Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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other nurses, midwives or healthcare providers. The nurse who observes an elevated temperature of 39.5°C in a person scheduled for surgery that morning must report this to the nurse unit manager and to the surgeon, who might then cancel surgery. Failure to communicate this finding could result in the person receiving preoperative sedation, being taken to the operating theatre and even having the surgery performed under less than optimal conditions. Similarly, a nurse who hears a person making suicidal remarks must

communicate this information to the healthcare team, so that all are alerted to the danger and that suicide precautions may be taken immediately. If you are unsure of the significance of a particular finding you are well advised to consult with another colleague. In some situations years of experience are needed to distinguish significant from non-significant findings. Neither ignorance nor the fear of appearing less than competent justifies failure to report critical data (Box 15-4).

DATA VALIDATION

Situation A

Situation B

Person is usually quiet whenever her husband is present. On one occasion she recoiled when he touched her.

Person’s baseline BP is 120/80. You just got a reading of 140/90.

Identify cues

Person may be afraid because her husband is abusive.

Person may be hypertensive.

Make inferences about cues

Literature lists as possible causes of falsely high BP: • Using a manometer not calibrated at the zero mark • Assessing the blood pressure immediately after exercise • Viewing the meniscus from below eye level • Applying a cuff that is too narrow • Releasing the valve too slowly • Reinflating the bladder during auscultation.

Literature lists above behaviours as clinical manifestations of abuse.

Validate cues and inferences

Clarifying statement: ‘I can't help but notice how quiet you are whenever your husband is here, and you’ve even pulled back from his touch. It seems like you are afraid of him.’

Person begins to talk about her fear and her husband’s abusive behaviour.

The equipment checks out. Another expert nurse gets a

reading of 128/80. You remember having had difficulty hearing, and you recall that you reinflated the bladder several times during auscultation and then released the valve slowly.

INFERENCE VALIDATED

INFERENCE REJECTED

Figure 15-2 Illustration of the process used to validate cues and inferences