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Assessing LEARNING OUTCOMES After completing the chapter, the learner should be able to accomplish the following: 1.
Define and describe the purpose of four types of health assessments
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Explain the relationship between health assessment and medical assessment
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Differentiate objective and subjective data
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Describe the purpose of observation, interview and physical assessment
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Obtain a health history using effective interviewing techniques
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Identify important sources of data
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Plan the health assessment by identifying assessment priorities and structuring the data to be collected systematically
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Identify common problems encountered in data collection, noting their possible cause
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Explain when data need to be validated and several ways in which this may be accomplished
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Describe the importance of knowing when to report significant data and the associated documentation
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Obtain and document complete, accurate, factual and relevant assessment data.
KEY TERMS assessment
health assessment
observation
assessment frameworks
health history
physical health assessment
cue
inference
subjective data
data
initial assessment
time-lapsed health assessment
database
interview
validation
emergency assessment
minimum data set
focused assessment
objective data
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SSESSING IS THE FIRST PHASE in the process of planning, delivering and evaluating care. This process of assessment is explored throughout this chapter in the context of person-centred care. Health assessment is the systematic, comprehensive and continuous collection, validation and communication of data about a person. These data reflect how health functioning is enhanced by health promotion or compromised by illness or injury. Data may be elicited from many sources and these include the individual, the family, the community, colleagues and other healthcare providers. The purpose of assessment is to identify current or potential health problems and the person’s strengths. A database is developed during this phase to capture all the pertinent personal information collected by the nurse or midwife and other healthcare providers. The database enables a collaborative, comprehensive and effective plan of care to be designed and implemented. The collection of personal data is a vital phase in the process of care because the remaining phases depend on complete, accurate, factual and relevant data. The following scenario is introduced in this chapter and developed further in each of the following Chapters 16, 17, 18 and 19. Critical questions are posed with each scenario to encourage you to reflect on each phase of the process of care. Through this activity you will continue to strengthen your clinical reasoning and reflection skills as the basis for thoughtful practice. The focus of the scenario in this chapter is on comprehensive and continuous assessment.
Claire is an 18-year-old female who lives at home with her parents. She is in her final year of high school and is hoping to go to university next year to study for a teaching degree. Claire plays competition tennis every Saturday and goes out on weekends with her girlfriends. She is a non-smoker but does drink alcohol when socialising. She has just got her driver’s licence and has become increasingly independent; she has a part-time job at a local fast-food outlet 8–10 hours per week. Claire was diagnosed with Type 1 diabetes at age nine. She has been attending the same community centre since that time and has built up a rapport with the healthcare team there.
Person-centred care focuses on knowing the person and establishing an enabling relationship to ensure the person’s physical, emotional, cultural and spiritual wellbeing. The establishment of an enabling relationship is an important consideration when assessing the person. As you assess Claire and plan her care, ask yourself and reflect on the questions outlined in Box 15-1.
BOX 15-1 Person-Centred Assessment 1. Did I listen attentively to the person? 2. Did I maintain the person’s identity by allowing them to express their values and beliefs? 3. Did I acknowledge the person’s abilities, strengths and resources? 4. Did I clarify understanding and ask for the person’s feedback at each stage of the initial and continuing assessment? 5. Did I include the person’s family or significant others in the assessment process? 6. Did I collaborate with other members of the healthcare team? 7. Did I identify any community related issues that needed to be considered? 8. Did I plan care that met the person’s needs and involved the person in decision making throughout the assessment process?
The initial comprehensive health assessment results in baseline data that enable you to: Make a judgement about the person’s health status, ability to manage self-care and if there is a need for nursing or midwifery care. Refer the person to a doctor or other healthcare provider, if indicated. Plan and deliver individualised, holistic care that draws on the person’s strengths and allows he or she to participate in that care. Ongoing assessments are made in addition to the initial assessment. Any changes identified in the person’s responses to health and illness during these ongoing assessments will highlight the necessity for changes to the plan of person-centred care offered by colleagues or other healthcare providers. Ongoing health assessments may be problem focused, time lapsed or emergency based. During the assessment phase of the process of personcentred care: A database is established by interviewing the person to obtain a health history A physical health examination is performed to collect data Personal information may also be obtained from the person’s family and significant others, the person’s record, the records of other healthcare providers, and nursing, midwifery or other healthcare literature 277
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Assessing • Identify assessment priorities determined by the purpose of the assessment and the patient’s condition • Organise or cluster the data to ensure systematic collection • Establish the data base • Continuously update the database • Validate data • Communicate data
Review of the patient record and nursing literature Consultation with the person’s support people and healthcare providers
Evaluating Care
Health history Physical examination
Identifying Health Problems
Figure 15-1 Assessing. The primary source of personal information is the person. Resources include the person’s support people, the personal record, information from other healthcare providers and information from nursing and midwifery and healthcare literature
Data is collected continuously because the person’s health status can change quickly Questionable data is verified (validated) All pertinent data is recorded and, when appropriate, communicated to other healthcare providers so that the data can best benefit the person (see Figure 15-1).
When nurses or midwives make health assessments, they often work in partnership with doctors. A nursing or midwifery assessment does not duplicate a medical assessment based on a biomedical model but supplements it by adopting a holistic approach. Medical assessments target data pointing to pathological conditions, whereas nursing and midwifery assessments focus on the person’s responses to his or her health problems. For example, what limits the person’s ability to meet basic human needs? Can the person perform the activities of daily living? Although the findings from a nursing and midwifery health assessment may contribute to the identification of a medical diagnosis, the unique focus of such an assessment is on the individual’s responses to current or potential health problems. Many experienced nurses and midwives use intuition as a component of the assessment process. Students are encouraged to use a systematic approach when performing assessments and formulating their conclusions based on those findings. Intuitive thinking comes with experience and practice, and it should not replace the systematic assessment process where quantifiable data is collected. See Chapter 14 for an outline of intuitive thinking as part of the clinical reasoning process.
Implementing Care
Planning Care
TYPES OF HEALTH ASSESSMENTS Health assessments include the comprehensive initial assessment, the focused assessment, the emergency assessment and the time-lapsed assessment. This chapter will focus on assessing the health status of a person. As you develop expertise in health assessments, you will be able to assess communities and special populations, such as school children, older people or people with infectious diseases. Your learning through reflection can now be applied to enrich your understanding of the following types of assessment performed by nurses and midwives.
Initial Assessment The initial assessment is performed shortly after the person is admitted to a healthcare facility or service. Most institutions have policies specifying the time interval within which the assessment must be completed. The purpose of this initial assessment is to establish a comprehensive database for identifying health problems and strengths and for planning care. Data is collected concerning all aspects of the person’s health, establishing priorities for ongoing focused assessments and creating a reference for future comparison. During this assessment many aspects and dimensions of the person’s life should be explored and examined (including such things as his or her values, cultural, social or familial beliefs about health and illness); see Box 15-2. The person and his or her family or significant others should be encouraged to be actively involved throughout this assessment process.
