Description of the assessment

Nursing Assessment is the first step of the five steps of the nursing process, involves the
systematic and continuous collection of data; sorting, analyzing, and organizing data; and
documentation and communication of the data collected.

In conducting nursing assessment, critical thinking skills must be applied during the nursing
process to provide a decision making framework to develop and guide a plan of care for the
patient incorporating evidence-based practice concepts.

The Nursing Assessment includes gathering information from the patient about the patient's
physiological, psychological, sosiological, and spiritual needs. Subjective and Objective data
collection are a part of this process. And it is the first step in the successful evaluation of a
patient. The nurse must focus to listen and write any data collected during the process.

BAHAN MATERI TENTANG HIPERTENSI

1. Definition of hypertension
Blood pressure is the force exerted by circulating blood against the walls of the
body’s arteries, the major blood vessels in the body. Hypertension is when blood
pressure is too high. Hypertension is diagnosed if, when it is measured on two
different days, the systolic blood pressure readings on both days is ≥140 mmHg
and/or the diastolic blood pressure readings on both days is ≥90 mmHg.

2. Risk factor for hypertension

Modifiable risk factors include unhealthy diets (excessive salt consumption, a diet
high in saturated fat and trans fats, low intake of fruits and vegetables), physical
inactivity, consumption of tobacco and alcohol, and being overweight or obese.

3. Common symptoms of hypertension

headaches, nosebleeds, irregular heart rhythms, vision changes, and buzzing in
the ears. Severe hypertension can cause fatigue, nausea, vomiting, confusion,
anxiety, chest pain, and muscle tremors.

4. Complications of uncontrolled hypertension

Among other complications, hypertension can cause serious damage to the
heart. Excessive pressure can harden arteries, decreasing the flow of blood and
oxygen to the heart. This elevated pressure and reduced blood flow can cause:
• Chest pain, also called angina.
 • Heart attack, which occurs when the blood supply to the heart is blocked and
heart muscle cells die from lack of oxygen. The longer the blood flow is blocked,
the greater the damage to the heart.
• Heart failure, which occurs when the heart cannot pump enough blood and
oxygen to other vital body organs.
• Irregular heart beat which can lead to a sudden death.
Hypertension can also burst or block arteries that supply blood and oxygen to the
brain, causing a stroke.

In addition, hypertension can cause kidney damage, leading to kidney failure.

5. The burden of hypertension can be reduced

Reducing hypertension prevents heart attack, stroke, and kidney damage, as well as
other health problems.

Prevention

• Reducing salt intake (to less than 5g daily)

• Eating more fruit and vegetables
• Being physically active on a regular basis
• Avoiding use of tobacco
• Reducing alcohol consumption
• Limiting the intake of foods high in saturated fats
• Eliminating/reducing trans fats in diet

Management

• Reducing and managing mental stress

• Regularly checking blood pressure
• Treating high blood pressure
• Managing other medical conditions

6. Some of the foods should eat when get hypertension

● Skim or 1% milk, yogurt, Greek yogurt (calcium-rich foods can lower blood
pressure).
● Lean meat.
● Skinless turkey and chicken.
● Low-salt, ready-to-eat cereals.
● Cooked hot cereal (not instant).
 ● Low-fat and low-salt cheeses.
● Fruits (fresh, frozen, or canned without added salt).
● Vegetables (fresh, frozen or canned, no added salt).
○ Richly colored green, orange, and red items are high in potassium and
minerals that help lower blood pressure.
○ The goal is 5-9 servings of fruits and vegetables per day.
● Plain rice, pasta, and potatoes.
● Breads (English muffins, bagels, rolls, and tortillas).
● Lower salt "prepared" convenience food.

Unsalted seeds (pumpkin, squash, sunflower) and unsalted nuts are mineral-rich foods
that lower blood pressure.

Foods should eat less of

● Butter and margarine.

● Regular salad dressings.
● Fatty meats.
● Whole milk dairy products.
● Fried foods.
● Salted snacks.
● Canned soups.
● Fast foods.
● Deli meats.

Resources

Toney-Butler TJ, Unison-Pace WJ. Nursing Admission Assessment and Examination. [Updated
2020 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Hypertension. 2019. World Health Organization.

https://www.who.int/news-room/fact-sheets/detail/hypertension​ [ Accessed 2020-11-15 ]
Dialogue
N : Nurse
P : Patient
F : Patient’s family

(SCENE DUDUK)
N : Hello Good Morning..I’m Syifa. I’m a nurse who has a responsibility to do assessment while
you are here. Can you tell me your full name?
P : Hi Good Morning nurse, my name is Gisa Agustin
N : Okay, ma’am Gisa. May I know your date of birth?
P : Sure, it’s 08 August 1975
N : Next, where do you live?
P : I live in Garut street Miramare number 11
N : May I know your phone number?
P : Of course, 08123456789
N : Do you have any health insurance?
P : Yes, I do. It’s BPJS
N : Can you tell me the name of your next of kin?
P : Sure, she is my daughter, Syahida Ayu.
F : Hi nurse, I’m Ayu, Gisa’s daughter
N : Hi, Ayu. May I know your phone number? in case something happen
F : Oh sure, 08987654321
N : Okay thank you for the information, please wait a moment for further examination.
P,F : Okay nurse.

