Assessment Process of Nursing Care Plan

Nursing Assessment

Assessment is the basic idea of the nursing process which aims to collect information or data about the client, in order to identify, recognize problems, health and nursing needs of clients, whether physical, mental, social and environmental (Effendy, 1995).

Systematic assessment in nursing is divided into four phases of activities, which include; data collection, data analysis, systematic data and problem determination.

Those that add to the activity data documentation (although each step of the nursing process should always be documented as well). Collecting and organizing data must describe two things: the status of the client's health and strength - health problems experienced by the client.

Nursing assessment of comprehensive baseline data is a data set that contains the health status of the client, the client's ability to manage the health and nursing against itself and the results of a medical consultation or other healthcare professional.

Focus data : data on the changes or the client's response to health and health issues, as well as things that include actions taken to clients.


1. DATA COLLECTION

Data collection is a collection of information about the client are carried out systematically to determine the problems, as well as the needs of nursing and healthcare clients. Information gathering is an early stage of the nursing process. From the information collected, obtained basic data about the problems faced by clients. Furthermore, the basic data used to determine nursing diagnosis, nursing care plan, as well as nursing actions to address the problems of clients.

Data collection began in client hospital admission (initial assessment), as long as the client was treated continuously (ongoing assessment), and review for the add / complete data (re-assessment).


2. PURPOSE OF DATA COLLECTION

• Obtain information about the state of health of the client.
• To determine the client's health and nursing problems.
• To assess the state of health of the client.
• To make the right decisions in determining the next steps.

3. CHARACTERISTICS OF DATA

a. Complete
All data necessary to identify the client's nursing problems. The collected data must be complete in order to help clients adequately address the problem. for example; the client does not want to eat - assessed in depth, why the client does not want to eat (not suitable food, physical conditions refuse to eat / pathological, or other causes).

b. Accurate and real
To avoid mistakes, the nurse must think accurately and to show where true / false what was heard, seen, observed and measured through examination of whether there is a validation of all the data that are likely to doubt. Nurses may not directly make inferences about a client's condition. For example, the client does not want to eat. Nurses should not directly write: `client does not want to eat because of severe depression '. Further investigation is needed to establish the client's condition. Document is in accordance found during the assessment.

c. Relevant
Recording of comprehensive data usually requires a lot of data that must be collected, so that time-consuming to identify the nurse.


5. INFORMATION REQUIRED

1. Everything about the client as being a bio-psycho-social and spiritual.
2. The ability to solve problems in everyday life.
3. Health and nursing problems that interfere with the ability of the client.
4. Present circumstances related to the nursing care plan that will was done on the client.

6. DATA SOURCE

1. Primary Data Source: The primary data source is the data collected from the client, which can provide detailed information about the health and nursing problems that it faces.
2. Secondary Data Source: Secondary data sources are data collected from the people closest to the client (family), such as parents, siblings, or others who understand and are close to the client.
3. Other Data Sources: Notes client (client's treatment or medical records) which is a history of the disease and the treatment of clients in the past.

In general, the data sources can be used in data collection are:

1. Clients themselves as the primary data source (primary).
2. People nearby.
3. Notes client.
4. History of the disease (physical examination and progress notes).
5. Consultancy.
6. The results of diagnostic examinations.
7. Medical records and other health team members.
8. Other nurses.
9. Bibliography.

7. TYPES OF DATA

1. Objective Data: This is data that is obtained through a measurement and inspection using a recognized standard (effective), such as: color, vital signs, level of consciousness, etc. The data was obtained through `senses`: Sight, smell, hearing, touch and taste.
2. Subjective Data: This is data obtained from the complaints submitted by the client, such as pain, dizziness, nausea, fear, anxiety, ignorance, etc.