Fundamentals of Nursing and Midwifery 2e

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-

BOX 15-1 Person-centred assessment

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. 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?

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