English in Nursing Paper

FUNDAMENTAL OF ASSESTMENT
IN NURSING PROCESS

By Group I

Aditya Reinhardt PO.62.20.1.17.200

Ahmad Fajar Rizky PO.62.20.1.17.201
Edwin PO.62.20.1.17.210
Irwandi Franiko PO.62.20.1.17.221
Laela Agustinah PO.62.20.1.17.223
Sefira Gustina Pusvita Putri PO.62.20.1.17.232
Siti Azizah PO.62.20.1.17.233
Yesi Listyaningsih PO.62.20.1.17.238

Group Supervisior

DR. Marselinus Heriteluna, SPd, MA

NIP. 19710515 199403 1 004

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN

PALANGKA RAYA
DIII KEPERAWATAN
2019
 TITLE PAGE
FUNDAMENTAL OF ASSESTMENT

IN NURSING PROCESS

By Group I

Aditya Reinhardt PO.62.20.1.17.200

Ahmad Fajar Rizky PO.62.20.1.17.201
Edwin PO.62.20.1.17.210
Irwandi Franiko PO.62.20.1.17.221
Laela Agustinah PO.62.20.1.17.223
Sefira Gustina Pusvita Putri PO.62.20.1.17.232
Siti Azizah PO.62.20.1.17.233
Yesi Listyaningsih PO.62.20.1.17.238

Group Supervisior

DR. Marselinus Heriteluna, SPd, MA

NIP. 19710515 199403 1 004

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN

PALANGKA RAYA
DIII KEPERAWATAN
2019

i
 PREFACE

Thank, the writer offered the presence of God Almighty because of the blessing of
His grace, we were Group I subject English in Nursing in Regular Class XX Force Nursing
DIII can complete this paper with the title Fundamental Of Assestment in Nursing Process
with on time.

The author also expressed gratitude for material and non-material assistance from
various parties involved in making this paper, especially for our group supervisior, DR.
Marselinus Heriteluna, SPd, MA who have patiently gieded us.

The author realizes that this paper is far from perfect, so we really need criticism
and suggestions from readers.

Hopefully this paper can be useful for all of us.

Palangka Raya, March

2019

Author

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 TABLE OF CONTENTS
TITLE PAGE .................................................................................................................... i
PREFACE ........................................................................................................................ii
TABLE OF CONTENTS .................................................................................................. iii
CHAPTER I PRELIMINARY ............................................................................................ 1
A. Background ........................................................................................................ 1
B. Formulation Of the Problem ............................................................................... 1
C. Writing Purpose.................................................................................................. 2
CHAPTER II DISCUSSION ............................................................................................. 3
A. Understanding of assessment in nursing process .............................................. 3
B. Purpose of assessment in nursing process ........................................................ 3
C. Type of assessment in nursing process ............................................................. 4
D. Types of data in assessment in nursing process................................................ 4
E. Data sources in assessment in nursing process ................................................ 5
F. Method of data collection in assessment in nursing process ............................. 5
G. Types of approaches of assessment in nursing process .................................... 8
H. Example format of assessment in nursing process .......................................... 10
CHAPTER III COVER ................................................................................................... 15
A. Conclusion ....................................................................................................... 15
B. Suggestion ....................................................................................................... 15
REFERENCE ................................................................................................................ 15

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 CHAPTER I
PRELIMINARY

A. Background
The nursing process is one of the most fundamental yet cucial aspects of the
nursing profession. It guiedes patient care in a manner that creates an effective, safe,
and health promoting process. The nursing process allows nurses to identify a
patient’s health status, their current health problems, and also identify any potential
health risks the patient may have. The nursing process is a broad assessment toot
that can be applied to every patient but results in an individualized care plan tailored
to the most important needs of the patient.

The nursing process consists of five steps, that is assessment, diagnosis,

planning, implementation and evaluation.

The first step of nursing process is assessment. Assessment is the initial and
basic stage in the nursing process. Assessment is the most decisive stage for the
next stage.

Based on the description above, the authors are interested to learning more
about the fundamental of assessment in nursing process.

B. Formulation Of the Problem

Formulation of the problem in this paper that is:

1. What is understanding of assessment in nursing process?

2. What is the purpose of assessment in nursing process?
3. What is the type of assessment in nursing process?
4. Mention the types of data in assessment in nursing process!
5. What are the data sources in assessment in nursing process?
6. What is the method of data collection in assessment in nursing process?
7. Mention the types of approaches of assessment in nursing process!
8. Give an example format of assessment in nursing process!

