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Free Powerpoint Templates Page 1 Free Powerpoint Templates PENGKAJIAN KEPERAWATAN (1) Nursing Assesment Dewi Baririet Baroroh Dept. Keperawatan Dasar :

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Presentasi berjudul: "Free Powerpoint Templates Page 1 Free Powerpoint Templates PENGKAJIAN KEPERAWATAN (1) Nursing Assesment Dewi Baririet Baroroh Dept. Keperawatan Dasar :"— Transcript presentasi:

1 Free Powerpoint Templates Page 1 Free Powerpoint Templates PENGKAJIAN KEPERAWATAN (1) Nursing Assesment Dewi Baririet Baroroh Dept. Keperawatan Dasar : Proses Dokumentasi Keperawatan PSIK FIKES UMM 2011

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3 Free Powerpoint Templates Page 3 Thursday, March 22, 2011

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5 Free Powerpoint Templates Page 5 Perawat melaksanakan tugas-tugas keperawatan hanya sebagai RUTINITAS kerja harian tanpa berpedoman dasar-dasar ilmiah dari tindakan itu sendiri. Pengakuan keperawatan sebagi suatu perofesi. Sebagai profesi mandiri, perawat dalam bertugas selalu menggunakan pendekatan proses keperawatan. Vs

6 Free Powerpoint Templates Page 6 Proses keperawatan merupakan pendekatan ilmiah dalam menyelesaikan masalah. PROFESIONAL

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8 Free Powerpoint Templates Page 8 Doctor assessment Vs Nursing assessment

9 Free Powerpoint Templates Page 9 Pengkajian adalah tahap pertama dalam proses keperawatan yang merupakan suatu proses yg sistematis dalam pengumpulan data dari berbagai sumber data untuk mengevaluasi dan mengidentifikasi status kesehatan klien (lyer et al., 1996)

10 Free Powerpoint Templates Page 10 Process of assessment : 1.Collect the data 2.Validated 3.Organized 4.Documented

11 Free Powerpoint Templates Page 11 To gather data that: Allows nurse to make judgment about patient’s health state Will be used for rest of nursing process Determines patient’s: Baseline Normal function Presence of (or risk for) dysfunction Strengths Purpose of Nursing Assessment

12 Free Powerpoint Templates Page 12 Being Accountable !! Using critical thinking before taking actions Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process

13 Free Powerpoint Templates Page 13 Assessment Emergency: Life threatening situation Focus on rapid identification of problems Assessment follows ABCs Time-Lapsed: Occurs after initial assessment and depends time period

14 Free Powerpoint Templates Page 14 Several types form of assess : Maternity, child, neonatus, mental health, family, community, gerontology

15 Free Powerpoint Templates Page 15 Assessment Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment – the data you gather to determine the status of a specific condition.

16 Free Powerpoint Templates Page 16 Types of Data To Collect : Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms)

17 Free Powerpoint Templates Page 17 Sources of Data Primary source: Client Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

18 Free Powerpoint Templates Page 18 Resources Client Other individuals Previous records Consultations Diagnostics studies Relevant literature

19 Free Powerpoint Templates Page 19 Characteristic of Data : 1. Lengkap ex : klien tidak mau makan selama 2 hari 2. Akurat ex : “Klien sll diam dan sering menutup mukanya dg bantal. Prwt busaha mengajak komunikasi klien ttp klien diam dan tdk menjawab”. Perawat menyimpulkan DEPRESI BERAT tanpa pengetahuan. 3. Nyata ex : perawat melakukan pengukuran suhu pada klien X, didapatkan suhu termometer 37◦C 4. Relevan ex : catat sesuai masalah klien. Fokus pada keluhan dan observasi.tdk sekedar berkomunikasi

20 Free Powerpoint Templates Page 20 Methode to ASSESS Observation Interview –Types of questions –Environment (physical and emotional) and Spiritual conciderations Examination

21 Free Powerpoint Templates Page 21 Something to think about: Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”

22 Free Powerpoint Templates Page 22 MARTHA ROGERS, NURSE THEORIST “When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”

23 Free Powerpoint Templates Page 23 What Are Your Responsibilities? Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment. Begin to think CRITICALLY !!!!!!

