NURSING ASSESSMENT

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Komentar (159)

Shavira13 September 2017

Name: Shavira
NIM: 131611133140
Class: A3 2016
Resume:
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. Assessment 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
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.
• 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.
Vital signs:
Temperature, respiratory rate, heart 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. 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:
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, and 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 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.

Hayu Ulfaningrum13 September 2017

NAMA MAHASISWA: Hayu Ulfaningrum
NIM: 131611133143
Kelas: A3
Resume Nursing Assessment:
Nursing Assessment
The guideline specifically seeks to provide nurses with:
o Indications for assessment
o Types of assessments
o Structure for assessments
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Admission assessment is comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Assessment must 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. 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.
Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet.
• 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
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 Examination
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.
Focussed 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.
Shift assessment is concise nursing assessment completed at the commencement of each shift or patient condition changes at any other time during your shift. Initial shift assessment is documented on the assessment flow sheet / progress notes. 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. 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. In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Agustina Lia Fitriani13 September 2017


Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
A. Aim
• 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
B. Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet.
• 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
C. Wellbeing
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
D. Shift assessment
Pada permulaan setiap shift, penilaian selesai pada setiap pasien dan informasi ini digunakan untuk mengembangkan rencana perawatanPenilaian Shift meliputi:
• 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. 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
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.







ariska windy hardiyanti13 September 2017

Nama: Ariska Windy Hardiyanti
NIM: 131611133131
KELAS: A3 (2016)
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.
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
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.


ARDINA NADYA WAHYUHERMANTO13 September 2017

NAMA MAHASISWA: ARDINA NADYA WAHYUHERMANTO
NIM: 131611133120
kelas: A3/2016
RESUME:
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. Must be completed within 24hours of admission, then documented on the nursing admission form. Privacy of the patient needs to be considered all times
a. 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.
• 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)
b. 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
• Communication
c. Vital Signs
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
d. Additional Measurements
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
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. 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
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. Includes; airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
4. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ENT, etc.
• Evaluation of assessment
1. Ensure the information collected is complete, accurate and documented appropriately.
2. 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. 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.

Restu Windi13 September 2017

NAMA MAHASISWA: RESTU WINDI
NIM:131611133144
KELAS: A3
Introduction
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 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.
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.
• 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.
• Neonate and Infant
o Parent-infant, infant-parent interaction
o Body symmetry, spontaneous position and movement
o Symmetry and positioning of facial features
o Strong cry
• Young Child
o Parent-child, child-parent interaction
o Mood and affect
o Gross and fine motor skills
o Developmental milestones
o Appropriate speech
• Adolescent
o Mood and affect
o Personal hygiene
o 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: 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
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. Assessment information includes, but is not limited to:
• Airway: noises, secretions, cough, artificial airway
• 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.
Wellbeing:
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
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.
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
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.

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. 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.

Ainul Fidiatun Nofa13 September 2017

Nama : AINUL FIDIATUN NOFA
NIM : 131611133123
Introduction : 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, 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 : 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)
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.
- 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
- Communication
Vital sign : Temperayure, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain.
Additional measurements : Weigh, 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.
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.
Musculosekeletal : 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.
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.

Ramadhani Wahyuningtyas13 September 2017

NAMA: RAMADHANI WAHYUNINGTYAS
NIM: 131611133110
KELAS: 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.

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
1. Patient history
2. General appearance
3. Vital signs
4. Additional measurement
5. Physical assessment
6. Wellbeing
7. Social/cultural

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.
1. Neurological system
2. Respiratory system
3. Cardiovascular
4. Gastrointestinal
5. Renal
6. Musculoskeletal
7. Skin
8. Eye
9. 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.

KHILYATUD DINIYAH13 September 2017

nama : Khilyatud Diniyah
NIM : 131611133107
kelas : A3 2016
resume:
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 aim of guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments

The definition of the type assessments are :
1. 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
- Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. the following explanation:
a)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.
b) 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.
c) 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

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.
- 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 (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.
• Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
• Social/cultural: Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements

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
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.

4. 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.

Handini Indah Rahmawati13 September 2017

Nama : Handini Indah Rahmawati
NIM : 131611133122
Kelas : A3

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The purpose is Indications for assessment, Types of assessments, 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(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system. General appearance: mood and affect, gross and fine motor skills, developmental milestones, appropriate speech, adolescentMood and affect, personal hygiene, communication. Additional measurements: Weight, Height, Head circumference, Blood sugar level (BSL). Physical assessment: 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. Psychosocial assessments e.g. HEADSS. Social/cultural: Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements. 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.

Dwi Yanti Rachmasari Tartila13 September 2017

Nama: Dwi Yanti Rachmasari Tartila
Nim: 131611133112
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
• 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 24hours 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.
• Vital signs
Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, and Pain.
• Physical assessment
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. Psychosocial assessments e.g. HEADSS
• Social/cultural: Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
• 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.
• 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
• 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.

ISMI SHONATUL CHOFIFAH13 September 2017


Introduction : 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, 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 : 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)
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.
-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
-Communication
Vital sign : Temperayure, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain.
Additional measurements : Weigh, 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.
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.
Musculosekeletal : 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.
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.

Nafiul ikroma wijayanti13 September 2017

NAME : Nafiul Ikroma Wijayanti
NIM : 131611133149
Class/ force : A3/2016
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
1. The guideline specifically seeks to provide nurses with:
2. Indications for assessment
3. Types of assessments
4. 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
General appearance
1. 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.
2. Neonate and Infant Parent-infant, infant-parent interaction
3. Body symmetry, spontaneous position and movement
4. Symmetry and positioning of facial features
5. Strong cry
6. Young Child Parent-child, child-parent interaction
7. Mood and affect
8. Gross and fine motor skills
9. Developmental milestones
10. Appropriate speech
11. AdolescentMood and affect
12. Personal hygiene
• Communication
Assorted assessment
1. Physical assessment
2. Social/cultural
3. Shift assessment
4. Focused 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.

INDAH AZHARI14 September 2017

NAMA : INDAH AZHARI
NIM : 131611133146
KELAS : A3
RINGKASAN : Nursing Assessment
 AIM
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.
 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.
 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.
- Neonate and Infant Parent-infant, infant-parent interaction
- Body symmetry, spontaneous position and movement
- Symmetry and positioning of facial features
- Strong cry
- Ext.
 Wellbeing:
- Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS.
 Social/cultural:
- Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
 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 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.

ADHELIA PUTRI PRASTIWI14 September 2017

Nama : Adhelia Putri Prastiwi
NIM : 131611133109
Kelas : 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.”
Aim : 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.
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. 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.
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
Communication

Vital sign : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain. Additional measurements : Weigh, 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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. 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. Musculosekeletal : 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. 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.

Sanidya Nisita Pratiwimba14 September 2017

Nama : Sanidya Nisita P
NIM : 131611133132
KELAS: A3 (2016)
Resume 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.
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.
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.


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
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
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
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.


Rezkisa D Prambudia14 September 2017

Nursing Assessment
Bu Ira Suarilah

• Nursing Assesment
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 provide nurses with indications for assessment, types of assessments, and structure for assessments.
Nursing assessment is divided into:
- 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.
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
- AdolescentMood 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.
Vital signs:
- 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:
- Airway
- Breathing
- Circulation
- Disability
- Focused Assessment
- Skin
- Input/Nutrition
- Output/Elimination
- Wellbeing
- Social/cultural

• Shift assessment
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
- 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.

timotius dwi kurnianto14 September 2017

Nama: timotius dwi kurnianto
Kelas: a3 a16
NIM: 131611133134
Resume:
Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient centred care.
The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
Definition of Assessment divide to
• 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
Assessment is doing look and observe overall physical, emotional and behavioral state. Its contain observe:
• General appearance like observer physical assessment use (inspection, palpation, percussion and auscultation)
• Vital signs like temperature, RR. HR, and blood pressure.
• Additional measurements:
Focused assessment is A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. Focus assessment contain:
• Neurological system
• Respiratory system
• Cardiovascular
• Gastrointestinal
• Renal
• Musculoskeletal
• Skin
• Eye
• Ear/Nose/Throat (ENT)
at the end assessment must have evaluation. Evaluation assessment is ensure the information collected is complete, accurate and documented appropriately. The nurse also must to draw on critical thinking and make problem solving skills to make clinical decisions and plan care for the patient being assessed.
Assessment is important because without assessment nurses cant make diagnosis and cant make outcomes, and intervention, if nurse don’t do well assessment or miss something it can be dangerous to the patient. Its how assessment important in nursing.

EKA APRILLIA DIYAH SANTI K14 September 2017

NAMA : EKA APRILLIA DIYAH SANTI K
NIM : 131611133125
KELAS : A3
 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

 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 :
1. Temperature
2. Respiratory rate
3. Heart rate
4. Blood pressure
5. Oxygen Saturation
6. Pain

 Additional Measurements:
1. Weight: on admission and/or weekly/daily as clinically indicated.
2. Height: as clinically indicated.
3. Head circumference: as clinically indicated.
4. Blood sugar level (BSL): as clinically indicated.

 Physical assessment :
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Focused AssessmentSkin
6. Input/Nutrition
7. Output/Elimination

 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.

Mitha Mulia Virdianty14 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 nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. A thorough and skilled assessment allows you, the nurse, to obtain descriptions about your patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses. Assessment uses both subjective and objective data. Subjective assessment factors are those that are reported by the patient. Objective assessment data includes that which is observable and measurable.
During the assessment period, you are given an opportunity to develop a rapport with your patient and their family. Remember the adage “first impressions are lasting impressions?” That adage is also very true in healthcare. You are often the first person your patient sees when admitted to your unit, returns from testing, or at the beginning of a new shift. Your interactions with your patient gives the patient and family lasting impressions about you, other nurses, the facility you are working in, and how care will be managed.
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.
All assessments should consider the patient’s privacy and foster open, honest patient communications.
ADMISSION ASSESSMENT
• Admission assessment is comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
• 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
SHIFT ASSESSMENT
• 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.
• 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:
FOCUSED ASSESSMENT
• Focused assessment is 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
• 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 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.
CONCLUSION
Obtaining a concise and effective health history and physical exam takes practice. It is not enough to simply ask questions and perform a physical exam. As the patient’s nurse, you must critically analyze all of the data you have obtained, synthesize the data into relevant problem focuses, and identify a plan of care for your patient based upon this synthesis. As the plan of care is being carried out, reassessments must occur on a periodic basis. The frequency of reassessments is unique to each patient based upon their diagnosis. The ability of the nurse to efficiently and effectively obtain the health history and physical exam will ensure that appropriate plan of care will be enacted for all patients.

Novalia Puspitasary14 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.

Cici Kurniatil Farhanah14 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.


Retno Galuh Kusumawardhani14 September 2017

Nama : Retno Galuh Kusumawardhani
NIM : 131611133145
Kelas: A3
Resume:
Nursing assessment
1. Introduction
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
2. Aim
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.
3. Definition of terms
3.1. 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.
- 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.
3.2. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. 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.

3.3. 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, ex: Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Eye :Inspection of the eye should always be performed carefully and only with a compliant child.
4. 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. 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.

Sekar Ayu Pitaloka14 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.

Desti Nayunda Lulu14 September 2017

Nama : Desti Nayunda Lulu
NIM : 131611133137
Kelas : A3
Resume 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.
• 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
1. Admission assessment : must be completed within 24 hours of admission
a. 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.
b. General appearance : Assessment of the patient’s overall physical, emotional and behavioral state.
c. Vital signs : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, Pain.
d. Additional measurements : Weight, Height, Head circumference, Blood sugar level (BSL).
e. Physical assessment : A structured physical examination allows the nurse to obtain a complete assessment of the patient. Assessment information includes, but is not limited to Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination.
f. Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
g. Social/cultural : Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements.
2. 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.
a. Airway
b. Breathing
c. Circulation
d. Disability
e. Focused
f. Pain
g. Hydration/Nutrition
h. Output
i. Risk
j. Wellbeing
k. Social
l. Review the history of the patient recorded in the IP summary
3. Focused assessment : A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required.
a. Neurological system
b. Respiratory system
c. Cardiovascular
d. Gastrointestinal
e. Renal
f. Musculoskeletal
g. Skin
h. Eye
i. Ear/Nose/Throat (ENT)
Evaluation of assessment : In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Galang Tegar Indrawan14 September 2017

NAME: GALANG TEGAR INDRAWAN
NIM: 131611133106
CLASS: A3

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. 1.) Admission assessment 2.) shift assessment. 3.) Focused 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. An admission assessment is a comprehensive nursing assessment including patien history, general appearance, physical examination and vital signs completed at the time of admission. So about physical, astructured 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. And than, 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. Focused assessment is 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. Than the last 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.

