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NURSING ASSESSMENT

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1. Cici Kurniatil Farhanah

pada : 14 September 2017

"Nama : Cici Kurniatil Farhanah
NIM : 131611133124
Kelas : A3
Nursing Assesments
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
Definition of terms :
1. Admission assessment: Comprehensive nursing assessment including patient history (of current illness/injury, relevant past history, allergies and reactions, medications, maternal history), general appearance (considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, posture and movement, etc.), physical examination and vital signs (such as temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain) completed at the time of admission. Must be completed within 24hours of admission. Privacy of the patient needs to be considered all times.
2. Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Assessment information includes, but is not limited to: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination, Wellbeing, Social/cultural
3. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. This information is used to develop a plan of care. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused, Pain, Hydration/Nutrition, Output, Risk, Wellbeing, Social, and Review the history of the patient recorded in the IP summary, ask questions to add additional details to the history
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. The nurse must ensure that appropriate action is taken if any abnormal. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift.


"


2. PUTRI HISAANAH

pada : 14 September 2017

"NAME: PUTRI HISAANAH
NIM: 131511133015
CLASS: A3
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.
This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, APGAR score, resuscitation required at delivery and Newborn Screening Tests
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
The Shift Assessment includes: airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, and social
Review the history of the patient recorded in the IP summary, However, it may be appropriate to ask questions to add additional details to the history
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. "


3. Achmad Ubaidillah Mughni

pada : 14 September 2017

"ACHMAD UBAIDILLAH MUGHNI/131611133128/A3-A2016
NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
1.Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
2.Shift assessment: Concise nursing assessment completed at the commen cement of each shift or if patient condition changes at any other time during your shift.
3.Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system
•Neurological system
•Respiratory system
•Cardiovascular
•Gastrointestinal
•Renal
•Musculoskeletal
Evaluation of assessment : In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.
an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs (Temperature, Respiratory Rate,Heart Rate, Blood Pressure, Oxygen Saturation, Pain and additional measurements that is weight, height, head circumference, blood sugar level), skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan."


4. Esti Ristanti

pada : 14 September 2017

"Nama: Esti Ristanti
NIM: 131611133129
KELAS: A3
Nursing assesment
Assessment is a key component of nursing practice, which is necessary for patient and family-centered planning and care provision so that nurses have the task of assessing, planning, implementing and evaluating nursing care. The guidelines aim to Indications for assessment, Types of assessments and Structure for assessments. There are three kinds of assessments, namely admission assessment : Assessment of acceptance should be documented on the nurse admission form, shift assessment : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history, and focused assessment.
Patient history : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.

General appearance : Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet
Physical assessment : A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required.
Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
Social/cultural : Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
Shift assessment : At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flowsheet and further assessments or changes to be documented in the assessment flowsheet/progress notes.
Focused assessment : A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
a. Neurological system
b. Respiratory system
c. Cardiovascular
d. Gastrointestinal
e. Musculoskeletal
f. Skin
g. Eye
h. Ear/Nose/Throat (ENT)
Evaluation of assessment : In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.


"


5. HAPPY PUSPITA RISNA

pada : 14 September 2017

"NAMA : Happy Puspita Risna
NIM : 131611133127
KELAS : A3
Nursing assesment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The Nursing ad Midwifery Board of Australia (NMBA) in the national competency standard for registered nurses states that, “The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.
Aim
• The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required.
Wellbeing:
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
Social/cultural:
Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
Shift assessment
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flowsheet and further assessments or changes to be documented in the assessment flowsheet/progress notes.
Focused assessment
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
a. Neurological system
b. Respiratory system
c. Cardiovascular
d. Gastrointestinal
e. Musculoskeletal
f. Skin
g. Eye
h. Ear/Nose/Throat (ENT)
Evaluation of assessment
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.
"


6. Ragil Titi Hatmanti

pada : 15 September 2017

"Nama : Ragil Titi Hatmanti
NIM : 131611133012
Kelas : A1 2016
Assessment is a key component of nursing practice, required for planning and provision of patient and family cented care. The aim of assessment is a guidline specifically seeks to provide nurses with indications for assessment, types of assessments, structure for assessment.
There are 3 assessments type, admission assessment, shift assessment, and focused assessment. We should know about patient’s history, general appearance, and vital sign before we assess patient. Patient history consist of History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history. General appearane is Assessment of the patient’s overall physical, emotional and behavioral state. Considerate by looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. Vital sign consist of patient’s temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, and pain. We can measure patient’s weight, height, head circumference and blood sugar level as additional measurement.
Physical assessment is a structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Physical assessment consist of the condition of airway, breathing, circulation, disability, focused assessment, skin, nutrition, and elimination.
"


7. Dwi Utari Wahyuning Putri

pada : 15 September 2017

"NAME : DWI UTARI WAHYUNING PUTRI
NIM : 131611133019
RESUME : Assessment → a key component of nursing practice for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care to achieve goals and health outcomes.

1. Admission assessment → Comprehensive nursing assessment including :
• Patient History : history of current illness/injury, allergies, family history.
• General Appearance : patient’s overall physical, emotional and behavioral state
• Physical Examination : observation, inspection, palpation, percussion and auscultation are techniques used to gather information includes airway, breathing, circulation, skin, and others. It also needs to observe the client’s vital signs to support clinical decision making process. Including : temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, and pain. And several additional measurements such as weight, height, head circumferences, and BSL.

