1. Head-to-Toe Assessment
Impact of Informatics on Patient Safety Assignment
NUR 330 Nursing Informatics and Healthcare Technologies
By Kelsea Ames, Kristy Blomquist, Sarah Camisao, Grace Donison, Alexandra Lyons, Colleen Regan

2. Epic’s Head-to-Toe Assessment Tools
“Epic software is quick to implement, easy to use and highly interoperable through industry standards,” (Epic Systems Corporation, 2015).
Helps alleviate confusion with documentation.
Provides basis for what is “normal” so that nurses can further identify what is and what is not normal - guides the nurse to “encounter problems more easily and more precisely” (Multicare Health System, 2014).
Helps ensure there is no miscommunication or misunderstanding of what exactly is meant by “normal.”
This assessment strategy helps nurses document faster and most efficiently. By using this method for head-to-toe assessment, nurses are also able to further understand what is meant by “normal” if that is what a nurse before them has written. For example, if the day shift nurse comes on the floor without thorough description of what is going on with their patient from the night nurse, they are able to look at the assessment documentation to see what areas need to be addressed more in depth than others. Because “normal” can mean different things to different people, Epic alleviates this confusion by defining what is normal for all nurses to use the same definition while assessing. The pros to this is that is alleviates confusion or misinterpretation of documented data, but there can be cons to. A con to this that I would imagine is that a nurse could quickly click “within defined limits” without fully assessing if the patient does veer away from this defined normal. If the patient does not fall “within defined limits” the nurse must further assess this area and document more in depth for all nurses and care providers to understand.
As a nurse, these tools can affect the profession by ensuring everyone understands what you are documenting, and also that you understand what others have documented. I believe that using this in a work setting would help alleviate the time it takes with documenting, therefore giving me more time with the patient. Epic’s assessment tools would also help me, as a nurse, understand what areas need to be looked at further so that I do not miss small signs or symptoms of deviation from “normal.” This can improve the nurse-patient relationship as well as the nursing care given.

3. “Within Defined Limits” (WDL) & “Brief Within Defined Limits (BWDL)
used for general assessment to gain quick knowledge of the patient when there are no obvious signs or symptoms of deviation from
‘normal’ or baseline
WDL and BWDL define what is ‘normal’ so that nurses are on the same page and so that there are no misunderstandings
These assessment tools give guidelines for assessment so that no areas of the head-to-toe assessment are missed
Alleviates the chance for misinterpretations of data
Helps nurses find what areas are not normal in order to assess that body system or physical region further
Provides an “intelligent chart review for locating salient details” that could easily be overlooked by the health care providers (Epic Systems Corporation, 2015).
WDL:
slightly more in depth look at the patient to assess whether the patient’s health is ‘normal’ or
baseline for him/her
Epic uses “Within Defined Limits” or “WDL” in the head-to-toe assessment section of their online documentation system. While assessing a patient, a nurse is able to look at what Epic lists as being WDL for each body system. Having limits defined of what is and what is not normal helps the nurse to understand what is and what is not normal with the patient they are caring for. It is possible that a nurse may miss one section of their assessment because they simply forget to do it, but Epic lists clearly what all the areas are that need to be assessed to help ensure this does not happen. If a patient did deviate from being WDL, the nurse can then document a more indepth assessment. This helps the nurse caring for the patient understand what needs to be assessed further, and helps other nurses understand what is going on with the patient without needing to ask the nurse about every single aspect of the assessment. A con to this could be that the nurses may be tempted to not give as thorough of a change-of-shift report because they know they already documented everything they need to. Pros to this also are that the shift report could be faster, more direct, and including only the most pertinent information to save time. “Participating in an Epic shared record solves many of the challenges community providers have with Meaningful Use and interoperability“ (Epic Systems Corporation, 2015). I believe these pros and cons could be argued both ways.
As an employed nurse in this setting, I believe this would help give me confidence in understanding that the patient is, or is not, within defined limits. I would hope that I would never miss anything important in my head-to-toe assessment, but it is possible that I missed something that should have been reported immediately. By using Epic tools for assessment, I would be able to confidently answer whether my patient was within defined limits or needed further assessment and care in one or more body system. I see that this would be especially helpful for a new nurse on the floor because it would help remind him/her what to check, and help him/her understand what “normal” is defined as by the institution where they are working. This would also help any nurse quickly see what is not normal in the patient they are about to provide care for.

