Documenti di Didattica
Documenti di Professioni
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RAHMAH WIDYANINGRUM
21 FEBRUARI 2019
STIKES MADANI YOGYAKARTA
Review
1. Introduction Stage
The introduction stage of the interview establishes the goals
for the interaction. The primary goal of the assessment
interview is the collection of data about the client. In this
phase of the interview, the purpose and use of the data
collection should be discussed.
‘‘I need to talk to you for a few minutes about your health so
that we can better plan your care.’’ Adequate time and privacy
should be allowed for the interview so that the client feels free
to share any information that may be relevant.
2. Working Stage
The working stage of the interview focuses on the details of
data collection. The scope of the assessment interview depends
on the type of assessment to be conducted (e.g.,
comprehensive or focused).
The interview may be structured and formal (used in situations
when a large amount of information needs to be obtained) or
unstructured and informal (used in interactions that focus on a
specific area of concern to the client). The nurse should be
familiar with the specific assessment format used by the health
care agency so that attention can be focused toward the client
rather than the form it self.
Closed questions: are questions that can be answered
briefly or with one-word responses. For example, the
question ‘‘Have you been in the hospital before?’’ is a
closed question that can easily be answered by a one-
word response.
Open-ended questions: are questions that encourage
the client to elaborate about a particular concern or
problem. For example ‘‘What led to your coming
here today?’’
3. Closure Stage
This action allows the client an opportunity to
present any other relevant information, and it avoids
surprises when the interview terminates. During the
closure phase, the nurse summarizes what was
covered or accomplished during the interview and
requests validation of perceptions with the client.
3. Health History
A primary focus of the data collection interview is the health history.
While the medical history concentrates on symptoms and the
progression of disease, the nursing health history focuses on the client’s
functional health patterns, responses to changes in health status, and
alterations in lifestyle plan of care and formulating nursing
interventions. Following are elements of the health history:
Demographic information
Reason for seeking health care
Client perception of health status
Previous illnesses, hospitalizations, surgeries
Client and family medical history
Immunizations and exposure to communicable disease
Allergies
Current medications
Developmental level
Psychosocial history
Sociocultural history
Activities of daily living
Review of systems
4. Physical Examination
KELOMPOK 1 (IKHWAN)
What is nursing diagnosis ?
Purposes of nursing diagnoses
The components of nursing diagnoses.
KELOMPOK 2 (AKHWAT)
Category of nursing diagnoses
Explore characteristics of the nursing diagnosis taxonomy.
Describe the process of developing a nursing diagnosis.
KELOMPOK 3 (AKHWAT)
Identify common errors in developing a nursing diagnosis.
Discuss limitations of nursing diagnoses.
Explore barriers that can affect the use of a nursing diagnosis.
Describe strategies to overcome limitations of and barriers to using nursing diagnoses.
Describe how a nursing diagnosis enables the delivery of holistic, comprehensive nursing care.