ICU Management & Practice, ICU Volume 8 - Issue 3 - Autumn 2008

Physical Assessment by Internal Medicine ICU Nurses: Theory into Practice

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Rabia Khalaila RN, MPH, PhD
Head Nurse,Internal Medicine ICU
Hadassah-Ein Kerem Medical Centre
Jerusalem, Israel

Anwar Kabaha, RN, BSN

Yana Tarnovsky, RN, BSN
Internal Medicine ICU
Hadassah-Ein Kerem Medical Centre
Jerusalem, Israel

Physical assessment is an important tool in nursing in general and in intensive care in particular. It helps in the identification of patients’ existing and potential nursing problems, and enables the staff to set care protocols accordingly. Despite the importance of physical assessment, many nurses have stated that this is not part of their job, and among some, assessment is perceived negatively.

The professional literature on nursing physical assessment focuses on theoretical and practical training provided within various instructional frameworks however, there is no structured program for training nurses in their natural workplace at the patient’s bedside. The following article is the first of its kind to present such a program.

Although Israel has no Nurse Practice Act, nurses have been fighting to transform it into an independent profession. Some efforts have been invested in transferring some clinical procedures from physicians only to also include registered nurses. These efforts have met with much resistance from the Israel Medical Association.

Physical assessment is an important part of the definition of the physician’s job, but is also an integral part of the definition of the nurse’s job. It is expected and necessary that nurses carry out physical assessment as part of their work. Throughout the entire history of the profession, from Florence Nightingale to the present, nurses have been the ones to carry out the physical assessment of patients, gathering basic data on blood pressure, weight and temperature. Nurses are the ones who examine patients’ bodies to make sure there are no bedsores or bruises (West 2006). However, some nurses do not consider these actions as physical assessment because they do not contain all of the details of a full physical assessment.

The literature points to a number of advantages to having nurses perform physical assessment:

  • Improved communication between nurses and other members of the interdisciplinary staff;
  • Improved nurse-patient communication;
  • Rapid identification of changes in the patient’s state of health;
  • Determination of nursing diagnosis;
  • Nursing interventions compatible with patient’s needs; and
  • Increased satisfaction of the nurses (Yamauchi, 2001).

 Nevertheless, despite these advantages, some nurses object to making physical assessment part of their job duties, out of fear that they will be seen as threatening to physicians, or as a result of insufficient knowledge and training, or simply a lack of self-confidence among nurses.

In-Service Education for Nurses on the Internal Medicine Intensive Care Unit
In Israel, the study of physical assessment is an integral part of the nursing curriculum and training in undergraduate studies, advanced courses and Master’s Degree studies in clinical nursing. However, despite the theoretical and practical training that nurses receive during their studies, this practice by nurses is not outstandingly evident in the ICU of the Internal Medicine Department. The literature shows that in practice, most nurses carry out only partial physical assessment according to the needs of the specific patient, the nurse’s own knowledge and sense of self-confidence in carrying out the assessment (Secrest, Norwood and DuMont 2005).

With the goal of improving the level of knowledge and skills of nurses in carrying out physical assessment, Wilson and Lillibridge (1995) proposed that three major elements should be included in each future training program:
(1) A broad, deep theoretical foundation; 

(2) Clinical experience enabling nurses to apply the theoretical knowledge and improve know-how; and
(3) Storage of knowledge by assimilating it in an orderly manner in the day-to-day work with the patients.
Based on these elements an evidence-based training program for the nurses was developed on the unit. The program included two stages: theoretical training for the entire nursing staff during a twoday program featuring a series of lectures on physical assessment of the respiratory, neurological, cardiovascular and gastrointestinal systems taught by clinical nursing specialists and specialist physicians and practical training at patients’ bedside. Each nurse had to practice making a comprehensive physical assessment of a patient together with a physician participating in the project. All of the nurses sat for an examination of the theoretical subjects learned in the training program and each nurse underwent a practical exam in carrying out a comprehensive physical assessment and reporting the findings. Following the training program nurses were required to report their physical assessments made during each shift. Several physical assessment parameters were also added to the nursing records such as pupil status, state of consciousness, GCS, air intake into lungs for ventilated patients, location of the nasogastric tube, peripheral pulse check for patients on intropic drugs, and skin condition. Additional assessments were added according to the patient’s condition.

Summary and Conclusions
A training program carried out in the workplace for nurses in the physical assessment of patients has empowered the role of nurses on the Internal Medicine Intensive Care Unit of the Hadassah Medical Center-Ein Kerem, Jerusalem. The nurses in the Unit feel more in control and more selfconfident in carrying out physical examinations and reporting resulting findings. Furthermore, the training program has improved the quality of nursing care, expressed in identifying unusual findings by nurses such as pulmonary emphysema and urinary obstruction. Such symptoms were then reported to the attending physician and treated in a timely manner. In conclusion, training staff nurses in their workplace, with the professional cooperation of the physicians, facilitates more successful training and improves the capacity, skills and self-confidence of nurses in carrying out patient care.

Authors<br>Rabia Khalaila RN, MPH, PhD Head Nurse,Internal Medicine ICU Hadassah-Ein Kerem Medical Centre Jerusalem, Israel <br> Anwar Kabaha, RN, BSN <br>

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