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C. Writing Purpose
Writing purpose in this paper that is:

1. To knowing about understanding of assessment in nursing process

2. To knowing about the purpose of assessment in nursing process
3. To knowing about the type of assessment in nursing process
4. To knowing about the types of data in assessment in nursing process
5. To knowing about the data sources in assessment in nursing process
6. To knowing about the method of data collection in assessment in nursing process
7. To knowing about the types of approaches of assessment in nursing process
8. To knowing about example format of assessment in nursing process

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 CHAPTER II
DISCUSSION

A. Understanding of assessment in nursing process

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 problems
that occur at this stage will determine the nursing diagnosis. Therefore, the
assessment must be carried out carefully and thoroughly, so that all the care needs
of the client can be identified. Activities in the assessment are data collection.

Data collection is an activity to gather information about the client's health

status. Normal and slack client health status should be collected, this is intended to
identify patterns of client health functions, both optimal and problematic. But because
of the practical importance and the constraints of the limited time of data collection
and documentation, some places we encounter policies that focus items in the format
of data collection with consideration of the priority of the study or the pattern of
function that is most influential with the system disruption that occurs. The review
process includes the following steps / steps.

1. Systematic data collection

2. Data verification
3. Data organization
4. Interpretation of data
5. Documentation of data

B. Purpose of assessment in nursing process

The purpose of the assessment phase is to collect information and also create
client base data, identify and identify problems faced by clients. According to the
American Nurses Association (ANA) there are several things that need to be
considered in conducting nursing studies, that is:

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 1. Assessment must be relevant to the client's needs
2. Collected from various sources
3. Collected from various techniques
4. Systematically followed
5. Documented in a good and correct format

C. Type of assessment in nursing process

1. Comprehensive assessment
a. Comprehensive assessment of the assessment process is usually carried out
at the beginning of the patient's registration to 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 at any time the patient returns to be
examined
2. Focused assessment
a. Focused assessment of this study is more focused on the part that has an
abnormality.
b. Assessment is only done in areas or tissue systems that the patient complains
about. For example assessment of patients who will give birth.
3. The 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. Purpose is to complete data that has not been obtained and assess the
development of the patient's condition.

D. Types of data in assessment in nursing process

1. Subjective data
Subjective data is data obtained from patients, including feelings of feelings and
all the things that patients complain about. This data can be obtained from the
charity with patients.
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 2. Objective data
This data is data that can be measured or observed, can be obtained from the
results of measurements during a physical examination, laboratory, photo, and
some of them.

E. Data sources in assessment in nursing process

1. Primary data source
Client Is the best data source because clients can provide subjective data that
cannot be given by others.
2. Secondary data sources
Family and close friends are important secondary sources of information to involve
them in the assessment if possible. They may provide information about the client's
response to the disease, stress experienced by the client before illness.
3. Client records, including information documented by various health professionals.
Contains data on client work, religion, and marital status
4. Health professionals
5. Literature, study nursing literature such as reference books

F. Method of data collection in assessment in nursing process

1. Observation
Do observations carefully. Observation can be done if there is contact with the
client. The parts that can be observed include physical and psychological
responses, emotional responses, and the security and comfort felt by the client.
Observation can help nurses to determine the client's physical and mental status.
By observing the client carefully, we can find out the various feelings of the client,
pain, anxiety, and anger.
2. Interview
There are several stages that are passed when conducting interviews, namely as
follows.

a. Preparation stage
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 It's a good idea for the nurse to bring a previous medical record or find out
the main complaints that the client is currently feeling. If the nurse is still not
understand the client's diagnosis, the nurse should study it first from available
sources.

b. Introduction stage
At this stage the nurse explains to the client about the importance of the
interview and the purpose of the interview. The opening is done by
introducing the nurse's identity. Give a quiet room and protect the privacy of
clients or family members. Listen attentively to clients and family
explanations. Try to do the interview in a sitting and facing position. Maintain
eye contact between the nurse and the client.
c. Working stage (open and closed questions)
At this stage the nurse begins to provide specific questions that discuss the
client's health problems and the client's main reasons and the main reason
the client comes to seek health assistance. Interviews can be done formally
and structured. Don't ask questions that are cornering or judging clients.
Questions can be either open or closed questions. Open questions will give
the client an opportunity to explain his condition. for example: "What do you
complain about for 3 days so that you come to the hospital?" while closed
questions will only provide the information we want and usually in the form of
confirmation. for example: "So for one day you have been defecating for 16
times?"
d. Closing
This stage indicates the data collection process has been fulfilled. Finished
by giving conclusions and comforting perceptions of the client's current
conditions.
3. Medical history
Health History is a summary of the client's health conditions from the past to the
reason why he is currently attending a health center. This history includes things
/ things as follows.
a. Demographic data

