How has nursing assessment changed?

[kool-aide, RN]

My question to nurses who started their careers in decades past is how has the nursing assessment changed over the course of your professional practice?

For instance, were you trained in the 60s and 70s to auscultate a pts heart and lung sounds? I'm watching a movie focusing on the lives of nurses from the 70s and these nurses don't seem to have much professional training, however that is not the focus of the movie. I'm just curious as to how accurate this portrayal is...

[amoLucia]

In between running the autoclave!

Yeah, and also sharpening those needle burrs off!

Stoked the boilers too, before I made the morning pots of gruel!

[la_chica_suerte85, BSN, RN]

I feel blessed that we had a very intensive H&P assessment course in our first quarter in my program, then. Everything we were taught (JVD from hepatojugular reflux, percussion, etc.) is intended to substitute for in-field work for when we don't have access to electronics to do all that stuff for us -- also, if we are unsure if equipment is working correctly then we can verify this, too. I guess this is something that is not too common in current nursing programs?

[HouTx, BSN, MSN, EdD]

(BSN 1981) I was lucky enough to be in a program that shared many resources with a medical school. Our assessment skills were tested with the same 'professional patients' - with murmurs, wheezes, mobility limitations, skin ailments, etc - used by the med students. Very challenging.

I would say that the biggest change in nursing assessment has been a tendency toward more reliance on technology rather than a hands-on approach. I fondly remember a venerable cardiologist who could accurately assess hemodynamic issues via pulses & circulatory indicators - Yep, he actually laid hands on his patients.

[classicdame, MSN, EdD]

A. I have never seen anything on TV that portrays nursing accurately.

B. One change I have noted is medication reconciliation is more in focus than many years ago. In the olden days your patient may not have had a great number of procedures, so that is a change. You did not see old patients with certain chronic illnesses because they simply did not survive to be old (in great numbers). Diabetes, Sickle Cell----that type of thing

[dudette10, MSN, RN]

You probably need to go back further than the 60s to see nurses trained differently. My step mother was born in 1927, and the training then, based on what she said, focused more on cleanliness, bed making, passing meds and some skills, such as dressing wounds.

[nurseprnRN, BSN, RN]

(BSN 1973) We weren't trained, we were educated and taught.

And yes, because a lot of the electronic noisemakers hadn't been put into clinical areas yet, we learned how to do a comprehensive, integrated physical assessment without them in our program:

*how and why to take blood pressures properly (a dying art, if you can go by what I see in my primary care's office)

*look at hepatojugular reflex and JVD, and check for a-waves for patients with irregular heartbeats (is it AF or something else?)

*take actual AP pulses, and notice the difference between the sharp pulse of arterial sclerosis, the mushy pulse of obliterative disease, and the normal bouncy feel of a healthy artery

*assess for aortic and mitral abnormal sounds and S3, S4 for early CHF

*listen for carotid bruits; look for color changes in mucous membranes and nail beds

*listen carefully to all lobes (how many is that?) to help guide positioning

*palpate all peripheral pulses and check skin and nails to assess for vascular disease

*why to shake the Foley drainage bag to check for proteinuria (Hint: albumen foams)

*look in ears for otitis media and wax

*look in eyes for cotton spots

*palpate and auscultate abdomens for liver size and consistency, colonic impaction, and hyper/hypo sounds

*wound healing as an active process

*gait and mobility, with the PT faculty

... and a lot more. And yes, there was a lot more emphasis on skin care, turning, cleanliness, and sleep cycles, also things I miss when I see a loved one hospitalized. So you could make the argument that we learned to do ... more.

Yes, as students. On live people, not SimMan. Although those of us of a certain age still remember Mrs. Chase. :)

Oddly, we were (and are) just as smart as the students of today. And no, I never polished lantern chimneys. But I did know how to prepare supplies, and pack and run an autoclave to sterilize them.

