A.

Assesment
Nursing assessment is the gathering of information about a patient’s
physiological. Psychological, sosiological, and spiritual status by licensed Registered
Nurse. Nursing assessment is the first step in the nursing process. A section of the
nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may
be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) It differs
from a medical diagnosis. In some instances, the nursing assessment is very broad in
scope and in other cases it may focus on one body system or mental health. Nursing
assessment is used to identify current and future patient care needs. It incorporates the
recognition of normal versus abnormal body physiology. Prompt recognition of
pertinent changes along with the skill of critical thinking allows the nurse to identify
and prioritize appropriate interventions. An assessment format may already be in
place to be used at specific facilities and in specific circumstances.
Ex. Terapeutik Communication in Assesment
1. Orientation
Ns : Hello; good morning, I’m nurse in charge. May I help you?
Pt : Yes, Good Morning Nurse, I need to see doctor because my leg is hurt.
Ns : What happened to your leg?
Pt : I feel down the stairs. I immediately, I felt a bad pain in my left hip and I
couldn’t stand at all.
Ns : When did it happen?
Pt : Two hours ago.
Ns : Have you taken any pain-killers?
Pt : No, I came directly here.
Ns : Ok. I will put you on the line but first, you have to register since you are new
patient in our hospital. Aside that I will do the physical examination too to check your
body condition. It will takes abouts 30 minutes . is it OK for you?
Pt : Ok nurse, no problem
2. Work Phase
Ns : Your full name sir?
Pt : Lukas Tiahahu
Ns : Your address sir?
Pt : Citra Grand City; Palembang
Ns : Where do you work ?
Pt : I’m retirement
Ns : Do you have any complain about your body beside this ?
Pt : Yes, I was diagnosed with hypertension and Diabetes Mellitus since 2 years ago.
But now under controlled.
Ns : Let me check your blood pressure. Please pull up your sleeve and make your
arms straight.. good.. that’s better… (Nurse put on the band and begin to pumping).
Let me know if it’s hurt you. Usually how high is you BP?
Pt : 130/90 or 130/100 it’s around that..
Ns :… (Nurse check the BP).. it’s 135/90. I think it’s good. How old are you?
Pt : I’m 65 years old Ns.
Ns : With your age it is ok. I will examine you, please lie on the bed, loosen your
belt. Point to the spot where you feel the most pain. Where is the pain location ? could
u show me?
Pt : it’s here nurse, around the left hip. I have hurt my right elbow. I can’t move it
because of the pain.
Ns : How did it happen?
Pt : When I was getting into the bus, I fell on my elbow. That happened this
morning.
Ns :is it still painful? On the score between 1-10. How pain is it.?
Pt : Yes. Since the accident it has been stiff and looks black and blue. At times it
feels numb. I think the score about 6-7.
Ns : it looks swollen and warm is it pain? Can you feel this, when I put in your hand?
Pt : Yes
Ns : After the accident, were you got fainted ? can you remember the place, time and
who’s help you ?
Pt : I didn’t faint but a little bit dizzy. I remembered the event better nurse. I was on
Sudirman road, this morning around 8.00AM when I was about get into the bus. A
young man help me to get here and he help me call my family as well. What a good
boy.
3. Termination
Ns : Thank GOD, now I will call doctor to meet you. Please stay here until he comes.
If need anything let me know. I will be in the next room.
Pt : Ok. Nurse, Thank you.
B. Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response
to actual or potential health conditions or needs. The diagnosis reflects not only that
the patient is in pain, but that the pain has caused other problems such as anxiety, poor
nutrition, and conflict within the family, or has the potential to cause complications—
for example, respiratory infection is a potential hazard to an immobilized patient. The
diagnosis is the basis for the nurse’s care plan.

c. Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for this patient that might include moving from bed to
chair at least three times per day; maintaining adequate nutrition by eating smaller,
more frequent meals; resolving conflict through counseling, or managing pain through
adequate medication. Assessment data, diagnosis, and goals are written in the
patient’s care plan so that nurses as well as other health professionals caring for the
patient have access to it.

d. Implementation
Nursing care is implemented according to the care plan, so continuity of care for
the patient during hospitalization and in preparation for discharge needs to be assured.
Care is documented in the patient’s record.
Ex. Terapeutik Communication in Implementation
Nurse: How are you, sir, are you ready?
Patient: Yes sir.
Nurse: Let's take a comfortable position.
Patient: Yes sir
Nurse: let’s take a comfortable upright sitting position, and then pull your elbows
back slightly and your chest expands. Take a deep breath through your nose. Hold
your breath and count to five. Exhale slowly from the nose, do you understand what I
am explaining?
Patient: Yes, sir
Nurse: can you repeat it sir?
Patient: Yes, sir.
(the patient does deep breathing exercises)
Nurse: okay. Now, now you can do it to reduce the paint. Do you have any questions
sir?
Patient: No sir, I think that's enough.

e. Evaluation
Both the patient’s status and the effectiveness of the nursing care must be
continuously evaluated, and the care plan modified as needed.

Ex. Terapeutik Communication in Evaluation

Evaluate the client's response to nursing actions
Subjective evaluation:
Nurse: How do you feel after doing the deep breathing technique?
Patient: Some what more nurse than before
Objective Evaluation:
Patient Shows feeling more comfortable, and more relaxed
Nurse: Oh yes sir, I recommend, don't do the deep breathing technique continuously.
If there is a change that we can see 1-2 hours after this I will come back to ask if the
pain is relieved sir
Patient: yes nurse
Upcoming contracts (topic, time, place):
Nurse: because I think it is better for you to finish it first, later I will do an evaluation
of your pain at 4 o'clock here, to re-observe whether your pain has decreased.
Nurse: Thank you for your cooperation, sir, I am nurse Erlina Rosida, I would like to
say goodbye to the nurse's office, if you need anything, you can ask your family to
call me at the nurse's office.
Patient: Yes, nurse, thank you
Nurse: your welcome