nurs assessment 1
TRANSCRIPT
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NURSING ASSESMENT INUZUL QURANIATI
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TOPICS:
1. Introduction to health assessment
2.The assessment interview and healthhistory
3. Physical assessment technique
4. Diagnostic test
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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 form the basis of nursing care.
1. Introduction to Health Assesment
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Data CollectionPrimary data source: patient
Secondary data source: Family members, medicalrecords, 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.
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Principles of Data CollectionLegal
Complete
Accurate
Relevance
New
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2. The Assessment Interview and Health HistoryA clinical data base consists of two main components (1) the healthhistory and (2) the record of physical examination.
The purpose of the assessment interview: collect data (judgment about apersons 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 thepersons special concerns and perception about health illness, healthpromoting behaviour, and health care.
The assessment interview requires: a systematic and comprehensiveapproach (B1-B6).
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The Interview ProcessMay be formal and structured to collect a widerange of information or informal and focused ona specific area of concern.
Three interrelated phase constitute an effectiveinterview: (1) the introductury phase, (2) theworking phase, (3) the termination phase.
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Termination Phase:This phase serves to end theinterview.
Presumary, sumary, and followup techniques may beincorporated into this phase
Working Phase:(2.a). to collect biographic data
(2.b). to collect data pertinent tothe clients health status
(2.c). To identify and respond to theclients needs.
*The structure interview begins with biographic information, should
proceed from general to specific.
Introductury Phase:(1.a) establishing rapport: beginw/ demonstrating respect for theclient as a person with a problemrather than the person as aproblem to be solved.
(1.b). Ensuring comfort: conductthe interview in a private setting,free from interruptions ordistraction
(1.c). Stating purpose: encouragethe person to participate in theinterview
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3. Physical Assessment TechniqueAssesment:
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
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Cont Inspection: systematic and deliberate visual observation to determine
health status
Palpation: avoid discomfort and your hands should be warm. Palpatepainfull areas last.
Percussion: tapping the body lightly but sharply to determine theposition, size, and density of underlying structures as well as to detectfluid or air in a cavity.
Auscultation: the skills of listening to body sounds created in thelungs, heart, blood vessels, and abdominal viscera. This technique isthe last technique used during the examination ( except abdominalexamination)
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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
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4. Diagnostic Test
In medicine, a diagnostic test is any kind of medicaltest performed to aid in the diagnosis or detection of disease. Forexample, such a test may be used to confirm that a person is freefrom disease, or to fully diagnose a disease, including to sub-classify it regarding severity and susceptibility to treatment.
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References
Nursalam (2010), English in nursing midwifery science andtechnology, Salemba Medika, Jakarta.
Fuller, J, Jennifer, S.A, J.B(1994), Health Assessment: a nursingapproach Lippincott Company, Philadelpia.