2. Shift assessment → Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during nurse’s shift. This assessment includes : airway, breathing, circulation, pain, nutrition, output, risk, wellbeing, social and review the history of the patient recorded in the IP summary,

3. Focused assessment : Detailed nursing assessment of specific body system(s) relating to the presenting problem of the patient. This may involve one or more body system. Including the system of :
• Neurological : neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
• Respiratory
• Cardiovascular : evaluates the adequacy of cardiac output and includes.
• Gastrointestinal : inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness.
• Renal : includes all aspects of urinary elimination.
• Musculoskeletal
• Skin → can identify cutaneous problems as well as systemic diseases.
• Eye
• Ear/Nose/Throat (ENT) → is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis.

In the evaluation of assessment, ensure the information collected is complete, accurate and documented appropriately. To make clinical decisions and plan care for the patient, the nurse must have a critical thinking and problem solving skills. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken."


8. Endah Desfindasari

pada : 15 September 2017

"Nama : Endah Desfindasari
NIM : 131611133119
Kelas: A3 A16
Resume :
Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.
AIM : The guideline specifically seeks to provide nurses with, indications for assessment, types of assessments, and structure for assessments
Definition of terms :
• Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
• Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
• Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24 hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
Patient history : History of current illness, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance : Neonate and Infant Parent-infant, infant-parent interaction, body symmetry, spontaneous position and movement, symmetry and positioning of facial features, strong cry, Young Child Parent-child, child-parent interaction, mood and affect, gross and fine motor skills, developmental milestones, appropriate speech, adolescentMood and affect, personal hygiene, and communication
Vital signs : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process. ( temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain.

Additional measurements:
• Weight: on admission and/or weekly/daily as clinically indicated.
• Height: as clinically indicated.
• Head circumference: as clinically indicated.
• Blood sugar level (BSL): as clinically indicated.
Physical assessment, Wellbeing, Social/cultural, Shift assessment, Focused assessment, Neurological system, Respiratory system, Cardiovascular, Gastrointestinal Renal, Musculoskeletal, Skin, Eye , Ear/Nose/Throat (ENT), Evaluation of assessment.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.
"


9. RENDHY RIAN KOESMA BACHTIAR

pada : 15 September 2017

"Name: Rendhy Rian Koesma Bachtiar
NIM: 131611133121
Class: A3
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes. The guideline specifically seeks to provide nurses with: Indications for assessment, type of assessments, and structure for assessments. Definition of terms: Admission assessment, comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission; Shift assessment, concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift; Focused assessment, detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times. History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history. Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process: temperature, respiratory rate, heart rate, blood pressure, oxygen saturation and pain. Additional measurements: weight, height, head circumference, and blood sugar level. Focused assessment a detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.



"


10. NURUL HIDAYATI

pada : 15 September 2017

"NAMA : NURUL HIDAYATI
NIM : 131611133022
KELAS : A1-2016
RESUME :
NURSING ASSESSMENT
Assessment is the first step to determine health status. It is the gathering of information to make a clear picture of the person’s health status. The entire plan of care is based on the data collect during this phase and make every effort to ensure that information is correct, complete and organized in a way that will begin to get a sense of patterns of health or illness. Every country has their own system or guidelines of assesment but it might be a similiraty. The example is Indonesian system same as Australian system but it is different in America, Africa or Europe system. The guideline specifically seeks to provide nurses with indications for assessment, types of assessments, and structure for assessments.
Purpose of Nursing Assessment :
1) To gather information regarding client’s health.
2) To organized the collected information.
3) To confirm hypothesis growing out of the nurse’s interview.
4) To enhance investigation of nursing problems.
5) To frame nursing diagnosis.
6) To identify the health problems.
7) To identify client’s strengths.
8) To identify need for health teaching.

There are three types of assessment, it is admission assessment, shift assessment and focused assessment. All of these types has a different indications and structure.
1. Admission assessment
Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. In admission assessment the nurse must assess about : Patient history, General appearence, Vital signs, Additional measurements, etc.
2. Shift Assessment
Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. The shift assessment includes:
a. Airway : noises,secretion,cough,or artificial airway
b. Breathing : breath sounds, respiratory rate, rhytm, etc
c. Circulation : pulses, peripheral temperature, colour and capillary refill time, skin, lip, oral mucosa and nail bed colour
d. Disability : mobility transfer requirements, prostethics/orthotics required, etc.
3. Focused Assessment
Detailed nursing assessment of specific body system (s) relating to the presenting problem or current concern (s) of the patient. This may involve one or more body sistem. Focused Assessment includes :
a. Neurogical systems : neurogical observations, cognitive growth, and development, fine and gross motor skills, sensory function, seizures and any other concerns
b. Respiratory systems : respiratory distress
c. Cardiovascular : the adequacy of cardiac output

The nurse that already registered can assesses, plans, implements, and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes. To be a registered nurse, he/she should pass the test so they are ready to work.
Methods of Nursing Assessment :
1) Observing
Observation is a conscious, deleberate skill that is developed only through and with an organized approach.
2) Interviewing
An interview is a planned communication or a conversation with a purpose.
3) Examining
The physical examination is a systematic data collection method that uses observational skills to detect health problem"


11. Shintia Ekawati

pada : 15 September 2017

"Assessment is a key component of nursing practice,required for planning and provision of patient and family centred care.