4. Cognitive, Perceptual & Neurological Patient Assessment
EPIC Standards -Within Defined Limits or not WDL: alert, opens eyes spontaneously, oriented to person place and time, follows commands, speech spontaneous, well paced logical, purposeful motor response, behavior appropriate to situation. Gait stable, no tremors or weakness, swallowing intact
How to Assess: Assess patient’s neurological status by watching their behavior, gait, speech. Assess if patient is alert and oriented x3. If necessary, give an in-depth neurological assessment to assess cranial nerves and other aspects of patient’s neurological system such as their motor system, sensation, and mental status.
Neurological Assessment:
Glascow Coma Scale: Eyes spontaneous (4) To Verbal Command (3) To Pain (2) No Response (1)
Best Verbal Response: Oriented and Converses (5) Disoriented and Converse (4) Inappropriate Words (3)
Pupil Reaction: (N)=Normal (S)= Sluggish (F)= Fixed *Measure pupil size in mm*
GCS Total______
Pupil Size & Reaction ______
Moves: Normal Strength (4) Lifts and holds (3) Moves on bed (2)
Arm and Leg Movement
Level of Consciousness: Alert (4) Lethargic (3) Confused (2) Unconsious (1)
Why is it important to assess cognition/perception/neuro: It is critical to assess a patient’s cognition, perception and neurological system because it can be the beginning of the entire assessment. If something is wrong, then it will surely affect the rest of the patient’s healthcare.
Pros and cons: This is another standardized assessment that keeps nurses on the same page about how to assess a patient’s cognitive, perceptual, and neurological system. That is a pro to this cognitive, perceptual and neurological assessment and I don’t believe that there are any cons to this assessment.
Imagine using it as a working RN: I will definitely be using this type of assessment on my future patients when I am a nurse because it will keep my data organized and on the same page with other nurses. I will use an assessment like this to begin my patient’s assessment especially when gathering data on their cognitive, perceptual and neurological status.
How it affects working nurses: It affects working nurses because it gives them a standardized way to assess a patient’s neurological system and to make sure their cognitive and perception is in a proper and healthy manner. It gives them a guideline for what their should check and assess with each patient they are assigned to.

5. Sleep, Rest & Relaxation Patient Assessment
Within Defined Limits: “WDL of sleep” or no problem identified. Subjective data about how patient slept.
How to Assess: Assess patient’s sleep, rest, relaxation by communicating with patient. Ask patient how they slept, what their normal sleep pattern is, if they nap regularly, ect. Assess why patient did or did not have a difficult time sleeping or resting. Monitor patient’s behavior and asses if it correlates to the amount of sleep they had.
Sleep/ Rest/ Relaxation Assessment:
Ask patient: “How did you sleep last night?”
“Why didn’t you sleep well?”
“What helps you sleep?”
“Do you feel rested from your sleep?”
“Have you taken a nap?”
“Do you normally take naps?”
“Did pain prevent you from sleeping?”
Why is it important to assess sleep/rest/relaxation: It is important to assess sleep, rest and relaxation because that is the essential importance of a patient’s healing and it is important that a patient has the proper amount of sleep whilst being in a hospital. Nurses need to monitor patient’s sleep so that they can track how well a patient is healing.
Pros and cons: The pro to this assessment allows nurses to be on the same page when they assess a patient and they sleep status. There doesn’t seem to be any cons to this assessment’s organization tool for sleep, rest and relaxation.
Imagine using it as a working RN: I will definitely use this strategy when I work as a professional nurse someday with my patients for their sleep, rest and relaxation assessment in my nursing practice. It will give me a guideline of how I should check on my patient’s rest, sleep and relaxation status and monitor their care so they can heal further.
How it affects working nurses: It affects working nurses because it gives them a standardized way to ask a patient how they slept and assess their sleep status. It is a way to keep nurses on the same page about how they assess and record their patient’s data pertaining to their sleep, rest and relaxation status.