(SCENE PASIEN DIPANGGIL KE RUANG PEMERIKSAAN)

*di dalam ruangan, nurse membaringkan pasien*
N : Well, before I do the examination, you can lie down first ma'am, let me help you
P : Sure, Thanks nurse
N : Okay, I will do vital signs check first, which includes blood pressure, body temperature, pulse
rate, respiratory rate
P : okey sure, nurse
*nurse melakukan pemeriksaan TTV*
N : Okay ma’am the examination of the vital signs has been completed and the results are ;
blood pressure 160/100 mmHg which means very high, body temperature 37 C, pulse rate 80
times/minute, and respiratory rate 20 times/minute
P : Wow, is this dangerous for my body condition, Nurse?
N : For now I can't be sure, but let me do an assessment furthermore
P : Okey nurse
N : Anyway, can you tell me why you are here?
P : So I have a headache and then I can't see clearly because my vision also becomes blurry
N : How long have you got it?
P : Since last night, so I couldn't sleep
N : What causes your condition to improve or worsen?
P : the pain increases when I do strenuous activities or get up from a sleep position.
N : Alright then. Can you explain the pain? whether it feels sharp, stinging, pressure, severe
pain, colic, aching or stabbing pain?
P : The pain I felt was like being stabbed, very ill
N : Is the pain spread or focused on one point such as only in the middle or on the other side?
P : The pain I felt in the head, back, neck and shoulders, really makes me uncomfortable.
N : What is the pain like? If the pain score was on a scale of 1-10 with 0 being painless and 10
being the most painful, would you choose which scale for your pain?
P : I choose scale 8
N : When did the pain appear, appeared slowly or suddenly, or was it continuous or occasional?
P : My pain seems to come on constantly when I get up from a sleep position.
N : Have you got a history of diseases related to this condition?
P : Yes, I have had hypertension since 1 year ago.
N : If I may know, do you do regular check-ups regularly?
F : No she doesn’t, she never do routine check-ups because she feel better for the past 3
months
N : Okay, did you take medicine for your high blood pressure?
P : Yes nurse, I took Amlodipine 5 mg for my past medicine regularly, but for 3 months I have
not taken any medication because I feel better
N : Okay, then does your family suffer from the same disease as yours or even a different
disease?
P : Yes, my mother has hypertension too and had been hospitalized for it
N : How long has your mother had hypertension?
P : Hmm I think since she was 50 years old, and now she's 65 years old
N : That means it's been around 15 years,right?
P : Yes, right nurse
N : If I may know what caused she to experience the disease?
F : According to the doctor's statement, my grandma’s illness is caused by an unhealthy
lifestyle, especially she likes to eat unhealthy and nutritious foods
N : What foods does your family usually eat? Can you describe a typical family breakfast or
dinner?
F : She often cooks home meals that contain fat, such as meat. Then for breakfast my family
often eats noodles,and tends to prefer salty foods
P : Yes, that’s right nurse
N :Oh, i see, then w​hat are some daily activities that you do?
P : For now, as usual work from home in front of computer, clean the house, then I usually do
exercise at least three times a week to maintain my stamina
F : The daily activities I do for weekdays are helping my parents, online study, and for holidays I do
more for my own time, such as watching netflix and more active on social media
N : Okay, all the questions are done. Thank you for your answer and opportunity. I will contact the
doctor for further examination
P : Okay nurse, your welcome
F : okay nurse, your welcome
*nurse meninggalkan ruangan*
SCRIPT BREAKDOWN

NO TIME SCENE TALENT PROPERTY WARDROBE

1. 7’’ Opening - - -
- UNPAD logo
- Video title
- FKep logo

45’’ Pengantar dari dosen pembimbing Ibu Ristina - Pakaian

: bebas sopan
- Tujuan pembelajaran

1’ 30’’ Description of the assessment Kemeja, dan

(prinsip dan konsep pengantar) menggunakan
jas lab
Script :

Nursing Assessment is the first Dinda

step of the five steps of the
nursing process, involves the
systematic and continuous
collection of data; sorting,
analyzing, organizing data; and
also documentation and
communication of the data
collected.

In conducting nursing
Sofi
assessment, critical thinking skills
must be applied during the
nursing process to provide a
decision making framework to
develop and guide a plan of care
for the patient incorporating
evidence-based practice
concepts.

The Nursing Assessment Aurel

includes gathering information
from the patient about the
patient's physiological,
psychological, sosiological, and
 spiritual needs. Subjective and
Objective data collection are a
part of this process. And it is the
first step in the successful
evaluation of a patient. The nurse
must focus to listen and write any
data collected during the process.

