Jadi Tugas. Doc

7/27/2019 Jadi Tugas. Doc

1/6

NURSING ASSESSMENT

Nursing assessment is the gathering of information about a patient's physiological,

psychological, sociological, and spiritual status.

Stage one of the nursing process

Assessment is the first stage of the nursing process in which the nurse carries out a

complete andholistic nursing assessment of every patient's needs, regardless of the reason for

the encounter. Usually, an assessment framework, based on a nursing modelis 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".Nursing history

Taking a nursing history prior to the physical examination allows a nurse to establish

a rapport with the patient and family. Elements of the history include sush as the client's

overall health status, the course of the present illness including symptoms, the current

management of illness, the client's medical history (including familial medical history), social

history and how the client perceives his illness.

Psychological and social examination

The main areas considered in apsychological examination are intellectual health and

emotional health. Assessment of cognitive function, checking for hallucinations and

delusions, measuring concentration levels, and inquiring into the client's hobbies and interests

constitute an intellectual health assessment. Emotional health is assessed by observing and

inquiring about how the client feels and what he does in response to these feelings. The

psychological examination may also include the client's perceptions (why they think they are

being assessed or have been referred, what they hope to gain from the meeting). Religion and

beliefs are also important areas to consider. The need for a physical health assessment is

always included in any psychological examination to rule out structural damage or anomalies.

Physical examination

A nursing assessment includes a physical examination such as the observation or

measurement ofsigns, which can be observed or measured, or symptoms such asnauseaor

vertigo, which can be felt by the patient.

The techniques used may include Inspection, Palpation, Auscultation and Percussion

in addition to the "vital signs" oftemperature,blood pressure,pulse and respiratory rate, and
http://en.wikipedia.org/wiki/Nursehttp://en.wikipedia.org/wiki/Holistichttp://en.wikipedia.org/wiki/Holistichttp://en.wikipedia.org/wiki/Nursing_theoryhttp://en.wikipedia.org/wiki/Nursing_theoryhttp://en.wikipedia.org/wiki/Psychological_examinationhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Medical_signhttp://en.wikipedia.org/wiki/Symptomshttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Vertigo_(medical)http://en.wikipedia.org/wiki/Palpationhttp://en.wikipedia.org/wiki/Auscultationhttp://en.wikipedia.org/wiki/Percussion_(medicine)http://en.wikipedia.org/wiki/Temperaturehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Holistichttp://en.wikipedia.org/wiki/Nursing_theoryhttp://en.wikipedia.org/wiki/Psychological_examinationhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Medical_signhttp://en.wikipedia.org/wiki/Symptomshttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Vertigo_(medical)http://en.wikipedia.org/wiki/Palpationhttp://en.wikipedia.org/wiki/Auscultationhttp://en.wikipedia.org/wiki/Percussion_(medicine)http://en.wikipedia.org/wiki/Temperaturehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Nurse


2/6

further examination of the body systems such as the cardiovascular or musculoskeletal

systems.

Documentation

The assessment is documented in the patient's medical ornursing records, which may

be on paper or as part of the electronic medical record which can be accessed by all members

of the healthcare team.

Vocabulary Part Of The Body

1. Rambut = hair - alopecia

2. Kepala = head

3. Dahi = forehead

4. Alis = eyebrow

5. Mata = eyes

6. Hidung = nose

7. Mulut = mouth

8. Bibir = Lips

9. Pipi = cheek

10. Telinga = ears

11. Dagu = chin

12. Leher = neck

13. Pundak = shoulder

14. Dada = breast, chest

15. Lengan = arm

16. Sikut = elbow

17. Tangan = hand

18. Jari = finger

19. Perut = stomach

20. Pinggang = hip

21. Paha = thigh

22. Lutut = knee

23. Betis = calf

24. Kaki = foot

Example Disease of The Part Body

1. Growing Toenail

DefinisionGrowing Toenail is a State where the tip of the nail grows into

the skin around it.

Causes

Ingrown toenail can occur if toe nail deformities that havegrown into the skin or if the skin around the nails grow

quickly and cover most of the nails. Other things that can also

cause or worsen ingrown toenail is wearing Nail Polish, shoe

size which is too narrow and cuts nails that form arches with

the tip of a very short.

Symptom Ingrown toenails at first do not cause symptoms, but could

eventually cause pain, especially if the area is depressed. The

affected area is usually looks reddish and palpable warmth. If
http://en.wikipedia.org/wiki/Cardiovascularhttp://en.wikipedia.org/wiki/Musculoskeletalhttp://en.wikipedia.org/wiki/Medical_recordhttp://en.wikipedia.org/wiki/Nursing_recordshttp://en.wikipedia.org/wiki/Cardiovascularhttp://en.wikipedia.org/wiki/Musculoskeletalhttp://en.wikipedia.org/wiki/Medical_recordhttp://en.wikipedia.org/wiki/Nursing_records


3/6

left untreated, likely will happen an infection. The infected

area is very visible redness and pain, swell and can form

blisters containing pus (paronikia).

