Systems assessment

[UKPedsRN]

Hello all,

I am a UK trained nurse who worked in the US for 13 + years, I am now back in the UK and am writing a refelctive essay on the differences in practise in the two countries.

One of the issues I am covering is system assessments. Nurses here in the UK do not complete formal systems assessments during the shift. They do a part assessment, but do not listen to breath or heart sounds, neither do they listen to bowel sounds. Obviously I have my thoughts on this and am trying to present why I think it is important for both the nurse and patient that this is done.

I would like to know from nurse educators a couple of things

a) How important do you rate this practise and skill

b) At what point in the circulum is it taught and for how long

c) Do you think you can effectively nurse a patient without completing a head to toe systems assesment at least once during the shift

- When I worked in CA we did them every four hours - That was ten years ago, perhaps things have changed. I look forward to any responses!

Also if you have any assessment forms that you can share, I would include in my paper.

Thanks

[dorimar, BSN, RN]

Assessment is an integral part of the nursing process: Assessment, plan, intervention, evaluation. How does one determine the necessary interventions and evaluate the response to those interventions without assessment? Assessment is one of the first courses taught in nursing curriculum in the US.

[classicdame, MSN, EdD]

The primary nurse is responsible for the WHOLE patient. Our state mandates a full assessment every 24 hours by an RN if a patient is in the hospital. The expectation is head-to-toe. We learn this in Fundamental Nursing (first semester) and then practice it all thru nursing school. If a post-op patient's bowel sounds are not present, how would you know they could eat without risk of an ileus???

[UKPedsRN]

My thoughts exactly, however I know that some of my english colleagues do not see eye to eye with my on this topic, hence my post. Although they do assess their patients, do not think that they dont, it does is not a systematic approach as is done in the US

My current thoughts are we talk alot about holistic care, yet if we are not assessing the whole patient, how can we do this?

My refelctive piece is going to be far longer than what was requested at this stage.

I would love to hear from more nurse educators - oh and another question - when was systems assessment introduced into the nursing circuculum?

In 87 when I left the UK for the US, we did not do assessments neither did we cannulate or give IV drugs, we now do the later.

Thanks

[classicdame, MSN, EdD]

There was a time when USA nurses practiced like that, and we relied on the MD to cover for any mistakes or whatever. Patients accepted negative outcomes and whatever the MD said was law. No longer true. Nurses are expected to report to the MD when there is a change in condition so nurses need to know how to assess for a change (negative change of course).

[Lstcats]

Students rather in the PN or RN program perform assessments in lab and then carry over to the clinical area. For instance, last eveing I had the PN students start learning about skin assessments as they did their ADL's. It was their 3rd evening of the first semester. We start in nursing process after the first week of clinical. That has been in every college that I have taught at in MA (3 schools). I can't believe that the UK practices such archaeic methods of practice. Sounds like the 1950's 60's and perhaps 70's. What I would suggest is that you do some nursing research into nursing assessments/nursing process and the benefit of interventions & goals have in reporting findings to the MD and present these articles (evidence based practice articles) to your colleagues. Check into the theorists and the guru that writes about theorists who works at UMass Boston Dr. Jackie Faucett. Her research is timeless. Check out Dorothea Orem's theory on Self Care Defecit and the theorist who wrote about novice to expert (can't recall her name). May be of some help. Always back your opinions with actual nursing research. Your colleagues will then take you seriously. :typing

[marachne]

Students rather in the PN or RN program perform assessments in lab and then carry over to the clinical area. For instance, last eveing I had the PN students start learning about skin assessments as they did their ADL's. It was their 3rd evening of the first semester. We start in nursing process after the first week of clinical. That has been in every college that I have taught at in MA (3 schools). I can't believe that the UK practices such archaeic methods of practice. Sounds like the 1950's 60's and perhaps 70's. What I would suggest is that you do some nursing research into nursing assessments/nursing process and the benefit of interventions & goals have in reporting findings to the MD and present these articles (evidence based practice articles) to your colleagues. Check into the theorists and the guru that writes about theorists who works at UMass Boston Dr. Jackie Faucett. Her research is timeless. Check out Dorothea Orem's theory on Self Care Defecit and the theorist who wrote about novice to expert (can't recall her name). May be of some help. Always back your opinions with actual nursing research. Your colleagues will then take you seriously. :typing