Locita Artika Isti14 September 2017

Nama : Locita Artika Isti
NIM : 131611133008
Kelas : A1 2016
Resume : NURSING ASSESSMENT
Assesment is 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 aim for the nursing assessment is indications for assessment, types of assessments, stucture for assessments.
Definition of terms
1. Admission assessment : Comrehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
 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
 Blood Pressure
 Oxygen Saturation
 Pain
Additional measurements:
 Weight
 Heigth
 Head circumference
 Blood sugar level (BSL)
 Physical Assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Can doing with observation, inspection, palpation, percussion and auscultation are techniques used to gather information.
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.
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.
3. Focused assessment: Detailed nursing assessment of specific body system relating to the presenting problem or currentconcern of the patient. This may involve one or more body system.
Focus assessment, This may involve one or more body system. For example neurological system, respiratory system, cardiovaskular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat (ENT)
Evaluation:
Make sure the information collected is complete, accurate, and fully documented.
The nurse must think critically.
And if any findings are not normal the nurse must take appropriate action, and may communicate with other medical personnel.

Ragil Titi Hatmanti14 September 2017

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.

Fitrinia Puspita Sari14 September 2017

NAMA: Fitrinia Puspita Sari
NIM: 131611133139
KELAS: A3 2016
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, Structure for assessments.
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. 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.
- 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
- Communication
Vital sign : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain. Additional measurements : Weigh, 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.
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. Musculosekeletal : 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. 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 ed is completevaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. 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.

Nabila Hanin Lubnatsary14 September 2017

Name: Nabila Hanin Lubnatsary
NIM: 131611133011
Class: A1-2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Nursing assessment’s aim is the guideline specifically seeks to provide nurses with indications for assessment, types of assessments, structure for assessments. there are three types of assessment:
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance (assessment of the patient’s overall physical, emotional and behavioral state), physical examination (observation, inspection, palpation, percussion and auscultation are techniques used to gather information. There are many components, which is airway, breathing, circulation, disability, focused assessment, skin, input/nutrition, output/elimination) and vital signs (temperature, RR, heart rate, blood pressure, oxygen saturation and pain) completed at the time of admission.
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. There are many components, which is airway, breathing, circulation, disability, focused assessment, pain, hydration/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 or current concern(s) of the patient. This may involve one or more body system (neurological system, cardiovascular, repiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat)
Evaluastion assessment: In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Yohana Rahmawati Santoso14 September 2017

Nama : Yohana Rahmawati Santoso
NIM : 131611133111
Kelas : A-3 2016

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

things that need to be considered 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.
- 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)

Vital signs
- 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.
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

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:
Airway
Breathing
respiratory rate, rhythm, work of breathing
Circulation
Disability
Focused Assessment
Skin
Input/Nutrition
Output/Elimination
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
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.
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
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.







Afita Nur Dwiyanti14 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 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 and 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 and 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 : Temperature, repiratory rate, heart rate, blood rate, oxygen saturation and pain.
• Additional measurements : weight, height, head circumference and 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.

Afita Nur Dwiyanti14 September 2017

NAMA : Afita Nur Dwiyanti
NIM : 131611133114
KELAS : 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 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 and 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 and 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 : Temperature, repiratory rate, heart rate, blood rate, oxygen saturation and pain.
• Additional measurements : weight, height, head circumference and 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.

PUTRI HISAANAH14 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.

Achmad Ubaidillah Mughni14 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.

Esti Ristanti14 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.


HAPPY PUSPITA RISNA14 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.

Ragil Titi Hatmanti15 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.

Dwi Utari Wahyuning Putri15 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.

Endah Desfindasari15 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.

RENDHY RIAN KOESMA BACHTIAR15 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.



NURUL HIDAYATI15 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

Shintia Ekawati15 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.

RIZKY TRY KURNIAWATI15 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.

Novita Dwi Andriana15 September 2017

Name : Novita Dwi Andriana
NIM : 131611133116

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.”
The aim of guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
The definition of the type assessmentsare :
1. 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
- Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.the following explanation:
a) 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.
b) 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.
c) 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
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.
- 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:
1. Airway: noises, secretions, cough, artificial airway
2. 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.
3. 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.
4. 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.
5. 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.
6. Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.
7. 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.
8. Output/Elimination: Bowel and Bladder routine(s), incontinence management, drains and other losses.
9. Wellbeing :Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
10. Social/cultural:Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
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
o 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
o Respiratory illness in children is common and many other conditions may also cause respiratory distress.
• Cardiovascular
o Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
• Gastrointestinal
o 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
o An assessment of the renal system includes all aspects of urinary elimination
• Musculoskeletal
o 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.
4. 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.

MUHAMMAD DZAKIYYUL FIKRI WACHID15 September 2017

NAME: Muhammad Dzakiyyul Fikri Wachid
NIM: 131611133115
CLASS: A3
RESUME:

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.
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
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: 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

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.

Ayu Saadatul Karimah15 September 2017

Nama: Ayu Saadatul Karimah
NIM: 131611133020
Kelas : A-1 2016

NURSING ASSESSMENT
Assessment is the basic thought of a nursing process that aims to collect information or data about clients, in order to identify, identify problems, health needs and nursing clients, whether physical, mental, social, and environmental.

Nurses are tasked with conducting nursing processes such as assessment, diagnosis, intervention, implementation, and evaluation in providing nursing care in collaboration with health personnel or fellow nurses to achieve the expected goals.

There are several types of assessment:
1. Admission Assessment means the assessment undertaken by the nurse since the patient was first admitted to the hospital. This type of assessment should be done with parents, relatives or close relatives who bring patients to the hospital. Assessment should be completed within 24 hours of admission to hospital. Assessment conducted is patient history, patient appearance, physical examination and others.
2. Shift assessment means the assessment performed to the patient at the commencement of the shift.
3. Focused assessment means the assessment undertaken to examine in detail the specific problematic system of the body.

Patient History
History of current illness / injury suffered by patients resulting in hospital admission or past history of patients such as allergies, medications, immunization status and others. For newborn infants the history of the disease may consider a history of maternal diseases such as the type of labor, antenatal and others.

General Assessment
The general assessment in question is an assessment of the overall physical conditions, emotional, and behavioral conditions of the patient. Such as body symmetry, facial expressions, patient response, patient communication and others.

Vital sign
Vital signs should be noted since the patient is admitted to the hospital and should be documented on the patient's observation sheet. Nurses are mandatory to review the VICTOR graph to observe trending of vital signs and to assist in clinical decision-making. Vital signs that a nurse should examine are the temperature, RR, heart rate, blood pressure, and complaints experienced by the patient. If necessary the nurse should also assess the weight, height, head circumference, blood sugar level of the patient to assist the nurse in diagnosing the patient's problem.

Physical examination
Physical examination allows the nurse to obtain a complete patient assessment. In performing physical examination through observation, palpation, inspection, percussion and auscultation.

Psychosocial assessment
In this assessment the nurse assessed the psychosocial experienced by the patient such as emotional state, sleep patterns, coping, mood and other.

Social and cultural assessment
In this assessment the nurse assesses the patient's social and cultural conditions such as living arrangements, transportation, tradition or culture and others.

Shift Assessment
Assessment is done at every beginning of shift. This assessment is performed on each patient to see the progress of the patient's health by being documented on the assessment sheet.

Here are some body systems that need to be assess by nurses such as the nervous system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear, nose, and throat.

Assessment evaluation
At this stage make sure the information, data and physical examination are collected complete, accurate and well documented. Nurses must have the ability to think critically and can solve nursing problems to make clinical decisions and plan the care of the patients under assess. Patients should always be assessed to determine the development or decline in health experienced by patients so that nurses can perform actions quickly and precisely.

YENNI NISTYASARI15 September 2017

NAMA : YENNI NISTYASARI
NIM : 131611133035
KELAS : A1-2016
NURSING ASSESSMENT
Assessment is a component of the nursing practice necessary for planning in the provision of patient and family care. The nursing assessment is concerned with the plan, implementing and evaluating nursing care in collaboration with individual and multidisciplinary health teams so as to achieve health outcomes and outcomes.

Aim :
• 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. Admission assessment should be completed by the nurse with a parent, 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.
VITAL SIGNS
Vital signs should be made when the patient first enters, the results of vital signs checks should be recorded and documented that are useful for patient observation, vital signs are mandatory to review, and support clinical decision making. Vital signs includes : 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. Assessment information includes, but is not limited to : Airway, Breathing, Circulation, Disability, Skin, Input/Nutrition, Output/Elimination,Wellbeing, Social/cultural.
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, Pain, Hydration / Nutrition, Output (urine, bowels, drains, losses, fluid balance), Risk, Wellbeing (Mood), Social (family), 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
• Cardiovascular : Assessment of the cardiovascular system evaluates the adequacy of cardiac output and input.
• Renal : An assessment of the renal system includes all aspects of urinary elimination
• Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
• Musculoskeletal : A musculoskeletal assessment can be commenced while observing the infant. Be aware that during periods of rapid growth, children complain of normal muscle aches.
• 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.

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.

Alfia Dwi Sunarto15 September 2017


Name : Alfia Dwi Sunarto
NIM : 131611133105
Class : A3 2016
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.
Admission assessment
Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. 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. 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.

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. 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.


Ariska Windy Hardiyanti15 September 2017

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.

Ariska Windy Hardiyanti15 September 2017

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.

Nurrrochma Alyadira15 September 2017

Nama : Nurrochma Alyadira
NIM : 131611133152
Kelas : A3
Assessment : 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.”
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. 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.
- 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
- Communication.
Vital sign : 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.
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.
Musculosekeletal : 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 : Skim assesment can identify cutanous peroblems as well as systemic diseases.
Eye : Inspection of the eye should alays 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.

Ainul Fidiatun Nofa15 September 2017

Introduction : 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, 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 : 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)
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.
- 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
- Communication
Vital sign : Temperayure, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain.
Additional measurements : Weigh, 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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.
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.
Musculosekeletal : 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.
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.

Adhelia Putri Prastiwi15 September 2017

Nama : Adhelia Putri Prastiwi
NIM : 131611133109
Kelas : 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.”
Aim : 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.
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. 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.
- 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
- Communication

Vital sign : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain. Additional measurements : Weigh, 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 : 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 progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/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. 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. Musculosekeletal : 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. 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.

Reffy Shania Novianti15 September 2017

Nursing Assesment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. In amerika nurse who meet patient for the first time have to do the assesment.
Kind of Assesment
• Admission assessment
• Shift assessment
• Focused assessment
1. Admission assessment: comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.an admission assessment should be completed within 24hours of admission.
- Patient history: history of current illness/injury, relevant past history, allergies and reactions, medications, family and social history.
- General appearance : 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 : vital signs consists of temperature, respiratory rate,heart rate, blood pressure, oxygen saturation,and pain. additional measurements also needed such as weight, height, head circumference, blood sugar level.
- 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.
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. 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. The shift assessment includes airway, breathing,circulation, disability, focused, pain, hydration/nutrition, output, risk, wellbeing, review the history of the patient recorded in the ip summary
3. 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: includes history, inspection/observation, auscultation, palpation.
- Cardiovascular: evaluates the adequacy of cardiac output and includes inspection, palpation, auscultation.
- Gastrointestinal: includes 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: musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room.
- 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
• 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.

