CASE STUDY REPORT: NURSING ASSESSMENT

Arranged in order to completing the assignment of Basic Concept in Nursing

By:

Group B / Class International (C) / Semester II / Batch 2020

Fuzna Dahlia Mudzakiroh (I1J020010)
Harsanti Ratna Hanifah (I1B020053)
Mutiara Romadhon (I1B020040)
Nur Aljananti (I1J020004)

DEPARTMENT OF NURSING
FACULTY OF HEALTH SCIENCES
JENDERAL SOEDIRMAN UNIVERSITY
APRIL 2021
 CHAPTER I

INTRODUCTION

In today's complex healthcare environment, nurses must be able to solve problems

accurately, thoroughly and quickly. This means that nurses must be able to analyze large
amounts of information to make critical judgments. Nursing assessment is a systematic
process of collecting, verifying, and communicating data about clients.

The nursing process includes assessment, nursing diagnosis, planning, preparation of

outcome criteria, actions, and evaluation. The nurse uses clinical assessment and judgment to
formulate a hypothesis, or explanation of the presentation of the problem actual or potential
health risks and / or opportunities for promotion. All of these steps require knowledge of the
concepts underlying nursing science before patterns are identified according to clinical data
or accurate diagnosis.

In nursing practice, communication always plays an important role in the life process,
especially in determining the success of a nursing assessment. Communication is at the core
of human social life and is a basic component of human relationships. Many problems related
to humans can be identified and resolved through communication, but many small things in
human life become basic problems because of communication (Suryani, 2005).

The use of therapeutic communication is something that needs attention from nurses
to obtain accurate information and foster a trusting relationship between client and family.
Therapeutic communication is useful as a support in the implementation of nursing care, so
that you can find out what the client feels and needs (Mundakir, 2006).

In the nursing communication method, there are two questions, namely open
questions used when nurses need multiple answers from clients, open questions are objective,
do not direct the person being asked, and produce answers consisting of many words. With
open questions, nurses are able to encourage clients to express themselves (Antai-
Otongdalam Suryani, 2005). And closed questions are used when the nurse needs short
answers and closed questions are used to get only certain facts and pieces of information.
 CHAPTER II

REPORT CASE

I. Case
Lina planned to spend some time talking more deeply with Mrs. Devine about her knowledge
regarding the operation to be carried out. "Mrs. Devine, as we have talked about your
operation, I will ask some questions so that we can plan the treatment well. Before we start,
you have a question? (the client has no questions). "Well, let's start with a question from me.
What do you already know about the procedure after surgery? (the client answers that he will
often be examined by the nurse). "What do you mean by" check "? (client says the nurse will
watch him closely). "Will that make you less worried?" (The client said it would give a little
comfort knowing the nurse was nearby). "Is there anything else the doctor said about
healing?"
1. During interactions, what questions does Lisa use that are open-ended questions?
2. Does Lisa assess fatigue? If so, what is the purpose?
3. Evaluate Lisa's introductory way of communicating!
4. What are the advantages of using open-ended questions over closed-ended questions?

II. Answer
1. In that case, Lisa's open-ended question form are:
 “What do you already know about the procedure after surgery?”
 "What do you mean by" check "?
 "Will that make you less worried?"
 "Is there anything else the doctor said about healing?"
2.
Definition Fatigue Anxiety
1. Fatigue is a state of Anxiety is a vague feeling
increased discomfort of discomfort or worry
and decreased with an autonomic
efficiency as a result response (often
of overwork or nonspecific or unknown
excessive work sources) (nanda)
 (Dorland Dictionary)
2. Fatigue is the
continual exhaustion
and decrease in
physical and mental
work capacity at a
normal rate (nanda)
Related factors anxiety, stressors, a lifestyle stressor, needs that are not
without stimulation met
apathy, lack of interest in the fatigue, insomnia,
Characteristics
surroundings, lack of energy, decreased productivity,
unhealthy sleep patterns weakness

