Nursing Assessment is basic nursing process, required a thorough examination to problems for clients to give direction to nursing actions. The information will determine the needs and health problems of nursing which includes physical needs, psychosocial and environmental. As a source of information could be used in which patients, families, children, relatives, friends, health workers or secondary data sources. Data collection methods include: data collection, data classification, data analysis, formulation of nursing diagnosis.
The data that needs to be collected on the client with anemia were as follows :
- The main complaint: the main complaint would seem all of what clients perceived as weakness, decreased appetite, and pale.
- Previous medical history: past medical history will provide information on health or disease of the past has ever suffered.
- Activity / rest
- Symptoms: Fatigue / weakness continuously throughout the day.
Needs more sleep and rest. - Signs: Impaired gait
- Symptoms: Fatigue / weakness continuously throughout the day.
- Circulation
- Symptoms: Palpitations or pains.
- Signs: Blood pressure decreases, weak pulse, slow breathing, pale or cyanotic skin color, pale conjunctiva.
- Elimination
- Symptoms: Frequent urination, nocturia (nighttime urination).
- Ego Integrity
- Symptoms: worry, fear.
- Signs: Anxiety, restlessness.
- Food / fluid
- Symptoms: decreased appetite.
- Signs: Weight loss, poor skin turgor with bite marks, skin and mucous membranes appear dry.
- Hygiene
- Symptoms: Fatigue / weakness
- Signs: Appearances are not tidy.
- Neuro Sensory
- Symptoms: Headache / dizziness, visual disturbances.
- Signs: muscle weakness, decreased muscle strength.
- Pain / comfort
- Symptoms: Pain in the back, headache.
- Signs: Decreased range of motion, restlessness.
- Respiratory
- Symptoms: dyspnea while working.
- Signs: Wheezing
- Security
- Symptoms: History transfusion.
- Signs: Mild fever, loss of vision.
- Sexuality
- Symptoms: Loss of libido.
(Doenges, E, Marilynn, 2000, p.: 582-585).
Nursing Assessment for Anemia
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