a historical perspective b y

Virginia M. Fitzsim on s and

Louise P. Gallagher

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HE nurse’s use of physical assessment skills for health T maintenance and health promotion indicates a new, ex- panded role for the profession. Or does it? A look at the histor- ical development of physical assessment skills by the nursing profession discloses that these skills have been an integral part of nursing since the time of Florence Nightingale. For many years, nursing has been aware that physical assessment skills are indispensable as a tool for data collection. Nurses have developed, refined, and availed themselves of these methods in much the same manner as have physicians.

INSTRUMENTS USED FOR PHYSICAL ASSESSMENT

The narrow view of nurses adopted by the medical profes- sion has made it difficult to precisely define the function of nursing. Moreover, physicians have always jealously guarded the right to use medical tools, displaying a characteristic re- luctance to hand them over to nurses.

In the early 1930s, simple instruments of measure such as the clinical thermometer and the sphygmomanometer were considered exotic, and their use was regarded as being beyond the scope of nursing skills. In a graduation address given in 193 1 to nurses at the Massachusetts General Hospital, a phy- sician, referring to the clinical thermometer, stated, “At the beginning of nursing in the Massachusetts General Hospital there was a regulation that no nurse was to handle that ‘instru- ment of precision.’ ” The belief was that the thermometer “had to be used by a properly qualified medical man.” (Cabot, 193 1) However, no one today would question the use of a thermom- eter by a nurse in the course of collecting data regarding the

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patient. Taking the temperature is standard procedure for the nurse to follow, and is quite expected on the part of the patient.

About the same time Massachusetts General was struggling with the mighty problem of whether a thermometer was too in- tricate an implement for general use, nurses in the Kentucky Frontier Nursing Service were using the blood pressure cuff and stethoscope as part of their routine method for assessing a patient’s condition. Furthermore, in an effort to screen for toxemia of pregnancy, they did urine checks and took blood pressures on all prenatal women. Although the use of a sphyg- momanometer was considered avant garde in the thirties and raised some eyebrows, the prenatal program was such a suc- cess that one physician was heard to say, “Someday all nurses shall take blood pressure readings even though it is costly.” (Lester, 1931)

Today, the opthalmoscope is the precision instrument whose use by nurses is under question, and the issue is whether nurs- ing should consider incorporating the instrument into its rep- ertoire of tools for health screening. Use of the opthalmoscope would allow the nurse to collect more refined data about the cardiovascular system of the eye, and evidence of the systemic status of the cardiovascular system, instead of gathering data only on the gross cardiovascular system.

THE CARDINAL TOOLS OF PHYSICAL ASSESSMENT In the days of Florence Nightingale, the nurse had to rely on

her natural senses alone, commonly using the skills of inspec- tion and palpation. These skills were developed as a result of teachings by Nightingale, which focused on the importance of patient assessment by means of such naturally given aids as

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sight and touch as essential in fulfilling the nurse’s role. Through techniques of observation, the nurse collected

data about the patient’s condition, and implemented the pa- tient’s care accordingly. Then, as now, the nurse considered not only the disease process and treatment regime, but also the patient’s physical responses to the environment. The nurse realized the importance of observing the face and body for changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition and hydration. (Nightin- gale, p. 116)

Stressing that precision was needed to collect data, Nightin- gale stated, “the most important practical lesson that can be given to nurses is to teach them what to observe [and] how to observe. . . .” (p. 105)

To accomplish this objective, Nightingale taught the skill of palpation to measure pulse rate and quality, emphasizing that the nurse was responsible for gaining proficiency to ensure accuracy in decision making. Up-to-date treatment of Nightin- gale’s time also included the use of palpation and inspection in the care of the puerperal woman. The nurse was responsible for palpating the fundus and observing the woman’s responses to the stresses of delivery. The surgical nurse routinely observed patients’ respiratory patterns and inspected dressings.

DOCUMENTATION OF THE USE OF ASSESSMENT TOOLS

Nursing journals are filled with examples of accepted nurs- ing practice which include the use of independent inspection, palpation, and ausculation in the everyday role of the nurse.

In 1901, the American Journal of Nursing recorded that palpation was used by the nurse as a method of gastro-intes-

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tinal therapy. The nurse massaged the G.I. tract to increase peristaltic actions, and promoted bowel evacuation. To begin the procedure, the nurse identified the fundus of the stomach and the area of the pylorus. The complete length of the intes- tine was palpated and manipulated, including the cecum and the colon. An assessment of the results was then made by the nurse, and the treatment was repeated p.r.n. (Williams, 1901) In that same year, a doctor made the following observation in the American Journal of Nursing, “It is the duty of the nurse . . . to examine the eyes of the new-born baby each day during the lying-in period (for the signs of Blenorrhea Neonatorum) .” Included in the inspection was the cornea, conjunctiva, and lacrimal sacs. As one doctor observed, “Without the good nurse the doctor is powerless in these cases, and her responsi- bility is even greater than his, because upon her . . . care really depends the sight of a fellow creature.” (Wescott, 1901)

