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Clinical governance

As in all aspects of care, nurses must be aware of their ethical and legal responsibilities when assessing patients. Issues of honesty and confidentiality are frequently encountered during assessment (Wilkinson [91]).
Physical assessment is an advanced skill. While nurses may be able to practise skills through reading and work‐based learning, many courses are available to help them learn in a structured fashion. It is essential to have a solid understanding of anatomy and physiology, interpretation of findings, and knowledge of appropriate actions to take.
This chapter gives a basic overview of the techniques used when physically assessing patients. In order to perform physical assessment safely, nurses will require further education and supervised clinical experience to ensure competence. The Nursing and Midwifery Council's Code (NMC [55]) states that all nurses must be accountable for their actions and omissions and must practise within their sphere of competence at all times.

Consent

The Royal College of Nursing ([72]) states that registered nurses must ensure consent is obtained and clearly documented prior to commencing any procedure or treatment. Before gaining consent, information about the procedure should be given to the patient in a clear, honest and jargon‐free manner (NMC [55]).
According to Burns et al. ([12]), there are three main components of valid consent. To be competent (or to have the capacity) to give consent, the patient must:
  • understand the information that has been given
  • believe that information
  • be able to retain and evaluate the information so as to make a decision.
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