other nurses, midwives or healthcare providers. The nurse
who observes an elevated temperature of 39.5°C in a person
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 person 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 person making suicidal remarks must
283
Chapter 15 Assessing
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).
DATA VALIDATION
Situation A
Situation B
Identify cues
Make inferences about cues
Validate cues and inferences
Person is usually quiet whenever
her husband is present. On one
occasion she recoiled when he
touched her.
Person may be afraid because her
husband is abusive.
Literature lists above behaviours as
clinical manifestations of abuse.
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.’
Person begins to talk about her
fear and her husband’s abusive
behaviour.
INFERENCE VALIDATED
Person’s baseline BP is 120/80.
You just got a reading of 140/90.
Person may be hypertensive.
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 REJECTED
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.
Figure 15-2
Illustration of the process used to validate cues and inferences