From the data above, it can be concluded that fatigue and anxiety have a close
relationship. So, lisa assess fatigue. The client stated that she would feel less worried if she is
being near with the nurse. Fatigue can lead to the feeling of worried and anxiety.
The goal is to be able to take action decisions or not, and to be able to determine
nursing assessments for the next stage, to be able to provide effective care. Because one also
cannot assume that every patient with the same medical diagnosis will respond in the same
way, for example, every patient who undergoes a surgical procedure does not always
experience anxiety. This question is therefore asked to be approached from the point of view
of the nursing discipline and only made when it is based on patient-centered assessment.
3. The thing that needs to be evaluated in the preliminary stage of Lisa's communication
with clients are:
 Lisa as a nurse doesn't first greet like saying good morning, afternoon or evening.
 lisa also did not introduce herself before
 the third lisa also did not explain what the purpose was to come and ask the patient
like that.
 Lisa did not ask the patient's condition first and just immediately did what she
wanted to do
 Lisa did not ask the patient for a willingness in advance and also made an
agreement with the patient
4. The advantages of open-ended questions are:
 Allows respondents to convey information which he deems important
 Allows the interviewer to know lack of understanding of respondents in a field;
 Allows respondents to express their feelings, prejudices that may exist, and
stereotypes regarding an issue
 Allows the interviewer to know respondent's skills in communication.
 Open-ended questions are also able to provide opportunities for patients to mention
broad topics to be discussed and encourage patients to answer in as much detail as
possible.
 Open-ended questions make the client describe the problem in 2 or 3 words. This
allowing a discussion where the client is actively explaining his health status will
strengthen the relationship between nurse and client because open questions show
that the nurse is willing to listen to the client's thoughts and feelings.
 CHAPTER III

DISCUSSION

A. Definition and Stages of Nursing Assessment

Nursing Assessment is an effort to collect data completely and systematically to be studied
and analyzed so that the health and nursing problems faced by patients, whether physical,
mental, social or spiritual, can be determined. This stage includes three activities, namely
Data Collection, Data Analysis and Determination of Health Problems and nursing.
Assessment includes collecting subjective and objective information (eg, vital signs,
patient / family interviews, physical examination) and reviewing patient history information
provided by the patient / family, or found in medical records. The nurse also collects
information about the patient / family's strengths (to identify health promotion opportunities)
and risks (to prevent or delay potential problems). Assessment is the initial and basic stage in
the nursing process that is most decisive for the next stage. Therefore, the assessment process
must be carried out carefully and carefully, so that all the care needs of the client can be
identified so that it is used to gather information about the client's health status. Normal client
health status and gaps can be collected and this is intended to identify patterns of client health
function, both optimal and problematic.
Assessment can be based on certain nursing theories such as those developed by Florence
Nightingale, Wanda Horta, or Sr. Callista Roy, or on standard assessment work such as
Functional Health Patterns According to Marjory Gordon. These templates provide a way of
categorizing large amounts of data into manageable amounts based on patterns or related data
categories.
A nursing diagnosis is a clinical assessment of the human response to health disorders or
life processes, or susceptibility to these responses from an individual, family, group or
community (NANDA-I 2013). A nursing diagnosis usually contains two parts:

1. Descriptor or modifier
2. The focus of the diagnosis, or the key concepts of the diagnosis

The nurse diagnoses health problems, states risks and readiness for health promotion. A
problem-focused diagnosis should not be viewed as more important than a risk diagnosis.
Sometimes a risk diagnosis can be the diagnosis with the highest priority for the patient. This
may be especially true when the associated risk factors are identified in the assessment such
as poor vision, difficulty with gait, a history of falls, and increased anxiety with relocation.
Nursing assessment are used to identify the expected outcome of care and plan specific
nursing actions in order. Nursing outcome criteria refer to the measured behavior or
perceptions shown by an individual, family, group, or community that is responsive to
nursing actions. Nursing assessment "provide the basis for the selection of nursing
interventions to achieve outcomes that constitute nurse accountability" (NANDA-I, 2013).
The nursing process is often described as a gradual process, but in reality the nurse will
Return to Steps in the process. The nurse will move between nursing assessment and
diagnosis. The formulation of a nursing diagnosis refers to actuality, risk, probability,
wellness, and syndromes.
The purpose of the assessment stage is to collect information and also create client
baseline data, identify and recognize problems faced by clients, identify client health needs,
identify physical, mental, social and environmental clients. According to the American
Nurses Association (ANA) there are several things that need to be considered in conducting
nursing assessments, namely as follows (Delaune et al, 2002): 1.) Assessment must be
relevant to client needs 2.) Collected from various sources 3.) Collected from various
techniques 4.) Arranged systematically 5.) Documented in a good and correct format.
The nursing process itself also has its stages, namely: nursing assessment, nursing
diagnosis, nursing planning, nursing implementation and evaluation. While the assessment
stage includes data collection, data analysis, data validation, systematics or data grouping,
assessment data interpretation (problem identification) and data documentation.