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 b. Main complaints
c. Perception about current pain conditions
d. Previous disease history, surgical history, history of hospitalization.
e. Family disease history
f. Treatment that is currently being undertaken
g. Allergy history
h. Status of client's mental development
i. Psychosocial history
j. Sociocultural history
k. k.Daily activities (daily living activity)
4. Physical Examination
Physical examination can be done in four ways as follows.
a. Inspection
Using the senses of vision, requires help with good lighting, and careful
observation.
b. Entrepreneurs
This examination uses the principle of vibration and air vibration. It is done by
tapping the surface of the body with the examiner's hand.
c. Palpasi
Use sensory nerve fibers on the surface of the palm to find out humidity,
temperature, texture, presence of mass, and prominent location and size of
organs, and swelling. Palpation requires a systematic and firm but gentle
method to prevent pain in the client.
d. Acultation
Using the senses of hearing, can you use a stethoscope or not. Sounds in
the body are produced by air movement. for example breath sounds or organ
movements such as intestinal peristalsis
5. Other Diagnostic Checks
This examination is useful to support the establishment of a diagnosis, to know
the progress of the results of therapy, and to know the current health status of the
client.

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G. Types of approaches of assessment in nursing process
1. Head to toe
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, the circulatory
system, the nervous system, and so on. The nurse examines all parts of the body
and compares the results of examinations on each side of the body. for example
the lungs. However, this procedure can vary depending on the age of the
individual, the severity of the disease, the wishes of the nurse, the location of the
examination, and the priorities and procedures that apply in the institution.
2. Body system approach
The approach from head to toe is a symmetrical approach starting with the head
and ending with the feet. the system approach examines each body's system
freely. many nurses are critical of using a combination of approaches where the
approach from head to toe and the integrated body system approach, namely the
nurse begins the study with the head and evaluates the neurological system, then
examines the chest and includes the cardiovascular system and respiratory
system. this approach provides a logical development for assessment.
3. Approach to Bordon's health function pattern
Nurses collect data systematically by evaluating health function patterns and
focusing physical assessment on specific problems including:
a. Perception of health
b. Health management
c. Nutrition
d. Cognitive
e. Perceptual pattern
f. Related roles and patterns
g. Activities and training patterns
h. Sexuality and reproductive patterns
i. Coping and stress tolerance patterns
j. Values and patterns of belief.

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4. DOENGOES (1993)
Activity / rest, circulation, ego integrity, elimination, food and fluids, hygiene,
neurosensory, pain / discomfort, breathing, security, sexuality, social interaction,
counseling / learning.

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H. Example format of assessment in nursing process

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 CHAPTER III
COVER

A. Conclusion
Assessment is the initial and basic stage in the nursing process. Assessment
is the most decisive stage for the next stage.

The assessment has its own types, there are comprehensive studies, focused
assessments, and further studies. The assessment also includes data and data
sources, namely subjective and objective data. Subjective data is data obtained
directly from client complaints. Whereas objective data is data from the results of
nurse observations of clients. The assessment method is sorted by process starting
from the observation, interview, physical examination, medical history, to other
diagnostic tests. The types of approaches in the assessment process are head to toe
examination, body system approach and assessment approach according to Bordon.

B. Suggestion
Because assessment is the initial and basic stage in the nursing process and
the most decisive stage for the next stage, then it’s expected that nurses can be really
thorough and careful when doing this step, so that in the subsequent nursing process
there is no grap.

REFERENCE
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Mosby. 1997. Fundamental of Nursing Concepts, Process and Practice, Vol. 4. Jakarta:
Buku Kedokteran EGC.

Nikma, Rohman and Walia Saiful. 2009. Proses Keperawatan Teori dan Aplikasi.
Yogyakarta: AR-RUZZ MEDIA.

Azizah

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