Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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TABLE 15-4 Common problems of data collection, possible causes and suggested remedies

Problem

Possible causes

Suggested remedies

Review the guidelines for specifying pertinent data.

Failure to identify needed data and plan for comprehensive and continuous assessment. Use of inappropriate tools for data collection. Not following up on cues during data collection; inappropriate guidelines. Failure to identify specific purpose of data collection. Failure to review available personal records. Use of inappropriate tools for data collection. Failure to observe carefully or validate during data collection. Interviewer prejudices or stereotypes. Failure to establish sufficient rapport or use appropriate communication techniques. Failure to know what information is wanted. Hasty conclusion is drawn about the person’s behaviour, depriving others of the opportunity to explore possible causes of the behaviour with the person. Deficient validation. Erroneous belief that assessment is concluded after the initial database is recorded. Low priority attached to ongoing data collection.

Database inappropriately organised

Consider modifying tool for data collection or select an alternative tool. Identify potentially relevant factors in advance of collection. Practise interview strategies. Determine specific purpose of data collection for each person. Consider existing data before initiating collection. Consider modifying data collection tool or selecting alternative. Sharpen observation skills by independently observing the same situation with a peer and comparing notes afterwards. Role-play several validation techniques. Review and practise communication techniques discussed in Chapter 7. Role-play several explanations of purpose of data collection. Identify general data desired before collection.

Pertinent data omitted

Irrelevant or duplicate data collected

Erroneous or misinterpreted data collected

Failure to establish rapport

Review the distinction between data and interpretation of data. Practise documenting observed behaviour concisely.

Interpretation of data is recorded rather than the observed behaviour

Recollect that it is impossible to give quality, individualised care without knowledge of changes in the person’s status. Ongoing data collection is critical to the resolution or modification of old problems and the identification of new problems.

Failure to update the database

DATA COMMUNICATION The personal data collected by the nurse or midwife, both initially and as contact with the person continues, are of no benefit unless they are appropriately communicated. See Box 15-3. Appropriate communication involves correct timing and proper documentation, and this is further dis- cussed in Chapter 20. Timing Immediate verbal communication of data is indicated when- ever assessment findings reveal a critical change in the person’s health status that necessitates the involvement of

Consider what you have learnt so far in relation to the data that you collect during an assessment and the inferences that you make from these data. Apply this by revisiting the scenarios where you are the community nurse assessing Claire. Throughout the interview and assessment with you, Claire’s mother has been present. You are concerned that Claire may not be giving you complete answers to your health assessment questions. 1. What cues might Claire display to make you think this? 2. What inferences can you draw from her behaviour? Now reflect on how this may change the inferences that you draw from the data and how you might structure the next assessment.