of care to maximise health and well-being. For example,
knowing that a person has lost weight is not meaningful until
you discover (1) if the weight loss was intentional or uninten-
tional, (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 plan-
ning 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 deci-
sion making in relation to their care.
Factual and accurate
The person, nurse or midwife may intentionally or uninten-
tionally 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 carer who is supply-
ing the data is reliable. When you suspect that your own
personal bias or stereotyping is influencing your data collec-
tion, 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 person 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 state-
ment ‘The person 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
Unit III Thoughtful practice and the process of care
276
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 are 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 col-
lected 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 infor-
mation can be used to plan and implement care directed at
addressing their personal needs. Although data collected
from the person are usually accurate, you should be alert for
certain difficulties. For example, an acutely ill person may
not be able to communicate adequately if in severe pain or
the level of consciousness is altered in any way. An emo-
tionally 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 communicative
capacity, such as young children or older adults with demen-
tia, 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 carer for information communicates powerfully
that you either have no time for the person to express their
needs or mistakenly doubt the person’s ability to communi-
cate these needs.
Family and significant others
A person-centred approach to planning and delivering
care also includes family members and significant others
(e.g. friends, carers). 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 deter-
mine 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.
32-year-old man
Height: 180 cm
Weight:
18/9/XX—102 kg
18/11/ XX—92 kg
Posterior, left mid-calf is
warm and red.
Observed fidgeting with
bed covers; facial features
are tightly drawn.
‘I’m beginning to feel
better about myself now
that I’m losing weight
and I seem to have more
energy.’
‘My leg hurts when I
walk.’
’I’m so afraid of what they
might find when they cut
me open tomorrow.’
TABLE 15-2 Comparison of objective and
subjective data
Objective data
Subjective data