[Hancock330]

I graduated with my BSN on June 13, 1969. We weren't required, weren't even encouraged to buy our own stethescopes. I learned good techniques for taking B/Ps -- learned to listen for bowel sounds. We didn't listen to "breath sounds"; we did apical pulses if we couldn't plapate a radial pulse. There were monitors in the ICUs (those new units for the critically ill), but not on the "regular" units; we had, if I remember correctly, "Bird macines" (that was a company name) to do what nebulizers do today -- and they were run by the nurses, rarely by a respiratory therapist. No bedside glucometers -- "rainbow coverage" for determining insulin doses was based on urine tests -- the Clinitest for urine sugar and the Acetest for urine ketones. I didn't learn physical assessment until I got my MSN in 1977-1978. I saw no great value in the additional techniques then, either. I was at a teaching hospital -- the poor patients often were assessed by the attending physicians, the residents, the interns, and the med students. I saw no advantage to having someone else auscultating and palpating. The nurses "paid attention" to their patients and called a doctor if the respirations started sounding "wetter" or if other indicators of worsening condition occurred -- but I didn't see the need for the kinds of assessment I was taught (percussing the liver margin, for instance). I've never decided whether to suction a patient based on breath sounds, either. I could tell from the time I entered the room whether the patient needed suctioning. I learned to listen to breath sounds before and after suctioning so I could document in the chart that I had done so -- but I didn't decide whether to suction based on THAT assessment. It's my perception that some nurses spend too much time "assessing" parameters and not enough time assessing the patient AND conversely, that a lot of assessment data gets charted when it was never actually collected (pedal pulses on someone instead that the patient has warm, dry feet that have good sensation and color, for instance) -- nurses who have 7 or 8 patients to provide care for take "shortcuts" -- and prioritizing what parameters to assess on which patients is necessary though not desirable. Charting specifically things that weren't actually done is illegal and wrong -- and putting nurses in a situation where it's the only way to survive is terrible. Ah well. I'm retired now and don't plan to ever again provide nursing care as an employee; in fact, I don't plan to ever again provied care as a registered nurse. I think I'll limit my care to members of my immediate family. :-)

[FranEMTnurse, CNA, LPN, EMT-I]

I am thankful for being an EMT for 15 years before I went to nursing school. That taught me about what to look for in critical assessment as well as general assessment. So I was able to perform complete assessments every time I had a patient. That way nothing was missed.

[HeyNurse2014, ASN, RN]

My nursing school was only interested in teaching to pass the nclex. Never once have I looked in a patients ear while in school or during clinical. Nor were we allowed to start an IV. They said the hospital you get hired at will handle that training. Well... that training was a 10 min experience with a rubbery hose mounted on a board. Not too effective as a learning tool.

[cinlou, BSN, MSN, RN]

In he 70's I started out as an LPN, my program was 10 months 8 hours a day, 5 days a week, we had much more clinical time then. We learned how to care for patients and clean them without gloves. We had strict isolation procedures. We learned how to start IV's, give IM injections, and baths to our fellow students. I also learned how to run the autoclave, package equipment, shave the burrs off needles. We also inserted NGT on each other. We learned thorough assessments. palpation, percussion, I could do about 70% of my assessment when I walked in the room introduced myself to the patient, touched their hand.

I had assessed their mental status, ability to speak, skin temperature and turgor. I knew what the fingernails would tell you about a patients cardiac status. What the feel of their pulse meant, strong, thread, weak, bounding etc. lung sounds, heart sounds, medications and reversals. (there were not as many to learn then). I also had a class on chart presentation to the physician, get up and give your chair to the Doc and move to an area where you could hear him call for you but not see you until he wanted you. Our written narrative assessments were pages long.

