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6 LAYING THE FOUNDATION
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UNIT 1
for clinical justication. For example, if a person complains of increased incidences
of asthma in the mornings, the nurse should inquire about a history of heartburn,
also known as gastro-oesophageal reux disease (GORD). There is a documented
scientic link between GORD and asthma, in that many consumers who have one
condition are likely to have the other, and GORD may make asthma worse.
evaluation process examines the validity of the information and
The
hypothesis to allow the nurse to develop a judgement of the issue. For example,
the nurse assesses the incidences of GORD for the individual, and nds that when
the GORD is well controlled, their asthma is also less active. Therefore, a goal in
controlling their asthma will be to control their GORD as well.
Self-regulation via reective practice is a key component of the critical-
thinking process. During this process, the nurse reects on the critical-thinking
skills that were used and then determines which techniques were effective and
which were problematic. After interviewing a consumer, the nurse reects on
whether leading, biased or judgemental questions were asked. The nurse might also
reect on the use of open-ended questions and the effectiveness of an interpreter.
The recognition of both positive and negative outcomes is crucial to developing
higher-level thinking skills and professional expertise, but is often the most difcult
skill to develop without assistance. This is why most professional nursing programs
require students to engage with the reective process and to demonstrate a base
level of competency for this skill.
CRITICAL THINKING AND THE NURSING PROCESS
Critical thinking and clinical reasoning are essential for nurses in contemporary
health environments. In practice, these skills direct nurses to intervene effectively
and at the right time to keep consumers from deteriorating. In most cases, people
will have different levels of complexity requiring management; the nurse will need
to be able to decide which health problems must be prioritised. In order to do this,
the nurse must use critical thinking and clinical reasoning skills to enable safe and
effective assessment and prioritisation of health problems. In health care, using
frameworks helps standardise this type of thinking and guides decision making to
focus on consumer safety.
There are many frameworks for critical thinking used by the healthcare
professions. The nursing profession has developed its own unique tool to frame
critical thinking: the nursing process. The nursing process is described in
different ways, such as a four-, ve- or six-phased process:
> APIE: Assessment, Planning, Implementation and Evaluation
> ADPIE: Assessment, Diagnosis, Planning, Implementation and Evaluation
> APOPIE: Assessment, Patient problem, Outcomes identication, Planning,
Implementation and Evaluation.
In Australia and New Zealand these frameworks are also referred to as clinical
reasoning, as they assist practitioners with their critical thinking to apply
knowledge for clinical purposes. In this text we are using a simplied process of
Assess (including problem identication), Plan, Implement and Evaluate (APIE) as
the overarching organising structure to undertake physical examination. Once a
beginner nurse has a good understanding of this basic skills framework to assist in
the clinical reasoning process, a similar but more advanced approach to explain
how clinical reasoning should be approached is useful (see Figure 1.1). Decision
making, however, is also tied to scope of practice, so please refer to your national
competency standards (web links below) as well as your employer’s local regulations
on scope of practice within the organisation.
> Australia: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-
Statements.aspx
> New Zealand: http://www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/
Registered-nurse
THE NURSING ROLE IN HEALTH ASSESSMENT ANDPHYSICAL EXAMINATION 7
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Regardless of which nursing process framework is used, it remains dynamic and
uses information in a meaningful way through problem-solving strategies to place
the person, family or community in an optimal health state. The primary focus of
this text is assessment and what to do with that assessment. Physical, emotional,
mental, developmental,
spiritual and cultural assessments provide the foundation
for the other phases of the nursing process.
APIE has been used in this text for the layout of each chapter. It is used to
organise the knowledge required and the processes that the nurse will need to apply
to implement and evaluate the health assessment and physical examination of
patients across the life span. Health assessment and physical examination are the
basis for identifying health problems and deciding what nursing actions need to be
taken. Levett-Jones et al. (2010) have researched and rened a process that assists
nurses to extrapolate the critical thinking and clinical reasoning inherent in the
nursing process for applied nursing practice (see Figure 1.1).
The clinical reasoning cycle (Figure 1.1) is presented here in the broader view, and
the APIE way of organising information in each chapter forms the rst four parts
of the clinical reasoning cycle (e.g. consider the consumer’s situation, collect cues/
information, process information, identify problems/issues) used in caring for the
person. We have used the APIE process to present most of the content in this text,
and the clinical reasoning cycle is specically applied in each chapter that has a
consumer case study so you can see application to practice.