Treatment

Ingrown toenail that light could still be overcome by cutting it,

the tip is lifted vertically and under the nail bed sterile cotton

swab is inserted until the swelling is gone. Subsequent

inflammation will subside and usually this disease will not

relapse again.

Prevention

a. Trim your nails regularly to right direction. Avoid cutting

too focused and too short. When the nails are poking into,

and cut with a sterilized nail clippers.

b. Cure wound with an antiseptic remedy. If it occurs the

infection, consult a doctor and do not try to revoke his own

nail care pedicure

c. avoid places that are not clean and are not professional.

d. Immediately wash away with SOAP after cutting the nail

2. Alzaimer

Alzheimer's disease is not contagious, but rather a similar syndrome with apoptosis

of brain cells at the same time, so that the brain seems to constrict and shrink. Alzheimer's

disease is also said to be synonymous with the parents. Risk factor get alzheimer are

hypertensi suffer that reached the age of 40 years old and upward, diabetes suffer, physical

exaercise less, and genetics factor. Clinical symptom of the Alzheimer are:

a. Memory disorder affect skill work

b. Difficulty performing familiar tasks

c. Disorientation of time, place and people

d. Abstract thinking, such as difficulty

e. Changes in personality

f. loss of interest and initiative

Treatment of the Alzheimer are:

a. Donepezil is Donepezil medicine that is taken orally to treat Alzheimer's disease ranks

low to medium. Donepezil is available in oral tablet form. Side effects often occur

when taking Donepezil is headaches, pain throughout the body, lethargy, drowsiness,


4/6

nausea, vomiting, diarrhea, lost appetite, weight, cramps, joint pain, insomnia, and

increased frequency of urination.

b. Rivastigmine is medication that is taken orally to treat Alzheimer's disease ranks low to

medium. Rivastigmine is usually given twice a day after meals. The maximum dose is

usually up to 6 mg twice a day. If patients experience severe gastrointestinal disorders

increased because of drug side effects such as nausea and vomiting, medication should

be discontinued for a few doses and continued with the same doses or lower.

c. Memantine is a drug taken orally to treat disease Alzhaimer ranks Are heavy with

serious mechanisms to the different and unique with improving signal processing of

glutamate. This medicine is started with a low dose of 5 mg per week performed for 3

weeks to reach the optimal dose of 20 mg/day

Prevention of consuming fish oil, exercise routine and fill in crossword puzzles is

the activity that is beneficial to the brain. But according to recent studies, there is no

strong evidence that it can prevent Alzheimer's disease. A panel of experts consisting of

experts concluded, supplements, drugs or social interaction also has not been proven to

prevent brain degeneration disease. The Group of experts observed dozens of research that

suggests ways to prevent Alzheimer 's, a disease that destroys the brain and cannot be

treated. But it has not found any evidence that is strong enough to be the impact of

prevention.

Synonym Of Some Medical Terminology In English

No. Medical Synonyms

1. CurativeCuring, healing, medical, medicative, remedial,

restorative, therapeutic.

2. Healing, health-giving

Alleviative, beneficial, corrective, curing, healthful,

helpful, Invigorating, medicable, medicative, medicinal ,

pick-me-up, Remedial, remedying, restorative, salutary,

sanative, shot in the arm, therapeutic, tonic, vulnerary,

what the doctor ordered, wholesome

3. Medication

Biologic, cure, depressant, dope, essence, medicament,

medicinal , medicine, narcotic, opiate, pharmaceutic,

pharmaceutical, physic, pill, poison, potion, prescription,

remedy, sedative, stimulant, tonic

4. Pertaing to medicineAesculapian, corrective, curative, healing, iatric, iatrical,

Medicative, medicinal , therapeutic, therapeutical

5. Restorative Curative, curing, invigorating, medicinal , mending,


5/6

remedial

Notes: healing is a process in which an organism's health

is restored;curing is a method that promotes healing

6. TherapeuticAnaleptic, corrective, curable, healing, medicinal ,

remedial, tonic

Source

http://www.pustakasekolah.com/nama-anggota-tubuh-manusia-dalam-berbagai-bahasa.html

http://www.spesialis.info/?penyebab-kuku-jari-kaki-yang-tumbuh-ke-dalam,1233

http://id.wikipedia.org/wiki/Alzheimer

http://en.wikipedia.org/wiki/Nursing_assessment


6/6

ENGLISH TASK

NURSING ASSESSMENT

Disusun untuk memenuhi tugas Nursing-3

oleh Dosen Rahmat Mulyanto, SE, M. ACC

Disusun:

1. Agung Puja Nugraha2. Aningsih

3. Joko Eko S.

4. Rio Agus Purnomo

5. Rukmana

PROGRAM STUDI KEPERAWATAN

STIKES BORNEO CENDEKIA MEDIKA

KALIMANTAN TENGAH

2013

Jadi Tugas. Doc

Documents

Transcript of Jadi Tugas. Doc