Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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Students can develop such observation skills by training themselves to observe carefully, as they encounter a person in a clinical setting. Development of these skills requires that, at each interaction, the student should consider the following: • What are the person’s current responses (physical and emotional)? • What is the person’s body language indicating? Non- verbal behaviour may indicate how the person feels or relates to family, their illness and hospitalisation. • Are there signs of distress? Be alert to difficulty breathing, bleeding or heightened anxiety. Watch for facial expressions such as grimacing to pain, guarding of the abdomen, body position—for example, is the person hunched or sitting upright and comfortable? • What is the person’s body size and shape, and are there any distinguishing marks such as tattoos, rashes or piercing? • Is the person awake and alert or drowsy and non- responsive? The person’s appearance will give clues to their ability to manage self-care. • What is the immediate environment? Consider the safety of the environment as well as the functioning of equipment (intravenous therapy, oxygen, drain tubes). • Who are the people in the room with the person, and are there support systems in place now and for discharge? • What is the temperature and odour of the room? For example, a fruity odour may indicate ketoacidosis. • What is the person telling you about the current problem? Has the problem occurred before? How did the person respond to past situations? Observation is the first step in the assessment process and the data gathered from this are continually updated through- out the person’s engagement with the healthcare system. Health history Ideally, the health history captures and records the unique- ness of the person, so that the plan of care may be designed to meet individual needs, reflecting the person-centred approach. The health history should therefore be obtained as soon as pos- sible after a person presents for care and should be followed by the physical assessment. The latter also occurs concurrently with the remainder of the ongoing assessment. This history should clearly identify personal strengths and weaknesses, health risks, such as hereditary and environmental factors, and potential and existing health problems, and what the person does to maintain a healthy lifestyle. This history focuses on getting to know the person in order to establish an enabling relationship, a main characteristic of person-centred care. Engaging with and involving the person in the decision- making process at this point is crucial so that any healthcare decisions incorporate the person’s beliefs and values. Components of a health history Components of a health history include: • Profile: name, age, gender, marital status, religion, occupation, education

• Reason for seeking healthcare • Normal health habits and patterns and related needs for nursing or midwifery assistance • Cultural considerations in relation to diet, decision making, perceptions of health and illness, and activities • Current state of health, functioning of body systems, degree of pain, and past medical and surgical history • Current medications, allergies, record of immunisations and exposure to communicable diseases • Perception of health status and the meaning the person attributes to health and illness, and characteristic response or coping patterns • Developmental history, family history, environmental history and psychosocial history • The person’s and the family’s expectations of the healthcare team • The person’s and the family’s educational needs and ability and willingness to learn • The person’s and the family’s ability and willingness to participate in the plan of care • The person’s personal resources (strengths) and deficits • The person’s potential for injury. Interview An interview is a planned communication. The person is interviewed to obtain a medical and social history. Effective interviewing skills are needed to establish a successful working partnership with the person, to communicate care and concern, and to obtain the necessary personal data. It is also important to allow the person and family to feel that they are participating as an equal partner in this process and that what they are saying will have an impact on care planning. Allowing enough time to conduct the interview is imperative as the focus of person-centred care is getting to know the person and this cannot be achieved if it is rushed. The inter- view comprises four phases: preparatory phase, introduction, working phase and termination. More detailed information on interviewing techniques is provided in Chapter 7. Preparatory phase Before initiating the interview, prepare yourself by reading current and past records and reports, when available. During this phase, it is important not to let your stereotypes and prej- udices affect this interaction. Being aware of your own prejudices can help you deal with them constructively. It is important to learn to approach each person with an open mind and to be sensitive to the human needs that underlie diverse behaviours as part of appropriate person-centred care. During the preparatory phase of conducting the interview, you should ensure that the environment in which the interview is to be conducted is private and relaxed. Unless the person wants family members or friends present during the interview, you should interview the person alone, in a quiet area. Both the seating arrangement and the distance between you and the person being interviewed are important. Chairs placed at right angles to each other and about 0.9–1.2 metres apart facilitate an easy exchange of information. If the