AIM

The aim of this guideline to ensure all RCH patients receive consistent and timely nursing assessments.the guideline specifically seeks to provide nurses with :
• Indications for assessment
• Types of assessments
• Structure for assessment

General appearance

Assement of the patient’s overall physical, emotional and behavioral state. Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
• Neonate and infant
• Young child
• Adolescent

Vital signs

Baseline observations are recorded of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the VICTOR graph to observe trending of signs and to support your clinical decision.
• Teperature
• Repiratory rate
• Heart rate
• Blood rate
• Oxygen saturation
• Pain

Additional measurements :
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)

Physical assessment :
• Airway
• Breathing
• Circulation
• Disability
• Focused assessment
• Skin
• Input/nutrition
• Output/elimination

Shift assessment
• Airway
• Brething
• Circulation
• Disability
• Focused
• Pain
• Hydration/nutrition
• Output
• Risk
• Wellbeing
• Social
• Review the history of the patient recorded in the IP summary

Evaluation of assessment
In the evaluatin phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
"


12. RIZKY TRY KURNIAWATI

pada : 15 September 2017

"Name: Rizky Try Kurniawati
NIM: 131611133142
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. It have three definition of terms:
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
• Patient history: History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
• General appearance: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
• Vital sign: temperature, respiratory rate, heart rate, blood preasure, oxygen saturation, pain, weight, height, head circumference, blood sugar level (BSL)
• Physical assessment: observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Airway, breathing, circulation, disability, focused assessment, skin, input/nutrition, output/elimination.
• Wellbeing: Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
• Social/cultural: Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements.
2. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
• Airway, breathing, circulation, disability, focused, pain, hydration/nutrition, output,risk, wellbeing, social, review the history of the patient recorded in the IP summary.
3. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient.
• Neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat (ENT).
4. Evaluatin of assessment: In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
"


13. Verantika Setya Putri

pada : 15 September 2017

"Name : Verantika Setya Putri
Nim : 131611133026
Class: A1 2016
Assessment is a key component of nursing practice, which is necessary for the planning and provision of care centered on patients and families. Registered nurses assess, plan, implement and evaluate nursing care in collaboration with individuals and multidisciplinary health care team to achieve the goals and health outcomes. "
The purpose of this guide is to ensure that all RCH patients receive consistent and timely nursing assessments.
The guidelines specifically aim to provide nurses with:
• Indications for assessment
• Assessment type
• Structure for ssessments
Definition of terms
Ratings Login: nursing assessment includes a comprehensive history of the patient, the general appearance, physical examination and vital signs is completed at the time of admission.
Shifts assessment: Concise nursing assessment completed at the commencement of each shift or if the patient's condition changes at any other time during your shift.
Assessment focus: nursing assessment Detailed specific body system relating to the proposed issue or concern at this time of the patients. This may involve one or more body systems.
Assessment of revenue
Ratings entry must be performed by a nurse with a parent or caregiver, patient history
The current history of illness / injury (ie the reason for current admission), past relevant history, allergies and reactions, drugs, immunization status and family and social history.
General appearance
An overall assessment of the overall physical, emotional, and behavioral conditions of the patient.
Vital sign
Initial observations were recorded as part of the admission and documented assessment on the patient's observation flowsheet. It is mandatory because it is used for pe ngambilan clinical decisions.
Physical assessment:
Structured physical examination allows the nurse to obtain a complete patient assessment. Observation, inspection, palpation, percussion and auscultation techniques used to gather information.
Nervous system
Comprehensive neurological nursing assessment includes neurological observation, cognitive and developmental growth, fine motor skills and abusive, sensory function, seizures and other problems.



Respiratory system
Respiratory illnesses in children are common, and many other conditions that cause respiratory distress.
Respiratory assessment includes:
History, i nspeksi / observation, a uskultasi, r abaan
Cardiovascular
Assessment of the cardiovascular system evaluates the adequacy of cardiac output
Gastrointestinal
Assessment includes examination, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and tenderness / tenderness. The assessment includes a history, Inspection, Palpation , Light palpation only to identify, Auscultation

Kidney
Assessment of the renal system includes all aspects of urinary elimination
Musculoskeletal
Musculoskeletal assessment can begin when observing the baby / child in the bed or when they b ergerak around their room. Throughout this assessment the limbs / joints should be compared bilaterally.
Skin
Skin assessment can identify skin problems as well as systemic diseases.
Inspection / observation
Feel

Eye
Eye inspection should always be done carefully and only with obedient children.
Inspection / Observation
Ear / Nose / Throat (ENT)
Throat and mouth assessment is essential for upper respiratory tract infections, allergies; trauma of the mouth or face, dental caries and pharyngitis are common in children. This includes a thorough examination of the oral cavity. Examination of the throat and mouth is completed in younger and less cooperative children.
Inspection
Palpation

Evaluation assessment

In the evaluation phase of the assessment, make sure the collected information is complete, accurate and documented appropriately. Nurses should utilize critical thinking and problem-solving skills to make clinical decisions and plan for the care of the assessed patient.