FITRIANTI UMAYROH MAHARDIKA15 September 2017

NAMA : FITRIANTI UMAYROH MAHARDIKA
NIM : 131611133047
KELAS : A1
RESUME : Nursing Assesment
Assessment is important things of nursing practice. As a nurse we have to assesses, plans, implements and evaluates nursing care for patient health. There are some type of assessment :
1. Admission assessment. That assessment must be completed within 24hours of admission. Including patient history (illness/injury, allergies and reactions, medications, immunisation and social history), general appearance (include looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement, body simetry, strong cry), physical examination and vital signs (including temperature, respiratory rate, heart rate, blood pressure, oxygen saturation and pain ) of the patient.
2. Shift assessment. This assessment completed at the commencement of each shift or if patient condition changes. Include airway, breathing, circulation, disability, focused, pain, hydration or nutrition, output, risk, wellbeing, social and review the history of the patient recorded in the ip summary.
3. Focused assessment. This asseesment is about of specific body system. There is one or more body system. There are:
• Neurological system (includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.)
• Respiratory system
• Cardiovascular : evaluates the adequacy of cardiac output and input.
• Gastrointestinal : include inspection, auscultation and light palpation.
• Renal : Includes all aspects of urinary elimination
• Musculoskeletal
• Skin
• Eye
• Ear/Nose/Throat (ENT)
Evaluation of assessment. In this assessment the information collected is complete, accurate and documented appropriately. As a nurse we must have a critical thinking and problem solving skills to make clinical decisions and plan care for the patient.

Indriani Dwi Wulandari15 September 2017

NAME : INDRIANI DWI WULANDARI
NIM : 131611133034
CLASS: A1 2016
RESUME :
NURSING ASSESSMENT
Nursing Assessment is the important component of nursing practice,it’s consist of assesses, plans(intervention), implements and evaluate. In nursing assessment, we will find many kind of terms assessment, the example are :
1.admission assessment,
2.shift assessment, and
3.focused assessment.
Admission assessment is an assessment that nurse should do in the first time when we meet the patient, it must be completed in 24 hours. Admission assessment should be comprehensive, it should consist of :
1.patient history,
2.general appearance,
3.physical examination and
4.vital signs completed at the time of admission.
Shift assessment is a valuation that use when the beginning of shift or if patient condition changes at any other time during your shift. And focuses assessment is valuation that have a detail and specific assessment and may involve more than one body system.Nurse also ask for patient history, it is a history of current illness/injury. And then general appearance, it’s mean that doing patient’s assessment on overall physical emotional and behavior, the examples are mood and affect, communication, and personal hygiene. After that, nurse check the vital sign, it’s mean that the nurse checking for patient temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain, and sometimes check for weight, height, head circumference and blood sugar level. Nurse also checking for patient physical assessment, this process consist of some techniques like observation, inspection, palpation, percussion, auscultation. Then nurse also assess for well-being and social or cultural. Beside that, the nurse also doing shift assessment, shift assessment always usefull when shift change, it’s include airway, breathing, circulation, disability, etc.
The other important of nursing assessment is focused assessment, it’s focused on specific body systems, some of them are :
1.Neurological system
2.Respiratory system
3.Cardiovascular
4.Gastrointestinal
5.Renal
6.Musculoskeletal
7.Skin
8.Eye
9.Ear/nose/throat (ENT)
And the last process of nursing assessment is evaluation of assessment, this process are consist of ensure the information, using critical thinking and problem solving to making clinical decision or plan care for the patient.

Muhammad Rezza Romadlon15 September 2017

Name : MUHAMMAD REZZA ROMADLON
NIM : 131611133126

Nursing Assesment

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.
A. 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.

B. 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,

C. 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."

Siti Nur Aisa15 September 2017

NAME : SITI NUR AISA
NIM : 131611133138
CLASS : A3-2016

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
•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.

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.

General appearance :
•Neonate and Infant Parent-infant, infant-parent interaction
•Body symmetry, spontaneous position and movement
•Symmetry and positioning of facial features
•Strong cry
•Mood and affect
•Gross and fine motor skills
•Developmental milestones
•Appropriate speech
•AdolescentMood 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.
•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.

Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS

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

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 : Penilaian meliputi pemeriksaan, auskultasi dan palpasi ringan abdomen untuk mengidentifikasi kelainan yang terlihat; suara usus dan kelembutan atau kelembutan.

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.



Alfera Novitasari15 September 2017

NAMA : ALFERA NOVITASARI
NIM : 131611133029
KELAS : A1 2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Definition of terms includes :

1. 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.
• 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 (temperature, respiratory rate, blood pressure, oxygen saturation and pain). Additional measurements includes : 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. Includes : 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. Psychosocial assessments e.g. HEADSS.
• Socio/cultural
Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements.
2. 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.
3. Focused assessment is 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)

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.

Alfiana Permatasari15 September 2017

NAME : ALFIANA PERMATASARI
NIM : 131611133130
CLASS : A3
RESUME :

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 aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments.

- Admission assessment
Admission assessment is Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
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.
3. Vital signs : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet.
4. Additional measurements
5. Physical assessment
6. Wellbeing
7. Social/cultural

- Shift assessment
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. 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
Focused assessment is 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. Including the system of:
1. Neurological system
2. Growth & development
3. Respiratory system
4. Cardiovascular
5. Gastrointestinal
6. Renal
7. Skin
8. Eye
9. 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.

Verantika Setya Putri15 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.



Reffy Shania Novianti15 September 2017

NAMA:REFFY SHANIA NOVIANTI
NIM: 131611133010
RESUME:
Nursing Assesment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. In amerika nurse who meet patient for the first time have to do the assesment.
Kind of Assesment
• Admission assessment
• Shift assessment
• Focused assessment
1. Admission assessment: comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.an admission assessment should be completed within 24hours of admission.
- Patient history: history of current illness/injury, relevant past history, allergies and reactions, medications, family and social history.
- General appearance : 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 : vital signs consists of temperature, respiratory rate,heart rate, blood pressure, oxygen saturation,and pain. additional measurements also needed such as weight, height, head circumference, blood sugar level.
- 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.
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. 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. The shift assessment includes airway, breathing,circulation, disability, focused, pain, hydration/nutrition, output, risk, wellbeing, review the history of the patient recorded in the ip summary
3. 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: includes history, inspection/observation, auscultation, palpation.
- Cardiovascular: evaluates the adequacy of cardiac output and includes inspection, palpation, auscultation.
- Gastrointestinal: includes 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: musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room.
- 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
• 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.

Hanum Amalia Zulfa15 September 2017

NAMA : HANUM AMALIA ZULFA
NIM : 131611133040
KELAS : A1-2016
RINGKASAN :

NURSING ASSESSMENT
Assessment is a key component of nursing practice. Registered nurses assess, plan, implement and evaluate nursing care in collaboration with individual and multidisciplinary health care teams. In nursing assessment can be divided into:
1. Admission assessment :
Nursing assessment is performed by the nurse with the parents upon arrival at the ward and completed within 24 hours of admission. assessments must be documented as well as the privacy of the client should be considered at all times. A Comprehensive nursing assessment including :
• Patient history
Current history of illness / injury, relevant past history, allergies and reactions, medications, immunization status and family and social history are different from newborns.
• General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
• Physical examination
Structured physical examinations such as observation, inspection, palpation, percussion and auscultation allow the nurse to obtain a complete patient assessment.
• Vital signs completed at the time of admission
vital signs examined are Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation Pain. observations were made at the start of admission and should be reviewed as part of the assessment and documented on the observation sheet
• Additional measurements such as Weight, Height, Head circumference, Blood sugar level (BSL)
• Wellbeing
• Social/cultural
2. Shift assessment:
At the beginning of each shift an assessment is made on each patient used to develop a treatment plan. Initial assessments documented on the assessment flow sheets and further assessments will be documented in the assessment flow record. Shift Assessment includes: Airway, Breathing, Circulation, Disability, Pain, Hydration / Nutrition, Output, Risk, Wellbeing, Social, Review patient history recorded in IP summary.
3. Focused asssessment :
A detailed nursing assessment of specific body systemS relating to the presenting problem or other current concerns 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)
4. Evaluation 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.






Desi Choiriyani15 September 2017

NAME : DESI CHOIRIYANI
NIM : 131611133021
CLASS : A1-2016
RESUME :
Assessment is a key component of nursing practice, required for planning and provision of patient and family centered care.
Consist of three terms assessment, the example :
1.Admission assessment
Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. 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.
Same of them are : patient history, general appearance, vital signs, physical assessment, wellbeing, social/cultural.
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
3.Focused assessment
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
There are additional measurements:
1.Weight : on admission and/or weekly/daily as clinically indicated.
2.Height : as clinically indicated.
3.Head circumference : as clinically indicated.
4.Blood suger level (BSL) : as clinically indicated.
Shift assessment started by 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.
Focused assessment is a detailed nursing assessment of specific body systems relating to the presenting problem or other current concerns is required. This may involve one or more body system. The body system includes, neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ENT.
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.

NIMATUSH SHOLEHA15 September 2017

NAME: NI’MATUSH SHOEHA
NIM: 131611133009
CLASS: A1
Nursing Assesment
Assesment is a systematic method by which nursing: plans and provides care for patient and family centred. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individulas and the multidisiplinary health care team.
The purpose of assesment: to establish database all information about the patient.
There are three types of assesment , includes: admission asesment, shift assesment, and focussed assesment.
1.Admission assesment is performed when the patient enters a health care from a health care agency. Comprehensive nursing assesment including:
a)patient history: History of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
b)general appereane: Assessment of the patient’s overall physical, emotional and behavioral state.
c)physical examination: A structured physical examination allows the nurse to obtain a complete assessment of the patient.
d)vital signs: measurements of the body’s most basic functions.
e)etc
2.Shift assesment is Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. The shift assesment 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)Dissability: Any aids, mobility or transfer requirements, prosthetics/orthotics required. Blood sugar levels as clinically indicated.
3.Focussed assesment, nurse determine whether the problem still exist and whether the status of the problem has canged. The focussed assesment includes:
a)Neurological system: neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
b)Respiratory system: respiratory illness cause respiratory distress
c)Cardiovaskuler system: evaluate the adequecy of cardiac output and includes.
d)Gastrointestinal system: inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness.
e)Renal systems: all aspects of urinary elimination.
f)Etc
Evaluations of assesment ensure the information collected is complete, accurate and documented appropriately.



marceline putri 15 September 2017

Nama : Marceline Putri Chrisdianti
NIM : 131611133023
KELAS : A1
Assessment is the beginning of the patient care process. The assessment consists of admission assessment, shift assessment and focused assessment.
An admission assessment is done every 24 hours and should be written on the patient review sheet. Patient privacy must also be maintained. An admission assessment are like patient history, general appearance, physical examination and vital signs completed at the time of admission. Additional measurements are like Weight,Height,Head circumference, Blood sugar level (BSL)
• A history of illness is the reason a patient goes to a hospital. in addition, the patient's history contains the relevant past history, allergies and reactions, treatment, immunization status and family history. In infants, the history of the disease review included a history of the mother, the history of pregnancy, the type of labor and complications, the APGAR score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation).
• Physical examination considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. 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: airways, breathing, circulation, disability, focused assasment, skin, nutrion, and elimination.
• Vital Sign are needed to support the assessment of the patient. Vital signs examined include temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, and pain.

Shift 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 and Review the history of the patient recorded in the IP summary.
Focused Assessment is 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. Focused Assesment like Neurological system,Respiratory system, Cardiovascular, Gastrointestinal, Renal , Musculoskeletal, skin, eyes, or ENT.

Nabiila Rahma Ulinnuha15 September 2017

NABIILA RAHMA ULINNUHA
131611133136
A3/2016
Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
The kind of assesments
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 commencement 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
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.

EMMALIA ADHIFITAMA15 September 2017

Nama: EMMALI ADHIFITAMA
NIM: 131611133113
KELAS: A3 (2016)
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.
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
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.

ELIESA RACHMA PUTRI15 September 2017

NAME : ELIESA RACHMA PUTRI
NIM : 131611133009
SUMMARY : Nursing Assessment
Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used. The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".
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
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 : patient history, general appearance, vital signs, additional measurements, physical assessment (airway, breathing, circulation, disability, skin), wellbeing (psychosocial assessments e.g HEADSS), social/cultural
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: airway, breathing, circulation, disability, focused assessment, pain, hydration/uutrition, 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 systems relating to the presenting problem or current concerns of the patient. This may involve one or more body system. Focused assessment includes : neurogical systems, respiratory systems, cardiovascular, gastrointestinal, renal , musculoskeletal, skin, 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. 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.

dinda dhia aldin kholidiyah15 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.

Adji Yudho Pangaksomo15 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.

Mudrika Novita Sari15 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.

Hilmy Ghozi Alsyafrud15 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.

