Reviewing and Validating Findings

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments or assumptions. Self-awareness is a crucial factor in this interaction, because perceptions, judgments, and assumptions can easily color the assessment findings.

Validation is an ongoing process that occurs during the data-collection phase and upon its completion, when the data are reviewed and compared. The nurse should review the data to be sure that the recordings are factual, to identify errors of omission, and to compare the objective and subjective data for congruencies or inconsistencies that require additional investigation or a more focused assessment. Data that are grossly abnormal are rechecked, and any temporary factors that may affect the data are identified and noted. Validation is particularly important when the data are conflicting, when the data’s source may be unreliable, or when serious harm to the client could result from any inaccuracies. Validating the information reduces the possibility of making wrong inferences or conclusions that could result in inaccurate nursing diagnoses, incorrect outcomes, or inappropriate nursing actions. This can be done by sharing the assumptions with the individuals involved (e.g., client, significant other/family) and having them verify the accuracy of those conclusions. Sharing pertinent data with other healthcare professionals, such as the physician, dietician, or physical therapist, can aid in collaborative planning of care. Data given in confidence should not be shared with other individuals (unless withholding that information would hinder appropriate evaluation or care of the client).

Summary:
The assessment step of the nursing process emphasizes and should provide a holistic view of the client. The generalized assessment done during the overall data-gathering creates a profile of the client. A focused, or more detailed, assessment may be warranted given the client’s condition or emergent time constraints, or it may be done to obtain more information about a specific issue that needs expansion or clarification. Both types of assessments provide important
data that complement each other. A successfully completed assessment creates a picture of clients’ states of wellness, their response to health concerns or problems, and individual risk factors—this is the foundation for identifying appropriate nursing diagnoses, developing client outcomes, and choosing relevant interventions necessary for providing individualized care.