"


14. dinda dhia aldin kholidiyah

pada : 15 September 2017

"Name: Dinda Dhia Aldin kholidiyah
NIM: 13161133041
Class: A1
Resume: Nursung assessment
• Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. three types of assessment
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Admission assessment is to be documented on the nursing admission form. Component of the assessment:
 Patient history. History of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
 General appearance, Assessment of the patient’s overall physical, emotional and behavioral state.
 Physical assessment: Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Vital signs, envalop temperature, respiratory rate, heart rate, blood pressure, oxygen saturation. And additional measurements: weight, height, head
2. Shift assessment: Concise nursing assessment completed at the commencement or if patient condition changes of each shift.
3. Focused assessment: Detailed nursing assessment of specific body system relating to the presenting problem. Including system:
 Respiratory system
 Cardiovascular
 Gastrointestinal
 Renal
 Musculoskeletal
 Skin
 Eye
 Ear/nose/throat (ENT)
• Evaluation of assessment, In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.

"


15. Adji Yudho Pangaksomo

pada : 15 September 2017

"Name : Adji Yudho Pangaksomo
NIM : 131611133133
Class : A3/A2016

NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.
AIM
The guideline specifically seeks to provide nurses with:
1. Indications for assessment
2. Types of assessments
3. Structure for assessments
DEFINITION OF TERMS
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.
ADMISSION ASSESSMENT
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
PATIENT HISTORY
1. History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
2. For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, APGAR score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation)
GENERAL APPEARANCE
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
o Neonate and Infant
 Parent-infant, infant-parent interaction
 Body symmetry, spontaneous position and movement
 Symmetry and positioning of facial features
 Strong cry
o Young Child
 Parent-child, child-parent interaction
 Mood and affect
 Gross and fine motor skills
 Developmental milestones
 Appropriate speech
o Adolescent
 Mood and affect
 Personal hygiene
 Communication
VITAL SIGNS
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
o Temperature: Tympanic temperatures for children older than 6 months. Less than 6 months use digital per axilla.
o Respiratory Rate: Count the child’s breaths for one full minute. Assess any respiratory distress.
o Heart Rate: Palpate brachial pulse (preferred in neonates) or femoral pulse in infant and radial pulse in older children. To ensure accuracy, count pulse for a full minute.
o Blood Pressure: Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. A rough guide to appropriate cuff size is to ensure it fits a 2/3 width of upper arm. For neonates without previous hospital admissions do a blood pressure on all 4 limbs.
o Oxygen Saturation: As clinically indicated.
o Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool. Current pain relief medications/practices
Additional measurements:
o Weight: on admission and/or weekly/daily as clinically indicated.
o Height: as clinically indicated.
o Head circumference: as clinically indicated.
o Blood sugar level (BSL): as clinically indicated.
PHYSICAL ASSESSMENT :
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information.
WELLBEING :
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
SOCIAL/CULTURAL:
Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements.
SHIFT ASSESSMENT
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flow sheet and further assessments or changes to be documented in the assessment flow sheet/progress notes. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused, Pain, Hydration/Nutrition, Output, Risk, Wellbeing, Social, Review the history of the patient recorded in the IP summary.
FOCUSED ASSESSMENT
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
NEUROLOGICAL SYSTEM
A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
RESPIRATORY SYSTEM:
Respiratory illness in children is common and many other conditions may also cause respiratory distress.
EVALUATION OF ASSESSMENT
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
"


16. Mudrika Novita Sari

pada : 15 September 2017

"Name: Mudrika Novita Sari
ID Number: 131611133050
Clas: A1-2016
Summary:

Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient's family and other team members, that focuses on treating illness to improve quality of life. Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. In the national competency standard for registered nurses states that, “The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.” The guideline specifically seeks to provide nurses with: (1) Indications for assessment; (2) Types of assessments; (3) Structure for assessments; (4) Definition of terms.
Admission assessment is a comprehensive nursing assesment and should be completed and documented on the nursing admission form by the nurse with a parent or care giver, usually when the arrival of the patients to the ward or preadmission. It is must be done within 24 hours of admission and the nurse must keep patients privacy all times. Admission assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Shift assessment is a concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Shift assessment is documented on the assessment flow sheet and further assessments. The shift assessment includes: (1) Airway: noises, secretion, cough, or artificial airway; (2) Breathing: breath sounds, respiratory rate, rhytm, etc; (3) Circulation: pulses, peripheral temperature, colour and capillary refill time, skin, lip, oral mucosa and nail bed colour; (4) Disability : mobility transfer requirements, prostethics/orthotics required (5) Focused assessment.
Focused assessment is a detailed nursing assessment of specific body systems relating to the presenting problem or current concerns of the patient. This may involve one or more body system. Focused assessment includes: (1) Neurogical systems: neurogical observations, cognitive growth, and development, fine and gross motor skills, sensory function, seizures and any other concerns; (2) Respiratory systems: respiratory distress; (3) Cardiovascular : the adequacy of cardiac output; (4) Gastrointestinal : inspection, auscultation, and light palpation of the abdomen; (5) Renal : all aspects of urinary elimination.
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. "


17. Hilmy Ghozi Alsyafrud

pada : 15 September 2017

"NAMA :Hilmy Ghozi alsyfrud
NIM : 131611133108
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly."


