When working with the patient, the nurse begins planning nursing care. This is done by using the skills of data collection. Observation, interview, examination and medical record review are four methods the nurse uses to collect data. Although there are multiple sources the nurse may use for data collection, the patient is always the primary source. Even if the patient is unable to communicate verbally, the nurse can elicit valuable data by using observation and examination skills. Additional data sources may be the patient’s past medical record (chart), significant others and other person giving care to the patient. Professional journals, reference texts and clinical nurse specialists are also important sources of data.
Nursing observations result in objective of data. Objective data are factual data that are observed by the nurse and could be noted by any other skilled observer. During interaction, the nurse must be using his or her clinical eye. The nurse describes the signs or behaviors observed without drawing conclusions or making interpretations At this point the nurse focuses or establishing a comprehensive data base about the patient. Premature interpretation and analysis based on incomplete data may lead to errors.
Contrasted with objective data are subjective data. Subjective data consist of information given verbally by the patient. Examples of this type of data are the following statements:
“I feel so nervous”
“My stomach is burning”
“I want to be alone now.”
From the examples of subjective data listed above each nurse could infer many different interpretations. For example, the nurse might guess that the patient is nervous, fearing a diagnosis of cancer. This interpretation is not justified on the basis of the patient’s statement. The patient could be nervous for many different reasons. The task during data collection in merely to observe, collect and record data.
OBSERVATION
Observation is a high level nursing skill that requires a great deal of practice. The skills of observation and recall are difficult, but like all other skills, they can be learned with systematic study and practice. An inexperienced student nurse will find it hard to perform nursing tasks and simultaneously continue the observation process, yet it is this ability to perform constant, ongoing observation that is essential to assignment. For example, nursing student giving a first bed bath are concentrating so hard on the task that they may be unable to make observation or converse with the patient. As students gain skill in giving physical care, they can shift there attention to the total patient and begin to collect data through observation. They are now able to observe the skin condition, color, and temperature while bathing a patient. The quality, depth, and effort of respirations can be noted. The ability of the patient to move, as well as any pain associated with movement, is noted. While giving a back rub, the skilled student can view the skin over the lower back, which is often an area of breakdown. The condition of the mucous membrane is noted during oral hygiene. The ability of the patient to tolerate activity also may be observed as the nurse watches for signs of fatigue during and after the bath.
INTERVIEW
The interview is a structured form of communication that the nurse uses to collect data. Both the ability to ask questions and the ability to listen are essential to successful interviews.
The nursing history or nursing admission assessment is one type of interview. The focus of the nursing history is the patient’s response to actual or potential health problems. As a part of this process, the nurse reviews the patient’s past health history and coping methods that have been effective or ineffective. Data related to the patient’s life-style may also help identify health risk factors. The nursing history is not a duplicate of the medical history, which has the disease process as its main focus. The purpose of the nursing history is to enable the nurse to plan nursing care for the patient. The clearly and directly conveys this purpose to the patient at the beginning of the interview. The nurse may say something like the following:
“Mr. X, I am Ms. San Diego. I am the registered nurse who will be responsible for planning the nursing care you will receive while we are doing our nurse-patient interaction. I would like to spend about a half hour with you now talking about your health history and completing this nursing health history form. This information will help me work with you to begin to plan your nursing care. It is important that I tell you I will be sharing some of what we talk about with my professor and staff at clinical conference. I will not be sharing any information with your wife or children without your permission. If I feel a piece of information may be helpful, I will ask you first if I may share it”.
Note that the nurse has introduced herself in a professional manner and has clearly stated her professional accountability. This introduction is in contrast to “Hi, I’m Rose and I’m your nurse. I need to ask you some question.”
Before beginning the nursing history, the nurse helps make the patient as comfortable as possible. This would include assessing for pain and doing what his necessary to reduce this comfort. It may also be helpful to offer the patient the opportunity to go to the bathroom before beginning. Note that the nurse in the above example also gave the patient some indication of the amount of time the interview would take. This is helpful to a patient who may be expecting visitors. The nurse may also offer the patient a beverage if that is medically permitted. This may help put the patient at ease and contribute to openness in the interview process. It is also helpful if the nurse sits during the interview at a level where I contact between the nurse and the patient can be easily maintained. This reduces the superior ( nurse standing) – inferior (patient in bed) feeling of the nurse-patient relationship and conveys that the nurse has time to listen.
PHYSICAL EXAMINATION
Before the beginning of physical examination, the nurse established a relationship with the client. The nurse provides for the patient’s privacy and asks permission for the physical examination to proceed. The nurse is then ready to begin a physical examination of the patient. The nurse may choose to conduct a total body assessment or to focus on one or more specific areas, such as lung sounds, body built or a wound or any deformities.
In obtaining this examination data, the nurse uses a systematic approach to avoid omissions. The nurse may follows a cephalocaudal (head-to-toe) approach, which begins with an assessment of the hair, skull, eyes, ears, nose, mouth and facial skin and moves it downward direction. The nurse may select a body system approach, which may begin with a consideration of the respiratory system, moving to the digestive system then to the cardiovascular system and so forth. Any methodological, through approach is acceptable as long as it meets the need to gather relevant data that helps identify health problem.
There are four ways in physical examination:
1. Inspection – this is coupled with the use of the senses such as hearing, smelling and seeing the patient’s body. It is often the most appropriate starting place for a physical examination because the nurse will not cause the patient any discomfort.
2. Auscultation – This includes listening with a stethoscope to heart, lungs, and bowel sounds.
3. Palpation – this is use to feel or touch some part of the body. This may give the nurse information about organ position, body temperature, abnormal growths, abdominal rigidity or the location of pain.
4. Percussion – the tapping of the body’s surface, usually with the fingers. This is done to elicit responses, usually in the form of sound or movement that give information an underlying body part.
While it is necessary to establish a relationship with a patient before an examination, the examination itself can be a tool for showing concern and enhancing the relationship. It is the standard of care in most settings that the nurse takes five vital signs: temperature (TPR), blood pressure (BP), and pain. The first four vital signs have been well integrated into nursing practice.
MEDICAL RECORD REVIEW
The final activity in data collection is medical record review. The nurse reads a medical record (patient chart) to add to the comprehensive assessment. There are several purposes for reading the record:
To guide the other activities of data collection based on high frequency health problems associated with medical diagnoses and treatments identified in the chart.
To relate the past health care history of the patient to the present episode
To identify what medication the patient is taking so that the assessment can include the effectiveness of the medication and the occurrence of any side effects
To understand interdisciplinary care planning, since each discipline evaluates the patient and records its conclusion and recommendation in the chart
To understand the nursing diagnoses and interventions in past episode in order to build on them
To determine the presence and content of advance directives, that is, patients’ written wishes regarding the extent and continuation of medical treatment in the event that they are unable to speak for themselves.
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