Novalia Puspitasary15 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.

CUCU EKA PERTIWI15 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.



Yuliani Puji Lestari15 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

Nabila Hanin Lubnatsary15 September 2017

Name: Nabila Hanin Lubnatsary
NIM: 131611133011
Class: A1-2016
NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Nursing assessment’s aim is the guideline specifically seeks to provide nurses with indications for assessment, types of assessments, structure for assessments. there are three types of assessment:
1.Admission assessment: Comprehensive nursing assessment including patient history, general appearance (assessment of the patient’s overall physical, emotional and behavioral state), physical examination (observation, inspection, palpation, percussion and auscultation are techniques used to gather information. There are many components, which is airway, breathing, circulation, disability, focused assessment, skin, input/nutrition, output/elimination) and vital signs (temperature, RR, heart rate, blood pressure, oxygen saturation and pain) completed at the time of admission.
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. There are many components, which is airway, breathing, circulation, disability, focused assessment, pain, hydration/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 or current concern(s) of the patient. This may involve one or more body system (neurological system, cardiovascular, repiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat)
Evaluastion assessment: In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Putri Aulia Kharismawati15 September 2017

Nama : Putri Aulia Kharismawati
NIM : 131611133027
Class: A1 / 2016
Assessment is a key component of nursing practice, required for planning and provision
of patient and family centred care. The aim of guideline is to ensure all of patients receive
consistent and timely nursing assessments. The guideline specifically seeks to provide nurses
with indication for assessment, types of assessment, structure for assessment.
The definition of nursing assessment is divided into three stages:
1. Admission assessment (Comprehensive): patient history, general appearance, physical
examination and vital signs completed at the time of admission.
2. Shift assessment (Concise): completed at the commencement of each shift or if
patient condition changes at any other time during your shift.
3. Focused assessment (Detailed): covers of specific body system(s) relating to the
presenting problem or current concern(s) of the patient.
An admission assessment is to be documented on the nursing admission form and 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. Privacy of the patient
needs to be considered all times.
1. Patient history: History of current illness/injury, relevant past history, allergies and
reactions, medications, immunisation status and family and social history.
2. Vital sign: It is mandatory to review the ViCTOR graph to observe trending of vital
signs and to support your clinical decision making process.
a. Temperature: Tympanic temperatures for children older than 6 months. Less
than 6 months use digital per axilla.
b. Respiratory Rate (RR): Count the patient’s breaths for one full minute. Assess
any respiratory distress. Respiratory distress should be recorded as nil, mild,
moderate or severe.
c. 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.
d. Blood Pressure: Baseline measurement should be obtained for every patient.
e. Oxygen Saturation: As clinically indicated.
f. Pain scores: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool and
COMFORT- B scale.
Additional measurements: weight, height, head circumference, blood sugar level
(BSL).
3. General appearance (the patient’s overall physical, emotional and behavioral state) is
divide into three stages:
a. Neonate and infant: body symmetry, strong cry.
b. Young Child: mood and affect, gross and fine motor skills.

c. Adolescent: mood and affect, personal hygiene, communication.

4. Physical Assessment, Observation, inspection, palpation, percussion and auscultation
are techniques used to gather information. Assessment information includes, but is not
limite d to: Airway (cough, secretion), Breath (RR, breath sound), Circulation (skin
turgor, pulse), Disability (orthotics, transfer needs, hearing aids), Focussed assessment
(neurogical, cardiovascular), Skin (colour, turgor), Nutrion (appetite, food
intolerance), elimination (bladder, bowel).
5. Wellbeing: mood, emotional state, comfort objects
6. Social or cultural: siblings, career, parents, living arrangements
Shift assessments, at the commencement of every shift an assessment is completed on
every patient and this information is used to develop a plan of care. It is almost same with
admission assessments: Airway, Breathing, Disability, Circulation, Focused, Pain, Nutrion,
Elimination, Risk, Wellbeing, Social, and Review the history of the patient recorded in the IP
summary.
Focused assessments, a detailed nursing assessment of specific body system(s) relating to
the presenting problem or other current concern(s) is required. Neurogical system includes
neurological observations (pupil size and reaction to light, arm and leg movements),
cognitive growth and development (Observe the head, shape, size and mobility), fine and
gross motor skills (gait and balance, reflexes), sensory function (taste, smell), seizures
(precipitating factors) and any other concerns.
Respiratory system, respiratory illness in children is common and many other conditions
may also cause respiratory distress. Inspection, Palpation, percution, auscultation.
Cardiovascular, evaluates the adequacy of cardiac output and includes. Inspection,
Palpation, percution, auscultation.
Gastrointestinal, ensure stomach is not full at time of assessment as this may induce
vomiting. inspection, auscultation and light palpation of the abdomen to identify visible
abnormalities.
Renal, all aspects of urinary elimination.
Musculoskeletal, can be commenced while observing the infant/child in bed or as they
move about their room. Inspection, palpation.
Skin, can identify cutaneous problems as well as systemic diseases. Inspection, palpate.
Eye, should always be performed carefully and only with a compliant child. Inspection.
Ear, Nose, Throat (ENT), essential as upper respiratory infections, allergies; oral or facial
trauma, dental caries and pharyngitis are common in children. Inspection, palpation.
Evaluation assessments, ensure the information collected is complete, accurate and
documented appropriately. 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.

Gita Shella Madjid15 September 2017

Name : Gita Shella Madjid
NIM : 131611133049
Class : A1-2016
Summary :

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. There ae 3 terms of definition of terms, such as
1. 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.
2. 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.
3. 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.
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. In conducting nursing assessment, the nurse must also doing a vital signs checks, such as:
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
A nurse usually do a physical examination. Cause 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 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. The nursing assessment includes history of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
When 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.


DITA FAJRIANTI15 September 2017

NAMA : DITA FAJRIANTI
NIM : 131611133014
RESUME : NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Type of assessment :
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Additional measurements, weight, height, head circumference, blood sugar level (BSL).
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.
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.
Admission Assesment
Physical assessment, a structured physical examination allows the nurse to obtain a complete assessment of the patient. Assessment information includes, but is not limited to : Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, and Output/Elimination.
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: 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.
• 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
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. And body parts involved in focused assessment, Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Skin, Eye, and 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.

CHUSNUL HOTIMAHc16 September 2017

NAMA : CHUSNUL HOTIMAH
NIM : 131611133004
KELAS : A1

NURSING ASSESSMENT

Assessment is an important component of nursing practice, which is necessary for planning and providing care for patients and families. assessment is important because it is the first step in nursing practice that will determine the outcome of the treatment itself. There are several types of assessment. There are admission assessment, shift assessment, and focused assessment.
First, 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 including : a) patient history; b) general appearance; c) physical examination; and d) vital signs completed at the time of admission.
Furthermore, the other assessment is psychosocial assessments and social/cultural assessment. Psychosocial assessment is assessment about mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Social/cultural assessment is assessment about parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements.
Second, 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: a) Airway; b) Breathing; c) Circulation; d) Disability; e) Focused; f) Pain; g) Hydration/Nutrition; h) Output; i) Risk; j) Wellbeing; k) Social; and l) Review the history of the patient recorded in the IP summary.
Last, Focused assessment. Its 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 e.g. neurological system, respiratory system, cardiovascular system, gastrointestinal system, renal, musculoskeletal system, etc.
In the evaluation assessment phase, make sure the information collected is complete, accurate and well documented. Thinking critically and problem solving to make clinical decisions and plant the care. communicates the findings to the medical team, and the Nursing Unit Manager of the Association responsible for those changes.

NAFIDATUN NAAFIA16 September 2017

Name: Nafidatun Naafi'a
NIM: 131611133015
Class: A1

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. In Indonesia, registered nurse is nurse who pass UKNI and have a STR. Assessment as a guideline specifically seeks to provide nurses with: indication for assessment, types of assessments, structure for assessment.
There are three types of assessments:
• Admission assessment is a comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission, usually this is the assessment the nurse doing when the client is being hospitalized for the first time. This assessment should be completed by nurses with a parent or care giver within 24 hours. Admission assessment consist of patient history, patient’s general appearance, and vital signs (with addition BSL, head circumference, height, weight). During this assessment, nurse doing physical examination which consist of observation, inspection, palpation, percussion, and auscultation. The assessment information includes airway, breathing, circulation, etc.
• 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. At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care.
• Focused assessment is 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, such as neurological, respiratory, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, and ENT (ears/nose/throat).
The last of nursing process is doing evaluation. In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problems 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.

Elin Nur Annisa16 September 2017

NAMA : ELIN NUR ANNISA
NIM : 131611133037
RESUME :
Introduction
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.”
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.
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.
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.
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:
Wellbeing:
Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
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.
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.
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.
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.

INDAH LATIFA16 September 2017

NAMA : INDAH LATIFA
NIM : 131611133016
KELAS : A1/2016
Resume
Nusing assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assessment, plant, 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 provider nurses with:
- Indications for assessment
- Types of assessments
- Structure for assessment
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.
1. 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
2. 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.
3. General appearance; Neonate and Infant Parent-infant, infant-parent interaction, body symmetry, spontaneous position and movement, symmetry and positioning of facial features, strong cry.
4. 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
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.
Wellbeing: mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
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.
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. Like 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. 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.

Locita Artika Isti16 September 2017

Nama : Locita Artika Isti
NIM : 131611133008
Kelas : A1 2016
Resume : NURSING ASSESSMENT
Assesment is 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 aim for the nursing assessment is indications for assessment, types of assessments, stucture for assessments.
Definition of terms
1. Admission assessment : Comrehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
 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
 Blood Pressure
 Oxygen Saturation
 Pain
Additional measurements:
 Weight
 Heigth
 Head circumference
 Blood sugar level (BSL)
 Physical Assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Can doing with observation, inspection, palpation, percussion and auscultation are techniques used to gather information.
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.
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.
3. Focused assessment: Detailed nursing assessment of specific body system relating to the presenting problem or currentconcern of the patient. This may involve one or more body system.
Focus assessment, This may involve one or more body system. For example neurological system, respiratory system, cardiovaskular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat (ENT)
Evaluation:
Make sure the information collected is complete, accurate, and fully documented.
The nurse must think critically.
And if any findings are not normal the nurse must take appropriate action, and may communicate with other medical personnel.

REGYANA MUTIARA GUTI16 September 2017

Nama : Regyana Mutiara Guti
NIM : 131611133013
Kelas : A1-2016
Resume :
Nursing Assessment
The nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.
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.
1. Patient history
History of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
2. Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet, because observe trending of vital signs and will support your clinical decision making process. Vital sign includes temperature, Respiratory Rate, heart rate, blood pressure, pain and oxygen saturation. Additional measurements is weight, height, head circumference, and blood sugar level (BSL).
3. Physical assessment
Physical examination is the prevention of a person performed by a health worker (Ners) by using the sense of sight, hearing, statue, and smell and observation techniques that include inspection, palpation, percussion and auscultation. Physical examination is done by Head to Toe. The good ners will treat the client as a whole person, with his desires and problems, not just focusing only on case. Assessment information includes, but is not limited to airway, breathing, circulation, disability, focused assessment, skin, input/nutrition, and output/elimination.
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. Renal
f. Muskoloskeletal
g. Skin
h. Eye
i. Ear/Nose/Throat (ENT)
Ners should use a framework of functional health patterns to interpret physical examinations to facilitate diagnosis and identification of emerging problems beginning at the assessment stage. 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.

ANNISA FIQIH ILMAFIANI16 September 2017

NAMA:ANNISA FIQIH ILMAFIANI
NIM:131611133045
KELAS A1-2016

Nursing assessment
• Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
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, general appearance, physical examination and vital signs completed at the time of admission. Must be completed within 24hours of admission, then documented on the nursing admission form. Privacy of the patient needs to be considered all times
a. 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.
• 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)
b. General appearance
• 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
• Communication
c. Vital Signs
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
d. Additional Measurements
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
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. Clinical judgment should be used to decide on the extent of assessment required.
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. Includes; airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
4. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ENT, etc.
• Evaluation of assessment
Ensure the information collected is complete, accurate and documented appropriately.

