DEFINITION OF ASSESSMENT

Assessment is the initial and basic stage in the nursing process.

Assessment is the most decisive stage for the next stage. The ability to identify
nursing issues that occur at this stage will determine the nursing diagnosis. Therefore,
the assessment must be done carefully and carefully, so that all care needs of the client
can be identified.

Activities in assessment are data collection. Data collection is an activity

to collect information about the client's health status. Normal and gap client
health status should be collected, this is intended to identify the pattern of
client's health function, both optimal and problematic. However, because of
practical interests and the constraints of limited time to collect data and
documentation, in some places we find policies that focus items in data collection
formats with consideration of priority priorities or related function patterns most
influential with system disruption that occurs. The assessment process includes the
following steps:

1. Systematic data collection.

2. Data verification.

3. Data organization.

4. Data interpretation.

5. Data documentation.

TYPES OF ASSESSMENT

1. Comprehensive assessment.

a) This review process is usually done at the beginning of the patient's

registration with the health center.

b) Examination includes all body systems to determine abnormalities that occur

in the body.
 c) This examination will be the basic data if one day the patient returns to be
examined.

2. Focused assessment.

a) This study focused more on the part that experienced the disorder.

b) Assessment is only carried out on the area or network system that the patient
complains about.

c) For example: assessment of patients who will give birth.

3. Ongoing assessment

a) This assessment is carried out when the nurse observes the patient's
developmental status.

b) This assessment can be done in the room when the patient's condition starts
to improve or when taking action.

c) Its purpose is to complete data that has not been obtained and assess the
development of the patient's condition

DATA TYPES

1. Subjective data

Subjective data is data obtained from patients, including the feelings of patients
and all the things that patients complain about. This data can be obtained from
interviews with patients.

2. Objective data

This data is the data that the visa is measured or observed, can be obtained from
the results of measurements during physical examination, laboratories, photos,
and some
DATA SOURCE

Data sources are of two types, primary and secondary. Clients are the
primary source of data. Whereas the secondary includes families of the closest
people, client records, health professionals, literature.

1. Client

It is the best source of data because clients can provide subjective data that others
cannot give

2. Family from the closest person

Family and close friends are also an important secondary source of information to
involve them in the assessment whenever possible. They may provide
information about the client's response to the disease, the stress experienced by
the client before getting sick

3. Client note

Includes information documented by various health professionals. Contains data

on client work, religion and marital status

4. Health professionals

5. Literature

Review nursing literature such as reference books

DATA COLLECTION METHODS

1. Observation

Perform Observations carefully and carefully. Observations can be made if there

is contact with clients. Parts that can be observed include physical and
psychological responses, emotional responses, and the sense of security and
 comfort that clients feel. Observations can help nurses to determine the physical
and mental status of clients. By observing the client carefully, we can find out the
various kinds of feelings of the client, the pain, anxiety, and anger.

2. Interview

There are several stages that are passed when conducting interviews, namely as
follows.

a) Preparation phase

It is better for nurses to read medical records (medical records) earlier or find
out the main complaints felt by the client at this time. If the nurse still does
not understand the client's diagnosis, the nurse should learn it first from the
available sources.

b) Introduction stage

At this stage the nurse explains to the client the importance of the interview
and the purpose of the interview. The opening is done by introducing the
identity of the nurse. Give a quiet room and protect the privacy of clients or
family members. Listen attentively to client and family explanations. Try to do
the interview in a sitting position and face to face. Maintain eye contact
between nurses and clients.

c) Work phase (open and closed questions)

At this stage the nurse begins to provide specific questions that discuss the
client's health problems and the main reasons for the client and the main
reason the client comes to seek medical attention. Interviews can be done in a
formal and structured manner. Don't ask questions that are cornering or
judging clients. Questions can be in the form of open or closed questions.
Open questions will give clients the opportunity to explain their condition (for
example: "What did you complain about for 3 days so that you came to the
hospital?") While the closed question will only give you the information you
want and usually have an assertion (for example: "So for one today have you
runny 10 times? ")
 d) Cover

This stage indicates the collection process and has been fulfilled. Ended by
giving conclusions and comforting perception of the current client's condition.

3. Medical history

Health History is a summary of the client's health condition from the past to the
reason why he is currently attending a health center. This history includes the
following matters.

a) Demographic data

b) Main complaint

c) Perception about current sick conditions

d) History of previous illness, history of surgery, history of being treated in

hospital.

e) History of family illness

f) Treatment that is currently underway

g) Allergy history

h) Mental development status of the client

i) Psychosocial history

j) Sociocultural history

k) Daily activity (activity daily living)

 Nutrition / diet done before and after illness.