We cared for ventilator patients on the floor units. We gave all the RT treatments including postural drainage and percussion, IPPB treatments. We changed out tracheostomy tubes, we gave evening back rubs, peri care and hs snacks, we had 15 to 30 patients using team nursing, so we were a team of an LPN or RN with a CNA. We did not have unit doses so we had to mix all our own medications, we gave more IM injections, we provided pain management through comfort measures rather than opiates.

We worked with patients who were dying caring for them with respect and providing death with dignity. We tested diabetics via their urine using dip sticks at the bedside, and tested urine spec gravity with a test tube and a mercury weighted spinner. We took temperatures with glass thermometers. We took manual BP's on all patients in both arms. We did orthostatic VS. We used oral airways, we had circo-electric beds instead of the kin air and other types of beds. We turned our patients every 2 hours to prevent skin breakdown and we lotioned their bodies to help prevent skin breakdown. We had Harvard clamps instead of IV pumps. We calculated drip rates using our watches.

For pediatric patients we used buritrol so there was no chance of flooding them with fluids. As an LPN we could not give IVP meds even then so we would put 10cc of fluid in the chamber put the med in the chamber and infuse it. We weighed patients daily to monitor their fluid status. We used placebos to wean patients off from their narcotics before they were discharged. We provided extensive discharge instructions to patients. We were actively involved in changing the care of nursing from Gold standards to EBP. We took over the rolls of the doctors in starting IV's and caring for central lines and swan ganz monitors.

We learned how to do cardiac outputs using iced saline syringes, putting fluid on the transducers. calculating all the hemodynamics, without the use of a monitor that does it for you. I knew every formula. We also used the Fick method on pediatric patients. We used cloth diapers in the nursery and had to do the laundry and I remember folding many a diaper. When I worked in the burn unit we harvested placentas and used them to cover burns, before biobrain was invented. We also used pig skin.

Our last 2 weeks in nursing school was called senior experience and worked on a unit for those 2 weeks. I had the ER. We helped cast patients, and many other things. Most everything we use a calculator or ipad or monitor for now we calculated through formulas on paper. We made sure patients pooped before they were discharged, now they all return to the ER with complaints of constipation post op. The nurses of these years were in Viet Nam and other wars, they were killed and there are many names on the Viet Nam wall. They were called RVN's. They did the same thing as Doctors. They stitched, amputated, you name it, and all while provided care and comfort to those men who served our country.

So yes it is different.

I learned things that will never be taught again, some do not need to be, some should be. Much of what we did has gone to the wayside as it should be, but much of what we did provided early research in to what is now called EBP. Our patient to nurse ratios were higher we kept patients in the hospital longer. We didn't really have ICU's so we had the sick patients on ventilators on the regular units, cared for along with our other 15 patients. We worked 8 hour shifts instead of 12 (thank God). We had to count our narcs every shift with another nurse. we had keys to the cabinet. Some meds that are controlled now were not then. We had portable suctions called gomco's. IV's were glass bottles, syringes were glass and reusable.

EKG's were done using suction cups and you had to move them while you did the 12 lead and there were codes like Morse code, you used for each lead. We did many health fairs and provided this service to the community. We rotated through the health department, and did community service. I could go on and on but I think you get the picture.

[Been there,done that, ASN, RN]

As we all now slaves for the corporate master...

my assessment depends on how many patients I have.

Can I do a complete head to toe in 8 minutes? You bet. Do I have 8 minutes to do that? NO! I focus on the system currently being treated.

Sometimes my "assessment" is a visual once over while I scan the gazillion pills I push , spend an hour electronically charting on each patient, and kissing the family's patootie.

[Esme12, ASN, BSN, RN]

In he 70's I started out as an LPN, my program was 10 months 8 hours a day, 5 days a week, we had much more clinical time then. We learned how to care for patients and clean them without gloves. We had strict isolation procedures. We learned how to start IV's, give IM injections, and baths to our fellow students. I also learned how to run the autoclave, package equipment, shave the burrs off needles. We also inserted NGT on each other. We learned thorough assessments. palpation, percussion, I could do about 70% of my assessment when I walked in the room introduced myself to the patient, touched their hand.