24 Free Powerpoint Templates Page 24 Critical Thinking MENTAL OPERATIONS –decision making & reasoning KNOWLEDGE-having the facts & understanding the reason behind the knowledge ATTITUDES- curious/open- minded/non-judgmental….

25 Free Powerpoint Templates Page 25 TYPES OF INTERVIEWS DIRECTED NON-DIRECTED THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT

26 Free Powerpoint Templates Page 26 Preparatory Review medical record first Keep open mind & awareness of own issues Obtain/organize needed materials Provide privacy Introductory Develop rapport, explain purpose, content, duration & confidentiality Maintenance : Conducting interview Concluding : Summarize & answer questions Interviewing Phases

27 Free Powerpoint Templates Page 27 CULTURAL DIVERSITY MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS “This is not about you” ? Respect INDIVIDUAL’S DIFFERENCES, What is the significance of the problem or illness to the client? What does it mean in the family/community?

28 Free Powerpoint Templates Page 28 Interview dan MENDENGARKAN aktif : -Perkenalkan diri dan jaga kerahasiaan -Jelaskan tujuan -Posisi dan kontak mata -Fokus dalam bertanya. (Close Vs open, istilah asing, hindari pertanyaan pribadi) -Jadilah pendengar aktif -Jangan memotong pembicaraan klien -Bersabar bila klian “blocking” -Berikan perhatian penuh dan jangan tergesa- gesa. Bila perlu dg sentuhan terapeutik. -Klarifikasi dan simpulkan dg mengulang apa yg dikatakan klien

29 Free Powerpoint Templates Page 29 Hambatan Selama Komunikasi Internal Pandangan atau pendapat klien berbeda dg persepsi klien Cara bicara klien atau penampilan yg berbeda Klien dlm keadaan cemas atau nyeri Klien merasa tdk senang dgn perawat Perawat berpikir suatu hal yg lain Perawat sdg merencanakan pertanyaan berikutnya Perawat merasa terburu-buru Perawat sgt gelisah atau menggebu-gebu dlm bertanya

30 Free Powerpoint Templates Page 30 Eksternal Suara yg gaduh dr peralatan, pembicaraan, TV, radio, dll Kurang kerahasiaan Ruangan atau tempat yang tidak memadai untuk berbicara Adanya interupsi atau pertanyaan dari staf perawat lainnya

31 Free Powerpoint Templates Page 31 Observation Sight Smell Hearing Feeling Taste

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33 Free Powerpoint Templates Page 33 Physical Examination Inspection Palpation Perkusion Auskultation

34 Free Powerpoint Templates Page 34 Conducting physical examination 1.Head to Toe 2.ROS 3.Health Function Pattern

35 Free Powerpoint Templates Page 35 Hambatan dalam pengkajian : 1.Ketidakmampuan perawat mengorganisir data dasar 2.Kehilangan data yang telah dikumpulkaan 3.Data yang tidak relevant 4.Adanya duplikasi data 5.Mispersepsi data 6.Tidak lengkap 7.Adanya interpretasi data dalam mengobservasi perilaku 8.Kegagalan dalam mengambil data dasar terbaru

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37 Free Powerpoint Templates Page 37 Double-check - Discrepancies in subjective/objective data – Discrepancies in patient’s statements – Abnormal findings inconsistent with other data – If data source unreliable Methods – Confirm accuracy of abnormal findings – Clarify with patient – Verify with colleague Validated Data

38 Free Powerpoint Templates Page 38 * Cluster data to reveal patterns & identify client problems & strengths * Frameworks provide systems for both assessing & clustering data – Body Systems Model (medical model) Focuses on anatomical systems – Head to Toe Model Systematic approach starting with head &progressing downward Organized Data

39 Free Powerpoint Templates Page 39 Documented Data

40 Free Powerpoint Templates Page 40 Thanks a LOT


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