Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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Relevance of data The type of data collected is influenced by both the length of time spent with the person (e.g. same-day surgery versus surgery that necessitates a long recovery in an intensive care unit) and the nature of the care required (e.g. assistance with the birth of a baby versus support and home care throughout a terminal illness). A general guideline to follow is to gather only data that are helpful when planning and delivering care. It would be inappropriate, for example, to collect a detailed sexual history on an adolescent admitted to the hospital overnight after a slight concussion. Con- versely, you should ask such questions if a pregnant woman is admitted to the hospital for observation for vaginal bleed- ing during her first trimester. Practical considerations Before conducting an interview, first check to see if the person has presented before at the health facility. A personal record will provide data collected during previous visits, and these data should not be repeatedly sought, unless there is a need to validate them. Additionally, repetitious questioning can be annoying and may cause the person to question the lack of communication among healthcare providers. A careful review of the personal record before commencing the interview helps prevent these problems. Before meeting a person for the first time, it is helpful to take a minute to think carefully about the type of data needed to plan quality care. After a comprehensive health assessment has been completed, the priority of the identified health problems will dictate future interactions. Structuring the assessment Because many different types of data are collected during the assessment, there is a need to structure data collection systematically. A variety of assessment frameworks are available that provide systematic guidelines specifically developed for a health assessment to ensure that comprehen- sive, holistic data are collected for each person which will lead to the identification of health problems. Frameworks may be modified to suit the individual and the personal pref- erence of the nurse or midwife. Once you are familiar with these assessment frameworks, you can focus on the person rather than worrying about what to assess next. Most schools of nursing and midwifery and healthcare institutions use one or more assessment frameworks and have established a minimum data set that specifies what information should be collected. They then use a structured health assessment form to organise or cluster these data. Many nursing and midwifery assessment guides are based on holistic models rather than medical models. Holistic models encompass the physiological, psychological, socio- cultural, intellectual and spiritual aspects of each person. Examples of assessment frameworks include: • The human needs framework (Maslow, 1943) which uses a hierarchy of human needs identifying five levels

• The functional health patterns framework (Gordon, 2010) which identifies 11 functional health patterns and organises personal data into these patterns • The human response patterns framework which suggests health status is evidenced by observable phenomena that can be classified into one of the response patterns. This can then be used as a model for organising data collection • The head-to-toe framework which provides baseline data and uses a comprehensive systematic approach that can be undertaken in a timely manner to prioritise care. See Table 15-1 for an overview of the human needs, func- tional health patterns and head-to-toe assessment frameworks. The body systems model used to organise data collection is an example of a medical model. This framework organ- ises data collection according to organ and tissue function in various body systems. Although it is helpful in identifying health problems related to physiological factors, it neglects a person’s problems and strengths in psychosocial, cultural and spiritual dimensions of health and well-being. There are two types of data: subjective and objective. Sub- jective data are information perceived only by the affected person; that is, what the person is experiencing. These data cannot be perceived or verified by anyone else. Despite this, subjective data are sometimes capable of measurement; for example, pain scales may be used to measure a person’s experience of pain. Examples of subjective data are when a parent indicates that their child is ill or when a person states that they are feeling cold, nervous or nauseated. Subjective data are also called symptoms or clinical manifestations. Objective data are observable and measurable data that can be seen, heard or felt by someone other than the person experiencing them. Objective data observed by one nurse or midwife can be verified by another nurse or midwife observing the same person. Examples of objective data are an elevated temperature reading (e.g. 39°C), skin that is moist, and refusal to look at or eat food. Objective data are also called signs or clinical manifestations. Table 15-2 com- pares subjective and objective data. Paying attention to both subjective and objective data promotes critical thinking and clinical reasoning because the two types of data complement and clarify one another. Consider what you know about the types of data that may be collected during an assessment and apply it to the scenario. As part of your assessment of Claire you have discovered that she is stressed about her upcoming exams and her menstrual cycle is causing swings in her blood glucose levels. Claire also wants to fit in with her friends and when they go out she wants to do the same things they do, which includes drinking alcohol. She DATA COLLECTION Subjective and objective data