Pengkajian Keperawatan (Nursing Assessment)

Summary

This video explains the essential process of nursing assessment in healthcare. It covers the importance of collecting accurate and comprehensive data to identify health problems and formulate nursing diagnoses and care plans. Key components include gathering subjective and objective data through methods like anamnesis, observation, and physical examination. The video also highlights different data sources, such as primary, secondary, and other sources like medical records. It discusses the use of models like Gordon's functional health patterns and emphasizes the significance of effective communication, physical assessment techniques, and ethical considerations in nursing assessments.

Takeaways

• 😀 The nursing assessment is the first stage of the nursing process, where data is gathered to identify health or nursing problems of the client.
• 😀 Success in conducting a thorough and accurate nursing assessment determines the effectiveness of the nursing diagnosis formulation.
• 😀 Data collection includes basic and focused data from the client, such as general information, medical history, and health function patterns.
• 😀 Subjective data refers to the client's expressed complaints, such as pain, which need to be validated through objective data like physical examinations.
• 😀 Objective data includes measurable or observable information, such as blood pressure, pulse rate, and weight.
• 😀 Data should be complete, accurate, real, and relevant to support the nursing diagnosis and care planning.
• 😀 Primary data comes directly from the client, while secondary data comes from family members or close relatives if the client cannot provide information.
• 😀 Various data collection techniques are used, including anamnesis, observation (using the '2sh FT' method), physical examination, and document review.
• 😀 Physical examination techniques include inspection, palpation, percussion, and auscultation to observe physical conditions like edema, heartbeat, and lung sounds.
• 😀 The nurse must maintain professional ethics during the assessment by ensuring privacy, confidentiality, and accurate documentation of findings.

Q & A

What is the purpose of nursing assessment in the nursing process?

The purpose of nursing assessment is to collect data and information from the client so that health or nursing problems can be identified. The success of formulating a nursing diagnosis depends on the completeness and accuracy of this assessment.

What are the types of data collected during a nursing assessment?

The data collected in nursing assessment includes basic data, which covers general information, demographics, nursing history, health patterns, and examinations. Additionally, focused data, which refers to health status deviations from normal, is also collected.

What is the difference between subjective and objective data in nursing assessment?

Subjective data refers to the client's complaints or feelings about their health status, such as pain. Objective data refers to measurable and observable facts, such as blood pressure, heart rate, and body weight, obtained through physical examination.

What are the characteristics of good data in nursing assessment?

Good data should be complete (collected in detail and thoroughly), accurate (correctly measured), real (derived from actual measurements and not assumptions), and relevant (related to the client's issues for nursing diagnosis).

What are the primary and secondary sources of data in nursing assessment?

Primary data comes directly from the client, whereas secondary data is obtained from family members or close relatives. Other sources include medical records, diagnostic results, or consultations with healthcare professionals.

What are some methods used for data collection in nursing assessment?

Nurses can use methods such as anamnesis (communication to gather health information), observation (using the senses to observe client behavior), physical examination (using techniques like inspection, palpation, percussion, and auscultation), and documentation review.

What is the role of anamnesis in nursing assessment?

Anamnesis involves communication with the client and their family to share thoughts and feelings about the client’s health status. It can be verbal or non-verbal and helps in gathering subjective data.

What is the importance of physical examination in nursing assessment?

Physical examination is crucial as it helps the nurse gather objective data. It includes techniques like inspection, palpation, percussion, and auscultation, which provide insights into the client’s physical health.

What is the Gordon's Functional Health Patterns model, and how does it help in nursing assessment?

The Gordon’s Functional Health Patterns model includes 11 patterns that guide nurses in assessing the client’s health in different areas. For example, the Perception Management pattern helps nurses understand how clients manage their health, and the Nutritional Metabolism pattern helps assess the client’s eating habits and weight changes.

What are some common challenges in conducting a nursing assessment?

Common challenges include getting distracted by irrelevant information during anamnesis, inability to perform a comprehensive physical examination, and focusing only on vital signs rather than a full physical assessment, which may overlook changes in the client's condition.