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Journal of Nursing

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...”


 


For many pathophysiologic and metabolic reasons, a patient’s condition is unstable and a medication may not be warranted until the patient’s vital signs improve. During those times, the nurse may choose to delay medication administration, or decide not to give the medication altogether. “Deductive validity is a property of the inference (logic) from premises to conclusion.” 12 At these times, it would always best to call and collaborate with the physician and advice he/or she of the change in the patient’s status and to alert the physician that the nurse will not be administering the medication. Remember, to write down on a card or note-pad of these changes, then at the time of patient charting, document all changes include your deductive validity in detailing for both physician and hospital administration to see.


Advocate-


  One of the most important skills of a registered nurse is that of patient advocacy. The nurse with all his and/or her evidence-based practice must allow the ‘Art of Humanity’ i.e. ontology, the being and reality of nursing to step in and act on the patient’s behalf with other members of the multidisciplinary team caring for the whole patient. This art of nursing involves the sensory skills, and the systematic application of such skills and of knowledge in language, speech, reasoning, and motion in order to obtain the desired results. On an acute respiratory unit for example, the nurse alerts the respiratory team when a patient is having breathing issues.


 Also, this can mean acting as the patient’s advocate with the physician if the patient or nurse feels the treatment is unwarranted or dangerous to the patient. A registered nurse must have a strong back-bone at times when dealing with physicians and other medical professionals as he and/or she takes the proactive lead in advocating for the patient.


  If the patient is unable to speak or write then the nurse should have the ear of the family-members and find out the wishes and desires (after your full assessments) that would be in the best possible position for the patient.

Listener-


  As medical technology advancements present almost instant results over the monitoring systems for the registered nurses to review i.e. articulate with other medical professionals plus computerized templates for documentation, it is important remember that patient care is about nursing the patients and not machines alone. Frequently a medical devise may tell the nurse that the patient is stable, yet the patient is telling the nurse they are not. Medical devises can out-put false data and frequently present one picture of the patient, while the patient is presenting another.


  Listening to what the patient is saying, both verbal and non-verbal, is a very important tool in primary patient care and one that is frequently forgotten when new state-of-the-art devises make nursing care more convenient. Remember, without critical thinking, which includes the ‘art of listening’ both the physician and nurse risk quickly becoming simply mechanical practitioners of medical technologies.


Counselor-


  A registered nurse will perform the ‘art of triage’ or for this reason, administrate the act of counselor. A nurse counsels his and/or her patients at every meeting, i.e. whether an office visit or an in-patient admission to the hospital. Most patients will look to the nurse as an expert in healthcare. At times on or off her professional shift, the registered nurse will need to lead a simple counseling session. This will become an essential part of his and/or her routine duty and assess the patient for example on over-drinking that can lead to alcoholism or a teaching tutorial on newly diagnosed diabetic on how to check their blood sugar levels.


  Also, it is common for a registered nurse to sit down with the patient and go over all new medications, as well as to check the old medications for interactions. This ‘art of triaging’ does not start or end with the patient. The nurse will also, frequently need to counsel a patient’s family member or members in order to secure a stable and supportive environment for the patient. For the home health-care nurses and/or traveling nurses during times of extreme illness or an upset in the famiIly, the nurse will act as a counselor so that decisions for the patient can be made in a calm and informed manner. After all you do during the questions and answers from the patient and/or family member’s knowledge and experience will not be enough. You must allow a spiritual or metaphysical sense of reality to seep through your being; an unspoken act that allows the patient and/or family members to believe or have confidence in your thinking or judgment skills. For Schaffner, 13 the philosophy of evidence-based practice, including the ‘art of nursing’ requires strong communication and counseling skills, and should envelop knowledge, logic, methodology and metaphysics generated by and related to medicine.


Considerations-


  For many years nursing has been touted as being both an ‘art’ and a ‘science.’ In order for a nurse to succeed in his and/or her career today, you must perform all of the above duties as well as practice the art of nursing which is a more subtle tool learned over time. Part of this ‘art’ is in knowing when something is wrong, when though everything appears to be right. The old saying of “gut-feeling” is indeed an essential part of the nurse’s successful and safe practice with your patients. Wolpert, al 14 takes the old adage of “gut-feeling” and with the help of ontology re-defines the term intuition. Within the primary scope of nursing ‘intuition’ means the “quick perception of [possible] truth without conscious attention or reasoning…knowledge from within; instinctive knowledge or feeling.” It is an inherent part of a clinical or specialist nurse’s daily reasoning. Remember that good clinical intuition alone does not mean a free-floating mind. It must be grounded in clinical data and information.


The registered nurse is constantly bombarded with information regarding the patient, but knowing what are the important considerations at the time, is where the ‘art of nursing’ will thrive. The science part of nursing stems from lab values, known pathology of disease and vital signs. Note, all of these values must be interpreted and decisions made for care from them, along with the nurse’s sense of what the patient’s needs are. When a nurse learns to combine the science of nursing with the art of nursing, it is then he and/or she will succeed in carrying out her duties as a registered nurse and be a strong advocate for there patients.


Conclusion-


  With the advancement of medicine, evidence-based nursing has become specialized in order to keep up with the high demands of their physician’s based practice. There are more demands placed upon the registered nurse today with a higher proficiency placed on the nursing staff. As demand are growing for an aging generation, more is expected. Therefore, the nurse must keep his and/or her skills in-tune regularly, just as you would change the oil in your car. Remembering, at all times your evidenced-based reasoning skills in applied nursing. Also, take heed as recorded thousands of years ago, “…For he who hath an ear, let him hear…” 15 Become a patient pro-advocate, listener, and counselor , applying research evidence to a specific patient in a particular clinical or hospital setting through clinical expertise and fitting patient values to medical intervention.


