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ASSESSMENT

RAHMAH WIDYANINGRUM
21 FEBRUARI 2019
STIKES MADANI YOGYAKARTA
Review

1. When reviewing a client’s lab results, the nurse must have a


knowledge base that includes which of the following types of
knowledge in order to think critically?
a. Affective
b. Declarative
c. Nonjudgmental
d. Psychomotor
2. Which of the following phrases accurately describes the nursing
process? Select all that apply.
a. Applicable to every setting
b. Can be implemented by unlicensed personnel
c. Is a linear process
d. Organized care delivery framework
e. Used with adults only
4. Which of the following is an example of objective client data?
a. 500 mL of amber-colored urine in collection bag
b. Client complaint of nausea
c. Client states pain is 9 on a scale of 1–10
d. Self-report of insomnia
5. A client in the intensive care unit (ICU) has several health problems.
Which of the following nursing diagnoses should be of priority concern to
the nurse?
a. Imbalanced nutrition: less than body requirements
b. Impaired skin integrity
c. Ineffective airway clearance
d. Risk for injury (falls)
6. When referring to a client’s medical record for information, the nurse is
using which data source?
a. Analytical
b. Primary
c. Secondary
d. Tertiary
Definition & Purpose

 Definition: the first step in the nursing process and


includes systematic collection, verification,
organization, interpretation, and documentation of
data for use by health care professionals.
 The purpose is to establish a database concerning a
client’s physical, psychosocial, and emotional health
in order to identify health-promoting behaviors as
well as actual and potential health problems.
 Through assessment, the nurse determines the
client’s functional abilities and the absence or
presence of dysfunction.
Otitis media
Katarak
Types of assessment

Three types of assessment are:


1. Comprehensive assessment: usually performed upon
admission to a health care agency includes a complete
health history to determine current needs of the client.
This database include assessment of physical and
psychosocial aspects of the client’s health, the client’s
perception of health, the presence of health risk factors,
and the client’s coping patterns.
2. Focused assessment is an assessment that is limited in
scope problem or potential health care risks. Focused
assessments are not as detailed as comprehensive
assessments and are often used in health care agencies in
which short stays are anticipated
1. Outpatient surgery centers and emergency departments, in specialty
areas such as labor and delivery.
2. For example, the following is a list of sample questions used to assess a
client experiencing labor: When did your contractions begin?
Fraktur & Persalinan
Types of assessment

3. Ongoing assessment is an assessment that


includes systematic monitoring and observation
related to specific problems.
 This type of assessment allows the nurse to broaden the
database or to confirm the validity of the data obtained during
the initial assessment.
 Ongoing assessment is particularly important when problems
have been identified and a plan of care has been implemented to
address these problems.
 Systematic monitoring and observation allow the nurse to
determine client response to nursing interventions and to
identify any emerging problems.
Proses penyembuhan luka
TYPES OF DATA

 Client data include information that clients communicate


about perceptions of their own health status as well as
specific observations made by the nurse. These two types
of information are referred to as subjective and objective
data.
 Subjective data are data from the client’s point of view and include
feelings, perceptions, and concerns. These data (also referred to as
symptoms) are obtained through interviews with the client. They are
called subjective because they rely on the feelings or opinions of the
person experiencing them and cannot be readily observed by
another.
 Objective data are measurable data that are obtained through
observation, standard assessment techniques performed during the
physical examination, and laboratory and diagnostic testing. These
data (also called signs) can be seen, heard, or felt by someone other
than the person experiencing them.
SOURCES OF DATA

 A comprehensive database should consist of data


from every possible source, including:
 Client
 Family and significant other
 Other health care professionals
 Medical records
 Interdisciplinary conferences, consultations
 Results of diagnostic tests
 Relevant literature (journal ect)
Example …
METHODS OF DATA COLLECTION

 The nurse collects information through the following


methods: 1) observation, 2) interview, 3)
health history, 4) physical examination, and
5) laboratory and diagnostic data
 These approaches require systematic use of the
assessment skills discussed in the following text
1) observation

