The concept of "health" can be very difficult to define and many attempts have been made.

It can be seen as an ideal state, as defined by the World Health Organisation (WHO) - "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (WHO, 1948 (see Ewles and Simnett, 1992, p 6)). However, such an ideal state is unattainable.

A more realistic approach is to see health as a personal strength or ability, of which the most well-known is maybe that of Seedhouse - "a person’s optimum state of health is equivalent to the state of the set of conditions which fulfil or enable a person to work to fulfil his or her realistic or chosen and biological potentials." (Seedhouse, 1997, p 136).

A less wordy definition, which amounts to the same thing is that health is "the state of optimum capacity of the individual for the effective performance of the roles and tasks for which he has been socialised." (Parsons, 1981 (see MacLean, 1995)).

These both allow a certain amount of flexibility, whereas that of the WHO is entirely unrealistic and holds no place for, say, a very active paraplegic who competes in the Paralympics. Nor does it allow for the patient who will be discussed in this essay.

Both Seedhouse and Parsons, however, would agree that such a person, who is fulfilling their attainable potentials, can be described as "healthy". Seedhouse implies that the biological aspect is, perhaps, more important; however, Parsons, like the WHO, stresses that "health" is not merely a physical state, but also impinges, particularly, on the social state of an individual as well as the psychological aspects.

However, even this may not be enough. The term "biopsychosocial" can, perhaps be too limiting when applied to the health of the individual. Firstly, it restricts assessment to the three, admittedly main, aspects of a person’s health: namely the biological, psychological and social aspects. It could be convincingly argued that a person’s spiritual health is also important. It can also be said that a person can be "occupationally" unhealthy. While some may consider this an integral part of a person’s social health, it can also be seen as a separate issue.

That demonstrates another limiting factor. All too often, the different aspects are seen as separate entities whereas, in fact, they all interact and affect each other. When actually assessing a patient, the nurse must look at the whole person, and not just a part.

Therefore, when considering the "health" of a person, the nurse should consider all aspects of the assessment, in relation to the global picture offered by the individual.

The majority of global assessment tools used in hospitals within the Dundee area are based on Roper, Logan and Tierney’s model of living (Roper, et al, 1990). This model bases itself on 12 "Activities of Living" which all promote the process of living. The model argues that these cover all possible health problems and can form the basis of a global assessment.

These activities are:-

• Maintaining a safe environment
• Communicating
• Breathing
• Eating and drinking
• Eliminating
• Personal cleansing and dressing
• Controlling body temperature
• Mobilising
• Working and playing
• Expressing sexuality
• Sleeping
• Dying

(from Roper, et al, 1990)

However, most areas have adapted the model to suit their own needs. For example, in the surgical ward "Dying" has been removed, "Expressing sexuality" has been replaced with "Self esteem/ body image" and "Wound assessment", "Spiritual/ cultural needs", "Pain assessment" have been added. All of these changes better suit the particular area and are seen as being more relevant than the actual published model. However, the basic principles behind the model remain the same.

Sandy Beech (a pseudonym to maintain confidentiality) was admitted to the surgical ward a month after a work-related crush injury to his left index finger which had been splinted. However, his wound was not healing and he was queried as being MRSA-positive.

Sandy, a 32 year old man, appeared healthy in all other respects and this was confirmed by a global assessment upon admission. As well as the Activities of Living, a set of baseline recordings was taken.

As can be seen from his assessment, which is summarised in Appendix 1, the most important of Sandy’s health problems which required nursing intervention were related to his possible MRSA-positive status. Other problems which were identified include:-

• His pain was mild on admission and readily controlled via the use of symptomatic relief analgesia, in accordance with hospital policy.
• His wound was dressed on admission. After the dressing was taken down and seen by the medical staff, it was redressed using jelonet, a Betadine soak and dry gauze.

Sandy’s primary problems, however, lie with his MRSA-positive status. This accounts for five of the Activities of Living:-

• Maintaining Body Temperature
• Maintaining a Safe Environment
• Personal Hygiene
• Work and Recreation
• Self Esteem and Body Image

It might be seen by some that maintaining a safe environment (i.e. control of the infection) would be the main concern. However, hospital guidelines on the subject are very clear (Tayside Joint Infection Control Committee, 1996). Assessment of infection is easily achieved via the use of swabs of the nasal cavities, axillae and groins (the areas in which infection is most likely to occur) and also of the wound itself, which are sent to the hospital laboratories. Meanwhile, the patient is "Barrier Nursed" until his infection status is confirmed. The patient is started on a recognised antibiotics course, such as intra-venous vancomycin along with topical mupirocin (BNF, 1997). Once the status is confirmed, as it was with Sandy, the barrier nursing and antibiotic course will continue. Regular swabs are taken so that the patient’s infection status can be monitored.

