Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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PREPARING FOR DATA COLLECTION

Focused assessment In a focused assessment , data are gathered about a specific problem that has already been identified. A focused assess- ment may be undertaken during the initial assessment if health problems surface, but it is routinely part of ongoing data collection. Another purpose of the focused assessment is to identify new or overlooked problems. An example of this may be that during the initial interview it becomes apparent that the person is expressing feelings of sadness and despair. The assessment may then focus on this to ascer- tain if the person is experiencing a reaction to a specific situation identified in the assessment, such as a bereavement or a depressive episode that may require further referral. Emergency assessment When a physiological or psychological crisis presents, an emergency assessment is performed to identify life- threatening problems. A nursing home resident who begins choking in the dining room, a person brought to the emer- gency department with a stab wound, an unresponsive person in the rehabilitation unit and a farm worker involved in an accident with machinery are all candidates for an emergency assessment. Time-lapsed assessment The time-lapsed assessment is scheduled to compare a person’s current status to baseline data obtained earlier. Most people in residential settings and those receiving care over longer periods of time, such as people visited by a com- munity nurse or midwife, may have periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the plan of care. There are times when the features of each type of assess- ment may be combined. Consider what you have learnt about focused and time-lapsed assessment and apply it to the scenario. Claire and her mother present at the clinic for her three- monthly appointment with you, the community nurse. Claire has had several admissions to hospital with ketoacidosis in the past two years but has been relatively stable in recent months. You refer to her initial assess- ment and notice that since that time her entries in her diabetes record book have become very spasmodic and her blood glucose levels are fluctuating with increasing regularity. You ask Claire about the documentation and notice that her attitude is despondent. She angrily states: ‘I always stick to my diet and it still makes no difference. My blood glucose levels are always high and I just can’t do this any more.’ You now need to focus your assess- ment of Claire in order to collect data that will help you identify what issues may be arising for her. 1. What questions would you ask Claire and her mother? 2. What issues might you consider?

Establishing health assessment priorities and systematically structuring data collection are two important considerations when preparing for data collection. Establishing assessment priorities Before beginning data collection, you should have some idea of the types of data needed to develop a satisfactory plan of care. Nurses and midwives spend more or less time on different components of the health history depending on the reason why assistance is needed. For example, paediatric nurses are careful to establish the developmental age and milestones obtained from children admitted to a paediatric unit so that they can respect and promote these achieve- ments. A school nurse who suspects child abuse pays careful attention to the child’s statements about living conditions at home, and relationships with family members and carers. A midwife preparing to discharge a first-time mother from the maternity unit makes sure that the new mother has the support network needed to provide appropriate assistance and guidance. The purpose for which the assessment is being performed offers the best guideline about what type to use and how much data to collect. Assessment priorities are influenced by the individual’s health orientation, developmental stage and need for care. Health orientation Health assessments, such as the ‘A health style self-test’ in Chapter 2 and the ‘Promoting health’ displays in each clinical chapter may be used to help people identify poten- tial and actual health risks, and to explore their habits, behaviours, beliefs, attitudes and values that influence levels of wellness. There is a wide body of literature on specialised assessment tools that focus on relationships; psychological, environmental and physical self-care; relaxation; culture and spirituality; humour and play; movement and exercise; sleep and dreams; nutrition; and sexuality. All of these specialised assessment tools provide specific, pertinent information and may be differ- ent from the assessments of people being hospitalised for disease-related treatment. Developmental stage Assessments are modified according to developmental needs. For example, when assessing an infant, special atten- tion is given to weight gain and physical growth, feeding and elimination problems, sleep–activity cycles, and the parenting skills of carers. When a child is hospitalised, it is important to note how independent the child is with basic care measures (toileting, hygiene, dressing, eating), what words the child uses to indicate the need to void and defe- cate, and play preferences.