Performing nursing assessment

(pengkajian keperawatan)
orientasi
• Good morning mr/mrs/ms.....
• Welcome to “Mawar Ward”..I am ners
fakhriatul falah, you can call me ners rhia, i am
the nurse in charge today
• If you dont mind, i want to do a physical
assessment to you and some short interview
about your health history and disease. It will
take time about 20 minutes. May I ?
Keluhan Utama (chief complaint)

• So, tell me why you have come here today?

• Tell me what your biggest complaint is right now?
• What is bothering you the most right now?
• If we could fix any of your health problems right
now, what would it be?
• What is giving you the most problems right now?
Present Health Status (Riwayat
kesehatan sekarang)
• Provocative or Palliative: What makes the symptom(s)
better or worse?
• Quality: could you describe how the pain like ?
• Region or Radiation: Where in the body does the
symptom occur? Is there radiation or extension of the
symptom(s) to another area of the body?
• Severity: On a scale of 1-10, (10 being the worst) how
bad is the symptom(s)?
• Timing: Does it occur in association with something
else (i.e. eating, exertion, movement)?
• What others symptom do you have ?
Pengkajian khusus nyeri (PQRST)

• P - provocating and precipitating factors,

relieving factors (yang memicu dan
mengurangi nyeri)
Ask:
• What makes your pain worse?
• What makes your pain better?
• What previous treatment have you tried to
relieve your pain? Were they effective?
Kualitas nyeri
• Q - quality of pain (eg. Burning/terbakar,
stabbing/menusuk, gnawing/perih,)
• Ask:
• What does your pain feel like?
• What words would you use to describe your
pain?
• R - radiation
Ask:
Does the pain move anywhere?
• S - severity (use an appropriate intensity scale - see
Appendix E)
Ask:
• On a scale of 0 to 10 with O being no pain and 10 being
the worst pain you can imagine, how much does it hurt
right now?
• How much does it hurt at it’s worst?
• How much does it hurt at it’s best?
T - timing
Ask:
• When did your pain start?
• How often does it occur?
• Has its intensity changed?
• How long does it last?
Past health history (riwayat kesehatan
masa lalu)
• Do you have any medical problems or disease
before ?
• Have you ever received medical care? If so,
what problems/issues were addressed? Have
you ever undergone any procedures, X-Rays,
CAT scans, MRIs or other special testing?
• Ever been hospitalized? If so, for what?
• Have you ever been admitted to a hospital?
Spiritual Assessment
• Is religion or God important to you? If yes, in
what way?
• If no, what is the most important thing in your
life?
• Are there any religious practices that are
important to you?
• Do you have any spiritual concerns because of
your present health problem?
Interpersonal and Cultural
Environment
• Where did your parents or ancestors come
from? When?
• What language do you speak at home?
• Are there certain customs or values that are
important to you?
• Is there anything special you do to keep in
good health?
• Do you have any specific practices for treating
illness?
Self concept
• “How do you feel about your life in general?”
• Do you have any particular concerns
• about your body?
Neurological system
• Any past history of head injury? (location, loss of consciousness)
• Do you have frequent or severe headaches? (when, where, how often)
• Any dizziness or vertigo? (frequency, precipitating factors, gradual or
sudden)
• Ever had/or do you have seizures? (when did they start, frequency, course
and duration, motor activity associated with, associated signs, postictal
phase, precipitating factors, medications, coping strategies)
• Any difficulty swallowing? (solids or liquids, excessive saliva)
• Any difficulty speaking? (forming words or actually saying what you
intended)
• Do you have any coordination problems? (describe)
• Do you have any numbness or tingling? (describe)
• Any significant past neurologic history? (cerebral vascular accident, spinal
cord injuries, neurologic infections, congenital disorders)
eye

• Any vision changes or difficulty?

• Any eye pain?
• Do you have double vision?
• Any redness, swelling or discharge?
• Do you have a history of glaucoma?
• Do you wear glasses or contacts
ear

• Have you had many ear infections?

