How has nursing assessment changed?

classicdame, MSN, EdD · Jun 6, 2014

My grandmother was a nurse in the 1920-1940's. She got in trouble once for wearing a stethescope. Her supervisor asked "Who do you think you are? A Doctor?" That humiliation stayed with her for years.

Here.I.Stand, BSN, RN · Jun 6, 2014

But nursing is sooooo much more acute than it used to be, and we work harder than nurses eeeehver have! :sarcastic:

In all seriousness, if I wore a white cap it would be off to you! :nurse: You rock...that is all.

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.

classicdame, MSN, EdD · Jun 6, 2014

I firmly believe nurses are much better educated that 30 years ago and are doing some things that only MD's were allowed at that time. More is expected of us and, luckily, we are able to meet those expectations most of the time!

HikingEDRN, BSN, RN · Jun 7, 2014

These posts are so cool. I worked with some nurses who were involved in the early studies of surfactant on neonates. They were not supposed to know which babies had received it but said it was so obvious which ones had because of how well they did.

cinlou, BSN, MSN, RN · Jun 7, 2014

I firmly believe nurses are much better educated that 30 years ago and are doing some things that only MD's were allowed at that time. More is expected of us and, luckily, we are able to meet those expectations most of the time!

I'm not sure I can totally agree with you on that. But, many things we were taught are not taught today, there are many more medications to learn today. Technology is a big part, but if power went out would you know how to do many things and calculations without a monitor to do it for you? Times are different, but I think many things we learned back then should be resurrected for improved patient care. I think there were some things we were better at such as pain management methods other than medications. We have to spend so much time CYA instead of at the bedside. We learned a great deal of technology through our years but it came at us slower so we had time to learn it before the next phase came out. I how to use all kinds of monitoring, because each patient bed may have had a different one. When I worked open heart we had them in the unit for 5 or more days and we kept patients in the hospital much longer, so we did not see the ER returnes and readmissions that we do now, we had more time to give proper patient education. I look at new nurses now and they are not as attuned to discharge instructions as we were.

It was just a different time, and we participated in many changes towards EBP. There are those "older nurses" who fell in to stagnation, but I see many new nurses do the same thing. It is part of our roll as nurses to be life long learners and to stay up to date with the care we provide.

We transitioned from doctors doing things to the nurses doing things, so we learned a great deal on the job training. I think it depends on the individuals motivation to learn.

applewhitern, BSN, RN · Jun 7, 2014

I've only been an RN for 26 years, but I experienced most of what cinlou said. I work with a lot of young, new nurses now, and I can see the difference. They do not know how to mix any kind of meds, they don't know any formulas, they cannot determine the drip rate of any cardiac drip unless the pump figures it for them. My education was very intense. (Not only did we look in ears, but we had to perform hearing tests on them as well!) Some nurses today are totally lost without fancy equipment. I also notice a severe lack of education when it comes to assisting the doctors with procedures. Oh well. I guess that trans-cultural nursing class in the BSN program is more important than actual physical assessment of the patient. I am not trying to be mean, but I simply don't understand why newer nurses think we didn't learn anything in "the dark ages."

applewhitern, BSN, RN · Jun 7, 2014

I actually had a newer nurse say to me, just the other day, that there are a few "old school" nurses around our hospital. She was saying this as derogatory, but guess who she comes to almost every day with a problem she can't solve?

Ruas61, BSN, RN · Jun 7, 2014

I firmly believe nurses are much better educated that 30 years ago and are doing some things that only MD's were allowed at that time. More is expected of us and, luckily, we are able to meet those expectations most of the time!

I disagree with the education assessment.

I don't believe the nurses today are as skilled technically from the gate out as we were back than.

We were educated in a different time but I was certainly not in a substandard or mediocre program. We had a rigorous program both classroom and clinical wise.

There was a high passing rate on the first try for my school.

20 years from now the students will be saying the same thing about the current ones, I suspect.

Technology does not always translate as smarter or better equipped.

We are dealing with living beings.