6. Pain & Comfort Assessment
Pain Scales & Comfort Assessment
Within Defined Limits: No WDL for pain, every patient must be assessed
There are multiple scales used to define pain/comfort
Numeric Scale: 0-10 Numeric Pain Intensity Scale
The nurse will ask: Please rate your pain on a scale of 0-10
0= NO PAIN, 2-4=MILD, 5-7=MODERATE,7-10= SEVERE
If pain is present the nurse will assess:
Location,radiation: WHERE IS YOUR PAIN? DOES IT RADIATE?
Pain at rest/activity: DOES IT HURT WHILE AT REST OR ONLY WITH ACTIVITY?
Description:(frequency,quality)HOW OFTEN DO YOU FEEL THIS PAIN? IS IT STABBING,THROBBING,DULL OR ACHING
Non-verbal indicators if patient has epidural
Wong-Baker (FACES): This scale is used for patients that are unable to communicate efficiently
The nurse will show the patient a picture of the faces and ask them to indicate which face fits the way they are feeling best
F(face)L(legs)A(activity)C(cry)C(consolability) Scale:This scale is intended for children between the ages of 2 months and 7 years of age
Pain & Comfort Assessment
It is important to continuously assess pain/comfort on every patient. Pain control and comfort measures are important to restore the patient’s health. We must of course have baseline data on the patient’s pain to be able to recognize if the patient’s pain is being managed or worsening. If the patient’s pain is worsening, there may be another underlying issue that the nurse must further investigate.

7. Safety Assessment
Every patient must have a safety assessment completed each shift
WDL:
Bed low
Wheels locked
Call light within reach
Side rails raised x 2
Identification band on
For patients on suicide precautions:
Chart every 4 hours
The patient’s safety is always a priority. Nurses must continuously assess the patient's safety Some patients are not cognizant to their surroundings, therefore it is our job to keep them safe.
This tool helps the nurse recognize pertinent information. The nurse will use this tool continuously which will help her quickly assess this information upon entering any room. Nurses are constantly on the go, sometimes missing what we would consider “ the small things”, but those small things can make a big impact on the patient’s health. I like this tool because it helps identify the basics of a safety assessment.

8. Cardiovascular Assessment
BWDL:
vitals appropriate
absence of chest pain and peripheral edema
WDL:
regular rhythm
presence of S1 and S1 without murmur or rub
skin warm and dry with capillary refill time less than 3 seconds
absence of cyanosis and edema
absence of chest pain
Within the cardiovascular assessment, the nurse would check off:
WDL
Not WDL (the nurse would then comment, explaining what is outside of the defined limits)
Pacing wires
mA____ rate____ sensitivity_____
Telemetry
The cardiovascular assessment is one of the most important parts of the patient’s head-to-toe assessment. Having the WDL outlined for you, makes it very easy for the nurse to remember what to assess every time and recognize any changes that may deviate from the patient’s baseline. For this reason, I can definitely imagine using this as a nurse.
How it affects working nurses: I think it’s great that the BWDL and WDL are clearly outlined for the nurse, so that there is no confusion as to what one person might consider “normal” or not, so there is never any confusion.

9. Peripheral Neurovascular Assessment
No brief within defined limits for this section, must be fully assessed in all patients
WDL:
capillary refill less than 3 seconds
2+ pedal pulses
extremities warm
no abnormal color
no numbness or tingling
no edema
no calf tenderness
TEDS
SCD’s (sequential compression device)
IV insertion site WDL:
Site without redness, warmth, swelling, pain, streak formation, or drainage
Type ______
Site_______
Why is it important to assess periph neuro: make sure patient has proper circulation throughout the body. Especially important in post-op patients because you want to always be checking that they don’t have signs of a possible DVT. It’s also important to monitor the patient’s IV site every shift and also ask if they’re feeling any discomfort to avoid infiltration.
Imagine using it as a working RN: If the patient does fall outside of the defined limits outlined for the nurse, it will ensure that she further assesses the patient and determines the underlying issue.