18. Novalia Puspitasary

pada : 15 September 2017

"NAME : NOVALIA PUSPITASARY
NIM : 131611133044
SUMMARY : Nursing Assessment
Assessment is the first step of nursing practice,it is a step that help nurses planning and making a good intervention for patients need. Every country has their own system or guidelines of assesment but it might be a similiraty. The example is Indonesian system same as Australian system but it is different in America, Africa or Europe system. The guideline specifically seeks to provide nurses with indications for assessment, types of assessments, and structure for assessments.
The nurse that already registered can assesses, plans, implements, and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes. To be a registered nurse, he/she shoud pass the test so they are ready to work.
There are three types of assessment, it is admission assessment, shift assessment and focused assessment. All of these types has a different indications and structure
1. Admission assessment
Admission assessment is a comprehensive nursing assesment and should be completed and documented on the nursing admission form by the nurse with a parent or care giver, usually when the arrival of the patients to the ward or preadmission. It is must be done within 24 hours of admission and the nurse must keep patients privacy all times.
The nurse must assess about :
a. Patient history
b. General appearence
c. Vital signs
d. Additional measurements
e. Physical assessment (airway, breathing, circulation, disability, skin)
f. Wellbeing (psychosocial assessments e.g HEADSS)
g. Social/cultural

2. Shift assessment
Shift assessment is a concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Shift assessment is documented on the assessment flow sheet and further assessments.
The shift assessment includes:
a. Airway : noises,secretion,cough,or artificial airway
b. Breathing : breath sounds, respiratory rate, rhytm, etc
c. Circulation : pulses, peripheral temperature, colour and capillary refill time, skin, lip, oral mucosa and nail bed colour
d. Disability : mobility transfer requirements, prostethics/orthotics required
e. Focused assessment
f. Pain : FLACC, Faces,numeric scale
g. Hydration/Nutrition : oral, nasogastric,jejunal,fasting,breast feed, diet, IV fluids
h. Output : urine, bowels, drains, losses, fluid balance
i. Risk : pressure injury risk assessment, falls risk assessment, ID bands
j. Wellbeing: mood, sleeping habits, and outcome
k. Social: family/guardian, discharge plan
l. Review the history of the patient recorded in the IP summary

3. Focused assessment
Focused assessment is a detailed nursing assessment of specific body systems relating to the presenting problem or current concerns of the patient. This may involve one or more body system.
Focused assessment includes :
a. Neurogical systems : neurogical observations, cognitive growth, and development, fine and gross motor skills, sensory function, seizures and any other concerns
b. Respiratory systems : respiratory distress
c. Cardiovascular : the adequacy of cardiac output
d. Gastrointestinal : inspection, auscultation, and light palpation of the abdomen
e. Renal : all aspects of urinary elimination
f. Musculoskeletal
g. Skin
h. Eye and Ear/Nose/Throat (ENT)
Evaluation of assessment is ensure the information that already collected is complete, accurate, and documented appropriately. While assess a nurse must have crticial thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed."


19. CUCU EKA PERTIWI

pada : 15 September 2017

"NAME : CUCU EKA PERTIWI
NIM : 131611133007
CLASS : A1
Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.
The guideline specifically seeks to provide nurses with:
1. Indications for assessment
2. Types of assessments
3. Structure for assessments
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. The things that should be reviewed in the assessment are:
1. Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
2. General appearance
Assessment of the patient’s overall physical, emotional and behavioral state. Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. in general appearance is done at the level of Neonate and Infant, Young Child, Adolescent. Each level has a different category of assessment.
3. Vital signs
the things that need to be examined in vital signs are:
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
4. Additional measurements
things that need to be done in additional measurements are :
• Weight: on admission and/or weekly/daily as clinically indicated.
• Height: as clinically indicated.
• Head circumference: as clinically indicated.
• Blood sugar level (BSL): as clinically indicated.
5. Physical assessment
Physical assessment consists of observation, inspection, palpation, percussion and auscultation, hereinafter referred to as the technique used to gather information. Assessment information includes, but is not limited to:
• Airway
• Breathing
• Circulation
• Disability
• Focused Assessment
• Skin
• Input/Nutrition
• Output/Elimination
6. Wellbeing
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
7. Social/cultural
Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
8. Shift assessment
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. The Shift Assessment includes:
• Airway
• Breathing
• Circulation
• Disability
• Focused
• Pain
• Hydration/Nutrition
• Output
• Risk
• Wellbeing
• Social
• Review the history of the patient recorded in the IP summary
9. Focused assessment
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system. Such body systems include:
• Neurological system
• Respiratory system
• Cardiovascular
• Gastrointestinal
• Renal
• Musculoskeletal
• Skin
• Eye
• Ear/Nose/Throat (ENT)
Evaluation of assessment
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.



"


20. Yuliani Puji Lestari

pada : 15 September 2017

"Name : Yuiani Puji Lestari
NIM : 131611133003 / A1
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments.
The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
Definition of terms
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.
Patient history
History of current illness/injury relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
Additional measurements:
• Weight: on admission and/or weekly/daily as clinically indicated.
• Height: as clinically indicated.
• Head circumference: as clinically indicated.
• Blood sugar level (BSL): as clinically indicated.
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required.
Focused assessment
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system : Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Skin, Eye, Ear/Nose/Throat (ENT), Evaluation of assessment

"


21. Faizatul Ummah

pada : 17 September 2017

"NAME : FAIZATUL UMMAH
NIM : 131611133097
CLASS : A2

NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The aim of assessment is guidelines specifically seeks to provide nurses with indications, types and structure for assessments.
Admission assessment is comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Shift assessment is concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Focused assessment is detailed nursing assessment of specific body system relating to the presenting problem or current concern of the patient. This may involve one or more body system.
Patient history is history of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history. General appearance is assessment of the patient’s overall physical, emotional and behavior state. Vital signs is baseline obseravtions are recorded as part of an admission assessment and documented on the patiens observation flowsheet. Physical assessment is a structured physical examination allows the nurse to obtain a complete assessment of the patient.
Shift assessment at the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. The shift assessment includes airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
Focused assessment is a detailed nursing assessment of specific body system relating to the presenting problem or other current concern is required. This may involve one or more body system. The focused assessment includes neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat(ENT).
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

"


22. Ema Yuliani

pada : 18 September 2017

"Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.
Definition of terms
Admission assessment is Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Shift assessment is a Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system
Admission assessment
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.  Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to:
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system,that is Neurological system, Respiratory system, Cardiovascular Gastrointestinal, Renal, Musculoskeletal, Skin, eye, ect.