In 1901, the American Journal of Nursing examined the role of the nurse in testing the function of the eighth cranial nerve in patients. Early detection of defects was stressed, and while the technology of testing auditory acuity was primitive, the nurse was expected to take a measure of auditory function. (Kerr, 1901)

Other evidence substantiates the role of the nurse as a rec- ognized part of the health care team, both in maintaining and promoting health. During the early 1900s, contagious diseases posed major health threats to the population of New York City. In a concerted effort to stop the spread of the contagion, 141 nurses were employed by the city to work within the school system. (Kerr, 1901 ) Following the first school examination at the beginning of the term by the medical inspector, it became

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the nurse’s responsibility to examine the children at specific intervals. The nurse’s inspection included the eyes, hair, skin, mouth, and throat. Furthermore, the nurse’s role as health maintainer and health teacher extended not merely to the school child, but to the family and the community at large.

Although given an early start in New York City, school health supervision continued to be regarded as a new phenom- enon into the 1920s. The health team was employed by the city or school board. While the initial physical examination was not part of the nurse’s role, she was responsible for sub- sequent in-class inspections, “for the detection of communi- cable diseases and physical defects.” (Hiscock, 1923) In some cities, it was the nurse’s responsibility to find physical defects in children in grades two and three, while the physician was responsible for physical examination of children in grades one and four. “In Detroit the examination is made every three months by the nurse, who especially examines the throat, skin and head of the pupil,” Hiscock reports. The same source noted that the nurse was responsible for examining the children in all grades in Omaha and Des Moines. In eleven of the smaller cities, examinations were made either every other year or three times during the school years.

These accounts leave no doubt that the school nurse used her assessment skills of inspection extensively at regular in- tervals, especially during those times when certain diseases were prevalent. Furthermore, no longer were inspections con- fined to external body surfaces. Included in the exam was the assessment of internal structures such as the pharynx. It be- came standard practice for a school board to require a certifi- cate, signed by the school nurse, as a condition for re-admission

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for any child who had contracted a communicable disease, Hiscock states.

By 1938, physical assessment as a component of health maintenance was an integral part of the health program at the Lincoln School in New York City. The nurse screened for visual and auditory acuity, appraising the function of the second and eighth cranial nerves. Today, this procedure is recognized as an important component of the neurologic ex- amination. (Axelson, 1938)

In the classroom, the nurse did health inspections and teach- ing. She was responsible for the screening for communicable disease via ear, nose, and throat inspections in school-age children. By the 1940s, even colleges were relying on the nurse to screen students and give health consultations.

There is evidence of parallel developments in the field of public health nursing during the first part of the century. In 1912, the public health nurse was making routine inspections of the home. As reported in the American Journal of Public Health, MacNutt (1913) proposed the term “health nurse” in an address before the American Public Health Association, since the function of the board of health nurse was the “posi- tive promotion of health.”

In the 1930s, rural public health nursing flourished, afford- ing the nurse recognition as the vital force on the health team. Her role included casefinding, and carrying out prevention programs against typhoid, malaria, diphtheria, and other com- municable diseases. Using her physical assessment skills, she conducted integumentary and ear, nose, and throat examina- tions. The nurse was the primary person to reach out to the community, acting as health care liaison among the people,

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the physician, and the sanitary engineer. (Marriner, 1931) In addition, the nurse carried a full caseload of women for prenatal and perinatal care, Lester reports ( 193 1 ), adding that for a majority of these women, prenatal and perinatal care was previously unknown.

The public health nurse did urine-testing, took blood pres- sure measurements, and conducted abdominal examinations. Skilled in physical assessment techniques, she was the patient’s major contact with the health care system. The nurse under- stood the necessity of adapting skills to the particular psycho- logical and sociological concepts of the community. Often, the public health nurse’s system of assessment included confer- ences with patients to encourage them to participate in their own care, Lester notes. Complex cases were presented on nursing rounds, so that learning experiences could be shared with colleagues. As a professional practitioner with a de- veloped sense of autonomy and accountability, the public health nurse cared for virtually all the health needs of patients.

It should be noted that the greatest progress in freeing the nurse to fulfill her potential as a health care practitioner oc- curred in poor inner city areas, or in such special services as the Frontier Nursing Service or the rural Red Cross. (Lester, 193 1 )

The Red Cross nurse was analagous to the Frontier Nurse in that she created rural outposts and ran public health nursing centers. According to Ames (1928), “When the patient can- not go to the Outpost, the nurse goes to the patient. Where the physician is too far away to be available, the judgment of the nurse is called upon to an extraordinary extent.” Ames con- tinues, “Last year ( 1928), 3,088 patients received over 30,000

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days of attention of the Red Cross nurses. Seven hundred and forty-three babies were born, most of whose mothers would have gone unattended. Both preventive and curative work are done.” (p. 121)

In the poverty areas of the cities, immigrant groups accepted the nurse more readily than the physician. (Noble, 1923) Clinics became quite common. As early as 1923, the American Journal of Public Health documented that the nurse midwives’ use of the tools of inspection, palpation, and auscultation were essential to the delivery of prenatal services. If the woman did not come to the clinic, the nurse went to the patient’s home to check her urine and auscultate her blood pressure. (Ames, 1928) In this manner, nurses performed both a preventive and curative role as they attended their patients.