CHAPTER 1
Contemplate what
you have learnt from this
process and what you
could have done
differently.
outcomes
Evaluate the effectiveness
of action outcomes.
Ask: ‘Has the situation
improved now?’
Select a course of action
from different
alternatives available.
Evaluate
Describe or list
facts, context,
objects or people.
Reect on
process and
new learning
Take
action
Describe what you
want to happen: a
desired outcome, a
time frame.
Consider
the consumer
situation
CLINICAL
REASONING
CYCLE
Establish
goal(s)
Collect cues/
information
Process
information
Identify
problems/
issues
Synthesise facts and
inferences to make a
denitive diagnosis of
the consumer’s problem.
Review current information (e.g. handover
reports, consumer history, consumer charts,
results of investigations and nursing/medical
assessments previously undertaken).
Gather new information (e.g. undertake
consumer assessment).
Recall knowledge (e.g. physiology,
pathophysiology, pharmacology,
epidemiology, therapeutics, culture, context of
care, ethics, law etc.).
Interpret: analyse data to come to an understanding
of signs or symptoms. Compare normal vs abnormal.
Discriminate: distinguish relevant from irrelevant
information; recognise inconsistencies, narrow down
the information to what is most important and
recognise gaps in cues collected.
Relate: discover new relationships or patterns;
cluster cues together to identify relationships
between them.
Infer: make deductions or form opinions that follow
logically by interpreting subjective and objective
cues; consider alternatives and consequences.
Match current situation to past situations or current
consumer to past consumers (usually an expert
thought process).
Predict an outcome (usually an expert thought
process).
FIGURE 1.1 The clinical reasoning process with descriptors
LEV ETT-JO NES, T., HOFF MAN, K., DE MPSEY, J., JE ONG, S.Y., NOBLE, D ., NORTON, C .A., ROCH E, J. & HICKE Y, N. (2010). TH E ‘FIVE RIG HTS’ OF CL INICAL R EASONIN G: AN EDUCAT IONAL MO DEL TO ENH ANCE NURS ING STUDE NTS’ ABI LITY TO I DENTIF Y AND
MAN AGE CLINIC ALLY ‘AT RISK’ PATI ENTS. NURS E EDUCATION TODAY, 30, 515–20.
8 LAYING THE FOUNDATION
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UNIT 1
CRITICAL THINKING, CULTURAL CONSIDERATIONS
FORHEALTHCARE PRACTICE
Australia and New Zealand have diverse populations; therefore, nurses must be
able to apply cultural safety and cultural competence when undertaking health
history and physical examination. You will need to apply critical-thinking skills
to effectively embed cultural safety in caring for diverse populations, and examine
your own cultural identity to cognitively and actively provide culturally safe and
appropriate person-centred care. The cultural background of consumers has a
signicant inuence on beliefs about illness and death, and how illness and pain
are experienced and expressed. In the health system, it is important that healthcare
providers recognise that they hold power over consumers by the very nature of
the structure and practice of their roles (Shephard et al., 2019). Being aware of this
power helps to mediate the way providers interact with people in their care. Every
consumer has the right to safe healthcare provisions that respect their cultural
worldview, linguistic diversity, cultural practices and ways of viewing health
(Jongen, McCalman & Bainbridge, 2018). This means we need to be aware of and
mediate for racial bias.
Racial bias exhibited by health professionals affects the health care of
consumers in multiple ways. The research shows ‘racial bias at structural,
institutional and interpersonal levels’ produces healthcare disparities through
multiple pathways (Yearby in Jongen et al., 2018: 24). Racial bias occurs in policies,
legislation and the allocation of resources within and between institutions, as well
as the individual behaviour of health professionals. It affects how people are treated,
regarded and even believed. A negative inuence of a health provider’s racial bias
also affects communication and therefore all consumer interactions (Shen et al.,
2017). Therefore, there are serious implications not only for consumer–provider
interactions but also for treatment decisions and the individual’s health outcomes
when racial bias goes unexamined and unchecked.