"


23. Lukmania Andriani Putri

pada : 18 September 2017

"Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.”
The guideline specifically seeks to provide nurses with:
- Indications for assessment
- Types of assessments
- Structure for assessments
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, APGAR score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation)body system
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
General appearance :
• Neonate and Infant Parent-infant, infant-parent interaction
• Body symmetry, spontaneous position and movement
• Symmetry and positioning of facial features
• Strong cry
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
Temperature: Tympanic temperatures for children older than 6 months. Less than 6 months use digital per axilla.
Respiratory Rate: Count the child’s breaths for one full minute. Assess any respiratory distress.
Heart Rate: Palpate brachial pulse (preferred in neonates) or femoral pulse in infant and radial pulse in older children. To ensure accuracy, count pulse for a full minute.
Blood Pressure: Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. A rough guide to appropriate cuff size is to ensure it fits a 2/3 width of upper arm. For neonates without previous hospital admissions do a blood pressure on all 4 limbs.
Oxygen Saturation: As clinically indicated.
Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool. Current pain relief medications/practices



"


24. Ida Nurul Fadilah

pada : 18 September 2017

"Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates.
The guideline specifically seeks to provide nurses with indications for assessment, types of assessments, structure for assessments .
Definition of terms :
• Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
• Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
The Shift Assessment includes:
a. Airway: noises, secretions, cough, artificial airway
b. Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing, spontaneous/ supported/ ventilator dependent, oxygen requirement and delivery mode
c. Circulation: pulses (rate, rhythm and strength); peripheral temperature, colour and capillary refill time; skin, lip, oral mucosa and nail bed colour.
d. Disability: Use assessment tools such as, Alert Voice Pain Unconscious scale(AVPU) or University Michigan Sedation Score (UMSS) and record on observation chart. Any aids, mobility or transfer requirements, prosthetics/orthotics required. Blood sugar levels as clinically indicated.
e. Focused: assessment of presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
f. Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool.
g. Hydration/Nutrition: oral, nasogastric, gastrostomy, jejunal, fasting, breast fed, diet, IV fluids.
h. Output: urine, bowels, drains, losses, fluid balance
i. Risk: pressure injury risk assessment, falls risk assessment, ID bands
j. Wellbeing: Mood, sleeping habits and outcome, coping strategies, reaction to admission
k. Social: family/ guardian, discharge plan
l. Review the history of the patient recorded in the IP summary, However, it may be appropriate to ask questions to add additional details to the history

• Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.


"


25. Konita Shafira

pada : 18 September 2017

"nama : konita shafira
NIM : 131611133073
kelas : A2

Nursing Assesment
Assessment is a key component of nursing practice.
• Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. must be completed within 24 hours of admission. Privacy of the patient needs to be considered all times
• Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.
Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
• Neonate and Infant Parent-infant, infant-parent interaction
• Body symmetry, spontaneous position and movement
• Symmetry and positioning of facial features
• Strong cry
• Young Child Parent-child, child-parent interaction
• Mood and affect
• Gross and fine motor skills
• Developmental milestones
• Appropriate speech
• Adolescent Mood and affect
• Personal hygiene
• Communication