  The word ‘nursing’ now becomes a verb of action with “…the ability to solve problems by making sense of information using creative, intuitive, logical and analytical mental process… “ 16 Also, the wisdom in dealing with particular individual patients, specific needs, and detail of practical cases or actual situations. Therefore, as a critical base, you will learn to think outside the box.


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1. Dept. of Philosophy, Univ. of Guelph. Logic Outline  7th ed, rev. Guelph, Ontario, Canada:  Univ. of Guelph; 2006
2. American Association of Respiratory Care (2005). Clinical practice guidelines: Respiratory Care, 38, 495-499.
3. Fuller, J. & Schaller-Ayers, J. (2004).  Health assessment:  A nursing approach (4th ed.). Philadelphia:  Lippincott Williams & Wilkins.
4. Seidel, H,M., al. (2004).  Mosby’s guide to physical examination (5th ed). St. Louis:  Mosby.
5. ACC/AHA Task Force on Practice Guidelines (2005) ACC/AHA Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmic Devices. American College of Cardiology Foundation and Amer. H. Assoc. Inc. (2009) review,www.acc.org/clinical/guidelines/pacemaker.
6. ACC/AHA 2008, Guidelines Update for the Management of Patients with Unstable Angina. American College of Cardiology Foundation and Amer. H. Assoc. Inc.  www.acc.org/clinical/guidelines/unstable.
7. (2009) ACC/AHA Guidelines Update for cardiac exercise testing.  Circulation 136: 1884-1892.  www.acc.org/clinical/gudelines/update/exercise/summary 2007.
8. K.L. McCance, S.E. Huether editors (2008) eighth edition. Pathophysiology, Mosby, Inc.  St Louis, 1445-1520.
9. G.D. Goldberg, PhD (2008) Critical Thinking for Registered Nurses in Assessment, Angeles College of Nursing (State Approval for Licensing and Examination for Medical Professional 2008).
10. Murphy, E.A. The Logic of Medicine 4th ed.  Baltimore, Md:  The John Hopkins University Press; 2001 cited from www.acc.org/clinical/updated (2008).
11. Feinstein, A.R. Clinical Judgment.  Baltimore, Md:  Williams & Wilkins Co. 1970 ed.  Cited from a (2007) abstract on Nursing Skills and Assessments @www.ameri.nursing.assoc.com// 
12. Copi, I.M, Cohen, C., Introduction to Logic.  12th ed. (2005) Upper Saddle River, NJ:  Prentice-Hall.
13. Schaffner, K.F. Philosophy of medicine. In Conscise Routledge Encyclopedia of Philosophy. London, England: Routledge; 2004.  Cited: New England Jour. of Med. Vol.358 No.5 (2007) www.nejm.org/
14. Wolpert, L. Science:  an unnatural practice.  The Samuel Gee Lecture 1995. J.R. Coll Physic Lond. 2006; 40:155-160
15. The Holy Scriptures, according to the Masoretic Text.  The Jewish Publication Society 2007 ed. Psalms 17: 1-5. Also, The KJV (1611 version) Rev. 3:22.
16. Davis, F.D. Clinical Reasoning, and Pellegrino’s philosophy of medicine.  Theor Med Bioeth.  2005; 24: 178-190.


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Short Bio of Dr. Gary D. Goldberg, PhD 


Over 30 years experience in the Medical field, At UCLA and Pacific Hospital of the Valley, as a Chief Technologist and Analyst, Visiting Professor and Instructor for continuing education at UCLA School of Nursing and Writer/Speaker at the School of Medicine from 1978-2008.


From 2003-2008 Dr. Goldberg has collaborated and published through Blackwell Publishing Co. (Medical Division) and Journal of Americana College of Cardiology plus 15 published abstracts with UCLA Dept. of Bio-Medical Engineering and the Dept. of Cardiology.


Current title, Clinical Professor of Medical Education with Angeles College of Nursing, in Los Angeles, Ca.


Dr. Goldberg has written two major academic course textbooks for Angele College of Nursing and has represented advanced nursing education course curriculum through the State Dept. of California and approved by the ANA for CEU(s) and the AMA CMU Level 1 Credit for physicians.


Also, Dr. Goldberg is currently an adjunct Professor for Kaplan University (Owen by the Washington Post Inc.) South Florida, in the Dept. of Health and Science plus the Dept. of Humanities.


Cindy L. Capute, has been a registered nurse for over 20 years and has managed a 300 bed acute care facility with over 200 professional nurses from RN’s through CNA in the Los Angeles area. She keeps her ear in-tune with up-to-date nursing data and advancements in medical education. She has co-authored with me in 2005, paper presented to the Cardiology-Electrophsyology Research Group that has changed the dynamics of elector-static reading with regards to acute atrial anomalies. This finding allowed me to publish the Goldberg Protocol for Cardiac placements in the field and under clinical supervision using a tilt-table and the 12 +3 Leads or the vector poisoning for additional cardiac patient information.


To reach Dr. Gary D. Goldberg, please use e-mail address: [email protected] or [email protected] or to speak with his wife a Clinical ADA nurse with the Kaiser Permanente Foundation Inc. Cindy L. Capute, BSN, RN through her e-mail at [email protected] or [email protected]

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