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BOX 15-2 Assessment Collect and verify information to determine the person’s: • Understanding of the reason for admission and care processes • Expectations of services • Personal preferences such as requirements for privacy, comfort measures, eye contact when communicating and decision-making processes • Gender-appropriate care provision requirements • Cultural and linguistic background • Family or significant other relationships and lifestyle patterns • Health beliefs, rules and usual health behaviours, including diet, food preparation and presentation, exercise patterns and personal care • Need for interpreter services to identify topics of discussion or practices that are taboo for the individual and family, such as personal hygiene, illness or treatment • Need for culturally appropriate greetings and farewells for nursing and midwifery staff, behaviours that denote respect and preferred use of their name • Ability to read own language.
Source: Chenoweth et al., 2006.
Focused Assessment In a focused assessment, data is gathered about a specific problem that has already been identified. A focused assessment may be undertaken during the initial assessment if health problems surface, but it is routinely part of ongoing data collection. Another purpose of the focused assessment is to identify new or overlooked problems. An example of this may be that during the initial interview it becomes apparent that the person is expressing feelings of sadness and despair. The assessment may then focus on this to ascertain if the person is experiencing a reaction to a specific situation identified in the assessment, such as bereavement, or a depressive episode that may require further referral.
Emergency Assessment When a physiological or psychological crisis presents, an emergency assessment is performed to identify life-threatening problems. A nursing home resident who begins choking in the dining room, a person brought to the emergency department with a stab wound, an unresponsive person in the rehabilitation unit and a farm worker involved in an accident with machinery are all candidates for an emergency assessment.
Time-Lapsed Assessment The time-lapsed assessment is scheduled to compare a person’s current status to baseline data obtained earlier.
Assessing
Most people in residential settings and those receiving care over longer periods of time, such as people visited by a community nurse or midwife, may have periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the plan of care. There are times when the features of each type of assessment may be combined. Consider what you have learnt about focused and time-lapsed assessment and apply it to the scenario. Claire and her mother present at the clinic for her threemonthly appointment with you, the community nurse. Claire has had several admissions to hospital with ketoacidosis in the past two years but has been relatively stable in recent months. You refer to her initial assessment and notice that since that time her entries in her diabetes record book have become very spasmodic and her blood glucose levels are fluctuating with increasing regularity. You ask Claire about the documentation and notice that her attitude is despondent. She angrily states: ‘I always stick to my diet and it still makes no difference. My blood glucose levels are always high and I just can’t do this anymore.’ You now need to focus your assessment of Claire in order to collect data that will help you identify what issues may be arising for her. 1. What questions would you ask Claire and her mother? 2. What issues might you consider?
PREPARING FOR DATA COLLECTION Establishing health assessment priorities and systematically structuring data collection are two important considerations when preparing for data collection.
Establishing Assessment Priorities Before beginning data collection, you should have some idea of the types of data needed to develop a satisfactory plan of care. Nurses and midwives spend more or less time on different components of the health history depending on the reason why assistance is needed. For example, paediatric nurses are careful to establish the developmental age and milestones obtained from children admitted to a paediatric unit so that they can respect and promote these achievements. A school nurse who suspects child abuse pays careful attention to the child’s statements about living conditions at home and relationships with family members and caregivers. A midwife preparing to discharge a first-time mother from the maternity unit makes sure that the new mother has a support network needed to supply appropriate assistance and guidance. The purpose for which the assessment is being performed offers the best guideline about what type to use and how much data to collect. Assessment priorities are influenced by the individual’s health orientation, developmental stage and need for care.
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Health Orientation Health assessments, such as the ‘A Health Style Self-Test’ in Chapter 2 and the ‘Promoting Health’ displays in each clinical chapter may be used to help people identify potential and actual health risks, and to explore their habits, behaviours, beliefs, attitudes and values that influence levels of wellness. There is a wide body of literature on specialised assessment tools that focus on relationships; psychological, environmental, and physical self-care; relaxation; cultural, spirituality; humour and play; movement and exercise; sleep and dreams; nutrition; and sexuality. All of these specialised assessment tools provide specific, pertinent information and may be different from the assessments of patients being hospitalised for disease-related treatment.
Developmental Stage Assessments are modified according to developmental needs. For example, when assessing an infant, special attention is given to weight gain and physical growth, feeding and elimination problems, sleep–activity cycles, and the parenting skills of caregivers. When a child is hospitalised, it is important to note how independent the child is with basic care measures (toileting, hygiene, dressing, eating), what words the child uses to indicate the need to void and defecate, and play preferences.
Relevance of Data The type of data collected is influenced by both the length of time spent with the person (e.g. same-day surgery versus surgery that necessitates a long recovery in an intensive care unit) and the nature of the care required (e.g. assistance with the birth of a baby versus support and home care throughout a terminal illness). A general guideline to follow is to gather only data that is helpful when planning and delivering care. It would be inappropriate, for example, to collect a detailed sexual history on a adolescent admitted to the hospital overnight after a slight concussion. Conversely, you should ask such questions if a pregnant woman is admitted to the hospital for observation for vaginal bleeding during her first trimester.
Practical Considerations Before conducting an interview, first check to see if the person has presented before at the health facility. A personal record will provide data collected during previous visits, and this data should not be repeatedly sought unless there is a need to validate them. Additionally, repetitious questioning can be annoying and may cause the person to question the lack of communication among healthcare providers. A careful review of the personal record before commencing the interview helps prevent these problems. Before meeting a person for the first time, it is helpful to take a minute to think carefully about the type of data needed to plan quality care. After a comprehensive health
assessment has been completed, the priority of the identified health problems will dictate future interactions.
Structuring the Assessment Because many different types of data are collected during the assessment, there is a need to structure data collection systematically. A variety of assessment frameworks are available that provide systematic guidelines specifically developed for a health assessment to ensure that comprehensive, holistic data are collected for each person which will lead to the identification of health problems. Frameworks may be modified to suit the individual and the personal preference of the nurse or midwife. Once you are familiar with these assessment frameworks, you can focus on the person rather than worrying about what to assess next. Most schools of nursing and midwifery and healthcare institutions use one or more assessment frameworks and have established a minimum data set that specifies what information should be collected. They then use a structured health assessment form to organise or cluster this data. Many nursing and midwifery assessment guides are based on holistic models rather than medical models. Holistic models encompass the physiological, psychological, sociocultural, intellectual and spiritual aspects of each person. Examples of assessment frameworks include: The Human Needs framework (Maslow, 1943) uses a hierarchy of human needs identifying five levels The Functional Health Patterns framework (Gordon, 1994) identifies eleven functional health patterns and organises personal data into these patterns The Human Response Patterns framework suggests health status is evidenced by observable phenomena that can be classified into one of the response patterns. This can than can be used as a model for organising data collection The Head-to-Toe framework provides baseline data and uses a comprehensive systematic approach that can be undertaken in a timely manner to prioritise care. See Table 15-1 for an overview of the Human Needs, Functional Health Patterns and Head-to-Toe assessment frameworks. The body systems model used to organise data collection is an example of a medical model. This framework organises data collection according to organ and tissue function in various body systems. Although it is helpful in identifying health problems related to physiological factors, it neglects a person’s problems and strengths in psychosocial, cultural and spiritual dimensions of health and wellbeing.
