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Chapter 15 Assessing
advanced practice roles perform comprehensive physical
assessments similar to their doctor colleagues, which iden-
tify 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 assess-
ment 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 cerebrovascu-
lar accident (stroke) is examined to determine their 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 identi-
fication of health problems and the establishment of a
database for care interventions. It also allows the nurse or
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 dif-
ferent purposes. Nurses in the coronary care unit use
sophisticated, high-technology assessment techniques,
whereas nurses in a rehabilitation centre use a wide range of
physical assessment skills that focus on identifying func-
tional and non-functional 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, omis-
sion 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.
Identifying data to be validated
Because validation of all data is neither possible nor neces-
sary, nurses and midwives need to decide which items need
verification. For example, data need to be verified when
there are discrepancies. For example, a person may tell you
they are fine and have no concerns, but you note that they
demonstrate tense body musculature and seem curt in their
responses. When there is a discrepancy between what the
person is saying and what you are observing, validation is
necessary to determine accuracy. 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 val-
idate 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
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
In Chapter 14, the processes of critical thinking and clin-
ical reasoning that include collecting cues and making
inferences is explained. Nurses and midwives use this lan-
guage 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
judgement 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 under-
taken in multiple ways:
•
Physical examination, using 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 infer-
ences. You may validate data as they are collected or at the
end of the data-gathering process. When it is clear that the
data are correct, you are ready to analyse the data and for-
mulate any identified health problems—the next phase of
the process of care.
