NURSING ASSESMENT I

NUZUL QURANIATI

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

TOPICS:
1. Introduction to health assessment
2.The assessment interview and health
history
3. Physical assessment technique
4. Diagnostic test

1. Introduction to Health Assesment

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

basis of nursing care.

form the

Data Collection
Primary data source: patient
Secondary data source: Family members, medical
records, 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 Collection

Legal
Complete

Accurate
Relevance

New

2. The Assessment Interview and Health

History
A clinical data base consists of two main components (1) the health
history and (2) the record of physical examination.
The purpose of the assessment interview: collect data (judgment about a
persons 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 the
persons special concerns and perception about health illness, health
promoting behaviour, and health care.
The assessment interview requires: a systematic and comprehensive
approach (B1-B6).

The Interview Process

May be formal and structured to collect a wide
range of information or informal and focused on
a specific area of concern.
Three interrelated phase constitute an effective
interview: (1) the introductury phase, (2) the
working phase, (3) the termination phase.

Introductury Phase:
(1.a) establishing rapport: begin
w/ demonstrating respect for the
client as a person with a problem
rather than the person as a
problem to be solved.
(1.b). Ensuring comfort: conduct
the interview in a private setting,
free from interruptions or
distraction
(1.c). Stating purpose: encourage
the person to participate in the
interview

Working Phase:
(2.a). to collect biographic data
(2.b). to collect data pertinent to
the clients health status
(2.c). To identify and respond to the
clients needs.
*The structure interview begins
with biographic information, should
proceed from general to specific.

Termination Phase:
This phase serves to end the
interview.
Presumary, sumary, and follow
up
techniques
may
be
incorporated into this phase

3. Physical Assessment Technique

Assesment:
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. Palpate

painfull areas last.

Percussion: tapping the body lightly but sharply to determine the

position, size, and density of underlying structures as well as to detect
fluid or air in a cavity.

Auscultation: the skills of listening to body sounds created in the

lungs, heart, blood vessels, and abdominal viscera. This technique is
the last technique used during the examination ( except abdominal
examination)

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 medical
test performed to aid in the diagnosis or detection of disease. For
example, such a test may be used to confirm that a person is free
from disease, or to fully diagnose a disease, including to subclassify it regarding severity and susceptibility to treatment.

References
Nursalam (2010), English in nursing midwifery science and
technology, Salemba Medika, Jakarta.
Fuller, J, Jennifer, S.A, J.B(1994), Health Assessment: a nursing
approach Lippincott Company, Philadelpia.