DATA COLLECTION Subjective and Objective Data There are two types of data: subjective and objective. Subjective data is information perceived only by the affected person; that is, what the person is experiencing.
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TABLE 15-1 Examples of Assessment Frameworks Human Needs (Maslow)
Functional Health Patterns (Gordon)
Head-to-Toe
Physiological (Survival) Needs: Food, fluids, oxygen, elimination, warmth, physical comfort
Health Perception/Health Management: Perception of wellbeing and adherence to preventive health practices
Head and Face: Symmetry, cranial nerves, hair
Safety and Security Needs: Things necessary for physical safety (e.g. a cane) and psychological security (e.g. a child’s favourite toy) Love and Belonging Needs: Family and significant others Self-esteem Needs: Things that make people feel good about themselves and confident in their abilities (e.g. being well groomed, having accomplishments recognised) Self-actualisation Needs: Need to grow, change and accomplish goals
Nutritional–Metabolic: Patterns of food and fluid intake, electrolyte balance, general ability to heal Elimination: Patterns of excretory function (bowel, bladder, skin) and person’s perception Activity/Exercise: Pattern of exercise, recreation and factors that interfere with desired or expected individual patterns Cognitive–Perceptual: Adequacy of vision, hearing, taste, touch, smell, pain perception, cognitive functional abilities Sleep/Rest: Quality, quantity and patterns of sleep and rest-relaxation during 24-hour day Self-perception/Self-concept: Attitudes about self, perception of abilities, body image and identity Role/Relationship: Perception of major roles and responsibility in current life situation Sexuality and Reproductive: Perceived satisfaction or dissatisfaction with sexuality and reproductive state Coping/Stress Tolerance: General coping pattern, stress tolerance and ability to control or manage situations Values/Beliefs: Values, goals or beliefs that guide choices or decisions
These data cannot be perceived or verified by anyone else. Despite this, subjective data is sometimes capable of measurement, for example, pain scales may be used to measure a person’s experience of pain. Examples of subjective data are when a parent indicates that his or her child is ill or when a patient states that he or she is feeling cold, nervous or nauseated. Subjective data also are called symptoms or clinical manifestations. Objective data are observable and measurable data that can be seen, heard or felt by someone other than the person
Eyes: Visual acuity, colour vision, extraocular muscles, internal and external structures Ears and Nose: Otoscopic exam, nostril patency, olfactory sense Mouth and Throat: Breath odour, mucous membranes, gag reflex Neck: range of motion (ROM), musculature, carotid arteries, jugular veins, lymph nodes Upper Extremities: Nail beds, joints, ROM, pulses Back, Posterior and Lateral Thoraxes Spine, thoracic expansion, diaphragmatic excursion Heart: Pulsations, thrills, apical pulse, cardiac landmarks Breasts: Colour, vascularity, thickening, oedema, size, lymph nodes, gynaecomastia Abdomen: Contour, symmetry, pigmentation, colour, scars, striae, visible peristalsis, masses, pulsations, bowel sounds Inguinal Area: Lymph nodes, inguinal hernias, femoral pulses Lower Extremities: Colour, capillary refill, ulcerations, hair distribution, varicose veins, oedema, popliteal/dorsalis pedis/posterior tibial pulses, ROM, muscle size, tone, temperature Female Genitalia, Anus and Rectum: External and internal genitalia
experiencing them. Objective data observed by one nurse or midwife can be verified by another nurse or midwife observing the same person. Examples of objective data are an elevated temperature reading (e.g. 39°C), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or clinical manifestations. Table 15-2 compares subjective and objective data. Paying attention to both subjective and objective data promotes critical thinking and clinical reasoning because the two types of data complement and clarify one another.
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TABLE 15-2 Comparison of Objective and Subjective Data Objective Data
Subjective Data
32-year-old man Height: 180 cm Weight: 18/9/XX—102 kg 18/11/ XX—92 kg
‘I’m beginning to feel better about myself now that I’m losing weight and I seem to have more energy.’
Posterior, left mid-calf is warm and red.
‘My leg hurts when I walk.’
Observed fidgeting with bed covers; facial features are tightly drawn.
’I’m so afraid of what they might find when they cut me open tomorrow.’
Consider what you know about the types of data that may be collected during an assessment and apply it to the scenario. As part of your assessment of Claire you have discovered that she is stressed about her upcoming exams and her menstrual cycle is causing swings in her blood glucose levels. Claire also wants to fit in with her friends and when they go out she wants to do the same things they do, which includes drinking alcohol. She admits that her parents are worried and that she has been skipping meals as she is so busy with work, tennis and study. Clarify in your mind the difference and the relationship between subjective and objective data by answering the following questions: 1. Can you differentiate the objective and subjective data that you have gathered as part of your health assessment of Claire? 2. Why is the subjective data so important in the assessment phase?
Characteristics of Data Data is not only subjective or objective, it also has additional characteristics. When collecting and recording personal data, nurses and midwives ensure that the data is complete, accurate, factual, relevant and contemporaneous.
Complete It is important that as much health data as possible is identified in order to understand the problem(s) and develop a plan of care to maximise health and wellbeing. For example, knowing that a person has lost weight is not meaningful until you discover (1) if the weight loss was intentional or unintentional, (2) if it was related to changes in eating or exercise patterns or to some underlying pathological condition, and (3) how the person views and is responding to the
weight loss. When undertaking a person-centred approach to planning care and delivery, it is important to gain an understanding of the person’s perspective when gathering data. A person who feels involved and part of the assessment process will provide information that allows for better decision making in relation to his or her care.
Factual and Accurate The person, nurse or midwife may intentionally or unintentionally misrepresent or distort information. For example, a person who values being thin may describe a weight gain of several kilograms as the onset of obesity. In order to confirm the accuracy of the person’s ‘facts’, it is important to verify what you hear and observe and validate all questionable data. At the outset of data collection, it is crucial to determine whether the person, family member or caregiver who is supplying the data is reliable. When you suspect that your own personal bias or stereotyping is influencing your data collection, you should consult with another colleague. It is also best to describe observed behaviour rather than to interpret the behaviour. Such a description may read: ‘The patient was frequently observed lying with his face to the wall. Attempts to engage him in conversation fail. He refused lunch today and ate only soup for dinner.’ On the other hand, the statement ‘The patient is depressed’ is the nurse or midwife’s interpretation of the behaviour; it is not a factual statement. Recording behaviours factually allows other healthcare providers to explore causes of the behaviour.
Relevant Recording comprehensive data can become an endless task. One challenge facing the nurse and midwife is to determine what type of data and how much data to collect for each person. This chapter describes ways to do this. The aim is to record concisely all pertinent data. Often, only experience teaches nurses and midwives what data is needed in specific cases, and this is learnt in most cases through trial and error. Learning how to collect, validate and communicate data that are complete, accurate, factual and relevant is the focus of the remainder of this chapter.