Vital signs :
• Temperature : Tympanic temperatures for children older than 6 months. Less than 6 months use digital per axilla.
• Respiratory Rate : Count the child’s breaths for one full minute. Assess any respiratory distress.
• Heart Rate : Palpate brachial pulse (preferred in neonates) or femoral pulse in infant and radial pulse in older children. To ensure accuracy, count pulse for a full minute.
• Blood Pressure : Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. A rough guide to appropriate cuff size is to ensure it fits a 2/3 width of upper arm. For neonates without previous hospital admissions do a blood pressure on all 4 limbs.
• Oxygen Saturation : As clinically indicated.
• Pain : FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool. Current pain relief medications/practices
Physical assessment :
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Techniques used to gather information is observation, inspection, palpation, percussion and auscultation.
• Breathing: bilateral air entry and movement, breath sounds (normal and adventitious), respiratory rate, rhythm, work of breathing: spontaneous/ laboured/supported/ ventilator dependent, any oxygen requirement and delivery mode.
• Circulation: pulses (location, rate, rhythm and strength); peripheral temperature, skin colour and moisture, skin turgor, capillary refill time; lip, oral mucosa and nail bed colour.
• Disability: Use assessment tools such as, Alert Voice Pain Unresponsive score (AVPU) or University Michigan Sedation Score (UMSS), Gross Motor Function Classification System (GMFCS). Identify any aids required such as mobility aids, transfer needs, glasses, hearing aids, prosthetics, orthotics etc. Any abnormal movement or gait.
• Focused Assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems. For example, cardiovascular, respiratory, neurological.
• Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.
• Input/Nutrition: appetite, appropriate weight for age, food intolerance, nausea or vomiting, dietary requirements , breast fed, formula, oral, NG, Gastrostomy, Jejunal, IV, Fluids, Hydration state.
• Output/Elimination: Bowel and Bladder routine(s), incontinence management, drains and other losses.
Shift Assesment :
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flow sheet and further assessments or changes to be documented in the assessment flow sheet/progress notes.
The Shift Assessment includes :
• Airway: noises, secretions, cough, artificial airway
• Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing, spontaneous/ supported/ ventilator dependent, oxygen requirement and delivery mode
• Circulation: pulses (rate, rhythm and strength); peripheral temperature, colour and capillary refill time; skin, lip, oral mucosa and nail bed colour.
• Disability: Use assessment tools such as, Alert Voice Pain Unconscious scale(AVPU) or University Michigan Sedation Score (UMSS) and record on observation chart. Any aids, mobility or transfer requirements, prosthetics/orthotics required. Blood sugar levels as clinically indicated.
• Focused: assessment of presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
• Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool.
• Hydration/Nutrition: oral, nasogastric, gastrostomy, jejunal, fasting, breast fed, diet, IV fluids.
• Output: urine, bowels, drains, losses, fluid balance
• Risk: pressure injury risk assessment, falls risk assessment, ID bands
• Wellbeing: Mood, sleeping habits and outcome, coping strategies, reaction to admission
• Social: family/ guardian, discharge plan
• Review the history of the patient recorded in the IP summary, However, it may be appropriate to ask questions to add additional details to the history
Neurological system : A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
Respiratory system : Respiratory illness in children is common and many other conditions may also cause respiratory distress.
Cardiovascular : Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
Gastrointestinal : Assessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness.
Renal : An assessment of the renal system includes all aspects of urinary elimination
Musculoskeletal : A musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room. Be aware that during periods of rapid growth, children complain of normal muscle aches.
Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
Eye : Inspection of the eye should always be performed carefully and only with a compliant child."


26. Grace Marcellina B

pada : 18 September 2017

""Nama:Grace Marcellina B
NIM: 131611133061
KELAS: A2
Nursing assesment
Assessment is a key component of nursing practice, which is necessary for patient and family-centered planning and care provision so that nurses have the task of assessing, planning, implementing and evaluating nursing care. The guidelines aim to Indications for assessment, Types of assessments and Structure for assessments. There are three kinds of assessments, namely admission assessment : Assessment of acceptance should be documented on the nurse admission form, shift assessment : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history, and focused assessment.
Patient history : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required.
Wellbeing:
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
Social/cultural:
Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
Shift assessment
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flowsheet and further assessments or changes to be documented in the assessment flowsheet/progress notes.
Focused assessment
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
a. Neurological system
b. Respiratory system
c. Cardiovascular
d. Gastrointestinal
e. Musculoskeletal
f. Skin
g. Eye
h. Ear/Nose/Throat (ENT)
Evaluation of assessment.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly."


27. Ishomatul Faizah

pada : 18 September 2017

"Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
Additional measurements:
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to:
• Airway
• Breathing
• Circulation
• Disability
• Focused Assessment
• Skin
• Input/Nutrition
• Output/Elimination

Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.

The Shift Assessment includes:
• Airway
• Breathing
• Circulation
• Disability
• PainHydration/Nutrition
• Output
• Risk

Focused assessment
• A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
Neurological system
• A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.

Evaluation of assessment

In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.
This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.


"


28. Ishomatul Faizah

pada : 18 September 2017

"NAMA: ISHOMATUL FAIZAH
NIM: 131611133053
KELAS: A2

Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
Patient history
History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process.
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
Additional measurements:
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to:
• Airway
• Breathing
• Circulation
• Disability
• Focused Assessment
• Skin
• Input/Nutrition
• Output/Elimination

Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.

The Shift Assessment includes:
• Airway
• Breathing
• Circulation
• Disability
• PainHydration/Nutrition
• Output
• Risk

Focused assessment
• A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
Neurological system
• A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.

Evaluation of assessment

In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.
This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.


"


29. Asih Parama Anindhia

pada : 18 September 2017

"NAMA: ASIH PARAMA ANINDHIA
NIM: 131611133075

RESUME NURSING ASSESSMENT
Nursing assessment is a a key component of nursing practice, required for planning and provision of patient and family centrheed care. The guideline specifically seeks to provide nurses with: indications for assessment; types of assessments; structure for assessments
Definition of terms:
• Admission assessment
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24 hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times
• Shift assessment
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flow sheet and further assessments or changes to be documented in the assessment flow sheet/progress notes. The Shift Assessment includes:
• AirwayBreathing
• Circulation.
• Disability
• Focused
• Pain
• Hydration/Nutrition
• Output
• RiskWellbeing
• Social
• Review the history of the patient recorded in the IP summary

• Focused assessment
A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.

Evaluation of nursing assessment
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.
The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.
This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.

"


30. BLANDINA EASTER GRACE WAIRATA

pada : 18 September 2017

"Nursing Assessment
The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team.
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
- Patient History is history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
- General appearance shows the looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement of the patient.
- Physical examination (observation, inspection, palpation, percussion and auscultation)
- Vital Signs are temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain.

2. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
The shift sssessment includes : Airway, Breathing, Circulation, Disability, Pain, Hydration/Nutrition, Output, Risk, Wellbeing, Social, Review the history of the patient recorded in the IP summary.

3. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system. For example, Neurological system, Respiratory system:, Cardiovascular, Gastrointestinal, Musculoskeletal, Skin, Ear/Nose/Throat (ENT), and Eye."


