Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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Whenever data are gathered from support people, this should be indicated in the health history. When the person does not speak English, the services of an interpreter are needed. It is important not to assume that a family member is accurately translating what you are trying to communicate to the person. It is now policy in many health services that family members are not used as interpreters since family members might misinterpret medical content or paraphrase the person’s response incorrectly, or the person might be uncomfortable sharing certain information with the family interpreter. For example, in some cultures it is inappropriate to discuss certain issues with one gender, and using a family member may cause embarrassment to both parties. When using family and friends as a source of information, you can add to the knowledge and understanding of the person and this can assist with validating the problems identified. Patient record Records prepared by different members of the healthcare team provide information essential to the delivery of com- prehensive care. You should review records early when gathering data—in some instances, before the first contact with the person. Such a review helps to focus the health assessment and to confirm and amplify information obtained from other sources. The patient health record or chart, which lists demo- graphic information such as age, gender, occupation, religious preference and next of kin, is one type of record. The patient record includes information entered by various health professionals, such as doctors, social workers, dieti- cians, physiotherapists and laboratory technicians. You must be familiar with the many sections of the patient record, in addition to the documentation of the plan of care and notes. The following are important sources of data. Medical history, physical examination and progress notes Medical history, physical examination and progress notes record the findings of doctors as they assess and treat the person; they focus on identifying pathological conditions and their causes and on determining the medical regimen for treatment. Consultations The person’s doctor may invite specialists to assess and to work with the person. Their focus is on identifying findings that help to establish a medical diagnosis or on planning and executing the treatment regimen. Reports of laboratory and other diagnostic studies Reports of laboratory studies and other diagnostic tests, such as X-rays, offer objective data that can either confirm or conflict with data collected during the health history or examination. Results of diagnostic studies are helpful to doctors for establishing a diagnosis and monitoring the person’s response to treatment. The results of these same studies may also be helpful in evaluation of care and the success of your care interventions.

Reports of therapies by other health professionals Other healthcare professionals who interact with the person also record their findings and note any progress that the person is making in their specific areas—for example, nutrition, physiotherapy or speech therapy. These reports help you assess the person’s progress and are useful when determining their ability to return home and manage care independently. Records of previous admissions for healthcare and records from other health agencies, such as a social service agency or community agency, are also valuable sources of data. They contain information about the person’s previ- ous medical or surgical problems and response patterns, which may be important determinants of the current plan of care. Other health professionals You can learn a great deal about a person’s normal health habits and patterns and their response to illness by talking with colleagues, doctors, social workers and others in the healthcare team. Although such communication is always important, it can be crucial when a person is transferred from home to a hospital or from one hospital to another. The only way to ensure continuity of care is to make special efforts to share pertinent information. To obtain a comprehensive personal database, it may be nec- essary to consult the nursing, midwifery and related literature on specific health problems. For example, if you have not cared for a person with Paget’s disease before, it is important for you to read about the clinical manifestations of the disease and its usual progression to know what to look for during the assessment. In addition to information concerning medical diagnoses, treatment and prognosis, literature review offers you important information about problems, developmental norms and psychosocial and spiritual prac- tices, which is helpful when assessing and providing care. Components of data collection Components of data collection include the health history and physical assessment. These data may be documented on a separate assessment tool or incorporated into a combined database assessment form. Observation Observation is a fundamental skill that all nurses and mid- wives require and will use in many key aspects of practice. This includes gathering the health history or performing the physical examination. Observation is the conscious and deliberate use of the five senses to gather data. Skilled nurses and midwives use each interaction with the person to observe and to interpret meaningful data. This process begins from the first encounter with the person and family. Nursing and midwifery and other healthcare literature