 Elimination (BAK → urine elimination and CHAPTER → elimination of

alvi) experienced before and after illness.

 Pattern of rest and sleep before and after illness

 Activities and routines performed every day and after illness.

  Beliefs / patterns of worship that are owned before and after illness.

 Pattern of sexual activity carried out and after illness.

4. Physical examination

Physical examination can be done in four ways as follows.

a) Inspection (I)

Using the sense of sight, requires good lighting assistance, and careful
observation.

b) Percussion (P)

This examination uses the principle of air vibration and vibration. It is done
by tapping the body surface with the examiner's hand. Can be used to
estimate the density of body organs / tissue being examined.

c) Palpation (P)

Palpation uses sensory nerve fibers on the surface of the palm to determine
humidity, temperature, texture, presence of mass, and protrusion of the
location and size of the organ, and swelling. Palpation requires a systematic
and firm but gentle way to prevent the onset of pain in the client.

d) Anscultation (A)

Using the senses of exposure, can use a tool (stethoscope) or not. Sound in
the body is produced by air movements (such as breathing flares) or organ
movements (for example: intestinal peristalsis)

5. Other Diagnostic Checks

Diagnostic examination is used to complete and lengthen the results of the

assessment that has been obtained. Inj examination is useful to support the
establishment of a diagnosis, to know the progress of therapeutic results, and to
know the client's current health status
TYPE OF ASSESSMENT APPROACH

1. Head to toe approach

Cephalokaudal or head-to-toe approaches begin examination of the head,

continuing to the neck, chest, abdomen and extremities, and finally to the toes.
Nurses who use the body system approach examine each system separately,
namely the respiratory system, circulatory system, nervous system, and so on.
Perwat examines all parts of the body and compares the results of examinations
on each side of the body (eg, lungs).

However, this procedure can vary depending on the individual's age, the
severity of the disease, the desire of the nurse, the location of the examination,
and the priorities and procedures that apply at the institution.

Following are the sequence of head-to-toe checks:

a) Age survey

b) Vital sign

c) Head:

 Hair, scalp, face skull

 Eyes and glare

 Ear and hearing

 Nose and sinuses

 Mouth and orovaring

 Cranial nerve

d) Neck:

 Skin and nails

  Strength and muscle tone

 Range of motion of the joint

 Brachial and radial pulse

 Biceps tendon reflex

 Reflex tendon

 Sensation

e) Chest and Back:

 Shape and size of the chest

 Lungs

 Heart

 Spinal cord

 Breast and axillary

f) Abdomen:

 Skin

 Abdominal sound

 Specific organs (eg liver, bladder)

 Femoral pulse

g) Genitalia:

 Testicles

 Vagina

 Urretra

h) Anus and rectum

 i) Lower extremity:

 Skin and fingernails

 Gait and balance

 Range of motion of the joint

 Politea, posterior tibialis, and pedis

 Tendon and plantar reflexes

2. Body system approach

The head to toe approach is a symmetrical approach starting with the head and
ending with the feet. the system approach examines each body system freely.
many critical nurses use a combination of approaches where the head-to-toe
approach and the integrated body system approach, namely the nurse starts the
study with the head and evaluates the neurological system, then examines the
chest and covers the cardiovascular system and respiratory system. this approach
provides a logical development for assessment.

3. Gordon's health function pattern approach, 1982

Nurses collect data systematically by evaluating health function patterns and

focusing physical assessment on specific problems including: perceptions of
health-health management, perceptual patterns, related patterns, exercise patterns,
reproductive sexuality, pattern coping stress tolerance, values of belief patterns.

4. Doengoes (1993)

Activity / rest, circulation, ego integrity, elimination, food and fluid, hygiene,
neurosensory, pain / discomfort, breathing, security, sexuality, social interaction,
education / learning.
Patient: Good morning Nurse
Nurse: Good morning, please sit down
Patient: My name ... and this is my child ....
Nurse: can I help you, ma'am?
Patient: Sus, I have some health problems.
Nurse: Can you tell me what your complaints are?
Patient: my head is dizzy and my body is hot.
Nurse: how long have you felt it?
patient: it's been three days.
Nurse: OK ma'am, I check the temperature
Patient: Yes sir
Nurse: the temperature of the mother is 38 degrees Celsius, for that Edo can help to compress the
mother with a towel that has been soaked in warm water so that the heat drops.
Child: Alright, sir
Nurse: in addition, also drink lots of water and eat nutritious food and adequate rest.
Patient: Okay sus
Child: Well sus, we excuse you thank you sus
Nurse: okay, both. hope you get well soon ma'am