31. Reza Ramadhana R

pada : 18 September 2017

"Name : Reza Ramadhana R
Class : A2/2016
NIM : 131611133066
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
The aim of nursing assessment is to determine indications, types and structures of assessment.
An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times
The nurse must ask the patient of history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history to fill in the assesment.
The nurse must check the Assessment of the patient’s overallphysical, emotional and behavioral state. Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
The vital signs of patient must be checked when the nurse fill the assessment, like the Temperature, Heart Rate, Blood Pressure and Oxygen Saturation to support clinical decision making.
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition and Output/Elimination.
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flow sheet and further assessments or changes to be documented in the assessment flow sheet/progress notes"


32. Sekar Ayu Pitaloka

pada : 18 September 2017

"Nama : Sekar Ayu Pitaloka
NIM : 131611133025/A1
Resume :
Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The people who must doing assessment is, the first people who meet patient in the work unit. Here is the kind of assessment :
a. Admission assessment : this assessment conducted in 24 hours of the first patient in hospital. The next nurses must to follow what has been be assessed. The assessment conducted on :
• Vital sign as a purpose to support your clinical decision making proses, includes the temperature, respiratory rate, heart rate, blodd pressure, oxygen saturation and pain.
• Additional measurements, includes the weight , height, head circumference, and blood sugar level (BSL).
b. Shift assessment : consies nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. And this information used to develop a plan of care. The shift assessment includes airway, breathing, circulation, disability, focused, pain, hydration/nutrition, output, risk, wellbeing, social, and review the history of the patient recorded in the IP summary.
c. Focused assessment : detailed nursing assessment of specific body system relating to the presenting problem or current concern of the patient. This may involve one or more body system.
Neurological System
A comprehensive assessment neurological nursing assessment includes neurogical observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concern.
Respiratory System
Respiratory illness in children is common and many other condition may also cause respiratory distress. Respiratory assessment includes history, inspection/observation, auscultation, palpation, and percussion.
• Inspection, we have to look at the condition of the respiratory are of the patient, inclues : colour (centrally and peripherally), respiratory rhythm, rate and depth, respiratory effort, use of accessory muscle, symmetry and shape of chest, tracheal position, thraceal tug, audible sounds, and monitor for oxygen saturation.
• Auscultation, we have to listen for absence/equality of breath sounds.
• Palpation, we have to look bilateral symmetry or chest expansion, skin condition, capillary refill, fremitus tactile and subcuneous emphysema by groping with our hands.
• Percussion is an act of the examination by listening to the sound of vibrations/ sound waves deliveres from the body surface of the examined body. The examination is done by tapping a finger or hand on the surface of the body. With percussion we can know the exixtence of abnormalities such as excess fluid in the lungs, the presence of mass in the lungs, and etc.
Cardiovascular : assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes. The examination is similar to a respiratory system that includes inspection, palpation, auscultation, and percussion.
Gastrointestinal : assessment will include inspection, aucustation, and light palpation of the abdomen to indentify visible abnormalities
Renal : an assessment of the renal system includes all aspects of urinary elimination.
Musculoskeletal : a musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room. Be aware that during periods of rapid growth, children complain of normal muscles aches. Throughout this assessment limbs/joint should be compared bilaterally.
Skin : this assessment can identify cutaneous problems as well as systemic diseases. At the inspection we have to examinated of colour, rash, brusing/wounds/pressure injuries, nevi/moles and hair.
Eye : inspection of the eye should always be performed carefully and only with a compliant child.
Ear/Nose/Throat (ENT) : assessment of throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children. This includes a through examination of the oral cavity. The examination of the throat and mouth is completed last in younger, less cooperative children.
Evaluation of Assessment
In the evaluation phase of assessment , ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken.
This may include communicaying the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift. Patients should be continuously assessed for chages in condition while under RCH care and assessment are documented regularly.

"


33. Mutiara Citra Dewi

pada : 18 September 2017

"Name : Mutiara Citra Dewi
NIM : 131611133078
Class : A2 2016

Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
a. Admission assessment : Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
• Patient history : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history.
• General appearance : Assessment of the patient’s overall physical, emotional and behavioral state. Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
• Vital sign : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is mandatory to review the ViCTOR graph to observe trending of vital signs and to support your clinical decision making process. Temperature, respiratory rate, hearth rate, blood pressure, oxygen saturation, pain.
• Physical assessment : a structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Airway, breathing, circulation, disability, focused assessment, skin, input/ nutrition, output/elimination.
b. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Airway, breathing, circulation, disability, focused assessment, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
c. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system
• Neurological system : A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
• Respiratory system : Respiratory illness in children is common and many other conditions may also cause respiratory distress.
• Cardiovascular : Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
• Gastrointestinal : Assessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness. Ensure stomach is not full at time of assessment as this may induce vomiting.
• Renal : An assessment of the renal system includes all aspects of urinary elimination
• Musculoskeletal : A musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room. Be aware that during periods of rapid growth, children complain of normal muscle aches. Throughout this assessment limbs/joints should be compared bilaterally.
• Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
• Eye : Inspection of the eye should always be performed carefully and only with a compliant child.
• Ear/Nose/Throat (ENT) : Assessment of throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children. This includes a thorough examination of the oral cavity. The examination of the throat and mouth is completed last in younger, less cooperative children.
Evaluation of assessment
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed.
"


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