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Clinical Nursing: Keeping Your Skills In-Tune

By Gary D. Goldberg, PhD
Clinical Professor of Medical Education

Assessment

  The primary duty of every nurse is the assessment of a patient’s physical and emotional well-being. This basic-skill learned in the very first nursing class is the one skill and primary duty the nurse will use every day with his and/or her patients. A complete assessment will quickly alert the nurse to the patient’s current state of health, i.e. positive or negative the findings. It is this assessment upon which he and/or she will base there ‘premises’ i.e. care-giving over the next moments during any day or evening shift. “…thinking directed towards reaching a conclusion. The reasons from which it begins are called ‘premises’; what they lead to and support is called the ‘conclusion’…” 1

  Typically in an in-patient setting a patient is assessed every few hours. In an ambulatory setting the nurse will greet the patient chart in hand and following each step of the way through. Among the body systems a nurse will assess are: Respiratory; “...the adequacy of oxygenation and ventilation is measured by partial pressure of arterial oxygen (Pao₂)…” 2 Explore the patient’s symptoms through characterization and history taking to help anticipate needs and future plan care. Circulatory; “…monitor for signs and symptoms…” 3ʹ 4 Taking the CVP, i.e. Circulating Volume Pressure, vital signs, orthostatic blood pressure, and heart rate to detect hypovolemia. Discuss with your patients the importance of maintaining exercise, decreasing cholesterol and fat intake, and changing other risk factors, such as stress, obesity, carcinogenic intake and reducing risk of thromboembolic complications. Cardiovascular; “…Focus the physical assessment on what is essential when examining your patient in acute distress.” 5 Observe your patient’s general build (e.g. thin, emaciated, or obese) also, skin tone (e.g. pink, pale, ruddy, flushed, or cyanotic). Assess your patient for shortness of breath and possible distention of the neck veins. Vital Signs: “…assess pulse rate and rhythm using the radial artery. Compare apical and radial heart rate (pulse deficit). Monitor blood pressure. Note presence of pulsus alternans-loud sounds alternate with soft sounds with each auscultatory beat. Assess for orthostatic hypotension. Also, note any changes in heart rate and blood pressure in at least two of three positions.” 6ʹ 7 Integementary, i.e. skin, and digestive diseases. Assess for common skin abnormalities such as Macule, (i.e. freckles, flat moles), Papule, (i.e. wart verruca, elevated moles, lichens). Patch, (i.e. port-wine stains). Plaque, (i.e. psoriasis, elevated, firm and rough lesions with a flat top surface). SCAR, (i.e. thin to thick fibrous tissue that replaces normal skin). Scale, (i.e. flaking of skin with seborrheic dermatitis) and Fissures, (i.e. cracks at the corner of mouth, feet, hands, trunk and/or extremities). 8

  A skilled nurse will also, assess a patient’s spiritual and emotional well-being as part of his and/or her care-giving practice. For example, what is there? (Ontology and metaphysics, i.e. being and reality). How can we know? (Epistemology, i.e. knowledge). What follows? (Logic, i.e. inference). What are we to do? What are correct, good, and/or bad choices to make in life? (Ethics, i.e. values). These questions and the answers to them will have a profound impact on decision-making, and to the overall assessment of the patient. To the skilled nurse, this application in medicine will mean: “…an activity in spiritual and emotional assessment whose aim is to understand the general principles and ideas that lie behind our views, in understanding and decisions about health, disease, and care.” 9 Murphy, E.A al states: “Its objective is not a new or old finding (science follows this objective), but the understanding of the concepts and principles used to interpret phenomena that surround us and that concern us.” 10 Therefore, in assessing from a philosophy in medicine not only examines our ways of doing things and making decisions. It also examines the methods used by medicine to formulate a nursing hypotheses and directions on the basis of evidence, as well as the grounds on which claims about patients and health issues may find justification.

Medications-

  Also, a very important secondary duty for the nurse would be the administration of medications. Usually, all medications will be prescribed by a physician unless the nurse has an advanced role, such as a nurse practitioner and some clinical nurse specialists. These nurses are able to use their assessment skills to determine which medication a patient needs and may then write the prescription. For medications prescribed by a physician, a nurse must rely on her assessment skills as to whether or not the medication is proper, at that time, for the patient to take. Feinstein suggest, 11 “…with regards to the administration of medications, both the physician and nurse must demonstrate clinical expertise. This means the ability to use clinical skills, reasoning, judgment and experience at all stages of clinical work with the patient...”

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