CULTURE
In this textbook we take the approach that culture is a learned and socially
transmitted orientation and way of life of a group of people. Culture enables
members of large groupings of people to nd coherence and to survive in the world
around them through the development of unique patterns of basic assumptions and
shared meanings (Chao, Kung & Yao, 2015). The cultural beliefs, values, customs
and norms that result from these assumptions and meanings shape how the group
members think, act, and relate to and with others, as well as how they perceive
aspects of life such as time, space, health, illness, and family, spousal, parental, work
and community-member roles. The beliefs, values and norms of a cultural group are
passed informally from one generation to another and exert a powerful force on all
group members.
Over the last ve decades, healthcare services and providers globally have
recognised the vital importance of respecting and responding appropriately to a
consumer’s culture and cultural worldview when providing health care (World
Health Organization, 2020). In this way consumers are not harmed or injured
through ignorance, stereotyping or discrimination based on their culture, and they
can feel safe and comfortable to engage with and receive care.
Dening cultural competence and cultural safety
In the Australian and New Zealand health contexts, two key approaches
that relate to the provision of culturally appropriate person-centred care are
cultural competence and cultural safety. These are acknowledged as guides to
the provision of safe and equitable healthcare practice and are expanded on in
thischapter.
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Cultural competence is best dened by Cross et al. (in Jongen et al., 2018:1)
as ‘a set of congruent behaviours, attitudes and policies that come together in a
system, agency or among professionals that enable the system, agency or profession
to work effectively in cross-cultural situations’. This denition is well recognised
and applied across the world, as it is inclusive of marginalised minority groups
and goes beyond ethnicity and race to encompass the diversity prole. This prole
includes gender, age, ability and sexual orientation, as these are all variables that
inuence a person’s culture, worldview and the way they view health and wellbeing.
Recent research regarding health differences also recommends that the diversity
prole incorporates different language groups and social cultural differences, such as
status of education levels (Jongen et al., 2018).
The approach of cultural safety as dened by Williams (1999) is the provision
of a safe environment that is free from assault and challenge, and accepts an
individual’s identity and needs. This includes consideration of the physical, mental,
social, spiritual and cultural aspects of an individual’s wellbeing. The main aim
of cultural safety is to respect every individual’s culture and beliefs, and to ensure
that it is free from discrimination (Australian Human Rights Commission, 2011;
CATSINaM, 2016; McGough, Wynaden, Gower, Duggan & Wilson, 2022). The
concept of cultural safety is implemented widely in the Australian and New Zealand
healthcare sectors, in response to improving the provision of appropriate health
care and improved health status of our First Nations peoples. Chapter 4, ‘Aboriginal
and Torres Strait Islander peoples’ health’, provides historical and cultural
considerations that impact the health and wellbeing of Australian Aboriginal and
Torres Strait Islander people today. Providing culturally safe health care is relevant
when caring for any person, and means the focus of care is person-centred.
Given these two denitions, providing culturally competent care means to
take a culturally safe approach to healthcare provision to ensure that everyone
has equitable access to safe and respectful health care, while cultural safety
encompasses the approach that a health practitioner should take to each consumer
care interaction. What this means, in practice, is to create an environment that
is composed of trust, equal power and a genuine partnership. In the next section
these two approaches will be explored in more detail and related to the healthcare
context and the role of the healthcare professional.
CHAPTER 1
Cultural competence
The approach to cultural competence has shifted and merged to encompass many
things over the last ve decades. It was originally developed and became a model of
social justice born out of the civil rights movement in the USA (Rosenjack Burchum,
2002). This was part of a response to improve health care in minority population
groups, who were marginalised through discriminatory policy that created processes
and procedures that limited access to basic rights and health care.
In today’s society, we continue to witness through popular media the atrocities
being carried out by extremist groups or individuals who seek to punish and harm
others because of their culture. This portrays a lack of respect for differences in
culture, language, faith, geographical location, laws and practices. In Australia
and New Zealand, we have diverse individuals from different cultures, who may
have ed their homes and nations because of acts of genocide, poverty and more.
As a result, they often arrive traumatised, impoverished, and in poor health care
(Department of Health, Victoria, 2022). Although it can be challenging, it is
important to understand and acknowledge the signicance of the impact that
discrimination has, particularly if you have not been exposed to being penalised as
a consequence of your culture. How we as health professionals care for people in
these situations can either extend the trauma and harm they have experienced, or it
can make a positive difference and provide a safe healthcare encounter.