During that same year, the state of Pennsylvania, with the object of keeping “well babies well,” opened clinics for chil- dren. After the initial visit with the physician, according to Noble, the child was seen by the nurse for “weighing and visC.” All state centers were run by the nurse, who saw the baby on all return visits to the clinic, and also made home visits. In an effort to reduce the rate of infant mortality, nurses as- sumed the responsibility of initiating campaigns to improve sanitary conditions. These efforts were focused primarily on the home and children, stressing clean water and the necessity of milk in the diet. (Noble, 1923)

In more recent times, industry as well as health care institu- tions have shown a greater recognition of the value of using the nurse as the initial performer in the health care schema.

In 1953, the telephone firm of Bell Canada began using nurses to do initial health reviews for their employees, orient-

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ing the program to maintain and promote health. Included in the plan were the taking of a complete history and physical examination. Initially, nurses examined only female patients, but by 1968, all applicants were referred to the nurse. (Bewes and Baillie, 1969)

A study to explore and evaluate the effect of introducing a public health nurse to work in association with a physician was conducted by Montefiore Hospital in New York City be- tween 1963 and 1967. The nurse in obstetrics was to deter- mine fetal position, weight gain, fetal heart sounds, as well as to give anticipatory guidance and handle medical and emo- tional problems. In pediatrics, the nurse, in addition to taking routine measurements, was to give anticipatory guidance, dis- cuss problems with the mothers, conduct a physical examina- tion, and check the children’s developmental milestones. The results of this study indicated that patients were satisfied with the care they received from these nurses. In fact, a majority preferred the combined nurse-physician approach to being seen just by a physician. (Ford, 1966)

The Harvard Community Health Plan, originating in the 1960s, provided another study in which nurses could use their skills in a group practice organization. (Bates, 1972) Nurses were able to manage 70-80 percent of the patients they saw in this setting. According to the plan, nurses were used at the point of first contact with the patient and throughout the en- tire process. Nurses received all telephone calls from adult medical patients seeking appointments; took a preliminary history and decided on a course of treatment; requested lab- oratory tests, made diagnoses, and had input into management decisions; were active in the triage process, interviewing pa-

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tients and making physical and psychosocial assessments. The attitude of the nursing staff was summed up by one member who stated, “What we’re doing is not really new. We’ve been doing it in public health for years.” (Bates, 1972)

CONCLUSION Nursing has made and will continue to make, critical con-

tributions to the viability of the health care system through the use of physical assessment si<iIls. Florence Nightingale called the nurse a “health conservationist,” convinced that the pri- mary focus of nursing was health maintenance and health promotion. That focus has not changed. The perspective of history shows us that physical assessment skills have been a traditional tool of the nurse for many decades, aiding in the competent fulfillment of responsibility by the professional practitioner.

REFERENCES

Ames, Miriam, “Public Health Nursing,” American Journal of Public Health,. 18(1):121, 1928.

Axelson, Alfhild, “Health in a Progressive School,” American Journal of Nursing, 38(7) :516-519, 1938

Bates, Barbara, “Nursing in a Health Maintenance Organization : Report on the Harvard Community Health Plan,” American Journal of Public Health, 62 (7) : 99 1-994, 1972.

Bewes, D. C. and J. H. Baillie, “Preplacement Health Screening

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by Nurses,” American Journal of Public Health, 59( 12) :

Cabot, Richard, “What is Worthwhile in Nursing,” American Journal of Nursing, 31(3):279, 1931.

Ford, Patricia A., Seacat Milvoy, and George Silver, “The Rela- tive Roles of the Public Health Nurse and the Physician in Prenatal and Infant Supervision,” American Journal of Public Health, 56(7): 1097-1103, 1966.

Hiscock, Ira V., “School Health Supervision,” American Journal of Public Health, 13(4) :259-269, 1923.

Kerr, Anna W., “School Nursing in New York City,” American Journal of Nursing, lO(2) : 106-108, 1901.

Lester, Betty, “The Experience of a Midwifery Supervisor in the Kentucky Hills,” American Journal of Nursing, 3 1 ( 5 ) : 573- 577, 1931.

MacNutt, J. Scott, “The Board of Health Nurse: What She Can Do for the Public Welfare in a Small City,” American Journal of Public Health, 3(3) :344-350, 1913.

Marriner, Jessie L., “Rural Public Health Nursing: A Vocational Study of Interest to Student Nurses,” American Journal of Nursing, 31(1):45-52, 1931.

Nightingale, Florence, Notes on Nursing What It Is and What It Is Not,. Unabridged replication of first American edition, Dover Publications, London, 1969.

Noble, Mary Riggs, “Child Health Work In Pennsylvania,” Amer- ican Journal of Public Health, 13(9)756-759, 1923.

Wescott, Cassius D., “The Management of Blenorrhoea Neona- torum with Especial Reference to the Duties of the Nurse,” American Journal of Nursing, 1 (9) 635-639, 1901.

Williams, Kate W., “Massage for Constipation,” American Journal of Nursing, 1(10):713-715, 1901.

2178-2184, 1969.

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