Sources of Data Person The person is the primary and usually the best source of information. Unless otherwise specified, it is assumed that the data recorded in the health assessment history were collected from the person. When taking a person-centred approach to planning care delivery, the person should be an integral part of the assessment process and encouraged to share information throughout the entire process. This information can be used to plan and implement care directed at addressing his or her personal needs. Although data collected from the person is usually accurate, you should be alert for certain difficulties. For example, an acutely ill
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patient may not be able to communicate adequately if in severe pain or the level of consciousness is altered in any way. An emotionally upset person may distort information; for example, people who are anxious because they fear that their illness may threaten their work or life may deny certain symptoms or deliberately give misleading facts. If the nurse or midwife becomes aware that a person’s report of symptoms differs from physical findings or data obtained from other sources, it is important to note this and to explore the cause of the discrepancy. People with limited mental or communication capacity, such as young children or older adults with dementia, might not be able to accurately report their information. Children and people with decreased mental capacity or impaired verbal ability should, however, be encouraged to respond to interview questions as best they can. Bypassing such people and automatically turning to a family member, friend or caregiver for information communicates powerfully that you either have no time for the person to express his or her needs or mistakenly doubt the person’s ability to communicate these needs.
with the person. Such a review helps to focus the health assessment and to confirm and amplify information obtained from other sources. The patient health record or chart, which lists demographic information such as age, gender, occupation, religious preference and next of kin, is one type of record. The patient record includes information entered by various health professionals, such as doctors, social workers, dieticians, physiotherapists and laboratory technicians. You must be familiar with the many sections of the patient record, in addition to the documentation of the plan of care and notes. The following are important sources of data.
Family and Significant Others
Consultations The person’s doctor may invite specialists to assess and to work with the person. Their focus is on identifying findings that help to establish a medical diagnosis or on planning and executing the treatment regime.
A person-centred approach to planning and delivering care also includes family members and significant others (e.g. friends, caregivers). They are especially helpful sources of data when the person is a child or has limited capacity to share information. Partners can supply pertinent information. Friends often accompany a person to a healthcare facility and can supply useful information. Care must be taken to determine that the person does not object to data being gathered from friends and that the friends want to participate. There should be a clear understanding by the person, family and friends of the confidentiality of the data collected. Whenever data is gathered from support people, this should be indicated in the health history. When the person does do not speak English, the services of an interpreter are needed. It is important not to assume that a family member is accurately translating what you are trying to communicate to the person. It is now policy in many health services that family members are not used as interpreters since family members might misinterpret medical content, paraphrase the person’s response incorrectly, or the person might be uncomfortable sharing certain information with the family interpreter. For example, in some cultures it is inappropriate to discuss certain issues with one gender, and using a family member may cause embarrassment to both parties. When using family and friends as a source of information, you can add to the knowledge and understanding of the person and this can assist with validating the problems identified.
Medical History, Physical Examination and Progress Notes These sources record the findings of doctors as they assess and treat the person; they focus on identifying pathological conditions and their causes and on determining the medical regime for treatment.
Reports of Laboratory and Other Diagnostic Studies Reports of laboratory studies and other diagnostic tests, such as X-rays, offer objective data that can either confirm or conflict with data collected during the health history or examination. Results of diagnostic studies are helpful to doctors for establishing a diagnosis and monitoring the person’s response to treatment. The results of these same studies may also be helpful in evaluation of care and the success of your care interventions. Reports of Therapies by Other Health Professionals Other healthcare professionals who interact with the person also record their findings and note any progress that the person is making in their specific areas—for example, nutrition, physiotherapy or speech therapy. These reports help you assess the person’s progress and are useful when determining the his or her ability to return home and manage care independently. Records of previous admissions for health care and records from other health agencies, such as a social service agency or community agencies, are also valuable sources of data. They contain information about the person’s previous medical or surgical problems and response patterns, which may be important determinants of the current plan of care.
Patient Record Records prepared by different members of the healthcare team provide information essential to the delivery of comprehensive care. You should review records early when gathering data—in some instances, before the first contact
Other Health Professionals You can learn a great deal about a person’s normal health habits and patterns and his or her response to illness by talking with colleagues, doctors, social workers and others
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in the healthcare team. Although such communication is always important, it can be crucial when a patient is transferred from home to a hospital or from one hospital to another. The only way to ensure continuity of care is to make special efforts to share pertinent information.
Nursing and Midwifery and Other Healthcare Literature
To obtain a comprehensive personal database, it may be necessary to consult the nursing, midwifery and related literature on specific health problems. For example, if you have not cared for a patient with Paget’s disease before, it is important for you to read about the clinical manifestations of the disease and its usual progression to know what to look for during the assessment. In addition to information concerning medical diagnoses, treatment and prognosis, literature review offers you important information about problems, developmental norms and psychosocial and spiritual practices which is helpful when assessing and providing caring.
Components of Data Collection Components of data collection include the health history and physical assessment. These data may be documented on a separate assessment tool or incorporated into a combined database assessment form.
Observation Observation is a fundamental skill that all nurses and midwives require and will use in many key aspects of practice. This includes gathering the health history or performing the physical examination. Observation is the conscious and deliberate use of the five senses to gather data. Skilled nurses and midwives use each interaction with the person to observe and to interpret meaningful data. This process begins from the first encounter with the person and family. Students can develop such observation skills by training themselves to observe carefully, each time they encounter a patient in a clinical setting. When developing these skills, at each interaction the student should consider the following: What are the person’s current responses (physical and emotional)? What is the person’s body language indicating? Nonverbal behaviour may indicate how the person feels or relates to family, his or her illness and hospitalisation. Are there signs of distress? Be alert to difficulty breathing, bleeding or heightened anxiety. Watch for facial expressions such as grimacing to pain, guarding of the abdomen, body position—for example, is the person hunched or sitting upright and comfortable? What is the person’s body size and shape, and are there any distinguishing marks such as tattoos, rashes or piercing?
Is the person awake and alert or drowsy and nonresponsive? The person’s appearance will give clues to his or her ability to manage self-care. What is the immediate environment? Consider the safety of the environment as well as the functioning of equipment (intravenous therapy, oxygen, drain tubes). Who are the people in the room with the person, and are there support systems in place and for discharge? What is the temperature and odour of the room? For example, a fruity odour may indicate ketoacidosis. What is the person telling you about the current problem? Has the problem occurred before? How did the person respond to past situations?
Observation is the first step in the assessment process and the data gathered from this is continually updated throughout the person’s engagement with the healthcare system.
Health History Ideally, the health history captures and records the uniqueness of the person, so that the plan of care may be designed to meet individual needs, reflecting the personcentred approach. The health history should therefore be obtained as soon as possible after a person presents for care and should be followed by the physical assessment. The latter also occurs concurrently with the remainder of the ongoing assessment. This history should clearly identify personal strengths and weaknesses, health risks, such as hereditary and environmental factors, and potential and existing health problems, and what the person does to maintain a healthy lifestyle. This history focuses on getting to know the person in order to establish an enabling relationship, a main characteristic of personcentred care. Engaging with and involving the person in the decision-making process at this point is crucial so that any healthcare decisions incorporate the person’s beliefs and values.