Over time, there has been an increased recognition of the need to address
issues that go beyond those associated with cultural differences. As a result, the
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UNIT 1
concept of cultural competence has developed to encompass a more inclusive focus
on diversity in population groups, with healthcare providers striving to identify
and respond to all forms of bias and stereotyping. Identifying biases, redressing
historical and ongoing experiences of racism and discrimination, and focusing on
the social determinants of health, have all come to be included within the scope of
cultural competence (Jongen et al., 2018).
In Australia and New Zealand, cultural competence is a key priority in addressing
healthcare inequalities related to access and quality of care for cultural groups (AIHW,
2015). An important point here is that cultural competence cannot be achieved
in the short term, or by an individual. Creating a culturally competent healthcare
system is a cumulative process: there is not one single step or action that can be
taken to accomplish overall cultural competence, nor can a single person’s behaviour
change the entire system. It requires commitment at all levels – systemic, professional
and consumer-care – to change processes and behaviour, in order to create improved
healthcare outcomes for everyone (Sherwood & Russell-Mundine, 2017).
Cultural safety
Cultural safety is a concept that builds on cultural competence, with specic
relevance for Australia and New Zealand. It was developed in the 1990s from the
work of Maˉori nurse and scholar Irihapeti Ramsden. In cultural safety, the term
‘safety’ is used because the concept is about preventing the injury that often occurs
when a health professional is racist, discriminatory or rude to a consumer. ‘Unsafe
cultural practice comprises any action that diminishes, demeans or disempowers the
cultural identity and wellbeing of an individual’ (Nursing Council of New Zealand,
2020). Extreme, but unfortunately not uncommon, examples include cases of
Aboriginal people who have died unnecessarily in mainstream healthcare settings,
as a result of culturally unsafe health care.
The concept of cultural safety goes beyond the recognition of cultural
differences, to acknowledge the circumstances that have historically led to some
individuals and groups being marginalised, and aims to recognise the social
determinants that affect their health outcomes. This includes, notably, First Nations
peoples in both New Zealand and Australia, who suffered personal and institutional
marginalisation by new settlers to their countries, but also people with disabilities
or mental illness, LGBTQI+ people, and older adults. These are all groups who have
been, and in many cases continue to be, marginalised by social institutions. People
in these groups have historically not been allowed to fully participate in decisionmaking processes that affect all aspects of their lives (Richardson, 2015).
Unlike cultural competence, cultural safety is an approach that can be practised
by an individual. The pathway to culturally safe person-centred care involves six
phases (Dementia Training Australia, 2017; see
personal cultural awareness at an individual level, recognising that there are
differences between your own and other cultures, and reecting on the effects of
those differences. It also includes gaining an understanding of another culture,
and learning to respond respectfully, with cultural safety the overall aim (National
Aboriginal Community Controlled Health Organisation, 2011).
It is important to note that cultural competence and cultural safety go hand in
hand. This means that for a consumer to feel culturally safe is also dependent on
the nurse being culturally competent (AIDA, 2018). To provide culturally safe and
culturally competent nursing care, the nurse must rst be willing and able to confront
their own cultural biases, or ethnocentrism, and stereotyping, to whatever extent
they exist. Nurses then need to examine the impact these biases may have on the
consumer, with an intention to adjust their future interactions and practice.
Five essential elements contribute to your ability to become more culturally safe:
1. Reect on your own practice.
2. Seek to minimise power differentials.
3. Engage in discourse with the patient.
Figure 1.2), and starts with developing
THE NURSING ROLE IN HEALTH ASSESSMENT ANDPHYSICAL EXAMINATION 11
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4. Undertake a process of decolonisation.
5. Ensure that you do not diminish, demean or disempower others through
your actions (Best, 2018).
It is also important to note that whether nursing practice is culturally safe or
unsafe is determined by the person or family who is receiving care. Knowing how
to deal with one individual or group in a culturally safe manner does not mean
you are automatically able to do so with another group or in another context; it
needs to be taken on a case-by-case basis, with awareness of the specic needs of the
person/group you are providing care for. These considerations for cultural safety and
how this impacts the nurses’ behaviours are very important for comprehensive and
effective health assessment and physical examination.
