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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
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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
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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,
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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,
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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
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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