Fundamentals of Nursing and Midwifery 2e

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.

TABLE 15-2 Comparison of objective and subjective data

Objective data

Subjective data

‘I’m beginning to feel better about myself now that I’m losing weight and I seem to have more energy.’

32-year-old man Height: 180 cm Weight:

18/9/XX—102 kg 18/11/ XX—92 kg

Sources of data Person

‘My leg hurts when I walk.’

Posterior, left mid-calf is warm and red. Observed fidgeting with bed covers; facial features are tightly drawn.

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.

’I’m so afraid of what they might find when they cut me open tomorrow.’

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