Arinda Naimatuz Zahriya16 September 2017

Name : Arinda Naimatuz Zahriya
NIM : 131611133024
Class : A1/2016

Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care
Aim :
• The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
Definitation 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
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

Shift assessment
• 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.
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

NOVIA TRI HANDIKA16 September 2017

NAME : NOVIA TRI HANDIKA
NIM : 131611133042/ A1
Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centered 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.
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 relating to the presenting problem or current concerns of the patient.
Patient history. History of current illness/ injury, relevant past history, allergies and reactions, medications, immunization 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. General appearance , assessment of the patients 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. Temperature is tympanic temperatures for children older than 6 months. Less than 6 month use digital per axilla. Respiratory rate is count the childs breaths for one full minute. Heart rate is palpate brachial pulse or femoral pulse in infant and radial pulsen in older children. Blood pressure is baseline measurement should be obtained for every patient. Oxygen saturation 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. 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. Focused assessment a detailed nursing assessment of specific body system relating to the presenting problem or them current 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.

Sarah Maulida Rahmah17 September 2017

Name : Sarah Maulida Rahmah
NIM : 131611133006

Resume : Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
1. Definition of admission assessment is Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. 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.
a. 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.
b. General appearance: Assessment of the patient’s overall physical, emotional and behavioral state. Considerations for all patients include, looks well or unwell.
c. Vital signs : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. It is temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain.
d. Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient. Physical assessment check like airway, breathing, circulation, etc.
e. Wellbeing: Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
f. 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. At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. It is airway, breathing, circulation, disability, 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 system. Including the system of:
a. Neurological
b. Respiratory
c. Cardiovascular
d. Renal and urinary elimination
e. Musculoskeletal
f. Skin
g. Eye
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.

Erva Yulinda Maulidiana17 September 2017

NAMA:Erva Yulinda Maulidiana
NIM:131611133033
RESUME:
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Aim:
• Indications for assessment
• Types of assessments
• Structure for assessments
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.
Vital signs
• Temperature
• Respiratory rate
• Hearth rate
• Blood pressure
• 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
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.
• 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
• 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.

KUSNUL OKTANIA17 September 2017

NAME : KUSNUL OKTANIA
NIM : 131611133043
CLASS : A1/2016
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.
1.Admission assessment: Comprehensive nursing assessment including:
-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 examination and vital signs completed at the time of admission.
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.
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. Including system:
a.Respiratory system : Respiratory illness in children is common and many other conditions may also cause respiratory distress
b.Cardiovascular : Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes
c.Gastrointestinal : Assessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness
d.Renal : An assessment of the renal system includes all aspects of urinary elimination
e.Musculoskeletal : A musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room.
f.Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
g.Eye : Inspection of the eye should always be performed carefully and only with a compliant child
h.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
-> 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.

Erlina Dwi Kurniasari17 September 2017

NAME : ERLINA DWI KURNIASARI
NIM : 131611133028
CLASS : A1-2016
NURSING ASSESMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
There are 3 type of assessment :
1. 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. Admission assessment consist of patient history,, general appearance, vital sign and additional measurement about weight, height, head circumference, blood sugar level. 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.
2. 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, etc.
3. 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. Focused assessment include :
- neurological system (cognitive growth and development, sensory fuction, etc)
- respiratory system (many illness in children about respiratory distress)
- cardiovascular (evaluates the adequacy of cardiac output and includes)
- gastrointestinal (inspection, auscultation and light palpation of the abdomen)
- renal (all aspects of urinary elimination)
- musculoskeletal (tthis assessment limbs/joints should be compared bilaterally)
- skin (identify cutaneous problems as well as systemic diseases)
- eye (inspection of the eye should always be performed carefully)
- ENT (assessment of throat and mouth is essential as upper respiratory infections)

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.





Hanum Amalia Zulfa17 September 2017

NAMA : HANUM AMALIA ZULFA
NIM : 131611133040
RINGKASAN :

NURSING ASSESSMENT
Assessment is a key component of nursing practice. Registered nurses assess, plan, implement and evaluate nursing care in collaboration with individual and multidisciplinary health care teams. In nursing assessment can be divided into:
1. Admission assessment :
Nursing assessment is performed by the nurse with the parents upon arrival at the ward and completed within 24 hours of admission. assessments must be documented as well as the privacy of the client should be considered at all times. A Comprehensive nursing assessment including :
• Patient history
Current history of illness / injury, relevant past history, allergies and reactions, medications, immunization status and family and social history are different from newborns.
• General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
• Physical examination
Structured physical examinations such as observation, inspection, palpation, percussion and auscultation allow the nurse to obtain a complete patient assessment.
• Vital signs completed at the time of admission
vital signs examined are Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation Pain. observations were made at the start of admission and should be reviewed as part of the assessment and documented on the observation sheet
• Additional measurements such as Weight, Height, Head circumference, Blood sugar level (BSL)
• Wellbeing
• Social/cultural
2. Shift assessment:
At the beginning of each shift an assessment is made on each patient used to develop a treatment plan. Initial assessments documented on the assessment flow sheets and further assessments will be documented in the assessment flow record. Shift Assessment includes: Airway, Breathing, Circulation, Disability, Pain, Hydration / Nutrition, Output, Risk, Wellbeing, Social, Review patient history recorded in IP summary.
3. Focused asssessment :
A detailed nursing assessment of specific body systemS relating to the presenting problem or other current concerns 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)
4. Evaluation 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.






Listya Ernissa Mardha17 September 2017

"Name : Listya Ernisaa Mardha
NIM : 131611133017
Class : A1
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 to achieve goals and health outcomes.
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. 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 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.
- 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.

Elyn Zoegestyn17 September 2017

NAMA : ELYN ZOEGESTYN
NIM : 131611133088
KELAS : A2
RESUME : “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 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.
Nursing assessment it covers :
1. Admission assessment : admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
2. 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.
3. 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, mood and young child parent-child, child-parent interactio affect, personal hygiene, and communication.
4. Vital signs : Temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain.
5. 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.
6. Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
7. 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.
Focused assessment : 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.

Elyn Zoegestyn17 September 2017

NAMA : ELYN ZOEGESTYN
NIM : 131611133088
KELAS : A2
RESUME : “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 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.
Nursing assessment it covers :
1. Admission assessment : admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
2. 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.
3. 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, mood and young child parent-child, child-parent interactio affect, personal hygiene, and communication.
4. Vital signs : Temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain.
5. 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.
6. Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
7. 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.
Focused assessment : 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.

Sabila Nisak17 September 2017

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
(a) 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.
(b) General appearance -> The patient’s overall physical, emotional and behavioral state (looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement).
(c) Physical examination -> Observation, inspection, palpation, percussion and auscultation
(d) Vital signs -> 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 assessment includes: Airway, Breathing, Circulation, Disability, Focused, Pain, Output, Hydration/Nutrition, 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.

(4) Evaluation of assessment: ensure the information collected is complete, accurate and documented appropriately.

ANNISA FIQIH ILMAFIANI17 September 2017

NAMA : ANNISA FIQIH ILMAFIANI
NIM : 131611133045
KELAS : A1-2016

Nursing assessment
• Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
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, general appearance, physical examination and vital signs completed at the time of admission. Must be completed within 24hours of admission, then documented on the nursing admission form. Privacy of the patient needs to be considered all times
a. 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.
• 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)
b. General appearance
• 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
• Communication
c. Vital Signs
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
d. Additional Measurements
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
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. Clinical judgment should be used to decide on the extent of assessment required.
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. Includes; airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
4. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ENT, etc.
• Evaluation of assessment
Ensure the information collected is complete, accurate and documented appropriately.

Eka Hariyanti17 September 2017

[Eka Hariyanti-131611133076/A2]

NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. 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.
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:
o Neonate and Infant Parent-infant, infant-parent interaction
o Body symmetry, spontaneous position and movement
o Symmetry and positioning of facial features
o Strong cry
o Young Child Parent-child, child-parent interaction
o Mood and affect
o Gross and fine motor skills
o Developmental milestones
o Appropriate speech

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 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 df;qQpvd6 GH*L?@

Yuniar rahma shofroin17 September 2017

Name : Yuniar Rahma Shofro'in
NIM :131611133069

NANDA or nursing diagnosis is defined as “ a clinical judgment about an individual, family or community responses to actual and potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”(NANDA, 2009).
There are three variations of nursing diagnosis: actual diagnosis, risk diagnosis, health diagnosis. While the 3 components of Nursing Diagnosis :
1. Label or Name and definition
2. Related Factors or Risk Factors
3. Defining Characteristics

NOC or nursing outcomes classification is a classification of nurse sensitive outcomes. NOC outcomes and indicators “allow for measurement of the patient, family, or community outcome at any point on a continuum from most negative to most positive and at different points in time.” ( Iowa Outcome Project, 2008)
There are three components:
1. Neutral label or name used to characterize the behavior or patient status
2. List of indicators that describe client behavior or patient status
3. Five-point scale to rate the patient’s status for each of the indicators.

NIC or nursing interventions classification is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.” (Iowa Intervention Project, 2008)
While interventions are treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” (Iowa Intervention Project, 2000,p.3)
There are three components of NIC :
1. Name or label
2. A definition
3. A set of activities the nurse does to carry out the intervention.

Alfiana Nur Halimah17 September 2017

Alfiana Nur Halimah/131611133063/A2 2016

NURSING ASSESSMENT

Nursing assessment is a key component of nursing practice, required for planning and provision of patient and family centered care.
1. Admission assessment: comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. An admission assessment should be completed by nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission.
- Patient history. History of current illness/injury (i.e., reason for current admission), relevant past history, allergies and reactions, medications, immunization status and family, and social history.
- General appearance. Assessment of the patient’s overall physical, emotional and behavioral state, include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement, etc.
- 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 clinical decision making process. Vital signs consist of temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, and 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. Assessment information includes, but is not limited to: airway, breathing, circulation, disability, skin, input/nutrition, output/elimination, etc.
- Social/cultural: parents/careers/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 shift. Initial shift assessment is documented or the assessments or changes to be documented in the assessment flow sheet/progress notes. 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.

3. 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.

- Respiratory system.
- Cardiovascular: evaluates the adequacy of cardiac output and includes.
- Gastrointestinal: include 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: identify cutaneous problems as well as systemic diseases
- Eye
- Ear

Ni Putu Neni Indriyani17 September 2017

NAME : Ni Putu Neni Indriyani
NIM : 131611133031
SUMMARY :
NURSING ASSESSMENT

Nursing assessment is an important step of the whole nursing process. Assessment can be called the “base or foundation” of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet that you can print and use to guide you throughout the first step of the nursing process.
There are three types of assessment, it is admission assessment, shift assessment and focused assessment.
a. Admission assessment: Comprehensive nursing assessment including Patient history, General appearence, Vital signs, Additional measurements, Physical assessment (airway, breathing, circulation, disability, skin), Wellbeing, Social or cultural.

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. The shift assessment includes:

• Airway : noises, secrection or artificial airway
• Breathing : breath sounds, respiratory rate, rhytm, etc
• Circulation : pulses, peripheral temperature, colour and capillary refill time, skin, lip, oral mucosa and nail bed colour
• Disability : mobility transfer requirements, prostethics/orthotics required
• Focused assessment
• Pain : FLACC, Faces, numeric scale
• Hydration/Nutrition : oral, nasogastric, jejunal, fasting, breast feed, 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 or 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

c. 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. Focused assessment includes :
• Neurogical systems : neurogical observations, cognitive growth, and development, fine and gross motor skills, sensory function, seizures and any other concerns
• Respiratory systems : respiratory distress
• Cardiovascular : the adequacy of cardiac output
• Gastrointestinal : inspection, auscultation, and light palpation of the abdomen
• Renal : all aspects of urinary elimination
• Musculoskeletal
• Skin : identify cutaneous problems as well as systemic diseases
• Eye and Ear/Nose/Throat (ENT)

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.

Silvia Farhanidiah17 September 2017

NAMA : SILVIA FARHANIDIAH
NIM : 131611133072
KELAS : A2-2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment. Types of assessments, Structure for assessments. Structure for assessment :
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), it’s must be completed at the time of admission. 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
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. 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
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.
Assessment information includes, but is not limited to: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination, Wellbeing, Social/cultural.

