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Chapter 15 Assessing
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injury. Data may be elicited from many sources; these
include the individual, the family, the community, col-
leagues and other healthcare providers. The purpose of
assessment is to identify current or potential health prob-
lems and the person’s strengths. A
database
is developed
during this phase to capture all the pertinent personal infor-
mation 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 as the remaining phases depend on
complete, accurate, factual and relevant data.
The following scenario is introduced in this chapter and
developed further in 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 social-
ising. She has just gained her driver’s licence and has
become increasingly independent; she has a part-time
job at a local fast-food outlet for 8 to 10 hours per week.
Claire was diagnosed with Type 1 diabetes at age 9. 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 well-being. 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.
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 them 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 person-
centred 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
•
Data are collected continuously because the person’s
health status can change quickly
•
Questionable data are verified (validated)
•
All pertinent data are 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, which is based on a biomedical model, but
supplements it by adopting a holistic approach. Medical
assessments target data pointing to pathological condi-
tions, whereas nursing and midwifery assessments focus
on the person’s responses to their 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 identi-
fication of a medical diagnosis, the unique focus of such
an assessment is on the individual’s responses to current
or potential health problems.
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?