Barrier nursing (or contact isolation) simply involves taking Universal Precautions. These include the wearing of protective clothing (gloves and plastic disposable aprons), covering any open cuts or abrasions, careful attention to hand washing techniques, and separate disposal of both linen and other waste (Mercier, 1997; Meers, et al, 1997).

Maintaining body temperature: Sandy’s temperature was closely monitored during his stay on the ward, as the infection could have caused an alteration from the norm. However, it never strayed from what would be considered normal limits.

While Sandy was able to attend to his own daily personal hygiene needs, he was advised to use an antimicrobial soap, such as Hibiscrub in order to help prevent further spread of the infection.

Body image: His MRSA-positive status meant that Sandy felt he was "unclean" and vastly lowered his self-esteem. This was also affected by anxiety about his work. Sandy worked in the catering industry and was worried that his being diagnosed with such an infamous infection would adversely affect his ability to work.

While there exists no specific tool for assessing Sandy’s body image and anxiety over his work situation, a nurse should be able to properly assess how Sandy feels and act accordingly.

When the student nurse first met Sandy, he appeared to be in fine health, with a relatively small dressing on his finger. He had been previously warned about Sandy’s MRSA-positive status. The student had encountered MRSA control methods on a previous placement and was not unduly worried, as he knew about barrier nursing.

However, Sandy seemed very anxious and very quickly started asking questions. His first concern was that he had equated "MRSA" with the so-called "flesh-eating bug". The student quickly assured him that this was not the case and sat down to try and answer any other questions Sandy may have had.

It transpired that his main worry was his ability to work. Sandy worked in the catering industry. He was assured that, from a Health and Safety aspect, there should be no problem of returning to work once his infection had cleared up. (HSE, 1988).

It can be seen that, while a specific tool does not exist for "measuring" anxiety, as one would use the Waterlow score for pressure sore risk, assessing a patient’s worries are as important, in this case possibly more important, than measuring, say, his perception of pain or whatever.

It is here that a nurse’s assessment skills come to the fore. He must show empathy with the patient, and read between the lines in a patient’s conversation. It took a while for Sandy to admit that he was worried about returning to work; a nurse who would have merely answered his specific questions on the MRSA virus, may have missed this aspect of Sandy’s worries.

With this in mind, then, it could be argued that the best assessment "tool" a nurse can use, is not the Waterlow scale, or even Roper, Logan and Tierney’s Activities of Living. Rather, it is his communication skills which he has built up over his career, which he uses every day, often unconsciously, in his day-to-day dealing with the patients.

The importance of an assessment tool should not be overlooked, as they do provide a solid basis on which to make an assessment. Nevertheless, they should not be seen as the beginning and end of assessment, which is seen as an ongoing process in all of the widely used Models of Nursing.

This essay was introduced with the concept of health, and continued with the assessment of a patient whom the author had known during the course of his clinical placement. It can be seen that the whole assessment, whichever tool or tools are used, is based on finding a suitable concept of health and comparing that with the current state of the individual client.

A lot of tools of assessment, or models of nursing, work in this way and Roper, Logan and Tierney is no exception. However, deciding upon a suitable definition of health is no easy task. The author introduced three, widely accepted, definitions of health, all of which, while having some common ground, differ in some degree.

The WHO definition of health is recognised as being an impossible goal, where health is something to be strived for, rather than attained.

Seedhouse concentrates on the physiological side of health, while acknowledging that other aspects are involved. Parsons goes a step further and infers that to be healthy, one must be able to accomplish one’s social role. Biological aspects are, therefore, understood to be an underlying part of this.

Sandy Beech is not healthy, according to the WHO definition of health, but then no-one is. According to Seedhouse, Sandy will be healthy once he has got rid of his infection and his wound is healed. However, even once this has happened, Sandy may well still have a low self-esteem and be unable to return to work, depending on the attitude of his superiors. Psychologically and occupationally, Sandy will be "unhealthy".

So, one must return to Parsons’ definition. Is Sandy going to be able to perform the "roles and tasks for which he has been socialised" (Parsons, 1981 (see MacLean, 1995))? Obviously the answer is no.

Hence, it can be seen that the concept of health is a complex one. While one individual may appear healthy according to one person, he may be unhealthy to another - and this is not restricted to health professionals. Even once Sandy considered himself healthy, once the MRSA infection was eradicated, his superiors at work may hold a different viewpoint. Even in health care settings, Sandy may well be routinely screened on any future admissions and will be referred to the Infection Control nurse (Tayside Joint Infection Control Committee, 1996), perhaps implying to Sandy that the Health Board are treating him as "unhealthy".

Therefore, it is perhaps best not to rely on any preconceived ideas of health and apply one’s own judgement to each individual case. Using one’s own assessment skills to determine the "biopsychosocial" state of a patient’s health remains the best way of laying a foundation so that one can carry on to determine, plan and carry out a client’s care.

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