Components of a Health History Components of a health history include: Profile: name, age, gender, marital status, religion, occupation, education Reason for seeking health care Normal health habits and patterns and related needs for nursing or midwifery assistance Cultural considerations in relation to diet, decision making, perceptions of health and illness, and activities Current state of health, functioning of body systems, degree of pain, and past medical and surgical history Current medications, allergies, record of immunisations and exposure to communicable diseases Perception of health status and the meaning the person attributes to health and illness, and characteristic response or coping patterns Developmental history, family history, environmental history and psychosocial history
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The person’s and the family’s expectations of the healthcare team The person’s and the family’s educational needs and ability and willingness to learn The person’s and the family’s ability and willingness to participate in the plan of care The person’s personal resources (strengths) and deficits The person’s potential for injury.
Interview An interview is a planned communication. The person is interviewed to obtain a medical and social history. Effective interviewing skills are needed to establish a successful working partnership with the person, to communicate care and concern, and to obtain the necessary personal data. It is also important to allow the person and family to feel that they are participating as an equal partner in this process and that what they are saying will have an impact on care planning. Allowing enough time to conduct the interview is imperative as the focus of person-centred care is getting to know the person and this cannot be achieved if it is rushed. The interview comprises four phases: preparatory phase, introduction, working phase and termination. More detailed information on interviewing techniques is provided in Chapter 7. Preparatory Phase Before initiating the interview, prepare yourself by reading current and past records and reports, when available. During this phase, it is important not to let one’s stereotypes and prejudices affect this interaction. Being aware of one’s own prejudices can help you deal with them constructively. It is important to learn to approach each person with an open mind and to be sensitive to the human needs that underlie diverse behaviours as part of appropriate personcentred care. During the preparatory phase of conducting the interview, you should ensure that the environment in which the interview is to be conducted is private and relaxed. Unless the person wants family members or friends present during the interview, you should interview the person alone, in a quiet area. Both the seating arrangement and the distance between you and the person being interviewed are important. Chairs placed at right angles to each other and about 0.9–1.2 m apart facilitate an easy exchange of information. If the person is in bed, placing a chair at a 45-degree angle to the bed is helpful. If the interviewer stands at the foot or side of the person’s bed and physically talks or looks down at the person, a superior–inferior relationship is communicated and can negatively affect the interview. Whenever possible, it is best to communicate with a person at eye level. The interview should be scheduled when both you and the person are free of concerns and distractions, so that the person concentrates on the task. Ten to fifteen minutes may be all that is necessary in some circumstances, whereas an
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hour or more may be required in others. Information can be gathered in several meetings, especially if you notice that the person is tiring or is in pain. Introduction The introduction to the interview is crucial because it sets the tone not only for the remainder of the interview but also for every following interaction. At the end of this phase of the interview, the person should know your name, what care to expect, sense your competency, and should also know what is expected of him or her in terms of developing the plan of care and participating in its execution. You initiate the interview by stating your name and status, identify the purpose of the interview, and clarify your role and that of the person. A typical introduction might run like this: ‘Good afternoon, Miss Jones. My name is Lisa Gray and I am the student looking after you today. Right now I’d like to ask you a few questions about yourself so that we can plan your care together. Feel free to respond only to those questions you feel comfortable answering, and know that your responses will be treated confidentially by the staff. This will take about twenty minutes. Is this time convenient for you? Do you need anything before we start?’ The initial impression you create is crucial, especially with people who are new to the healthcare environment. All nurses or midwives whom the person encounters in the future may be judged in light of this first impression. Showing genuine concern and respect will encourage the person to discuss his or her health problems and worries freely. The interpersonal qualities of a respectful presence, professionalism and caring encourages confidence and ensures that the person feels that help is available. During the introduction, you should assess the person’s comfort and ability to participate in the interview. It is also appropriate to assure the person of confidentiality. The person should know where the data being recorded are stored, how they will be used and who has access to them. Some nurses and midwives record data on the appropriate form while with the person, whereas others may take notes and complete the form later. The use of bedside computers is now facilitating quick documentation. However, documenting data should not interfere with the sharing of information during the interview. In unusual situations in which a contractual agreement that clearly identifies the responsibilities of person and nurse or midwife is indicated (e.g. a nurse practitioner or independent midwife), terms are discussed at this time. Working Phase During the working phase of the interview, you gather all the information needed to form the subjective database. The accuracy, completeness and relevance of the database depend on your use of the interviewing and basic communication techniques discussed in Chapter 7. The communication techniques highlighted in Box 15-3 are important guidelines for a successful interview.
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BOX 15-3 Communication Techniques for a Successful Interview • Focus on the person during the interview, demonstrating interest and concern: use the person’s name of choice, use eye contact appropriately and avoid rushing. • Listen attentively to the person; use reflection and paraphrase to communicate that you understand what the person is saying. • Ask about the person’s main problem first, using terminology the person understands; save personal or delicate questions for later, when a rapport has been established. Defer less important questions until a later interview if the person is too ill or upset to communicate easily. • Pose questions and comments to the person in the manner best suited to produce the desired communication (see Chapter 7): • Closed questions elicit specific information. For example, yes/no answers. • Open-ended questions allow the person to verbalise freely. • Reflective questions encourage the person to elaborate on thoughts and feelings. • Direct questions can validate information, clarify information or place events into a meaningful sequence. • Avoid comments and questions that impede communication (see Chapter 7)—clichés, questions that require a ‘yes’ or ‘no’ answer only, intimidating ‘why’ or ‘how’ questions, probing questions, giving advice, using judgmental comments, changing the subject and giving false assurance. • Use silence and touch appropriately.
Personal issues may positively or negatively affect the outcome of an interview. Table 15-3 identifies personal variables that can negatively influence an interview unless you respond appropriately. Termination The successful interview is concluded carefully. The person should be advised that the interview is coming to an end. It is helpful to summarise the interview, highlighting key points. All parties involved in the interview should be satisfied that the important data are recorded. A helpful strategy is to ask the person after the summary: ‘Is there anything else you would like us to know that will help to plan your care?’ This gives the person an opportunity to add data you did not think to include. Before terminating the interview, it is helpful to alert the person what to expect. The person should also know when you will re-establish contact; for example, ‘Thank you for answering these questions, Miss Jones. Please feel free to keep us informed of anything you think we should know. I’ll be leaving soon, but when I return tomorrow morning, we will discuss your plan of care. This afternoon will be busy for you—some blood tests and a chest X-ray have been ordered. Your evening will probably be quiet. Do you have any questions? Is there anything else I can do for you before I leave?’