Cultural Safety
Cultural Competence
(Ability to interact effectively
with people of another culture)
Cultural Respect
(Responsiveness to another culture)
Cultural Knowledge
(Factual understanding of a culture)
CHAPTER 1
(Self-reection on the effect of differences between cultures)
(Realisation of differences between one’s own and another culture)
FIGURE 1.2 The pathway to culturally safe person-centred care
DTA (FEB RUARY 20 17). CULTUR AL ASSES SMENT FO R ABORIGI NAL AND TO RRES STR AIT ISL ANDER PE OPLE WI TH DEMEN TIA GUIDE F OR HEALT H PROFES SIONAL S. DEMENT IA
TRAINING AUSTRALIA. RETRIEVED FROM: WWW.DEMENTIATRAININGAUSTRALIA.COM.AU.
Cultural Sensitivity
Cultural Awareness
ASSESSMENT: TAKING THE PATIENT’S HEALTH HISTORY
Assessment is the rst phase of the nursing process, and in this text also includes
identifying consumer problem areas to focus on. It is the orderly collection of
information concerning the individual’s health status using the health history and
identifying areas for opportunistic health promotion.
The health history interview is a means of gathering
usually from the individual or, in the case of children (or adults unable to answer
questions), close family members. This data is subjective in that it cannot always
be veried by an independent observer. Subjective data includes what the person
says, and is regarded as the person’s attitudes and beliefs. In some instances,
however, this information can be validated during the physical examination;
for instance, the existence of an individual’s self-reported breast lump may be
conrmed throughpalpation.
The health history can also be obtained from sources other than the person.
Relatives and friends can provide insightful data for the health history. In some
instances, bystanders may be the only source of information; for example, in the
case of a severe trauma in which the individual is unconscious. The consumer’s old
charts or medical records are additional sources of information, as are healthcare
colleagues. The nurse can and should use every available medium to gather as much
information about the person as possible. The health history is further discussed
in Chapter 3. However, you must remember that in most cases the consumer is the
primary source of information for good reason, as others around them will only be
able to provide information through their own biases, perceptions and motivations,
which can at times not be as accurate as consumer-held data.
subjective data,
12 LAYING THE FOUNDATION
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UNIT 1
PLANNING FOR PHYSICAL EXAMINATION
Planning (including goal setting) is the second phase in the nursing process and
in this text refers to evaluating subjective data collected during the health history
in order to narrow the focus for the collection of physical examination data. Within
the planning phase, the nurse considers what additional objective data needs to
be collected or validated. Planning for a successful physical examination requires
consideration of the environment and equipment required. Throughout the text
you will nd checklists to use in planning for the physical examination specic to
the body system focused on in each chapter.
IMPLEMENTATION: CONDUCTING THE PHYSICAL
EXAMINATION
The third phase in the nursing process is implementation. In this phase, the
nurse executes physical examination based on the health history, using clinical
reasoning to progress through the assessment. Within this section of the text, skills
for physical examination are outlined within a framework specic to the chapter
focus (e.g. inspection, palpation, percussion, auscultation), along with normal and
abnormal ndings. Where appropriate, further information to support advanced
examination is provided and highlighted. As some techniques fall outside the scope
of many Registered Nurses (e.g. anal Pap testing) in Australia and New Zealand, they
are included as online resources.
Implementation is a dynamic process. The nurse is continually interacting with
the consumer or family, during the examination. During this time, new information
may be uncovered which may reshape the focus of the examination. The nurse
will use clinical reasoning to determine the inclusion or exclusion of specic
examination techniques to ensure a complete picture is constructed.
ALAMY STOCK PHOTO/GLOW WELLNESS
FIGURE 1.3 Physical examination is one
component of building a comprehensive
picture of the patient’s health status.
Physical examination ndings
Physical examination ndings constitute the second means of obtaining
information (or collecting cues/information) used in the clinical reasoning cycle.
Physical examination ndings constitute
observable and measurable and can be veried by more than one person. This data
is obtained using the senses of smell, touch, sight and hearing. This text describes
the systematic approach and level of foundation to advanced physical examination
techniques that will elicit this data (see Chapters 6–20).
