Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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concise and easily retrievable format. The data should be written legibly, using good grammar, and only the abbrevia- tions required by the healthcare facility should be used. See Appendix C for a list of commonly used abbreviations. To facilitate quick data retrieval, data should be presented under clearly marked headings, using the appropriate assessment framework adopted by the healthcare organisation. Whenever possible, subjective data should be recorded using the person’s own words. Quotation marks should be used: ‘I feel tired from the moment I first get up in the morning. It seems I have no energy at all anymore.’ These reports may also be paraphrased: ‘The person reports feeling dyspnoeic, has difficulty catching breath when walking one flight of stairs.’ The tendency to record data using non-specific terms that are subject to individual definition or interpretation—words like adequate, good, average, normal, poor, small, large— should be avoided. One nurse or midwife’s sense of what constitutes an average fluid intake may be very different from that of another nurse or midwife. It is important to be specific. Chapter 20 offers general documentation guidelines. data lists and inferences. Describe to one another how you plan to validate your inferences. Explore possible reasons for the differences you discover. 2. Allow another student to perform a comprehensive assess- ment (interview and physical assessment) on you. Reflect on what you experienced. Offer the student feedback about which of their behaviours were helpful, comforting or distressing. Change roles and talk about what you learned from this experience. 3. Collect several different forms for recording the initial assessment (hospital, nursing home, home care, and school of nursing and midwifery forms). Identify and explain the differences you see. Experiment with using the different forms and make a list of features that help you get all the data you need in the easiest way possible. 1. While administering a medication to relieve a person’s pain, you wonder if there are some non-pharmacological interventions that would enhance relief by complement- ing the pain medication. When you discuss this with your facilitator you are most likely to hear: a. ‘You should wait until after you evaluate the effect of the medication you just administered before planning a different intervention.’ b. ‘One step at a time, dear. Don’t start planning a new intervention until you evaluate the old.’ c. ‘Let’s talk about this … we often get new information that we can incorporate successfully into the plan of Review questions

BOX 15-4 Legal alert

Documentation The initial database should be entered into the computer or recorded in ink, using the designated healthcare facility forms, on the same day the person is admitted. If, for any reason, important data cannot be obtained during the initial assess- ment, this needs to be documented so that they are obtained as soon as possible. Objective and subjective personal data should be summarised and written in a comprehensive, Nurses and midwives are responsible for alerting the appropriate healthcare providers whenever assessment data differ significantly from the person’s baseline, indi- cating a potentially serious problem. Interventions for which they may be legally responsible include increas- ing the frequency of assessments and initiating necessary changes in the treatment regimen. In this chapter you have been learning about assessment as part of the process of care. Once you have had the opportu- nity to practise the process of person-centred care and carry out assessments you will be more confident to practise these identified skills and procedures. What have you learnt? • Basic knowledge of how to complete an assessment • The ability to collect the appropriate data to complete an assessment of the person • Knowledge of what constitutes accurate and appropriate data for person-centred care assessment • Ability to understand and interpret the meaning of the collated data • How to recognise actual and potential barriers to being able to collect accurate and appropriate data for person- centred care assessment. Developing knowledge skills

To enhance your learning and facilitate further understanding of this chapter, refer to thePoint and LNPS online resources.

Developing critical thinking skills

1. Working with another student, interview people in both home and healthcare settings, and record your findings separately. Make a list of the objective and subjective data you gather on each person interviewed and the inferences you make from these cues. Compare your