B. Kinds and Sources of Data for Nursing Assessment

1) Kinds of data
a. Basic Data, all information about the client's health status that shows the pattern of
effective or optimal health function so that the data used is the basis for establishing a
prosperous nursing diagnosis. Baseline data includes: general data, demographic data,
nursing history, health function patterns and examinations.
b. Focus data, client health information that deviates from normal conditions, which can be
in the form of a client's expression or the result of a direct examination by the nurse.
c. Subjective Data, expressing client complaints directly from clients directly or indirectly
through other people who know the client's situation directly and convey the problems
that occur to the nurse based on what happens to do anamnesis.
d. Objective data, this data is data that can be measured or observed, it can be obtained
from measurement results during physical examinations, laboratories, photographs, and
so on. There are two kinds of data sources, primary and secondary. The client is the
primary source of data. Meanwhile, the secondary includes the family of the closest
person, client records, health professionals, literature.

2) Data Source
a. Primary data sources
The primary data source is the client. If the client is unconscious, has speech or hearing
problems, the client is still an infant or for some reason the client cannot provide direct
subjective data, the nurse uses objective data to enforce nursing diagnoses. However, if it
is necessary to clarify subjective data, the nurse should take anamnesis with the family.
b. Secondary data sources
Includes family, closest people, friends, and other people such as doctors, nutritionists,
physiotherapists, laboratories, and radiologists.

C. Data Collection Technique

1. Anamnesis
Anamnesis is a question and answer or direct communication with the client (auto-history)
or indirectly (allo-anamnesis) with his family to explore the client's health information.
The communication used is therapeutic communication, which is a pattern of interpersonal
relationships between clients and nurses that aims to gather information about the client's
health status and help solve problems that occur. The stages in this history taking are:
a. Preparation phase. It is better if the nurse first reads the medical record or finds out the
main complaints that the client is currently feeling. If the nurse still does not understand
the client's diagnosis, it is better if the nurse learns it from the available sources.
b. Introductory stage. At this stage the nurse explains to the client the importance of the
interview and the purpose of conducting the interview. Opening can be done by
introducing the identity of the nurse. Provide a quiet room and maintain the privacy of
clients or family members. Listen to client and family explanations attentively. Try to
 conduct the interview in a sitting and facing position. Maintain eye contact between
nurse and client.
c. Work stage (open and closed questions) At this stage the nurse begins to give specific
questions that discuss the client's health problems and the client's main reason and the
main reason the client comes looking for health assistance. Interviews can be conducted
in a formal and structured manner. Do not ask questions that are cornering or
judgmental of the client. There are four types of questions when conducting interviews
including:
1) Closed questions, these questions are used in directive interviews, are restrictive in
nature and usually require only “yes” or “no” answers or short factual answers that
provide specific information from the patient. (For example: "So during this one
day, have you had 10 watery stools?")
2) Open questions, this question is appropriate with non-directive interviews inviting
the patient to explain about the patient's health. Open-ended questions only state
broad topics for discussion, and encourage the patient to answer as much detail as
possible. These open-ended questions often begin with 5W 1H questions. (For
example: "What did you complain about during these 3 days that you came to the
hospital?")
3) Neutral questions. This question is a question that can be answered by the patient
without prior guidance from the nurse and is used in non-directive interviews.
4) Guided questions, this question is the opposite of neutral questions that the patient
needs to direct first by the nurse. This question is used in directive interviews.
(Kozier, 2010)
d. Closing. This stage indicates the collection process and has been fulfilled. It ends by
providing a conclusion and equating perceptions of the client's current condition.
2. Observation
This stage is carried out by general observations of the client's behavior and condition.
a. Examination
 Physical examination includes 4 ways:
 Inspection. The observation process is carried out by observing. Inspection is
used to detect physical signs related to physical activity. The focus of
inspection on every part of the body includes body size, color, shape, position,
symmetry, injuries, changes that occur in the skin, anatomical abnormalities.
  Palpation. For examination by means of touch. Hands and fingers are sensitive
instruments to sense changes that occur in the body. Palpation is used to
collect data on temperature, turgor, shape and size, mass, humidity, vibration,
and texture.
 Percussion. Method of examination by tapping. The aim is to determine the
boundaries of an organ or part of the body by feeling the vibrations that are
caused by the movement that is exerted under the tissue.
 Auscultation. The method of examination is by listening with a stethoscope.
Aims to listen to heart sounds, breath sounds, bowel sounds, fetal heart rate
and measure blood pressure.
 Supporting investigation. Conducted in accordance with the indications, examples
of the approach from head to toe, body systems approach, health function pattern
approach, chest radiograph, laboratory, heart recording, etc.
b. Medical History
Medical History is a summary of the client's health condition from the past to the
reasons why he currently comes to the health center. This history includes the
following: Demographic data, main complaints, Perception of current illness, history of
previous illnesses, history of surgery, history of hospitalization, family history of
illnesses, current medications being undertaken, history of allergies, mental
development status clients, psychosocial history, sociocultural history, daily living
activities.