Physical examination data can be obtained in a body system or head-to-toe
approach. Table 1.3 lists the body systems that are examined. Other approaches to
physical examination exist, such as Gordon’s Functional Health Patterns, which
group human behaviours into 11 patterns that facilitate nursing care (Gordon,
2006). Table 1.4 lists the functional health patterns. This text, however, uses
the head-to-toe, body systems approach for physical examination, as this is a very
common approach in most clinical contexts.
objective data, or information that is
Diagnostic and laboratory data
The nal information that needs to be gathered in collecting data/information is
any diagnostic and laboratory data that is relevant to the consumer’s complaint.
Results of blood and urine samples, cultures, X-rays, and various diagnostic
procedures constitute objective data, which further contribute to understanding
the consumer’s overall health status. The collection of some of this data cannot be
initiated by the nurse and may require an order by the medical ofcer (depending
on the scope of practice of the nurse).
It is imperative that the nurse documents all the examination ndings. The
written record is a legal requirement used to chart the consumer’s current health
status. Chapters 3 and 22 discuss documentation and cover the legal issues of the
THE NURSING ROLE IN HEALTH ASSESSMENT ANDPHYSICAL EXAMINATION 13
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TABLE 1.3 Body system examination
1. General survey, vital signs and pain
2. Mental status and neurological techniques
3. Integumentary
4. Head, neck and regional lymphatics
5. Eyes
6. Ears, nose, mouth and throat
7. Breasts and regional nodes
8. Respiratory
9. Cardiovascular
Gastrointestinal
10.
11.
Musculoskeletal
12.
Genitourinary
TABLE 1.4 Gordon’s Functional Health Patterns
1. Health perception–health
managementpattern
2. Nutritional–metabolic pattern
3. Elimination pattern
4. Activity–exercise pattern
5. Sleep–rest pattern
6. Cognitive–perceptual pattern
7. Self-perception–self-concept pattern
8. Role–relationship pattern
9. Sexuality–reproductive pattern
Coping–stress-tolerance pattern
10.
11. Value–belief pattern
health record. The documented health assessment and physical examination also
serves as a means of communicating information to other healthcare colleagues.
It is often valued over other forms of communication by clinicians and is a key
contributor to safety.
CHAPTER 1
ANDBA RTLET T.
SOURCE: MANUAL OF NURSING DIAGNOSI S (11TH ED.), BY M. GOR DON, 200 6, SUDBUR Y, MA: JONES
EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION FINDINGS
Evaluation is the nal phase of the nursing process. In this text we have used
evaluation to draw together all information collected during the health assessment
and physical examination to identify what needs to occur next. Within Chapters
6–20, the documentation and evaluation of a consumer case study pertinent to the
chapter content is provided to enable you to determine how information can be
grouped and documented. At the end of the case study, documented information
is presented in a section titled ‘Evaluation and clinical reasoning for case study’.
Within this section the specic data is linked to processing information as described
in the clinical reasoning cycle (see
Figure 1.1) by interpreting, discriminating, relating,
inferring, matching and at times predicting. The synthesis of the data that informs
clinical reasoning specic to the consumer and their context is thendiscussed.
Putting it all together
It is here that we highlight the clinical reasoning that would accompany the
collection of information and possible actions required, in order to address priority
patient needs or prepare goals for consumers and health teams to achieve. These
phases are indicated with the headings of Consider the consumer situation, Collect
cues/information, Process information and Identify problems/issues in these
consumer case studies. Examples of what the nurse would ‘do’ with this information
next are listed and prioritised.
A nursing-related consumer problem requires the nurse to work with
the consumer to develop and implement interventions that do not need other
disciplines. The nurse needs to ensure they remain within their scope of practice in
undertaking interventions that are nursing initiated.
A collaborative consumer problem requires the nurse to work jointly with
the specialist doctor and other healthcare workers in monitoring, planning and
implementing person-centred care (Figure 1.4). Some consumer problems are not
ISTOCK.COM/SOLSTOCK
FIGURE 1.4 Nurses may collaborate with
social workers, specialist doctors and
other members of the healthcare team to
maximise person-centredcare.