Cuddleswithpuddles · Jun 7, 2014

I have only been around nursing for 8 years and it seems that the amount of focus on skin assessments, particularly of wounds and pressure ulcers, has increased exponentially. There seems to be a heck of a lot more exacting terminology, measurement tools, expected documentation, rules, products etc. that I am sure are more driven by the legal and financial implications of pressure ulcers more than anything else. I sometimes wonder if the costs of the massive wound care cart we have could be offset by hiring one or two more aides or lift team personnel. Then we can turn and clean patients instead of having to use fancy stuff like the Skin IQ overlays, Magica-Gravity-Be-Gone 2000 beds and some of these dressings that must be gold-plated or sprinkled with unicorn dust considering how much they each cost.

(I do have to apologize for sounding cranky in this post. I do appreciate that wound care is one of the areas where nurses can have so much autonomy and impact.)

applewhitern, BSN, RN · Jun 7, 2014

We had to start IV's on each other, too, and give IM injections to each other. I now work with nurses who have never started an IV. We had to know how to accurately assess our patients, because we did not have little "sat probes" to pull out of our pockets, either. We had to intubate in ACLS, something new nurses don't have to do. When I worked with babies, we had to be able to intubate them, too. There is actually a lot of stuff that has been taken away from nursing, not added to it. Things that only doctors used to be able to do? That was really way, way back in time, not just the past few decades. I can think of more things that nurses "used to do" that have been taken away from nurses, instead of more things that only the "doctors used to do." Medications? We couldn't just look things up on the internet; we relied on drug books, and hoped the new med was actually in the drug book, because we usually didn't have the newest edition. We pretty much had to memorize them. Hospital pharmacies weren't open 24/7; usually just open on dayshift. Otherwise, you were on your own. IV fluids didn't come with potassium already added. YOU added everything, and it had better be right, or you could kill your patient.

applewhitern, BSN, RN · Jun 7, 2014

Skin care has been a big deal thru-out my 26 year career. It was drilled into us in the 80's, too. Yes, we had products such as the Carrington brand for skin issues. Some of the treatments we used for decubitus ulcers has now come back in vogue; our wound care doctor uses products we used in the 80's, such as betadine and balsam peru. When we had stage 4 decubitus "back then," it was usually because a nursing home had sent us the patient with an existing ulcer. We diligently practiced ulcer prevention, but we would get nursing home patients that were already in bad shape. We didn't have as many specialty units, either, so we got exposed to a wider variety of illnesses. For instance, we had burn patients and skin grafts on our med/surg/tele floors.

cinlou, BSN, MSN, RN · Jun 7, 2014

I have only been around nursing for 8 years and it seems that the amount of focus on skin assessments, particularly of wounds and pressure ulcers, has increased exponentially. There seems to be a heck of a lot more exacting terminology, measurement tools, expected documentation, rules, products etc. that I am sure are more driven by the legal and financial implications of pressure ulcers more than anything else. I sometimes wonder if the costs of the massive wound care cart we have could be offset by hiring one or two more aides or lift team personnel. Then we can turn and clean patients instead of having to use fancy stuff like the Skin IQ overlays, Magica-Gravity-Be-Gone 2000 beds and some of these dressings that must be gold-plated or sprinkled with unicorn dust considering how much they each cost.
(I do have to apologize for sounding cranky in this post. I do appreciate that wound care is one of the areas where nurses can have so much autonomy and impact.)

I don't think you sound cranky. These things that they are coming up with now are good but the old fashioned care and turning of patients is still the best no matter what we use. Sure we don't use the MOM with sugar packets and heat lamps, but the ointment is made of similar contents. We use to care for 15-30 patients turning everyone of them every 2 hours and doing back rubs and peri care with only 2-4 nurses and aides on the floor. The problem is that we have to do so much documentation away from the bedside to CYA that we need more staff to do the bedside care. One of the many reasons they should put LPN's back in the hospitals at the bedside while the RN's are doing all the paperwork and legal documentation. Team nursing has its place on particular units and it would save companies a great deal of many, because it would improve patient care and satisfaction for better reimbursements. But that is for another chat.