Physical Health Assessment Physical health assessment is the examination of the person for objective data that may better define the person’s condition and help in planning care. The physical assessment normally follows the health history and interview, and
may verify data gathered during the history or yield new data. Doctors traditionally have performed the initial physical assessment, which commonly is the mechanism of entry into the healthcare delivery system as well as the basis for medical treatment. Some nurses and midwives in advanced practice roles perform comprehensive physical assessments similar to their doctor colleagues, which identify health and illness states and then recommend or prescribe appropriate follow-up care. In any case, all nurses and midwives conduct selected aspects of physical assessment for their purposes. The nursing and midwifery physical assessment focuses on both the person’s illness and functional abilities. For example, if a neurological deficit is present, the nurse or midwife is concerned with identifying how this deficit affects the person’s reasoning and sensorimotor abilities. Another example is if a person who has had a cerebrovascular accident (stroke) is examined to determine his or her ability to comprehend and communicate information and execute the tasks of everyday life. The purposes of the nursing and midwifery physical assessment include the appraisal of health status, the identification of health problems and the establishment of a database for care interventions. It also allows the nurse and midwife to work with the person to identify strengths and weaknesses that need to be incorporated into the plan of care. See Chapter 30 for a detailed description of physical assessment skills. Nurses and midwives practising in different settings may use different physical health assessment techniques for different purposes. Nurses in the coronary care unit use sophisticated, high-technology assessment techniques, whereas nurses in a rehabilitation centre use a wide range of
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TABLE 15-3 Personal Variables that Can Negatively Influence an Interview and Suggested Responses Personal Variables
Effect on Interview
Nursing and Midwifery Response
High anxiety
The person may speak rapidly or incoherently and may jump from one topic to another; the person may deny or misrepresent what he or she is experiencing.
Normalise anxiety: ‘Many people find it difficult to talk about their health and become anxious’; approach the person gently, speak slowly and softly; underscore the importance of the person sharing what he or she is experiencing so you can be of help.
Pain
The person offers clipped responses and ‘yes’ or ‘no’ answers whenever possible; overriding concern is pain relief.
Do everything possible to make the person comfortable before the interview, including obtaining an order for and administering pain medication; if pain persists, obtain only vital data and defer the remainder of interview until the person is more comfortable.
Language difficulty (the person is not fluent in the interviewer’s language because the person speaks a different language, has limited education, or fears saying the ‘wrong thing’)
Vital personal data will not be communicated; the person may mistakenly be labelled ‘indifferent’ or ‘noncommunicative’
Speak clearly (do not raise your voice) using simple language; whenever possible, obtain the assistance of an interpreter (family member may help, but it is preferable to have a healthcare interpreter especially if the personal data are confidential)
Previous negative experience with healthcare professionals or healthcare delivery system
The person is aloof, unwilling to participate in the interview; and has the general attitude: ‘Why should I waste my time telling you anything … it won’t do me any good.’
‘I know other people who have had a tough time with healthcare professionals or the system … life isn’t perfect … but how about giving us a chance this time to show you what you can do?’
Unrealistic expectations of health professionals
The person expects healthcare professionals to magically know everything about him or her and to ‘take care’ of himself or herself; ‘surrenders’ himself or herself to the system—‘you know best’ attitude.
Communicate clearly that no-one knows or understands the person as well as they know and understand themselves, and invite them to become involved in their own care: ‘No two people are alike, and unless you tell me a little more about yourself and how you are feeling, there is no way we’ll be able to plan good care.’
physical assessment skills that focus on identifying functional and nonfunctional response patterns to disabilities. The physical health assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe framework (Table 15-1). Four methods are used to collect data during a physical assessment: inspection, palpation, percussion and auscultation. Nurses and midwives may also use physical assessment skills to evaluate selected body systems. These techniques and the basic skills for physical assessment are described in Chapter 30.
Problems Related to Data Collection Common problems encountered during data collection include inappropriate organisation of the database, omission
Communicate competence and respect for the person.
of pertinent data, inclusion of irrelevant or duplicate data, erroneous or misinterpreted data, failure to establish rapport and partnership, recording an interpretation of data rather than observed behaviour, and failure to update the database. Table 15-4 describes possible causes and remedies for such problems.
DATA VALIDATION Validation is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias and misinterpretation as possible. Validation is an important part of the assessment phase because invalid information can lead to inappropriate care.
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TABLE 15-4 Common Problems of Data Collection, Possible Causes and Suggested Remedies Problem
Possible Causes
Suggested Remedies
Database inappropriately organised
Failure to identify needed data and plan for comprehensive and continuous assessment.
Review the guidelines for specifying pertinent data.
Use of inappropriate tools for data collection.
Consider modifying tool for data collection or select an alternative tool.
Pertinent data omitted
Not following up on cues during data collection; inappropriate guidelines.
Identify potentially relevant factors in advance of collection. Practise interview strategies.
Irrelevant or duplicate data collected
Failure to identify specific purpose of data collection.
Determine specific purpose of data collection for each person.
Failure to review available personal records.
Consider existing data before initiating collection.
Use of inappropriate tools for data collection.
Consider modifying data collection tool or selecting alternative.
Erroneous or misinterpreted data collected
Failure to observe carefully or validate during data collection. Interviewer prejudices or stereotypes.
Sharpen observation skills by independently observing the same situation with a peer and comparing notes afterward. Role-play several validation techniques.
Failure to establish rapport
Failure to establish sufficient rapport or use appropriate communication techniques.
Review and practise communication techniques discussed in Chapter 7. Role-play several explanations of purpose of data collection.
Failure to know what information is wanted.
Identify general data desired before collection.
Hasty conclusion is drawn about person’s behaviour, depriving others of the opportunity to explore possible causes of the behaviour with the person.
Review the distinction between data and interpretation of data.
Interpretation of data is recorded rather than the observed behaviour
Practise documenting observed person behaviour concisely.
Deficient validation. Failure to update the database
Erroneous belief that assessment is concluded after the initial database is recorded.
Recollect that it is impossible to give quality, individualised care without knowledge of changes in the person’s status.
Low priority attached to ongoing data collection.
Ongoing data collection is critical to the deletion or modification of old problems and the identification of new problems.
Identifying Data to Be Validated Because validation of all data is neither possible nor necessary, nurses and midwives need to decide which items need verification. For example, data needs to be verified when there are discrepancies. For example, a person may tell you he or she is fine and have no concerns, but you note that the person demonstrates tense body musculature and seems curt in his or her responses. When there is a discrepancy between what the person is saying and what you are observing, validation is necessary to determine accu-
racy. Validation in this instance may take the form of you saying: ‘You tell me you feel fine, but right now your body and behaviours are telling me something else. Tell me more about this.’ Data also need verification when they lack objectivity. For example, you suspect that the person hears in one ear but does not seem to hear well in the other. You should validate the data before proceeding and determine whether the person does indeed have a hearing problem. Suspicions are not objective. In this instance, the person’s hearing in both ears needs to be tested. Speaking towards the suspected
Chapter 15 better hearing ear, you explain: ‘It seems to me that you hear better out of one ear than the other. I would like to test this. I’ll bring a watch slowly towards your right ear first and then towards your left. Please look straight ahead and tell me when you first hear the watch ticking.’ You then record how far the watch was from each ear when the person first heard it ticking.
