ASSESSMENT

By: Group 1
 Definition

• Assessment is the initial and basic stage in the nursing

process.

• Assessment is the systematic and continuous collection,

organization, validation, and documentation of data
(information)
 Types of assessment in nursing
process
• Comprehensive assessment
Comprehensive assessment of the assessment
process is usually carried out at the beginning of
the patient's registration to the health center.

• Focused assessment
Focused assessment of this study is more focused on the part that has an
abnormality.

• The ongoing assessment

This assessment is carried out when the nurse observes the patient's
development status.
 Data sources in assessment in nursing
process
• Primary data source
Client Is the best data source because clients can provide
subjective data that cannot be given by others.

• Secondary data sources

Family and close friends are important secondary sources of
information to involve them in the assessment if possible. They may
provide information about the client's response to the disease, stress
experienced by the client before illness.

• Client records, including information documented by various health

professionals. Contains data on client work, religion, and marital status

• Health professionals
 Method of data collection in
assessment in nursing process
1. Observation
2. Interview
3. Medical history
4. Physical Examination
5. Other Diagnostic Checks
 Types of approaches of assessment in
nursing process
1. Head to toe

2. Body system approach

3. Approach to Bordon's health function pattern

4. DOENGOES (1993)
Example format of assessment in nursing
process
 Conclusion

Assessment is the initial and basic stage in the nursing

process. Assessment is the most decisive stage for the
next stage.

The assessment has its own types, there are

comprehensive studies, focused assessments, and further
studies. The assessment also includes data and data
sources, namely subjective and objective data. Subjective
data is data obtained directly from client complaints.
Whereas objective data is data from the results of nurse
observations of clients. The assessment method is sorted
by process starting from the observation, interview,
physical examination, medical history, to other diagnostic
tests. The types of approaches in the assessment process
are head to toe examination, body system approach and
assessment approach according to Bordon
 Suggestion

Because assessment is the initial and basic stage in the

nursing process and the most decisive stage for the next
stage, then it’s expected that nurses can be really thorough
and careful when doing this step, so that in the subsequent
nursing process there is no grap.