Fathma Hanifati17 September 2017

Name : Fathma Hanifati
NIM : 131611133084
Class : A2-2016
Summary :
NURSING ASSESSMENT
1. Definition
Nursing assessment is a key component of nursing practice, required for planning and provisison 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.
2. Aim
The guideline secifically seeks to provide nurses with :
- Indication for assessments
- Types of assessments
- Structure for assessments

3. Definition of terms
a. Admission assessment : should be completed by the nurse with a parent or care giver, ideally upon arriva; 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 illnes, relevant past history, allergies and reactions, medications, immunisation status and family and social history. For neonates and infamts consider maternal history, antenatal history, delivery type and complications if any, APGAR score, resuscitation required at delivery and Newbron Screening Tests
• General appearance :
- assessment of the patient’s overall physical, emotional, and behavioral state
- neonate and infant parent-infant, infant oarent unteraction, body symmetry, strong cry
- young child parent-chold, child-parent interaction, mood and affect, gross and motor skills, developmental milestones, appropriate speech
- adolescent mood and affect, personal hygiene, communication
• Vital signs : Temperature, RR, HR, Blood pressure, oxygen saturation, pain
• Additional measurements : weight, height, head circumference, BSL (Blood sugar level)
• 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, disabilty, focused assessment, skin, input/nutrition, output/elimination
b. 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 patient recorded in the IP summary

c. Focused assessment : A detailed nursing assessment of specific body systems relating to the presenting problem or other current concerns is required. This may involve one or more body system.
• Neurological sysstem : neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seixures and any other concerns.
• Raspiratory system : Respiratory illness in children is common and many other conditions may also cause respiratory distress.
• Cardiovascular : 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 : all aspets of urinaria elimination
• Muskuloskeletal : 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 : identify cutaneous problems as well as systematic diseases
• Eye : Inspection of the eye should always be performed carefully and only with a compliant child.
• ENT (ear, nose, throat) : Assessment of throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children.
4. Evaluation of assessment : In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.The result can communicate the findings to the medical team.

Silvia Farhanidiah17 September 2017

NAME : SILVIA FARHANIDIAH
NIM : 131611133072
CLASS : A2-2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment. Types of assessments, Structure for assessments. Structure for assessment :
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), it’s must be completed at the time of admission. 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
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. 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
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.
Assessment information includes, but is not limited to: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination, Wellbeing, Social/cultural.

DEVI RAHMANINGRUM WARDANI17 September 2017

NAME : DEVI RAHMANINGRUM WARDANI
NIM : 131611133099
CLASS : A-2
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: indications for assessment, types of assessments, and structure for assessments.
Admission assessment is a comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. The patient history are 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 are 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. And then physical examination, 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. And the last is 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. The Shift Assessment includes: airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, and social. Focused assessment is 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. Focused assessment includes : neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, and ENT (ear/nose/throat).
The evaluation of assessment is 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.

Neisya Pratiwindya Sudarsiwi17 September 2017

Name : Neisya Pratiwindya Sudarsiwi
NIM : 131611133092
Class : A2 2016

Nursing Assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse who assessing, planing, implementing and evaluating nursing care in collaboration with individuals and the multidisciplinary health care team must know about indications for assessment, types of assessments, structure for assessments.

Three points about the definition of assessment are admission assessment, shift assessment, focused assessment.

Admission assessment consist of patient history, general appearance, physical examination and vital signs completed at the time of admission.

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

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. Body system consist of neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/thrat (ENT).

The evaluation of assessment
Nurse must ensure that the information which 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.

Mitha Permata Dini17 September 2017

Nursing assesment
- Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Aim
• The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
- 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.
- 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.

MARATUS SHOLIHAH RAMADHANI17 September 2017

ASSESSMENT is a key component of nursing practice, required for planning and provision of patient and family centred care.
DEFINITION:
1. ADMISSION ASSESSMENT: Comprehensive nursing assessment including
• Patient History
• General Appearance
• Physical Examination
• Vital Signs (Temperature, RR, Heart Rate, Blood Pressure, Oxygen Saturation, Pain)
• Physical Assessment
Admission assessment completed at the time of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.
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:
• 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. This may involve one or more body system, e.g :
• Neurological system : includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
• Respiratory system
• 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
• Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
• 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. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly.

Faizatul Ummah17 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.

Septin Srimentari LD17 September 2017

Name: Septin Srimentari Lely D.
NIM: 131611133046
Class: A1-2016
Resume Nursing Assessment
The nursing care practice is composed five systematic steps for helping patient. There are assessment, making diagnosis, planning, implementation, and evaluation. Assessment is a first step that must be done correctly, because it is a basic action which determines correct or not the nursing care practice. The types of assessment are admission, shift, and focused assessment.
When patient enters in the hospital, the nurse starts comprehensive assessment to the patient including patient history, general appearance, physical examination and vital signs in 24 hours. This assessment is called by admission assessment. Patient history is personal data about history of current illness or injury, allergies and reactions with something, medications, family, and social history. General appearance are complete assessment about the physical, emotion, and behavior of patient that can examinate directly. Physical examination include observation(research on the far distance), inspection (watching for condition of patient directly), palpation (feeling the vibration or something with the hand’s nurse), percussion (knocking on the part body’s patient) and auscultation (listening with stethoscope) techniques. There is included airway, breathing, circulation, focused assessment, skin, nutrition, and elimination. Vital sign is measured by health equipment to find out patien’s condition including temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, weight, height, and ect. Shift assessment is implemented completely on each of practice schedule by nurse. In Indonesia, nurse practices three shift every day. Focused assessment is detailed nursing asssessment of specific body system that related by their health problem. The body system consists of neurologycal system (related to sensory funtion, development, gross motor skill), respiratory system, skin, cardiovascular (the adequacy of cardiac output and includes), gastrointestinal , renal (urinary system), muskuloskeletal, eye, Ear/Nose/Throat(ENT).

Neisya Nabila Pawestri17 September 2017

NAME: Neisya Nabila Pawestri
NIM: 131611133058
Class: A2
NURSING ASSESSMENT
Assessment is a “key component” of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, and Structure for assessments

Several terms on assessments:
a. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
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.
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

Assessment stage includes assessment of vital signs, general appearance, patient history, additional measurements, physical assessment, wellbeing, social/cultural, neurological system, cardiovascular, respiratory system, gastro intestinal, renal, musculoskeletal, skin, eye, and ENT,
a. Vital signs covers temperature, respiratory rate, blood pressure, oxygen saturation, and pain.
b. Patient history: history of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
c. 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.
d. Additional measurements like weight, height, head circumference, and blood sugar level (BSL).
e. Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient.
f. Wellbeing: Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission.
g. Social/Cultural: Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements

EVALUATION OF ASSESSMENT
In the evaluation phase of assessment, ensure the information collected 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 on the patients, the nurse must ensure that appropriate action is taken.

Siti Nur Cahyaningsih18 September 2017

NAME: SITI NUR CAHYANINGSIH
NIM: 131611133054
CLASS: A2
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.
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

Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
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, and review the history of the patient recorded in the IP summary.

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.
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 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.

tantya edipeni putri18 September 2017

NAMA : TANTYA EDIPENI PUTRI
NIM : 131611133074
KELAS :A2/2016

INTRODUCTION
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

DEFINITION OF TERMS
1. 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. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
2. 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.
Concise nursing assessment completed at the commencement 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.

EVALUATION OF ASSESMENT
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.

Khosnul Khotimah18 September 2017

Nama: Khosnul Khotimah
NIM: 131611133085
Kelas: A2
Admission assessment is comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
1. Patient history
History of current illness / injury, relevant past history, allergies and reactions, medications, immunization status and family and social history
2. General appearance
Assessment of the patient’s overall physical, emotional and behavioral state.
3. Vital signs
Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet. Vital signs include temperature, respiratory rate, pulse, and blood pressure
4. Additional measurement
Include weight, height, head circumference, and blood sugar level
5. Physical assessment include airway, breathing, circulation, and disability. Focused Assessment with 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, skin, input/nutrition, and output/elimination
6. Wellbeing
7. Social/cultural

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. Shift assessment include airway, breathing, circulation, disability, pain, hydration/nutrition, output/elimination, risk, wellbeing, social, and review the history of the patient recorded in the IP summary.
Focused assessment is detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Detailed nursing assessments of specific body systems related to presentations or other current concerns are required. This involves a neurological system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear/nose/throat.
Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times. In the evaluation phase of the 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.

Nabiela Audina18 September 2017

Name : Nabiela Audina
NIM : 131611133102/A2

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. There are some definition of assessment :
• 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
1. 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
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. Clinical judgment should be used to decide on the extent of assessment required.
3. 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.
4. 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.
• Neurogical 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.
• 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.
• 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.
Evaluation of assessment :
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Dessy Syahfitri Pohan18 September 2017

NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
AIM
The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
TERMS OF NURSING ASSESSMENT
• Admission assessment
• Shift assessment
• Focused assessment
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
• Breathing
• Circulation
• Disability
• Focused assessment
• Pain
• Hydration/nutrition
• Output
• Risk
• Wellbering
• Social
• Review the history of 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
• Respiratory system
• Cardiovaskuler
• Gastrointestinal
• Renal
• Musculoskeletal
• Skin
• Sye
• Ear/Nose/Throat (ENT)
EVALUATION 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.


SABRINA SHEILA UMAR18 September 2017

NURSING ASSESSMENT
Assessment is a key of nursing practice, required for planning and provision of patient and family centered care.
Aim:
The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessment
• Structure for assessment
Admission assessment
Definitions 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 systems relating to the presenting problem or current concerns of the petient.
• 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.
• 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.
• 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
• 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: 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
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. Assessment information includes, but is not limited to:
• Airway: noises, secretions, cough, artificial airway
• 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.
Wellbeing
• Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
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: 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
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.
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. 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.

khoirun niswatul ulfa18 September 2017

Nursing assassment
Assassment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, and Structure for assessments.
Definition of terms
Admission assessment coverage 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.
Focused assessment: Detailed nursing assessment of specific 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 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.
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. Vital sign : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, Pain.
Additional measurement : weight, hight, head circumference, blood sugar level.
Physical assassment : airway, breathing, circulation, disability, focussed assassment, 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.
Shift assessment
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
Neurological system : A comprehensive neurological nursing assessment.
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
Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
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.





Fadilah Ramadhan Mushab Rahman18 September 2017

NAME: Fadilah Ramadhan Mush'ab Rahman
STUDENT ID NUMBER: 131611133080
CLASS: A2

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: 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. It is mandatory to review the VICTOR graph to observe trending of vital signs and to support your clinical decision making process.

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: Physical assessment, Wellbeing, and Social/cultural.
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.
Focused assessment: A detailed nursing assessment of specific body systems relating to the presenting problem or other current concern is required. This may involve one or more body system.

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.






khoirun niswatul ulfa18 September 2017

nama : khoirun Niswatul ulfa
NIM : 131611133098
kelas : A2


Nursing assassment
Assassment is a key component of nursing practice, required for planning and provision of patient and family centred care. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, and Structure for assessments.
Definition of terms
Admission assessment coverage 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.
Focused assessment: Detailed nursing assessment of specific 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 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.
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. Vital sign : Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, Pain.
Additional measurement : weight, hight, head circumference, blood sugar level.
Physical assassment : airway, breathing, circulation, disability, focussed assassment, 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.
Shift assessment
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
Neurological system : A comprehensive neurological nursing assessment.
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
Skin : Skin assessment can identify cutaneous problems as well as systemic diseases
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.





RIZKI JIAN UTAMI18 September 2017

NAME : RIZKI JIAN UTAMI
NIM : 131611133032
CLASS :A1-2016

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.”
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)
• 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
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: AdolescentMood and affect ,Personal hygiene,Communication
• Young Child Parent-child, child-parent interaction
• Mood and affect
• Gross and fine motor skills
• Developmental milestones
• Appropriate speech
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.







Dessy Syahfitri Pohan18 September 2017

NAME : DESSY SYAHFITRI POHAN
NIM : 131611133060
CLASS : A2

NURSING ASSESSMENT
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
AIM
The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
TERMS OF NURSING ASSESSMENT
• Admission assessment
• Shift assessment
• Focused assessment
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
• Breathing
• Circulation
• Disability
• Focused assessment
• Pain
• Hydration/nutrition
• Output
• Risk
• Wellbering
• Social
• Review the history of 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
• Respiratory system
• Cardiovaskuler
• Gastrointestinal
• Renal
• Musculoskeletal
• Skin
• Sye
• Ear/Nose/Throat (ENT)
EVALUATION 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.