10. Gastrointestinal Assessment
No Brief Within Defined Limits; must be full assessment each time
WDL= Within Defined Limits WDL
Not WDL
WDL: Abdomen non-distended, soft,
non tender. Stools within own normal NGT:
pattern and consistency; positive Drain:
bowel sounds
Ostomy: _________________ Last BM____________
Why it is important: A gastrointestinal assessment will be done every shift on a patient. This is extremely important for patients who are post-op and for bed-bound patients, but can still be vital in patients who comfortably ambulate as well. This is important because it can lead to the diagnosis of conditions that will need immediate intervention such as a bowel obstruction. This assessment can also put the nurses thoughts in the right direction for example if a patient was to have an ileus, this could give them the idea of what was happening with the patient before confirming with an x-ray. Also a nurse would want to be mindful of paralytic bowel after a patient has undergone surgery with anesthesia. If a patient falls out of the defined limits, it could also tell the nurse things such as constipation by the looks of the stool combined with report of the patient, and also could tell the nurse things such as whether there was bleeding in the GI tract or not.
Imagine using it as a working RN: As a nurse I will need to become comfortable with this assessment as I will need to perform it every shift on every patient. This is a great assessment tool, and will help me get to know a lot about the patient’s status because majority of the internal organs are in the abdomen. Understanding which organs are in which quadrant would help when assessing the abdominal pain, to keep in mind which complication may be relevant. Also it is important to as the patient what his normal bowel routine is like, because what may be constipation for one patient may be totally normal for another patient.

11. Genitourinary Assessment
WDL: No abnormalities in voiding/ WDL
ability to empty bladder, color, Not WDL
or characteristics of urine DTV
Urethral Catheter Insertion Date: ___________ Bladder Scanned ____ CCs
Urethral Catheter Day #: _________________
( From Providers Order Sheet) Toileting Offered
Urosotomy
Why it is important: Genitourinary assessment, like all assessments in the body, are vital to be done daily. Any abnormalities can point a healthcare provider to look at the functionality of the kidneys. This can also help assess for infection such as a UTI,or for males can be impacted by the prostate gland. It is also vital to assure that toileting is being offered to a patient regularly to rid of the waste. Also information stated such as the insertion date of a catheter can help the HCP assess for signs of infection with certain symptoms. The color and characteristics of the urine can also lead to more individualized blood tests needed such as a urine culture or a urinalysis.
Imagine using it as a working RN: This is something that nurses perform regularly is assess the urine and bladder function of a patient. There will not be a single shift where this assessment is not performed. So it is important to be comfortable with what is within defined limits for each individual patient and which is abnormal. Because as previously stated, when the genitourinary assessment comes up with abnormal findings it will always need nursing intervention. Things that could be learned from this assessment might be something such as dehydration, or proteins found in the urine, infection, or even kidney issues. Or for males it could be something such as enlargement of the prostate gland.T

12. Musculoskeletal Assessment
BWDL
Denies epigastric pain
Heart burn
Nausea
Vomiting
Constipation or Diarrhea
WDL
No swelling
No tenderness in joints
No overt deficits noted
Full active movements of all extremities
Other
Splints______
Casts______
Pin Sites______
Traction Tape____
Other_____
Within the Musculoskeletal assessment there is a box to check for WDL or Brief WDL. There is also a section below that leaves room to comment if the patient has splits, casts, pine sites, traction tape and an other column,
Why is it important to assess musculoskeletal: Importance of the musculoskeletal assessment weighs heavily in scoring a patient's ambulation score. It also gives an RN a sense of how the patient is feeling ie- nauseous, experiencing diarrhea, pain or swelling etc.
Pros and cons:
Cons: The contrast between the BWDL and WDL is vast. Under BWDL the questions are more related to how the patient feels such as N/V in comparison to WDL where the questions are more targeted to joint related issues.
Pros: The “Other” section allows the RN to explain any further issues the patient is experiencing this allows any gray area to be cleared up.
Imagine using it as a working RN: As a nurse I feel as though using the musculoskeletal assessment would give me a better understanding of the patient’s current state of wellness or restrictions the patient may have in relation to ambulation. This assessment would be a good tool to preview before going into my patients room, giving me a better sense of how the patient feels, ambulates etc.
How it affects working nurses: Epic has made documentation very straight forward, it clears the gray areas the patient may fall into and it allows nurses who are coming onto next shift a tool to look up the patient’s current condition.

