Assessment is an early stage and the foundation of the nursing process. The assessment is done carefully to know the client's problems, in order to give direction to nursing actions. The success of the nursing process is highly dependent on the accuracy and precision in the assessment phase. Assessment phase consists of three activities, namely: data collection, data grouping, formulation of nursing diagnoses. (Lismidar 1990: 1)
The data collection
In technical data collection is done through anamnesis either on the client, family and those closest to the client. Physical examination done by way of, inspection, palpation, percussion and auscultation.
1. Identity of clients includes: name, age, sex, occupation, marital status, religion, ethnicity, education, address, date / time entered hospital and medical diagnostics.
2. History of present illness
The main complaint the client tuberculous spondylitis / pott disease are pain in the lower back, thus encouraging the client to the hospital for treatment. At the beginning of radicular pain can be found surrounding the chest or abdomen. Pain is felt up at night and weight gain especially during the movement of the spine. In addition to the main complaint the client can complain, decreased appetite, body feels weak, sweating and weight loss.
3. History of previous illness
On the occurrence of tuberculous spondylitis is usually preceded by the client in the history of ever suffered from pulmonary tuberculosis.
4. Family health history
On the client with tuberculous spondylitis disease one of the causes is the client or former contact with other patients who suffer from tuberculosis or the family environment is suffering from infectious diseases.
5. Psychosocial history
Clients will feel anxious about the disease in the suffering, so it looks sad, with a lack of knowledge about the disease, treatment and care against the patient will feel fear and anxiety grew so emotionally unstable and would not affect the socialization of the patient.
Tuberculous Spondylitis - 11 Functional Health Patterns
1. Health Perception/Health Management
The existence of medical treatment and hospital care will affect the client's perception about the habits of taking care of themselves, that is because not all clients understand the true course of their illness. So that created a false perception of health care. And also the possibility of the presence of a history of the state of housing, nutrition and economic levels that affect client health state clients.
2. Nutritional Metabolic Pattern
As a result of the disease process client felt his body became weak and amnesia. While the need for increasing the body's metabolism, so that the client will experience a disruption in nutritional status.
3. Elimination patterns
Clients will experience a change in the way the original elimination could to the bathroom, because of weakness and pain in the back and carrying on with the stylist immobilization treatment, so if you like bowel and bladder should be in bed with a tool. With the change in the client is not accustomed to so it will interfere with the process of elimination.
4. Activity Patterns
Due to physical weakness and pain in the back and managed care immobilization would cause the client to limit physical activity and diminished ability to perform physical activity.
5. Sleep and Rest Patterns
There is pain in the back and the changes in the environment or the effects of hospitalization will cause problems in fulfilling the need for sleep and rest.
6. Role Relationship Pattern
Since the sick and hospitalized clients to change roles or unable to take on the role as where it should be, whether it is the role of the family or community. This disruption affects interpersonal relationships.
7. Self-Perception-Self-Concept Pattern
Clients with tuberculosis spondylitis often feel ashamed of her body shape and sometimes isolating themselves.
8. Sensory and Cognitive Patterns
Sensory function was not impaired clients unless there is complications of paraplegia.
9. Sexual Reproduction Patterns
Sexual needs of clients in terms of the act of intercourse will be disrupted for a while, because in the hospital. But in terms of the outpouring of love and attention from her partner by way of day-to-day care is not interrupted or can be implemented.
10. Stress Patterns
In response to stress for clients who do not understand the disease, will experience stress. To overcome the anxiety that creates a feeling of stress, clients will be wondering about the disease to reduce stress.
11. Value / Belief Pattern
On the client who in their daily lives are always obedient to practice, then during his illness he would run well worship according to his ability. In this case worship for those on the run as well as the handling of stress by believing in god.
Chronic Pain and Body Image Disturbance - NCP Tuberculous Spondylitis