Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

272

Assessing • Identify assessment

priorities determined by the purpose of the assessment and the person’s condition • Organise or cluster the data to ensure systematic collection

Health history Physical examination

Review of the patient record and nursing literature Consultation with the person’s support people and healthcare providers

• Establish the data base • Continuously update the database • Validate data • Communicate data

Evaluating care

Identifying health problems

Figure 15-1 Assessing. The primary source of personal information is the person. Resources include the person’s support people, the personal record, information from other healthcare providers and information from nursing and midwifery and healthcare literature

Implementing care

Planning care

Many experienced nurses and midwives use intuition as a component of the assessment process. Students are encour- aged to use a systematic approach when performing assessments and formulating their conclusions based on those findings. Intuitive thinking comes with experience and practice; however, it should not replace the systematic assessment process where quantifiable data are collected. See Chapter 14 for an outline of intuitive thinking as part of the clinical reasoning process. TYPES OF HEALTH ASSESSMENTS Health assessments include the comprehensive initial assessment, the focused assessment, the emergency assess- ment and the time-lapsed assessment. This chapter will focus on assessing the health status of a person. As you develop expertise in health assessments, you will be able to assess communities and special populations, such as school children, older people or people with infectious diseases. Your learning, through reflection, can now be applied to enrich your understanding of the following types of assess- ment performed by nurses and midwives. Initial assessment The initial assessment is performed shortly after the person is admitted to a healthcare facility or service. Most institu- tions have policies specifying the time interval within which the assessment must be completed. The purpose of this initial assessment is to establish a comprehensive database for iden- tifying health problems and strengths, and for planning care. Data are collected concerning all aspects of the person’s health, establishing priorities for ongoing focused assess- ments and creating a reference for future comparison.

During this assessment many aspects and dimensions of the person’s life should be explored and examined (including such things as their values, cultural, social or familial beliefs about health and illness); see Box 15-2. The person and their family or significant others should be encouraged to be actively involved throughout this assessment process.

BOX 15-2 Assessment

Collect and verify information to determine the person’s: • Understanding of the reason for admission and care processes • Expectations of services • Personal preferences such as requirements for privacy, comfort measures, eye contact when communicating and decision-making processes • Gender-appropriate care provision requirements • Cultural and linguistic background • Family or significant other relationships and lifestyle patterns • Health beliefs, rules and usual health behaviours, including diet, food preparation and presentation, exercise patterns and personal care • Need for interpreter services to identify topics of discussion or practices that are taboo for the individual and family, such as personal hygiene, illness or treatment • Need for culturally appropriate greetings and farewells for nursing and midwifery staff, behaviours that denote respect and preferred use of their name • Ability to read own language.

Source: Chenoweth et al., 2006.