I had assessed their mental status, ability to speak, skin temperature and turgor. I knew what the fingernails would tell you about a patients cardiac status. What the feel of their pulse meant, strong, thread, weak, bounding etc. lung sounds, heart sounds, medications and reversals. (there were not as many to learn then). I also had a class on chart presentation to the physician, get up and give your chair to the Doc and move to an area where you could hear him call for you but not see you until he wanted you. Our written narrative assessments were pages long.

We cared for ventilator patients on the floor units. We gave all the RT treatments including postural drainage and percussion, IPPB treatments. We changed out tracheostomy tubes, we gave evening back rubs, peri care and hs snacks, we had 15 to 30 patients using team nursing, so we were a team of an LPN or RN with a CNA. We did not have unit doses so we had to mix all our own medications, we gave more IM injections, we provided pain management through comfort measures rather than opiates.

We worked with patients who were dying caring for them with respect and providing death with dignity. We tested diabetics via their urine using dip sticks at the bedside, and tested urine spec gravity with a test tube and a mercury weighted spinner. We took temperatures with glass thermometers. We took manual BP's on all patients in both arms. We did orthostatic VS. We used oral airways, we had circo-electric beds instead of the kin air and other types of beds. We turned our patients every 2 hours to prevent skin breakdown and we lotioned their bodies to help prevent skin breakdown. We had Harvard clamps instead of IV pumps. We calculated drip rates using our watches.

For pediatric patients we used buritrol so there was no chance of flooding them with fluids. As an LPN we could not give IVP meds even then so we would put 10cc of fluid in the chamber put the med in the chamber and infuse it. We weighed patients daily to monitor their fluid status. We used placebos to wean patients off from their narcotics before they were discharged. We provided extensive discharge instructions to patients. We were actively involved in changing the care of nursing from Gold standards to EBP. We took over the rolls of the doctors in starting IV's and caring for central lines and swan ganz monitors.

We learned how to do cardiac outputs using iced saline syringes, putting fluid on the transducers. calculating all the hemodynamics, without the use of a monitor that does it for you. I knew every formula. We also used the Fick method on pediatric patients. We used cloth diapers in the nursery and had to do the laundry and I remember folding many a diaper. When I worked in the burn unit we harvested placentas and used them to cover burns, before biobrain was invented. We also used pig skin.

Our last 2 weeks in nursing school was called senior experience and worked on a unit for those 2 weeks. I had the ER. We helped cast patients, and many other things. Most everything we use a calculator or ipad or monitor for now we calculated through formulas on paper. We made sure patients pooped before they were discharged, now they all return to the ER with complaints of constipation post op. The nurses of these years were in Viet Nam and other wars, they were killed and there are many names on the Viet Nam wall. They were called RVN's. They did the same thing as Doctors. They stitched, amputated, you name it, and all while provided care and comfort to those men who served our country.

So yes it is different.

I learned things that will never be taught again, some do not need to be, some should be. Much of what we did has gone to the wayside as it should be, but much of what we did provided early research in to what is now called EBP. Our patient to nurse ratios were higher we kept patients in the hospital longer. We didn't really have ICU's so we had the sick patients on ventilators on the regular units, cared for along with our other 15 patients. We worked 8 hour shifts instead of 12 (thank God). We had to count our narcs every shift with another nurse. we had keys to the cabinet. Some meds that are controlled now were not then. We had portable suctions called gomco's. IV's were glass bottles, syringes were glass and reusable.

EKG's were done using suction cups and you had to move them while you did the 12 lead and there were codes like Morse code, you used for each lead. We did many health fairs and provided this service to the community. We rotated through the health department, and did community service. I could go on and on but I think you get the picture.

Yup that sounds right....I forgot all about those IPPB's. One we ran out of vents so we used the IPPB on "Q" circle...no alarms.