National Nurses United

N O V E M B E R 2 0 1 4 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 7 We continue our explorations of the life and career of Kay McVay, a longtime intensive care unit RN at Kaiser Permanente and pres- ident emeritus of the California Nurses Asso- ciation. In this installment, McVay discusses the art and science of RN assessments, which she is afraid is becoming a lost skill with the advent of technology. So what goes into a good, thorough RN assessment? What was your routine? Well, I would go in and start from head to toe. I'm looking at their eyes, how they move, listening to their voice, listening to their breathing, looking at the color of their skin, face, is it different from what's on the body? Is there something on the body different in coloring? I'm looking for anything that is not quite the same to make sure that nothing is developing with the patient. I ask if they can turn a little for me. I check their calves, touch their feet to check the pulses in both feet. Is there a difference in the pulses? Is it warm or cool or different from the other foot? You can't just look at the spot that's been operated on or sustained injury. You have to incorporate the whole patient. Yes, maybe they had abdominal surgery, but something is wrong in their leg because they've thrown a clot. Or there could have been an injury that was not picked up on before. There's so many different things you can pick up from a physi- cal eye-to-eye and touch evaluation of patients. And would you be doing this quietly or while talking to the patient? Oh my goodness. Defi- nitely while talking to the patient. That kind of chit chat is a vital part of the whole assessment process! When you engage them in conversation, that's how you assess the neurological aspect of the patient. Do they answer you? Are they having trouble talking? What does their voice sound like? Difficulty talk- ing means difficulty breathing. Are they under- standing what you're saying? Are they recogniz- ing where they are and what's going on? When they're talking, are they making any sense? Can they tell you about their pain? If you listen to them, listen to their language, they'll give you many clues by the words they use about their condition. Do you have some memorable examples of where your powers of RN assessment saved a patient? Oh, there were lots. But there are a couple that stick out in my mind. One time, I was up in the ICU, and that's when Kaiser wanted to put LVNs in the ICU. The LVN I was working with was good and nice and all that, but they just don't have the same assessment skills. I was very busy assisting the doctor with band- aging my other patient and I had asked the LVN to check in frequently on my other patient and come get me if there were any problems. After I was done, I came out of that room and said hi in the doorway to my other patient. I didn't get much of a response. When I walked in and looked at his color, I saw he couldn't talk much at all and he was having trouble breathing. I hit the code button because I realized he was having a heart attack. They were able to save him, and that's good. When I caught up with the LVN, I learned she had been checking on him like I asked and had given him some pain meds for his left arm because he was complaining of pain. He told her that it was tennis elbow. But tennis elbow doesn't cause that kind of pain or require push IV meds. He was having a heart attack and she was completely unaware. Another time, this one other patient, she actually didn't speak great English, but I watched her and listened to her very closely. I remember coming into the room one day just as the orderly was about to take away her meal tray and I said, "Just a minute." And I lifted the cover and took one look at the way the food on the tray had been eaten and immediately called the doctor. Well, she was in the OR before the hour was up. What happened? What did you see? She had eaten basically halfway down the tray. All the food on one side was untouched. This meant she couldn't see the other food! She was a new diabetic, but nobody had realized. She lost her eyesight in one eye, but thank goodness they were able to save her sight in the other one. If you don't pick these things up, you'll miss something. Wow. That's a great story. Tell us about what you observe about today's nurses' assessment practices and why you're worried these skills will be lost. First, I just see that nurses are more and more overreliant on machines and technology instead of their own observation skills. Us oldtimers, we were told to "Watch the patient." I'm not anti-technology at all, but the technol- ogy has to help you do your job, not do your job for you. And one issue nobody talks about is what happens if the power goes out. One time three nursing students came to shadow me and I told them, "Ok. Go into that room and assess that patient." They came out really quick and gave me a big sheet of numbers. I said, "Well, you assessed the machines, but you forgot to assess the patient." And we went back in and I started talking to the patient and we went through what I described earlier. Second, assessments take time, and with the short staffing nurses deal with, I don't know how it can be done. If you cannot give personal atten- tion to your patient, then you're not caring for your patient properly. "Conversations with Kay" appears in each issue of National Nurse. Through McVay's stories, we docu- ment the origins of the modern staff RN movement as well as the changing practice and culture of nurs- ing and healthcare. The first installment appeared in the January-February 2014 issue. Conversations with Kay

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