Identifying Cues and Making Inferences
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DATA COMMUNICATION The personal data collected by the nurse or midwife, both initially and as contact with the person continues, are of no benefit unless they are appropriately communicated. See Box 15-3. Appropriate communication involves correct timing and proper documentation, and this is further discussed in Chapter 20.
Timing
In Chapter 14, the processes of critical thinking and clinical reasoning that include collecting cues and making inferences is explained. Nurses and midwives use this language of cues and inferences to describe the process of validation. The subjective and objective data you identify (the person does not respond when I speak to her on her left side) is a cue that something may be wrong. The judgment you reach about the cue (the person’s hearing may be impaired on her left side) is an inference. Until you check the person’s hearing you cannot be sure that your inference is correct. Inferences should be validated through the gathering of evidence and this can be undertaken in multiple ways: Physical examination, using the proper equipment and procedure (you may need to have an expert confirm your findings) Clarifying statements (‘You said this is not a problem, but I sense you may still be worried.’) Sharing your inferences with other members of the team Checking your findings with research reports. See Figure 15-2 for an illustration of validating inferences. You may validate data as they are collected or at the end of the data-gathering process. When it is clear that the data is correct, you are ready to analyse the data and formulate any identified health problems—the next phase of the process of care. Consider what you have learnt so far in relation to the data that you collect during an assessment and the inferences that you make from this data. Apply this by revisiting the scenarios where you are the community nurse assessing Claire. Throughout the interview and assessment with you, Claire’s mother has been present. You are concerned that Claire may not be giving you complete answers to your health assessment questions. 1. What cues might Claire display to make you think this? 2. What inferences can you draw from her behaviour? Now reflect on how this may change the inferences that you draw from the data and how you might structure the next assessment.
Immediate verbal communication of data is indicated whenever assessment findings reveal a critical change in the person’s health status that necessitates the involvement of other nurses, midwives or healthcare providers. The nurse who observes an elevated temperature of 39.5°C in a patient scheduled for surgery that morning must report this to the nurse unit manager and to the surgeon, who might then cancel surgery. Failure to communicate this finding could result in the patient’s receiving preoperative sedation, being taken to the operating theatre and even having the surgery performed under less than optimal conditions. Similarly, a nurse who hears a patient making suicidal remarks must communicate this information to the healthcare team, so that all are alerted to the danger and that suicide precautions may be taken immediately. If you are unsure of the significance of a particular finding you are well advised to consult with another colleague. In some situations, years of experience are needed to distinguish significant from non-significant findings. Neither ignorance nor the fear of appearing less than competent justifies failure to report critical data (Box 15-4).
Documentation The initial database should be entered into the computer or recorded in ink, using the designated healthcare facility forms, on the same day the person is admitted. If, for any reason, important data cannot be obtained during the initial assessment, this needs to be documented so that they are obtained as soon as possible. Objective and subjective personal data should be summarised and written in a comprehensive, concise and easily retrievable format. The data should be written legibly, using good grammar, and
BOX 15-4 Legal Alert Nurses and midwives are responsible for alerting the appropriate healthcare providers whenever assessment data differs significantly from the person’s baseline, indicating a potentially serious problem. Interventions for which they may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regime.
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Thoughtful Practice and the Process of Care DATA VALIDATION Situation A Patient is usually quiet whenever her husband is present. On one occasion she recoiled when he touched her.
Patient may be afraid because her husband is abusive.
Literature lists above behaviours as clinical manifestations of abuse.
Situation B
Identify cues.
Make inferences about cues.
Validate cues and inferences.
Clarifying statement: ‘I can't help but notice how quiet you are whenever your husband is here, and you’ve even pulled back from his touch. It seems like you are afraid of him.’
Patient’s baseline BP is 120/80. You just got a reading of 140/90.
Patient may be hypertensive.
Literature lists as possible causes of falsely high BP: • Using a manometer not calibrated at the zero mark • Assessing the blood pressure immediately after exercise •Viewing the meniscus from below eye level • Applying a cuff that is too narrow • Releasing the valve too slowly • Reinflating the bladder during auscultation
Patient begins to talk about her fear and her husband’s abusive behaviour. The equipment checks out. Another expert nurse gets a reading of 128/80. You remember having had difficulty hearing, and you recall that you reinflated the bladder several times during auscultation and then released the valve slowly.
INFERENCE VALIDATED
INFERENCE REJECTED
Figure 15-2 An illustration of the process used to validate cues and inferences
only the abbreviations required by the healthcare facility should be used. See Appendix C for a list of commonly used abbreviations. To facilitate quick data retrieval, data should be presented under clearly marked headings, using the appropriate assessment framework adopted by the healthcare organisation. Whenever possible, subjective data should be recorded using the person’s own words. Quotation marks should be used: ‘I feel tired from the moment I first get up in the morning. Any more it seems I have no energy at all.’ These
reports may also be paraphrased: ‘The person reports feeling dyspnoeic, has difficulty catching breath when walking one flight of stairs.’ The tendency to record data using non-specific terms that are subject to individual definition or interpretation—words like adequate, good, average, normal, poor, small, large should be avoided. One nurse or midwife’s sense of what constitutes an average fluid intake may be very different from that of another nurse or midwife. It is important to be specific. Chapter 20 offers general documentation guidelines.
Chapter 15
Developing knowledge skills In this chapter you have been learning about assessment as part of the process of care. Once you have had the opportunity to practise the process of patient-centred care and carry out assessments you will be more confident to practise these identified skills and procedures. What have you learnt? Basic knowledge of how to complete an assessment The ability to collect the appropriate data to complete an assessment of the person Knowledge of what constitutes accurate and appropriate data for person-centred care assessment Ability to understand and interpret the meaning of the collated data How to recognise actual and potential barriers to being able to collect accurate and appropriate data for personcentred care assessment. To enhance your learning and facilitate further understanding of this chapter, refer to thePoint online resource.
Developing critical thinking skills 1. Working with another student, interview people in both home and healthcare settings, and record your findings separately. Make a list of the objective and subjective data you gather on each person interviewed and the inferences you make from these cues. Compare your data lists and inferences. Describe to one another how you plan to validate your inferences. Explore possible reasons for the differences you discover. 2. Allow another student to perform a comprehensive assessment (interview and physical assessment) on you. Reflect on what you experienced. Offer the student feedback about which of her or his behaviours were helpful, comforting or distressing. Change roles and talk about what you learned from this experience. 3. Collect several different forms for recording the initial assessment (hospital, nursing home, home care and school of nursing and midwifery forms). Identify and explain the differences you see. Experiment with using the different forms and make a list of features that help you get all the data you need in the easiest way possible.
