INTRODUCTION

Every person requiring healthcare will need assessment prior to instigation of any treatment. Data concerning their health status is usually collected by the first health professional they meet. Often it is the admitting nurse who collects the person’s health history and investigates their presenting complaint. Accurate data collection forms the basis of their management.

Physical examination and health assessment are skills that are used on a daily basis in the clinical setting. In order to be able to accurately perform these skills, you require an understanding of the structure and function of the system to be examined, signs and symptoms associated with that system, as well as extensive practice with the examination skill components, to develop a beginning proficiency.

By completing the readings, activities and review questions, then preparing and performing the clinical components identified throughout the student laboratory manual you will begin to develop your skills in physical examination and health assessment. The laboratory manual will provide a guide to the development of these skills, but further reading, self-directed learning and ongoing practice will be required to actually develop proficiency and to feel comfortable when performing the examinations.

In order to be able to assess and examine your patients you must have a thorough understanding of what data to collect, how to obtain the data and factors that may influence the data.

PURPOSE

Chapter 1 introduces concepts related to data collection, determinants of health, evolving definitions and models of health. As the purpose of the health assessment is to make a judgment or diagnosis, the chapter outlines how the data gathered during assessment varies with the physical condition of the person, their developmental stage, their place in the life span and their culture. This data will enable you to make informed decisions about the person’s health status and their subsequent management. The chapter provides an overview of types of data, approaches to health assessment, cultural and life span considerations that are required when performing examinations. Concepts of professional nursing and associated codes of conduct, ethics and competency standards are introduced. These concepts will be revisited in future chapters.

KEY CONCEPTS

• Assessment

• Data types

• Data collection

• Definitions of health

• Determinants of health

• Models of health

• Health promotion and disease prevention

• The profession of nursing

While you are completing your reading assignment, ensure you understand each of the key concepts listed above.

READING ASSIGNMENT

Jarvis, Forbes & Watt (JF&W): Jarvis’s Physical Examination and Health Assessment, Chapter 1, pp 1–4.

GLOSSARY

After reading the corresponding chapter in the text, learn the following terms. You should be able to cover the definition on the right and state the associated definition in your own words.

Assessment the collection of data about an individual’s health state; the point of entry in an ongoing process

Biomedical model western tradition that views health as the absence of disease

Database subjective and objective data plus patient’s record and laboratory studies

Environment the total of all the conditions and elements that make up the surroundings and influence the development of a person

Holistic health consideration of the whole person; views the mind, body and spirit as interdependent and functioning as a whole within the environment

Health ‘… a state of complete physical, mental, and social well-being and not merely the absence of disease, or infirmity …’ (The World Health Organization (WHO), 2001); an emerging state and not merely the absence of disease; state of wellbeing influenced by social, economic, cultural and political factors

Health prevention emphasises the link between health and personal behaviour; is achieved through counselling by primary care providers which is designed to change people’s unhealthy behaviours related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries and sexually transmitted infections. Any action directed towards promoting health and preventing the occurrence of disease

Health promotion WHO defined health promotion in the Ottawa Health Charter in 1986 as ‘… includes building public health policy, creating supportive environments for healthy living, strengthening community action, developing personal knowledge and skills, and reorienting the healthcare system’ (Talbot and Verinder, 2010).

Nursing ‘… collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people …’ (International Council of Nurses (ICN), 2010)

Objective data what you as the health professional observe by inspecting, percussing, palpating and auscultating during the physical examination

Social determinants of health ‘… are the conditions in which people are born, grow, live, work and age, including the health system.’(WHO, 2008)

Subjective data what the person says about themself during history-taking

Wellness is a dynamic process, a move towards optimal functioning

STUDY GUIDE

After completing the reading assignment, you should be able to answer the following questions in the spaces provided.

1. State whether the following data type is objective (O) or subjective (S) by placing the letter after each of the following:

temperature (T),__________ pulse (P)__________ and blood pressure (BP)__________

pain__________

blood sugar level (BSL)__________

weight__________

anxiety__________

lung sounds__________

2. A database includes the following four elements:

i. ___________________________________________________

ii. ___________________________________________________

iii. ___________________________________________________

iv. ___________________________________________________

3. State the purpose of the health assessment.

___________________________________________________

4. What factors must be considered when performing a health assessment?

___________________________________________________

5. Consider your own definition of health, and then review the WHO definition of health. Do they differ? If so, how?

___________________________________________________

6. Outline why the social determinants of health are responsible for health inequities.

___________________________________________________

7. Outline the social and biomedical models of health. What are their aims, key focuses and limitations?

___________________________________________________

8. When considering holistic health, identify the key premise concerning the person. How does holistic health differ from other models of health? Who may be involved in specific management of the patient?

___________________________________________________

9. Discuss why health promotion and disease prevention are key concepts related to health.

___________________________________________________

10. Relate each of the following concepts of health to the process of data collection: biomedical model

___________________________________________________

wellness

___________________________________________________

holistic health

___________________________________________________

health promotion and disease prevention

___________________________________________________

11. Develop your own definition of what nursing is. Reflect on this in light of the ICN (2010) definition.

___________________________________________________

12. Review the appropriate professional codes of conduct and codes of ethics for your country of practice. (Australian Nursing & Midwifery Council: Code of ethics for nurses in Australia, 2008. Code of professional conduct for nurses in Australia, 2008. Midwifery competency standards, 2006. National competency standards for the registered nurse, 4th edn, 2006a. Nursing Council of New Zealand: Code of conduct for nurses, 2009. The competencies for registered nurses, 2007. New Zealand College of Midwives: Code of ethics.) Ensure you are familiar with the content of the relevant documents.

13. Explain why it is important to assess a patient thoroughly prior to planning and implementing management.

___________________________________________________

14. What influence will a patient’s age have on their nursing management?

___________________________________________________

REVIEW QUESTIONS

This test is for you to check your own mastery of the content. Answers are provided in Appendix A.

1. The concept of health has expanded in the past 40 years. Select the phrase that reflects the narrowest description of health.

a. the absence of disease

b. a dynamic process towards optimal functioning

c. depends on an interaction of mind, body, and spirit within the environment

d. prevention of disease

2. Select the most complete description of a database.

a. subjective and objective data gathered from a patient

b. objective data obtained from a patient through inspection, percussion, palpation and auscultation

c. a summary of a patient’s record, including laboratory studies

d. subjective and objective data gathered from a patient plus the results of any diagnostic studies completed

3. Which of the following statements is incorrect concerning the development of the professional code of conduct, code of ethics and competency standards?

a. They provide regulatory bodies with a basis for evaluation of conduct.

b. They were developed to restrict nursing practice.

c. They outline minimum standards for nurses to uphold.

d. They inform the public of standards of professional conduct.

4. When assessing a child aged four, who presents with a rash and fever, in order of priority, which of the following are important considerations:

a. history from the mother of the conditions development

b. developmental stage of the child

c. communication skills that are age-appropriate

d. age-related normal findings

Select your priorities from the list below:

i. a, b, c, d

ii. d, b, a, c

iii. a, d, c, a

iv. d, a, c, b

5. The concept of health incorporates all of the following except?

a. health promotion

b. environmental context

c. healthcare system

d. disease prevention

e. social context

6. When a person accesses the healthcare system for treatment of illness, a number of factors pose potential risk for harm. These factors include all of the following except:

a. increasing age and comorbidities

b. the increasing use of complex technology

c. the use of numerous and complex interventions during an episode of illness

d. being cared for at home

e. movement between community and hospital health sectors