 The nurse uses the skill of observation to carefully


and attentively note the general appearance and
behavior of the client.
 Observation helps the nurse determine the client’s
status, both physical and mental. By carefully
watching the client, the nurse can detect nonverbal
cues that indicate a variety of feelings, including
presence of pain, anxiety, and anger.
 Observational skills are essential in detecting the
early warning signs of physical changes (ex: pallor
and sweating).
2) interview

 An interview is a therapeutic interaction that has a


specific purpose. The nurse interviews for a variety of
reasons throughout the nurse-client relationship,
including data collection, teaching, exploration of the
client’s feelings or concerns, and provision of
support.
INTERVIEW PREPARATION

 The interview is more productive if the nurse has an


opportunity to prepare for the interaction (client’s medical
records, conversations with other health care team members),
and research of the presenting medical diagnosis.
 This information can be useful in obtaining the client’s
relevant history and formulating a current needs assessment.
Interview stages:

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

 Use of visual, auditory, tactile, and olfactory senses with the


systematic assessment techniques.
 Inspection. Inspection involves careful visual observation.
 Palpation. Palpation uses the sense of touch to assess texture,
temperature, moisture, organ location and size, vibrations and
pulsations, edema, masses, and tenderness. Palpation requires a calm,
gentle approach and is used systematically.
 Percussion. Percussion uses short, tapping strokes on the surface of
the skin to create vibrations of underlying organs. It is used for
assessing the density of structures or determining the location and the
size of organs in the body. Structures with relatively more air (such as
the lungs) produce louder, deeper, and longer sounds with percussion
than more dense, solid structures (such as the liver.
 Auscultation. Auscultation involves listening to sounds in the body
that are created by movement of air or fluid. Areas most often
auscultated include the lungs, heart, abdomen, and blood vessels.
Although direct auscultation is sometimes possible, a stethoscope is
usually employed in order to amplify the sound.
5. Laboratory and Diagnostic Data

 Results of laboratory and diagnostic tests can be


useful objective data as these values often serve as
defining characteristics for various altered health
states; these can also be helpful in ruling out certain
suspected problems. For example, diabetic clients
who are poorly controlled on diet or medication will
usually have an elevated blood glucose level.
Lab diagnostik
Data verification

 Data verification is the process through which data


are validated as being complete and accurate. Once
the nurse completes the initial data collection, the
data are reviewed for inconsistencies or omissions.
DATA ORGANIZATION

 After data collection is completed and information is


validated, the nurse organizes, or clusters, the
information together in order to identify areas of
strengths and weaknesses.
 This process is known as data clustering. How data
are organized depends on the assessment model
used
Assessment model

 An assessment model is a framework that provides a systematic


method for organizing data. The use of a model helps to ensure
comprehensive and organized data collection.
 NON NURSING MODEL
 BODY SYSTEMS MODEL Approaching data collection by examining body
systems is sometimes referred to as the ‘‘medical model,’’ since it is frequently
used by physicians to investigate presence or absence of disease
 HIERARCHY OF NEEDS Maslow’s hierarchy of needs model (1971) proposes
that an individual’s basic physiological needs must be met before progressing
to higher-level needs (TUGAS 1)
 NURSING MODEL
 FUNCTIONAL HEALTH PATTERNS Gordon’s (2002) human functional
health patterns model provides a systematic framework for data collection
that focuses on 11 functional health patterns. (TUGAS 2)
 HUMAN RESPONSE PATTERNS The North American Nursing Diagnosis
Association (NANDA), in an effort to standardize terminology related to client
problems, has developed a taxonomy of nursing diagnoses (NANDA,2009)
 THEORY OF SELF-CARE The theory of self-care, developed by Orem (2001)
 ROY ADAPTATION MODEL The Roy adaptation model is organized around
adaptive behaviors (Andrews & Roy, 2008) dll
 DATA INTERPRETATION (tugas 3)
 DATA DOCUMENTATION (tugas 4)
Referensi

Delaune, Sue C; Ladner, Patricia K. 2011.


Fundamental of Nursing: Standards and Practice
Fourth edition (Pg. 89 – 107). USA: Delmar.
Jazakumullohu khairan ^^
PRESENTASI PEKAN DEPAN

 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.

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