The assessment interview provides: the opportunity to identify thepersons special concerns and perception about health illness, healthpromoting behaviour, and health care.

The assessment interview requires: a systematic and comprehensiveapproach (B1-B6).

The Interview ProcessMay be formal and structured to collect a widerange of information or informal and focused ona specific area of concern.

Three interrelated phase constitute an effectiveinterview: (1) the introductury phase, (2) theworking phase, (3) the termination phase.

Termination Phase:This phase serves to end theinterview.

Presumary, sumary, and followup techniques may beincorporated into this phase

Working Phase:(2.a). to collect biographic data

(2.b). to collect data pertinent tothe clients health status

(2.c). To identify and respond to theclients needs.

*The structure interview begins with biographic information, should

proceed from general to specific.

Introductury Phase:(1.a) establishing rapport: beginw/ demonstrating respect for theclient as a person with a problemrather than the person as aproblem to be solved.

(1.b). Ensuring comfort: conductthe interview in a private setting,free from interruptions ordistraction

(1.c). Stating purpose: encouragethe person to participate in theinterview

3. Physical Assessment TechniqueAssesment:

1. Consist of:

- Illness history: patients identity; chief complain, history of present illness, past nursing history, family history

- Observation of vital signs

- Physical examination (B1-B6 with IPPA approach)

- Result of Diagnostic test

2. Assesment data are documented:

- Accurately

- Completely

- Concisely

- Factually

Cont Inspection: systematic and deliberate visual observation to determine

health status

Palpation: avoid discomfort and your hands should be warm. Palpatepainfull areas last.

Percussion: tapping the body lightly but sharply to determine theposition, size, and density of underlying structures as well as to detectfluid or air in a cavity.

Auscultation: the skills of listening to body sounds created in thelungs, heart, blood vessels, and abdominal viscera. This technique isthe last technique used during the examination ( except abdominalexamination)

Assessment:

- Gathering data

- Validating data

- Organizing data

- Identifying patterns

- Reporting/ recording data

Interpreting data(analysis and synthesis

Diagnosis:-Identifying problems-Identifying risk factors-Predicting potential problems//complications- identifying resources and strength

4. Diagnostic Test

In medicine, a diagnostic test is any kind of medicaltest performed to aid in the diagnosis or detection of disease. Forexample, such a test may be used to confirm that a person is freefrom disease, or to fully diagnose a disease, including to sub-classify it regarding severity and susceptibility to treatment.

References

Nursalam (2010), English in nursing midwifery science andtechnology, Salemba Medika, Jakarta.

Fuller, J, Jennifer, S.A, J.B(1994), Health Assessment: a nursingapproach Lippincott Company, Philadelpia.