Review questions 1. While administering a medication to relieve a person’s pain, you wonder if there are some non-pharmacological interventions that would enhance relief by complementing the pain medication. When you discuss this with your facilitator you are most likely to hear:
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a. ‘You should wait until after you evaluate the effect of the medication you just administered before planning a different intervention.’ b. ‘One step at a time, dear. Don’t start planning a new intervention until you evaluate the old.’ c. ‘Let’s talk about this … we often get new information that we can incorporate successfully into the plan of care. Sometimes the phases of the process interact or overlap.’ d. ‘Think about this person. Non-pharmacological interventions wouldn’t be effective with her.’ 2. When a person you are admitting to the unit asks you why you are doing a health history and physical examination since the doctor just did one, your best reply is: a. ‘In addition to providing us with valuable information about your health status, the nursing and midwifery assessment will allow us to plan and deliver individualised, holistic person-centred care that draws on your strengths.’ b. ‘It’s hospital policy. I know it must be tiresome, but I will try to make this quick!’ c. ‘I’m a student nurse/midwife and need to develop the skill of assessing your health status and need for care. This information will help me develop a person-centred plan of care, individualised to your unique needs.’ d. ‘We want to make sure that your responses are consistent and that all our data are accurate.’ 3. When you receive the shift report, you learn that the person that you are caring for has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. You should: a. Correct the initial assessment form b. Redo the initial assessment and document current findings c. Conduct and document an emergency assessment d. Perform and document a focused assessment on skin integrity 4. Fearful of attempting your first health history, you ask your facilitator how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear: a. ‘There’s a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!’ b. ‘You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.’ c. ‘No-one ever really learns how to do this well because each history is different! I often feel like I’m starting afresh with each new person.’ d. ‘Don’t worry about learning all of the questions to ask. Every facility has its own assessment form you must use.’
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5. A person complains about feeling nauseated after lunch. This is an example of what type of data? a. Subjective b. Objective c. Signs and symptoms d. Overt 6. When you enter the person’s room to begin your health history, the person’s wife is there. You should: a. Introduce yourself to both and thank the wife for being present. b. Introduce yourself to both and ask the wife if she wants to remain. c. Introduce yourself to both and ask the wife to leave. d. Introduce yourself and ask the person if he would like the wife to stay. 7. The person is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond? a. Ask the son if he is willing to translate and be sure to thank him if he says yes. b. Determine if the son can translate medical information and if so, begin. c. After determining that the son can translate, evaluate if he can do so objectively and if the person wants him to serve in this capacity. d. Explain to the son that hospital policy discourages using family members as interpreters and you will need to organise a hospital-approved interpreter. 8. You are surprised to detect an elevated temperature (39.5°C) in a person scheduled for surgery. The person has been afebrile and shows no other signs of being febrile. The first thing you do is to: a. Inform the charge nurse/midwife b. Inform the surgeon c. Validate your finding d. Document your finding 9. You tell your facilitator that the person you are nursing is fine and has ‘no complaints’. You are likely to hear: a. ‘You made an inference that she is fine because she has no complaints. How did you validate this?’ b. ‘She probably just doesn’t trust you enough to share what she is feeling. I’d work on developing a trusting relationship.’ c. ‘Sometimes everyone gets lucky. Why don’t you try to help another person?’ d. ‘Maybe you should reassess the person. He has to have a problem—why else would he be here?’
2.
3.
4.
5.
6.
7.
8.
Answers with rationale 1. The correct answer is c. There may be much interaction and overlap among the process of care phases. In this case, though you want to evaluate the effect of the medication you administered (options a and b), there is no reason to wait for this to happen before exploring other valid options. (d) is incorrect because
9.
it is not possible to judge the effectiveness of nonpharmacological methods before their use, and the facilitator’s response possibly indicates a prejudice toward complementary and alternative modalities. The correct answer is a. Though it may be true that you need to develop assessment skills (c), the chief reason you are doing a history and examination is because there needs to be a documented admission assessment to serve as a basis for nursing and midwifery care. The fact that this is also hospital policy (b) is a secondary reason. The correct answer is d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone (b) or corrected (a). This is not a life-threatening event, and thus there is no need for an emergency assessment (c). The correct answer is b. Once you learn what constitutes the minimum amount of data required, you can adapt this to any nursing situation. It is not true that each assessment is the same even when you are using the same minimum data set (a), or is it true that each assessment is uniquely different (c). Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualised person-centred care or critical thinking. The correct answer is a. A personal report of ‘feeling nauseated’ cannot be perceived or validated by the nurse/midwife, and this is subjective data, not objective (b) or overt (d), which are observable and measurable. Answer c is wrong since signs are examples of objective data. The correct answer is d since the person has the right to indicate who he would like to be present for the history and examination. You should neither presume that he wants his wife there (a), nor that he does not want her there (c). Similarly, the choice belongs to the person, not the wife (b). The correct answer is d since it is now common policy not to use family members as interpreters. The son may not adequately translate medical information, may not be trusted to translate what is said without introducing his bias, and it may not be culturally sensitive to the person for him to serve in this capacity. Answer a is incorrect as policy prohibits family members from translating, (b) is incomplete and (c) also contravenes policy. The correct answer is c. You should first validate your finding if it is unusual, deviates from normal and is unsupported by other data. Should your initial recording prove to be in error, it would have been premature to notify the charge nurse/midwife (a) or the surgeon (b). You want to be sure that all data you record is accurate, so it should be validated before documentation if you have doubts (d). The correct answer is a. Your facilitator is most likely to challenge your inference that the person is ‘fine’
Chapter 15 simply because he is telling you that he has no problems. It is appropriate for her to ask how you validated this inference. Jumping to the conclusion that the person does not trust you (b) is premature and is an invalidated inference. Answer c is incorrect because it accepts your invalidated inference and d is wrong because it is possible that the condition is resolving.
Bibliography Alfaro-Lefevre, R. (2006). Applying nursing and midwifery process: Promoting collaborative care (6th edn). Philadelphia: Lippincott Williams & Wilkins. Amella, E.J. (2004). Presentation of illness in older adults: If you think you know what you’re looking for, think again. American Journal of Nursing, 104(10), 40–52. Baid, H. (2006). The process of conducting a physical assessment: A nursing perspective. British Journal of Nursing, 15(13), 710–14. Bickley, L. (2007). Bates’ pocket guide to physical examination and history taking (5th edn). Philadelphia: Lippincott Williams & Wilkins.
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Chenoweth, L. Jeon Y.H., Goff, M. & Burke, C. (2006). Cultural competency and nursing care: an Australian perspective. International Nursing Review, 53(1), 34–40. Duffy, J.R. (2003). Caring relationships and evidencebased practice. Can they coexist? International Journal for human Caring, 7(3), 45–50. Gordon, M. (2000). Manual of nursing diagnosis (10th edn). St. Louis. Mosby. Jarvis, C. (2008). Physical examination and health assessment. St Louis: Saunders Elsevier King, L. & Appelton, J.V. (1997) Intuition: A critical review of the research and rhetoric. Journal of Advanced Nursing, 26, 194–202. Kleiman, S., Frederickson, K. & Lundy, T. (2004). Using an eclectic model to educate students about cultural influences on the nurse-patient relationship. Nursing Education Perspectives, 25(5), 249–52. Lafluer, K.J. (2004). Taking the fifth [vital sign]. RN, 67(7), 30–7. Weber, J. & Kelley, J. (2007). Health assessment in nursing (3rd edn). Philadelphia: Lippincott Williams & Wilkins.
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