Soura Kristiani Tarigan18 September 2017

Name : Soura Kristiani Tarigan
Nim : 131611133059
Class : A2 2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
• Admission assessment
An assessment which 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. The nurses have to complete :
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
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
3. Vital sign
a. Temperature: Tympanic temperatures for children older than 6 months. Less than 6 months use digital per axilla.
b. Respiratory Rate: Count the child’s breaths for one full minute. Assess any respiratory distress.
c. 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.
d. 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.
e. Oxygen Saturation: As clinically indicated.
f. Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool. Current pain relief medications/practices
g. Weight: on admission and/or weekly/daily as clinically indicated.
h. Height: as clinically indicated.
i. Head circumference: as clinically indicated.
j. Blood sugar level (BSL): as clinically indicated.

• Physical Assessment
a. Airway: noises, secretions, cough, artificial airway
b. 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.
c. 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.
d. 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.
e. 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.
f. Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.
g. 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.
h. Output/Elimination: Bowel and Bladder routine(s), incontinence management, drains and other losses.
• Shift Assessment
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:
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
A detailed nursing assessment of specific body systems relating to the presenting problem or other current concern is required
a. Neurological system
b. Respiratory system
c. Cardiovascular
d. Gastrointestinal
e. Renal
f. Musculoskeletal
g. Skin
h. Eye
i. Ear, Nose, Throat
Evaluation of assessment: ensure the information collected is complete, accurate and documented appropriately.


Fatur Rizal Pratama18 September 2017

Nursing assessment
Definition
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 (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 patients. example: looks well or unwell, pale or flushed, lethargic or active, agitated or calm
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
Additional measurements
Weight
Height
Head circumference
Blood sugar level (BSL)
Physical assessment : Observation, inspection, palpation, percussion and auscultation are techniques used to gather information
Airway: noises, secretions, cough, artificial airway
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.
Wellbeing : Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission. Psychosocial assessments e.g. HEADSS
Social/cultural : Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
Focused assessment, include : Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeleta, 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

LAILA MUFIDA18 September 2017

NAME : LAILA MUFIDA
NIM : 131611133095
CLASS : A2-2016

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. Aim of assessment :
• The guideline specifically seeks to provide nurses with:
• Indications for assessment
• Types of assessments
• Structure for assessments
A. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
1) 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.
2) Vital sign, Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet, measurement :
3) Physichal 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, measurement:
4) Wellbeing
5) Social/cultural
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. The shift assessment include:
• 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: 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
1. Neurological system is A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
2. Respiratory system is Respiratory illness in children is common and many other conditions may also cause respiratory distress.
3. Cardiovascular is Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
4. Gastrointestinal is Assessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness.
5. Renal is an assessment of the renal system includes all aspects of urinary elimination
6. Skin
7. Eye
8. Ear/Nose/Throat (ENT) is Assessment of throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children.

Evaluation of assessment nursing 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.


Maulidiyah Mahayu Nilam Anindy18 September 2017

Name : Maulidiyah Mahayu Nilam Anindy
NIM : 131611133067
Class : A2
NURSING ASSESMENT
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
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
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
• 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
• 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:
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:
1. Airway:
2. Breathing
3. Circulation:
4. Disability
5. Focused
6. Pain
7. Hydration/Nutrition:
8. Output:
9. Risk:
10. Wellbeing:
11. Social
12. 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:
1. Neurological system
2. Neurological system
3. Cardiovascular
4. Gastrointestinal
5. Renal
6. Musculoskeletal
7. Skin
8. Eye
9. Ear/Nose/Throat (ENT)

Ayu Saadatul Karimah18 September 2017

Nama: Ayu Saadatul Karimah
NIM: 131611133020
Kelas : A-1 2016
NURSING ASSESSMENT
Assessment is the basic thought of a nursing process that aims to collect information or data about clients, in order to identify, identify problems, health needs and nursing clients, whether physical, mental, social, and environmental.
Nurses are tasked with conducting nursing processes such as assessment, diagnosis, intervention, implementation, and evaluation in providing nursing care in collaboration with health personnel or fellow nurses to achieve the expected goals.

There are several types of assessment:
1. Admission Assessment means the assessment undertaken by the nurse since the patient was first admitted to the hospital. This type of assessment should be done with parents, relatives or close relatives who bring patients to the hospital. Assessment should be completed within 24 hours of admission to hospital. Assessment conducted is patient history, patient appearance, physical examination and others.
2. Shift assessment means the assessment performed to the patient at the commencement of the shift.
3. Focused assessment means the assessment undertaken to examine in detail the specific problematic system of the body.

Patient History
History of current illness / injury suffered by patients resulting in hospital admission or past history of patients such as allergies, medications, immunization status and others. For newborn infants the history of the disease may consider a history of maternal diseases such as the type of labor, antenatal and others.

General Assessment
The general assessment in question is an assessment of the overall physical conditions, emotional, and behavioral conditions of the patient. Such as body symmetry, facial expressions, patient response, patient communication and others.

Vital sign
Vital signs should be noted since the patient is admitted to the hospital and should be documented on the patient's observation sheet. Nurses are mandatory to review the VICTOR graph to observe trending of vital signs and to assist in clinical decision-making. Vital signs that a nurse should examine are the temperature, RR, heart rate, blood pressure, and complaints experienced by the patient. If necessary the nurse should also assess the weight, height, head circumference, blood sugar level of the patient to assist the nurse in diagnosing the patient's problem.

Physical examination
Physical examination allows the nurse to obtain a complete patient assessment. In performing physical examination through observation, palpation, inspection, percussion and auscultation.

Psychosocial assessment
In this assessment the nurse assessed the psychosocial experienced by the patient such as emotional state, sleep patterns, coping, mood and others

Social and cultural assessment
In this assessment the nurse assesses the patient's social and cultural conditions such as living arrangements, transportation, tradition or culture and others.

Shift Assessment
Assessment is done at every beginning of shift. This assessment is performed on each patient to see the progress of the patient's health by being documented on the assessment sheet.

Here are some body systems that need to be assess by nurses such as the nervous system, respiratory system, cardiovascular, gastrointestinal, renal, musculoskeletal, skin, eye, ear, nose, and throat.

Assessment evaluation
At this stage make sure the information, data and physical examination are collected complete, accurate and well documented. Nurses must have the ability to think critically and can solve nursing problems to make clinical decisions and plan the care of the patients under assess. Patients should always be assessed to determine the development or decline in health experienced by patients so that nurses can perform actions quickly and precisely.

Rahmatul Habibah18 September 2017

NAMA : Rahmatul Habibah
NIM : 131611133079
KELAS : A2-2016
“Nursing assessment”
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. the aim is to provide care with: Indications for assessment assessment type, structure for assessment.
1. Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Include:
- 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.
- Vital signs: Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet
- Additional measurements: Weight, Height, Head circumference, Blood sugar level (BSL)
- Physical assessment: 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

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.

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: 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
- Cardiovascular: Assessment of the cardiovascular system 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: An assessment of the renal system includes all aspects of urinary elimination
- Musculoskeletal
- 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)

4. Evaluatin of assessment: In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately.

Nahdiya Rosa A18 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. Definition of terms : Admission assessment, Shift assessment, 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.
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 vital sign is : Temperature, Temperature, Heart Rate, Blood Pressure, Oxygen Saturation, Pain
Additional measurements : weight, height, heac circumference, blood sugar level.
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. Kind of Physical assessment : 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. Psychosocial assessments e.g. HEADSS
Social/cultural : Parents/ carers/ guardian, living arrangements, siblings, visiting plans, transport, specific cultural requirements
Shift Assessment : airway, breathing, circulation, disability, focused, and etc.
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


Annisa Fitriani Purnamasari18 September 2017

Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. 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. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times, but must be completed within 24 hours of admission.
A. Patient history : History of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
B. General appearance : Assessment of the patient’s overall physical, emotional and behavioral state.
C. 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. There is Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, Pain, and others Additional measurements (Weight, Height, Head circumference, Blood sugar level).
D. 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.

2. Shift assessment : Concise nursing assessment completed at the commencement of each shift. 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.

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. Focused Assessment include : Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Skin, Eye, ENT.

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 Evaluation of assessment in nursing ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on:
1. critical thinking and,
2. problem solving skills to make clinical decisions and,
3. 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.

Annisa Fitriani Purnamasari18 September 2017

Nursing assessment
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. 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. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times, but must be completed within 24 hours of admission.
A. Patient history : History of current illness/injury, relevant past history, allergies and reactions, medications, immunisation status and family and social history.
B. General appearance : Assessment of the patient’s overall physical, emotional and behavioral state.
C. 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. There is Temperature, Respiratory Rate, Heart Rate, Blood Pressure, Oxygen Saturation, Pain, and others Additional measurements (Weight, Height, Head circumference, Blood sugar level).
D. 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.

2. Shift assessment : Concise nursing assessment completed at the commencement of each shift. 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.

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. Focused Assessment include : Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Skin, Eye, ENT.

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 Evaluation of assessment in nursing ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on:
1. critical thinking and,
2. problem solving skills to make clinical decisions and,
3. 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.

NESYA ELLYKA18 September 2017

NAMA : NESYA ELLYKA
NIM : 131611133038
KELAS : A1
RESUME :
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
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
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.
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.
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.
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 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.

Dewi Indah Kumalasari18 September 2017

Name : Dewi Indah Kumalasari
NIM : 131611133087
Class : A2
Nursing Assessment
There are three components of nursing language that is NANDA, NIC and NOC
1. NANDA or Nursing Diaagnosis
- A nursing diagnosis is defined as “ a clinical judgment about an individual, family or community responses to actual and potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”(NANDA, 2009)
- There are three variations of nursing diagnosis: Actual diagnosis, Risk diagnosis, Wellness diagnosis. And there also three components of a nursing diagnosis: Label or Name and definition, Related Factors or Risk Factors, Defining Characteristics.

2. NOC or Nursing Outcomes Classification
- The nursing outcomes classification (NOC) is a classification of nurse sensitive outcomes
- NOC outcomes and indicators “allow for measurement of the patient, family, or community outcome at any point on a continuum from most negative to most positive and at different points in time.” ( Iowa Outcome Project, 2008)
- There are three components: A neutral label or name used to characterize the behavior or patient status, a list of indicators that describe client behavior or patient status, and a five point scale to rate the patient‘s status for each of the indicators.

3. NIC or Nursing Interventions Classification
- “The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.” (Iowa Intervention Project, 2008).
- Intervention is “any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” (Iowa Intervention Project, 2000,p.3)
- There three components: Name or label, a definition, and a set of activities the nurse does to carry out the intervention

Maulidiyah Mahayu Nilam Anindy18 September 2017

Name : Maulidiyah Mahayu Nilam Anindy
NIM : 131611133067
Class : A2
NURSING ASSESMENT
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
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
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
• 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
• 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:
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:
1. Airway:
2. Breathing
3. Circulation:
4. Disability
5. Focused
6. Pain
7. Hydration/Nutrition:
8. Output:
9. Risk:
10. Wellbeing:
11. Social
12. 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:
1. Neurological system
2. Neurological system
3. Cardiovascular
4. Gastrointestinal
5. Renal
6. Musculoskeletal
7. Skin
8. Eye
9. Ear/Nose/Throat (ENT)

ANGGA KRESNA PRANATA18 September 2017

Name : ANGGA KRESNA PRANATA
Class : A1-2016
Nim : 131611133030


Nursing assessment
• Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
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, general appearance, physical examination and vital signs completed at the time of admission. Must be completed within 24hours of admission, then documented on the nursing admission form. Privacy of the patient needs to be considered all times
a. 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.
• 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)
b. General appearance
• 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
• Communication
c. Vital Signs
• Temperature
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Oxygen Saturation
• Pain
d. Additional Measurements
• Weight
• Height
• Head circumference
• Blood sugar level (BSL)
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. Clinical judgment should be used to decide on the extent of assessment required.
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. Includes; airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
4. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ENT, etc.
• Evaluation of assessment
Ensure the information collected is complete, accurate and documented appropriately.