• Do you have any discharge from your ears?
• Do you have any hearing difficulty?
• Do you have any environmental or
occupational exposure to loud noises?
• Any ringing in your ears (tinnitus)?
• Any dizziness (vertigo) (Jarvis, 2008)?
nose

• Any nasal discharge?

• Do you get frequent colds?
• Do you have sinus pain?
• Do you get nose bleeds?
• Do you have allergies?
• Have you had a change in sense of smell
(Jarvis, 2008)?
Mouth and threat

• Do you have any sores or lesions in your mouth

or throat?
• Do you have a sore throat and hoarseness?
• Do you have a toothache or get bleeding gums?
• Any difficulty swallowing?
• Do things taste differently than usual?
• Do you smoke, drink or chew tobacco (Jarvis,
2008)?
Cardiac assessment

• Any chest pain? (use PQRST pneumonic)

• Do you ever get short of breath? (associated with what)
• How many pillows do you sleep on at night? (orthopnea)
• Do you have a cough? (describe, frequency, timing, severity, sputum
production)
• Are you frequently fatigued? (morning or night)
• Do you have any swelling or skin color changes? (edema, cyanosis,
pallor)
• How often do you get up at night to urinate? (nocturia)
• Do you have a past history of cardiac or cardiovascular events or
disorders?
• Do you have a family history of cardiovascular disease?
• Assess cardiac risk factors?
Pulmonary assesment

• Do you have a cough? (use PQRST pneumonic)

• Do you frequently get short of breath? (position,
associated night sweats, related to any triggering
event)
• Pain with breathing? (constant or periodic,
describe the quality, treatment)
• Any past history of breathing trouble or lung
disease? (frequency and severity of colds,
allergies, asthma family history, smoking,
environmental or occupational risk factors)
GI assessment

• Any change in appetite?

• Any difficulty swallowing? (dysphagia)
• Any abdominal pain? (use PQRST pneumonic)
• Any nausea or vomiting? (color, odor, presence of
blood, food intake in past 24 hours)
• Any change in bowel habits? (constipation, diarrhea,
blood in stool, or dark, tarry stools)
• Do you have any hemorrhoids? (bleeding, treatment)
• Any past history of abdominal problems? (gall bladder,
liver, pancreas, digestion, elimination)
Musculosceletal problem

• Any joint pain or problems? (Use PQRST pneumonic.)

• Any stiffness in your joints? Any swelling, heat or
redness in your joints?
• Any limitation of movement in your joints?
• Which activities are difficult? (Assess functional ability.)
• Any muscle problems (pain, cramping, aches,
weakness, atrophy)?
• Any bone problems (bone pain, deformity, history of
broken bones)? (Jarvis, 2008)
Genito urinary system (male)

• Do you urinate more than usual? (frequency, urgency, nocturia)

• Any pain or burning upon urination?
• Any difficulty starting or maintaining the stream of urine?
• Any difficulty controlling you urine? Any blood in your urine?
• Any problems with you penis? (pain, lesions, discharge)
• Any problems with your scrotum? (lumps, tenderness, swelling)
• Are you in a sexually active relationship and if so any difficulties in
this relationship related to the physical act of intercourse?
• Do you use contraceptives? (what type, questions or concerns)
• Any sexual contact with a partner whom may have had a sexually
transmitted disease?
• Do you perform self-testicular examinations monthly? (Jarvis, 2008)
Genito urinary system (female)
• Do you urinate more than usual? (frequency, urgency, nocturia); Any pain or burning upon
urination?
• Any difficulty starting or maintaining the stream of urine?
• Any blood in your urine? Any difficulty controlling you urine?
• Any unusual vaginal discharge?
• Are you sexually active? Any difficulties related to the physical act of intercourse?
• Do you use contraceptives? (what type, questions or concerns)
• Any sexual contact with a partner whom may have had a sexually transmitted disease?
• Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS,
age of first period, age of menopause).
• Have you ever been pregnant? (if so how many times, how many live births, any miscarriages
or abortions, any complications)
• Have your periods slowed down or stopped? (associated symptoms of menopause, estrogen
replacement therapy, psychological well-being)
• Any breast tenderness, lumps, discharge or concerns? Do you perform self-breast
examinations monthly?
• Do you have regular PAP smears?