D. Barriers to Data Collection

1. Not being able to do anamnesis appropriately, such as giving closed questions so that
the patient is unable to explain his complaint in detail.

2. Not being able to carry out a proper physical examination

3. Not able to organize data

4. Incomplete data

5. Inaccurate data

6. There are conflicting data

E. Kinds of Nursing Assessment

1. Comprehensive assessment.
a) This assessment process is usually carried out when the patient registers at the health
center.
b) The examination includes all body systems to find out abnormalities that occur in
the body.
c) This examination will become basic data if one day the patient returns to be
examined.
2. Focused assessment
a) This assessment is more focused on the part that has abnormalities.
b) The assessment is only carried out on the area or tissue system that the patient
complained about.
c) For example: assessment of a patient who is about to give
3. Ongoing assessment
a) This assessment is carried out when the nurse observes the patient's development
status.
b) This assessment can be done in the room when the patient's condition begins to
improve or when taking action.
c) Its use is to complement missing data and assess the progress of the patient's
condition.
 CHAPTER IV

CONCLUSION

Nursing Assessment is an effort to collect data completely and systematically to be studied

and analyzed so that the health and nursing problems faced by patients, whether physical,
mental, social or spiritual, can be determined. This stage includes three activities, namely
Data Collection, Data Analysis and Determination of Health Problems and nursing. The
purpose of the assessment stage is to collect information and also create client baseline data,
identify and recognize problems faced by clients, identify client health needs, identify
physical, mental, social and environmental clients.

In this case study there are several things that the nurse needs to find out. This case
study provides some questions to be answered regarding the nursing assessment. First of all,
Nurse Lisa asked using open-ended question. From the data, it can be concluded that fatigue
and anxiety have a close relationship. The client stated that she would feel less worried if she
is being near with the nurse. Fatigue can lead to the feeling of worried and anxiety. The goal
is to be able to take action decisions or not, and to be able to determine nursing assessments
for the next stage, to be able to provide effective care.
There are things that needs to be evaluated in the preliminary stage of Lisa's
communication with clients; (1) Lisa as a nurse doesn't first greet like saying good morning,
afternoon or evening, (2) Lisa also did not introduce herself before, (3) The third lisa also did
not explain what the purpose was to come and ask the patient like that, (4) Lisa did not ask
the patient's condition first and just immediately did what she wanted to do, (5) Lisa did not
ask the patient for a willingness in advance and also made an agreement with the patient.
However, Lisa used some open-ended questions during the assessment and this has
advantages. Open-ended questions make the client describe the problem in 2 or 3 words. This
allowing a discussion where the client is actively explaining his health status will strengthen
the relationship between nurse and client because open questions show that the nurse is
willing to listen to the client's thoughts and feelings.
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