Adelia Dwi Lailyvira Ramadhania18 September 2017

Penilaian merupakan kunci komponen dari praktek keperawatan, diperlukan untuk perencanaan dan pelaksanaan pasien dan keluarga. Perawat harus merencanakan, melaksanakan dan mengevaluasi perawatan bekerjasama dengan individu dan tim perawatan kesehatan lain untuk mencapai tujuan dan hasil kesehatan yang optimal.
Pedoman khusus berusaha untuk menyediakan perawat dengan:
• Indikasi untuk penilaian
• Jenis penilaian
• Struktur untuk penilaian
Penerimaan penilaian: menilai keadaan pasien saat mendaftar.
Pergeseran penilaian: ringkasan perawat apabila terjadi sesuatu pada pasien dan informasi untuk perawat lainnya.
Terfokus Penilaian: rincian perawat sistem tubuh pasien.
Penerimaan penilaian
Penilaian pendaftaran harus diselesaikan oleh perawat dengan orang tua atau yang menemani, idealnya setibanya ke bangsal, tapi harus diselesaikan dalam waktu 24 jam setelah masuk. Penerimaan penilaian adalah yang mendokumentasikan pada formulir pendaftaran dan selalu menjaga privasi pasien sepanjang waktu.
Sejarah pasien
Sejarah saat ini penyakit/cedera (yaitu alasan untuk masuk saat ini), relevan melewati sejarah, status imunisasi alergi dan reaksi, obat, dan keluarga dan sejarah sosial.
Penampilan Umum
pucat atau memerah, lesu atau aktif, gelisah atau tenang, compliant atau agresif, dan gerakan.
PENTING TANDA
Pengamatan dasar wajib di data untuk mengamati ttv dan mendukung keputusan klinis perawat membuat proses.
- Suhu
- Laju pernafasan
- Denyut jantung
- Tekanan darah
- Saturasi oksigen
- Rasa sakit
Pemeriksaan fisik: Pengamatan, inspeksi, palpasi, perkusi dan Auskultasi adalah teknik yang digunakan untuk mengumpulkan informasi.




Gita Aula Tribuana18 September 2017

NAMA: GITA AULA TRIBUANA
NIM: 131611133083
KELAS: A2
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.
Physical examination: 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.
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 and pain.
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
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, an review the history of the patient recorded.
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.

Fajrinandetya P18 September 2017

Nama : Fajrinandetya Paramita
NIM : 131611133082
Kelas : A2 2016

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.
•Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift.
•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: 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. 
•Vital sign : Baseline observations are recorded as part of an admission assessment and documented on the patients observation flowsheet (temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, weight, height, head circumference, 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 (airway, breathing, circulation, disability, focused assessment, skin, input/nutrition, output/elimination).
•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.

Mochammad Nur Cahyono18 September 2017

Assessment is very important for nursing practice. 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.

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission.
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

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.
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 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.

Galang Hasfiansyah18 September 2017

Penilaian merupakan kunci komponen dari praktek keperawatan, diperlukan untuk perencanaan dan pelaksanaan pasien dan keluarga. Perawat harus merencanakan, melaksanakan dan mengevaluasi kepada tenaga kesehatan lain untuk mencapai tujuan dan hasil kesehatan yang optimal.
Pedoman khusus berusaha untuk menyediakan perawat dengan:
• Indikasi untuk penilaian
• Jenis penilaian
• Struktur untuk penilaian
Penerimaan penilaian: penampilan umum, pemeriksaan fisik, dan ttv saat mendaftar.
Pergeseran penilaian: ringkasan penilaian dari perawat satu untuk perawat lain.
Terfokus Penilaian: perincian perawatan sistem tubuh
Sejarah pasien: Riwayat penyakit pasien terdahulu
PENAMPILAN UMUM
pucat atau memerah, lesu atau aktif, gelisah atau tenang, compliant atau agresif, dan gerakan.
• Interaksi induk-bayi, bayi-parent neonatus yang dikenal dan bayi
• Tubuh simetri, spontan posisi dan gerakan
• Simetri dan posisi fitur wajah
• Kuat menangis
• Muda anak orangtua-anak, anak-orangtua interaksi
• Suasana hati dan mempengaruhi
• Buruk dan baik keterampilan motorik
• Tahapan
• Kebersihan pribadi
• Komunikasi
PENTING TANDA
- Suhu - Laju pernafasan
- Denyut jantung - Tekanan darah
- Saturasi oksigen
Pengukuran tambahan:
• Berat • Tinggi
• Kepala lingkar • Tingkat gula darah (BSL)
Pemeriksaan fisik:
Pengamatan, inspeksi, palpasi, perkusi dan Auskultasi.
Pernapasan: masuknya udara bilateral dan gerakan, napas suara (normal dan adventitious), laju pernafasan, irama,

Nophyaningtias Tri Widya Ningsih18 September 2017

Name : Nophyaningtias Tri Widya Ningsih
NIM : 131611133056
Class : A2/2016
NURSING ASSESSMENT
Definition: Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
Aim: The guideline specifically seeks to provide nurses with:
a. Indications for assessment
b. Types of assessments
c. Structure for assessments
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.
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.
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
Additional measurements:
1. Weight: on admission and/or weekly/daily as clinically indicated.
2. Height: as clinically indicated.
3. Head circumference: as clinically indicated.
4. Blood sugar level (BSL): as clinically indicated.
Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient. Assessment information includes, but is not limited to: Airway, breathing, circulation, disability, focus assessment, skin, input/nutrition, output/elimination.
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.
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.

Fatatin Nazhifah18 September 2017

Thuesday, 29th August 2017
Resume English Subject
Mrs. Ira Suarilah


Name : Fatatin Nazhifah
NIM : 131611133089
Class :A2

Topic :
Nursing Assessment

Definition :
Nursing assessment is a key component of nursing practice

Function :
for planning and provision of patient and family centered care

Content :
nursing care in collaboration with individuals and multidisciplinary health care team
(a.) assesses
(b.) pants
(c.) implements
(d.) evaluates

Aim :
The guideline specifically seek to provide nurse with assessments’ idications, types, and structure
(Garispedomanspesifikmencariuntukmenyediakanperawat

Definition of terms :

(1.)Admission assessment :
(a.) patient history
(b.) general appearance
(c.) physical examination
(d.) vital signs
(e.) time of admission

(2.) Shift assessment :
(a.) commencement of each shift
(b.) patient condition changes at any other time during our shift

(3.) Focused assessment :
(a.) problem or current concern(s) in one or more patient’s specific body system(s) is required

(i.) neurological system
1.) observation
2.) cognitive growth and development
3.) fine and gross motor skill
4.) sensory function
5.) seizures
6.) etc

(ii.) respiratory system
1.) common
2.) many other condition

(iii.) cardiovascular
1.) evaluate adequacy of cardiac output

(iv.) gastrointestinal
1.) abnormalities
2.) bowel sound
3.) softness / tenderness

(v.) renal
1.) all aspect of urinary elimination

(vi.) musculoskeletal
1.) limbs / joints

(vii.) skin
1.) systemicdesease

(viii.) eye
1.) carefully
2.) only with compliant

(ix.) ear / nose / throat (ENT)
1.) upper respiratory infection
2.) allergies
3.) oraldan facial trauma
4.) dental caries
5.) pharyngitis

Note:
(a.) assessment should be complete by nurse with a parent or care giver
(b.) assessment complete within 24 hours of admission
(c.) nurse considers about patient’s privacy all times

Patient history :
(a.) illness / injury (i.e. reason for current admission)
(b.) relevant past history
(c.) allergies and reactions
(d.) medications
(e.) immunization status
(f.) family and social history

Add history for neonates and infants :
(a.) maternal history
(b.) antenatal history
(c.) delivery type
(d.) resuscitation required at delivery
(e.) newborn screening tests

General appearance :
(a.) overall physical
(b.) emotional
(c.) behavioral state

Check in general appearance :
(a.) well / unwell
(b.) pale / flushed
(c.) lethargic / active
(d.) agitated /calm
(e.) compliant / combative
(f.) posture
(g.) movement

General appearance in neonate and infant:
(a.) parent-infant
(b.) infant-parent interaction
(c.) body simmetry
(d.) spontaneous position
(e.) movement
(f.) symmetry of facial features
(g.) positioning of facial features
(h.) strong cry

General appearance in young child:
(a.) parent-child
(b.) child-parent interaction
(c.) mood
(d.) affect
(e.) gross
(f.) fine motor skill
(g.) developmental milestones
(h.) appropriate speech

General appearance in adolesenct:
(a.) mood
(b.) affect
(c.) personal hygiene
(d.) communication

Vital sign :
(a.) temperature
(b.) respiratory rate
(c.) heart rate
(d.) blood pressure
(e.) oxygen saturate

Additional measurement :
(a.) weight
(b.) height
(c.) head cicrumference
(d.)Blood sugar level

Physicl assessment
Technic :
(a.) observation
(b.) inspection
(c.) palpation
(d.)percussiom
(e.) auscultation
Function :
To decided on the next of assessment required
Include :
(a.) airway
(b.) breathing
(c.) circulation
(d.) disability
(e.) focused assessment
(f.) skin
(g.) output / elimination

Wellbeing
(a.) mood
(b.) emotional state
(c.) comfort objects
(d.) sleeping habits and outcome
(e.) coping strategies
(f.) support networks
(g.) reaction of admission

Social / Cultural :
(a.) parents / carers / guardian
(b.) living arrangements
(c.) siblings
(d.) visiting plans
(e.) transport
(f.) specific cultural requirements

Shift assessment
Task :
complete every patient in commencement of every shift
Function :
The information is used to develop a plan care
Includes :
(a.) airway
(b.) breathing
(c.) circulation
(d.) disability
(e.) focused
(f.) pain
(g.) hydration / nutrition
(h.) output
(i.) risk
(j.) wellbeing
(k.) social
(l.) revew the history of patient recorded ini the IP summary

Evaluation of assessment :
(a.) complete
(b.) accurate
(c.) documented appropriately

Skill:
(a.) critical thinking
(b.) problem solving
(c.) ensure that appropriate action is taken

Following nurse’s activity:
(a.) assess for the changes in condition while under RCH care
(b.) documented assessment regulary

Rufaidah Fikriya18 September 2017

Name: Rufaidah Fikriya
NIM: 131611133018
Class: A1-2016

Nursing assessment
• Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
The guideline specifically seeks to provide nurses with:
1. Indications for assessment
2. Types of assessments
3. Structure for assessments

• 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. Must be completed within 24hours of admission, then documented on the nursing admission form. Privacy of the patient needs to be considered all times
a. 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.
¥ 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)
b. General appearance
Assessment of the patient’s overall physical, emotional and behavioral stateConsiderations 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


c. VITAL SIGNS 
o Temperature
o Respiratory Rate
o Heart Rate
o Blood Pressure
o Oxygen Saturation
o Pain: FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool. Current pain relief medications/practices

d. 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. 

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. Clinical judgment should be used to decide on the extent of assessment required.
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. Includes; airway, breathing, circulation, disability, pain, hydration/nutrition, output, risk, wellbeing, social, review the history of the patient recorded in the IP summary.
4. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. Presenting problem(s) or other identified issues, eg. cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal, skin, eye, ENT, etc.
-Evaluation of assessment
Ensure the information collected is complete, accurate and documented appropriately.

muhammad hidayatullah al muslim18 September 2017

Nama: Muhammad hidayatullah al muslim
Nim: 131611133039
Kelas: A1-2016

RESUME
Introduction
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
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
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.
General appearance
• Neonate and Infant Parent-infant, infant-parent interaction
• Body symmetry, spontaneous position and movement
• Symmetry and positioning of facial features
• Strong cry
General appearance
• Young Child Parent-child, child-parent interaction
• Mood and affect
• Gross and fine motor skills
• Developmental milestones
• Appropriate speech
General appearance
• AdolescentMood and affect
• Personal hygiene
• Communication
Vital signs
• 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:
• 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: noises, secretions, cough, artificial airway
• 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.

Ema Yuliani18 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.


Lukmania Andriani Putri18 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



Ida Nurul Fadilah18 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.


Konita Shafira18 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.

Grace Marcellina B 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.

Ishomatul Faizah18 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.


Ishomatul Faizah18 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.


Asih Parama Anindhia18 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.

BLANDINA EASTER GRACE WAIRATA18 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.

Reza Ramadhana R18 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

Sekar Ayu Pitaloka18 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.

Mutiara Citra Dewi18 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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