13. Self Care & Activities of Daily Living Assessment
WDL
Followed up PT OT
Weight bearing______
ADL’S Needs Assistance
Dependant
Transfers with assist of ____
Device used to ambulate ____
CPM Trapeze Abductor
During assessment the Nurse must check off:
Self care
partial bath
full bath
indwelling catheter care
oral care
refused AM/PM care
ambulated-DIST
____ft ____ft ____ft
Each patient must be documented for Selfcare/Activity/ADL/Hygiene. If a patient is dependent there is more documentation the nurse would complete.
Why is it important to assess self care/ADLs: It is important to assess self care in all patients because it tells you one of two important points. First it tells you how independent a patient is and second it tells you how well the patient can move. This is a good tool for not only the nurses to use but also the CNA’s because they work directly with the patient during ADL’s.
Pros and cons:
Cons: The self care section leaves out how a patient prefers to do early morning routines.
Pros: The nurse is able to document whether a patient uses any assistive devices, if they have been seen by PT or OT or if they have a catheter. This is highly useful information to the care provider who is helping the patient with ADL’s, it allows they to prepare items they need before entering the room.
Imagine using it as a working RN: As an RN this would help not only myself but also the CNA working with me. If I was unsure of ambulation, drains or other assistive devices this section is a great reference.
How it affects working nurses: A nurse who is changing shift has use the ADL section to help verify the “heaviness” of the patient. Do they need more help? Are they more so independent? When did they last ambulate?

14. Pros and cons to utilizing Epic’s Head-to-Toe assessment tools
Pros of EPIC assessment as a strategy of informatics in healthcare
Cons of EPIC assessment as a strategy of informatics in healthcare
Organized way to document data
Keeps healthcare professionals, such as nurses, on the same page when documenting
Standardized assessment protocols keep data equivalent for patients during their hospital stay
Ensures pertinent patient information is noticed and addressed quickly
Creates an easy to use flowsheet for healthcare providers to recognize important and/or sudden changes in health status
EPIC assessment is a new medical software for healthcare professional employees, therefore it may take some adjustment to learn about and use with ease and knowledge.
New medical software may have glitches and relies on electricity and computers to run
Creates opportunity for misdocumentation by clicking the wrong thing when in a rush
It is possible for a healthcare provider to say that the patient is WDL or BWDL without thorough assessment of any deviations

15. The evidence that supports this EPIC strategy is this quote:
Describe the evidence to support the strategy with references (e.g. Are there national bodies to support this strategy? What does the literature suggest? Are there any outcome data?)
The evidence that supports this EPIC strategy is this quote:
“Epic has had a long history of embracing the Code's key values and practices including: responsible development, patient safety, interoperability and data portability, clinical and billing accuracy, privacy and security and patient engagement.”

16. How does Epic effect professional nurses
as direct patient care providers?
Standardizes the nurse’s head-to-toe assessment of all patients
Allows professional nurses to be on the same page without any misunderstandings
No assumptions are made without fully understanding what the previous meant by what they wrote
User friendly for healthcare professionals documenting patient information
Defines what is normal and what is not normal for further assessment
Clearly lists what is included in the Brief Within Defined Limits or Within Defined Limits documentation for each body system assessment
This documentation and assessment strategy affects the practice of professional nursing as direct care providers by standardizing the patient assessment. It allows professional nurses to be on the same page when they are assessing patients and documenting data so that no assumptions are made without fully understanding what the previous meant by what they wrote.
It would be nice to work in a healthcare setting that uses EPIC because it keeps hospital and patient data organized and user friendly for healthcare professionals documenting patient information.

17. Supporting Epic’s assessment tools in our future careers
Yes, we support this technological program for healthcare and would love to use EPIC in our careers
Gives prompts for patient assessment so we do not miss anything important, nor forget any parts of the head-to-toe assessment
Ensures that we, as nurses, understand what the nurse before us meant in their documentation and there is no confusion or misinterpretation of notes and data
Alleviates the changes of documentation errors
Defines what is “normal” and Within Defined Limits so we know what information veers from normal and requires further assessment and care
As a group, we absolutely support this strategy as future professional nurses. The reasoning that we support this EPIC strategy is because it standardizes the tools to assess patients. EPIC keeps its employees on the same page to limit errors when assessing and documenting data on patients. We would all seek employment at a healthcare facility which integrates this informatics strategy because it would make our nursing careers easier, and would help prevent errors with patient care.

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