14 LAYING THE FOUNDATION
Self-
actualisation
Self-esteem
Love and belonging
Safety and security needs
Physiological needs
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UNIT 1
completely within the domain of the nurse’s scope of practice and therefore require
the nurse to collaborate with other healthcare team members. For instance, the
consumer experiencing cardiac tamponade (medical level problem) with decreased
cardiac output and anxiety (nursing level problem) needs immediate nursing and
medical attention. The nurse is not ethically or legally permitted to do all that the
situation requires to alleviate the tamponade; the nurse, specialist doctor/nurse
practitioner, and healthcare team will work collaboratively to relieve the problem.
Prioritisation for consumer acuity
The nurse identies actual and potential patient problems and opportunities for
health promotion that are derived from the
more than one health problem, the nurse must determine which problem(s)
is/are the most vital to the individual’s wellbeing at that particular time; this is
called prioritisation. It is necessary to
health problem and to do this accurately over time. Critical-thinking and clinicalreasoning skills must be applied systematically. When possible, the patient should
assist the nurse with the prioritisation of needs. Individuals who are actively
involved with the decision-making process are more likely to be amenable to
nursing care, to assist with their care, and to be agreeable to the plan of care.
A theoretical framework that can be used to prioritise nursing diagnoses is
Maslow’s Hierarchy of Needs (
Figure 1.5). According to Maslow, basic needs such as
food and oxygen take priority over all other issues.
used to describe how unwell a person is or how urgent their healthcare needs are:
the sicker the person, the higher their acuity (it is also used to predict how many
people are needed to be able to provide safe care for the person’s acuity level)
(DiClemente, 2018). For example, the person experiencing a myocardial infarction
is seen as high acuity and must have their physiological needs met before safety
needs are attended to. In some instances, however, a person’s needs may not follow
Maslow’s hierarchy, or they may change over time, requiring reprioritisation of the
health problem. The person with terminal breast cancer may be more concerned
with playing with their children than staying well hydrated. Some problems
are equally important and can be prioritised at the same level. The nurse, in
conjunction with the consumer and their family, is continually re-evaluating and
revising the priority of the problems.
clustering of data. When there is
prioritise, or rank, the importance of each
Consumer acuity is a term
FIGURE 1.5 Maslow’s Hierarchy of Needs
ADAP TATION BAS ED ON MASLO W’S HIER ARCHY OF N EEDS.
THE NURSING ROLE IN HEALTH ASSESSMENT ANDPHYSICAL EXAMINATION 15
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Evidence-based practice
There is an imperative in health care for evidence-based practice. No longer are
healthcare practices being implemented ‘because they have always been done that
way’; nor are they being enacted intuitively. Rather, evidence-based practice uses
the outcomes of well-designed and well-executed scientic studies to guide clinical
decision making and clinical care. For example, the use of wound-care dressings
and interventions for chronic wounds in people with peripheral arterial disease
has undergone drastic changes in the last 10 years. Within the health assessment
and physical examination, an example of using evidence to guide practice may be
that we now ask individuals about their intention to quit smoking instead of just
advising them that they should. Research into behaviour changes identies that
linking consumer intentions to desired behaviour engages individuals in their care
more than just providing information or advice. The ultimate goal of evidencebased practice is to assist the person’s quality of life by improving outcomes. It
remains the nurse’s own responsibility to ensure currency with evidence.
CLINICAL (OR CRITICAL) PATHWAYS
Clinical pathways affect how and when we assess a consumer’s health status.
Clinical pathways are used as a cost-effective, high-quality patient care delivery
system.
consumer health goals over a period of time; that is, they state what activity
the person should be capable of performing daily, on the basis of the consumer’s
Diagnostic-Related Grouping (DRG). The critical incidents, or most crucial nursing
interventions for each step of the pathway, are delineated.
from expected
collaboration with other healthcare team members, plan and implement specic
interventions to deal with the variance. Evaluation is performed daily and,
although the terminology is different, clinical pathways incorporate the assessment,
planning, implementation and evaluation phases of the nursing process.
Clinical pathways or maps show the outcome of predetermined
One of the advantages of clinical pathways is the early recognition of variances
health outcomes. Once the variance is identied, nurses, in
CHAPTER 1
CHAPTER RESOURCES
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