7’ Role Play As a Patient : - Lembar Nurse :

Gisa Agustin catatan menggunakan
Script dialog : assessm jaslab dan
As a kin : ent / pakaian
(SCENE DUDUK) Syahida Ayu tablet seperti
N : Hello Good Morning..I’m (kalau perawat
As a Nurse : sudah
Syifa. I’m a nurse who has a
Syifa Aulia computer Pasien dan
responsibility to do assessment ized) keluarga :
while you are here. Can you tell - tensimet menggunakan
me your full name? er pakaian
P : Hi Good Morning nurse, my - termome bebas dan
ter sopan
name is Gisa Agustin
N : Okay, ma’am Gisa. May I
know your date of birth?
P : Sure, it’s 08 August 1975
N : Next, where do you live?
P : I live in Garut street Miramare
number 11
N : May I know your phone
number?
P : Of course, 08123456789
N : Do you have any health
insurance?
P : Yes, I do. It’s BPJS
N : Can you tell me the name of
your next of kin?
P : Sure, she is my daughter,
Syahida Ayu.
F : Hi nurse, I’m Ayu, Gisa’s
daughter
N : Hi, Ayu. May I know your
phone number? in case
something happen
F : Oh sure, 08987654321
N : Okay thank you for the
information, please wait a
moment for further examination.
P,F : Okay nurse.

(SCENE PASIEN DIPANGGIL

KE RUANG PEMERIKSAAN)
*di dalam ruangan, nurse
membaringkan pasien*
N : Well, before I do the
examination, you can lie down
first ma'am, let me help you
P : Sure, Thanks nurse
N : Okay, I will do vital signs
check first, which includes blood
pressure, body temperature,
pulse rate, respiratory rate
P : okey sure, nurse
*nurse melakukan pemeriksaan
TTV*
N : Okay ma’am the examination
of the vital signs has been
completed and the results are ;
blood pressure 160/100 mmHg
which means very high, body
temperature 37 C, pulse rate 80
times/minute, and respiratory rate
20 times/minute
P : Wow, is this dangerous for my
body condition, Nurse?
N : For now I can't be sure, but let
me do an assessment
furthermore
P : Okey nurse
N : Anyway, can you tell me why
you are here?
P : So I have a headache and
then I can't see clearly because
my vision also becomes blurry
N : How long have you got it?
P : Since last night, so I couldn't
sleep
N : What causes your condition to
improve or worsen?
P : the pain increases when I do
strenuous activities or get up from
a sleep position.
N : Alright then. Can you explain
the pain? whether it feels sharp,
stinging, pressure, severe pain,
colic, aching or stabbing pain?
P : The pain I felt was like being
stabbed, very ill
N : Is the pain spread or focused
on one point such as only in the
middle or on the other side?
P : The pain I felt in the head,
back, neck and shoulders, really
makes me uncomfortable.
N : What is the pain like? If the
pain score was on a scale of 1-10
with 0 being painless and 10
being the most painful, would you
choose which scale for your
pain?
P : I choose scale 8
N : When did the pain appear,
appeared slowly or suddenly, or
was it continuous or occasional?
P : My pain seems to come on
constantly when I get up from a
sleep position.
N : Have you got a history of
diseases related to this
condition?
P : Yes, I have had hypertension
since 1 year ago.
N : If I may know, do you do
regular check-ups regularly?
F : No she doesn’t, she never do
routine check-ups because she
feel better for the past 3 months
N : Okay, did you take medicine
for your high blood pressure?
P : Yes nurse, I took Amlodipine
5 mg for my past medicine
regularly, but for 3 months I have
not taken any medication
because I feel better
N : Okay, then does your family
suffer from the same disease as
yours or even a different
disease?
P : Yes, my mother has
hypertension too and had been
hospitalized for it
N : How long has your mother
had hypertension?
P : Hmm I think since she was 50
years old, and now she's 65
years old
N : That means it's been around
15 years,right?
P : Yes, right nurse
N : If I may know what caused
she to experience the disease?
F : According to the doctor's
statement, my grandma’s illness
is caused by an unhealthy
lifestyle, especially she likes to
eat unhealthy and nutritious
foods
N : What foods does your family
usually eat? Can you describe a
typical family breakfast or dinner?
F : She often cooks home meals
that contain fat, such as meat.
Then for breakfast my family
often eats noodles,and tends to
prefer salty foods
P : Yes, that’s right nurse
N :Oh, i see, then w​hat are some
daily activities that you do?
P : For now, as usual work from
home in front of computer, clean
the house, then I usually do
exercise at least three times a
week to maintain my stamina
 F : The daily activities I do for
weekdays are helping my parents,
online study, and for holidays I do
more for my own time, such as
watching netflix and more active on
social media
N : Okay, all the questions are
done. Thank you for your answer
and opportunity. I will contact the
doctor for further examination
P : Okay nurse, your welcome
F : okay nurse, your welcome
*nurse meninggalkan ruangan*

30’’ Penutup
- Subject (EFN 1)
- Kelompok tutor
- Dosen Tutor
- Nama dan NPM
- Kombinasi foto (opsional)
- Referensi
- Copyright
- Ucapan terima kasih