From Novice to Expert is by Patricia Benner

More recent nursing education theory which I think is very useful and moves the science forward is that by Chris Tanner (also the editor of Journal of Nursing Education). She moves away from "nursing process" to "clinical judgment" which is a lot less formulaic and more holistic and recognizes all that a nurse brings to a clinical situation

Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in nursing practice: Caring, clinical judgment, nd ethics. New York: Springer.

Tanner, C.A. (2006). Thinking like a nurse: a research-based model of clinical judgment. Journal of Nursing Education, 45(6), 204-211

[UKPedsRN]

Thanks for your comments and references. I am still plugging away at this paper, hopefully I can make solid arguements and notice will be taken.

Thanks

[UKPedsRN]

I have just spent the last two hours here in University in Necastle, searching for articles on nursing assessment, interventions and reporting findings to Physicans - without luck. Do you have any links I could use? Thanks

[knittwhit]

Assessment is an integral part of the nursing process: Assessment, plan, intervention, evaluation. How does one determine the necessary interventions and evaluate the response to those interventions without assessment? Assessment is one of the first courses taught in nursing curriculum in the US.

I absolutely agree with you. I teach freshman fundamentals. One of the first things we talk about before going into the clinical setting is beginning the assessment as soon as you walk into the room. I give my students a laminated pocket card the first day of clinical to help them remember the things they should be looking for. In our clinical conferences we talk about any questions they had or interesting findings. I want this process to become as automatic to them as breathing, it will make them better nurses.

[UKPedsRN]

Hi Knitwhitt,

Could you share the info you use on the laminated card you give your students?

Also, if anyone has any links to research articles on how reporting findings to physicans when assessing patients.- I would appreciate them.

Thanks

[knittwhit]

hi knitwhitt,

could you share the info you use on the laminated card you give your students?

i can't claim authorship. i found the original information on one of the boards here. i print on both sides of a 4x6 index card then can lay them out 3 to a standard sheet, laminate them then trim them. the students love them, and i love sneaking up on them and see them using them. you should be able to just copy and paste the information below to a word document. to use the 4x6 card you need to go to the page set up and choose a6 as your paper size. i have also done it in two columns on a standard 8/5x11 then folded, trimmed to the pocket card size. hope this as helpful to you and your students as it has been for us. i am using it with my third group and really feel it enhances their skill development.

side 1:

head to toe assessment

loc (alert/lethargic/non-responsive)

orientation (to person, place and time)

neuro check, if applicable

skin-color (pale/ pink/ruddy)

temp (cool/cold/warm/hot)

texture (dry/diaphoretic)

*any o2, ng tubes would go here

apical-rate

rhythm (regular/irregular or normal/abnormal)

intensity(loud/distant)

respirations-rate

effort (easy/non-labored)

deepth (deep/shallow/blowing)

*chest tubes would go here

upper extremities- if iv present, note the solution, the rate and the site. note the site for warmth, redness,edema etc.

abdomen-look (round/flat)

listen (boso present x 4 quads?rhythm of boso-normal/hyper/hypoactive and the intensity-high/low-pitched)

feel (soft/firm/hard)

side 2:

*any peg, pej, etc. tubes would go here.

bowel and bladder- voiding (color, clarity, amount)

postop flatus?

foley? (patent, note drainage system)

ostomy? (note stoma)

*this would include any suprapubic caths,drains,etc.

lower extremities-

homan's sign (negative/positive)

pedal pulses (+1=weak/faint, +2 palpitable, +3 bonding)

capillary refill (brisk/sluggish-how long if >3 seconds)

**put any dressings or wounds in the order they came. for example, a forearm dressing would go with the upper extremities. a cast would include a circ check with the corresponding area. edema include pitting (and the deepth) or nonpitting at the correspodning area.