What the Nurse Sees: Gait, Breath, Color, Affect

The nurse sees a patient walk to the bathroom. The physician sees a patient in bed.

This is not metaphorical. It is the difference between what the nursing curriculum teaches clinicians to observe and what the medical curriculum teaches clinicians to observe. The difference accumulates into different clinical knowledge about what the patient is.

Issue 004 of this publication argued that the nurse sees deterioration first because the nurse is at the bedside continuously. This essay is about what specifically the nurse sees when she is at the bedside that the physician does not see in a brief encounter in the patient's room.

Gait

A patient's gait tells a story the patient seated in bed does not tell.

The nursing curriculum teaches observation of gait as a formal clinical skill. The textbooks name it: balance, stride length, base of support, arm swing, turning, weight-bearing symmetry. These observations are taught alongside the medical concept of gait disturbance, but they are taught differently. Medical training teaches gait disturbance as a problem to identify — the patient who cannot walk is a patient with a gait problem, and the gait problem is a neurologic or orthopedic sign. Nursing training teaches gait as continuous data about the patient's functional status, confidence, pain, strength, neurologic state, and psychological state — all simultaneously visible in the walk from the bed to the bathroom.

The patient who walks with a shuffling gait and short stride may have Parkinson's disease — that is the neurologic sign medical training attends to. But the patient's gait also tells whether she is afraid of falling, whether she has pain with weight-bearing, whether she has weakness she did not report to the physician, whether she has orthostatic hypotension that resolved itself by the time she reached the bathroom, whether she is gaining confidence after several days of mobility or losing it. The nurse who watches the walk sees this complexity at once.

The physician who rounds on the patient in bed does not see the walk. The physician sees a patient who "is ambulatory" in the assessment. The ambulation has happened or not happened; it is past tense in the physician's note. The walk itself — the quality, the trajectory, the moment-to-moment risk — is available to the nurse and not to the physician.

Breath

Breathing is one of the first things the nursing assessment teaches clinicians to observe.

The medical curriculum teaches respiration in the framework of respiratory mechanics — minute ventilation, dead space, the work of breathing, the pathophysiology of respiratory disease. These are important frameworks. The nursing curriculum teaches them too. But nursing also teaches breathing as a visible, moment-to-moment sign of the patient's respiratory effort, anxiety, pain, neurologic state, and cardiopulmonary reserve.

The patient who breathes with pursed lips is managing their airway and breath control; the nurse recognizes this and understands it as adaptation rather than pathology. The patient who breathes with accessory muscles is doing work the resting patient should not be doing; the nurse sees this before the patient is short of breath enough to report it to the physician. The patient whose breathing pattern changes when the nurse enters the room — who breathes faster, shallower, more laboriously — is showing anxiety or fear the patient may not name; the nurse sees this as clinical data.

The patient's breathing at rest, while asleep, while moving, while talking, while in pain — the breathing changes across contexts. The nurse who is in the room across hours sees the range of breathing patterns. The physician who enters for a brief examination may see only the breathing that occurs during the encounter, which is often not the patient's resting breathing.

The respiratory rate is a vital sign and is recorded. The quality of that breathing — the work, the pattern, the change across context — is available to continuous observation and is not typically recorded except in nursing notes.

Color

Color is a form of clinical data the medical curriculum names as a clinical sign but teaches primarily in the framework of pathology — pallor as a sign of anemia or shock, cyanosis as a sign of hypoxemia.

The nursing curriculum teaches color observation as a continuous sign of perfusion, oxygenation, emotion, and circulatory status. The patient's skin color at baseline. The patient's color change with exertion or emotion. The patient's color in the early morning before activity, at midday with activity, in the evening when fatigue sets in. The color of the lips, the nail beds, the earlobes — different tissues perfuse differently and change at different thresholds.

The patient whose color is normal in bed but flushes with mild exertion may be compensating well at rest and decompensating with activity — information the physician who sees the patient at rest does not have. The patient whose lips are pale at the corners despite normal color elsewhere may be showing early signs of shock the vital signs have not yet captured. The patient whose color does not return to baseline quickly after exertion may have poor circulatory reserve.

These are not exotic observations. They are part of what careful bedside watching teaches any clinician. The difference is that nursing training explicitly names them as things to watch for, while medical training teaches them more often implicitly, if at all.

Affect

Affect — the patient's mood, anxiety, fear, confidence, engagement — is a clinical variable.

The medical curriculum teaches affect as a mental status examination component. The patient is alert, oriented, mood appropriate or labile, affect congruent or flat. The framework is diagnostic: what does the affect tell us about the patient's neuropsychiatric status? This is one clinical question.

The nursing curriculum teaches affect as a sign of how the patient is managing the illness, how the patient is tolerating treatment, whether the patient has psychosocial needs the clinical team has not identified. The patient whose affect is anxious may be having untreated pain. The patient whose affect is withdrawn may be depressed or may be conserving energy because the illness is more taxing than the vital signs suggest. The patient whose affect changes across the day — brighter in the morning, more withdrawn by evening — is showing fatigue or delirium the physician who rounds once daily may not see.

The affect is also relational. The patient's affect in conversation with the nurse is different from the patient's affect alone in the room, which is different from the affect in the presence of family, which is different from the affect when an unfamiliar physician enters. The nurse who observes across contexts sees the relational complexity. The physician who sees one slice of affect in one context has one data point.

The patient's emotional response to the clinical situation is not incidental to the clinical situation. It is part of what determines adherence, engagement, and outcome. The nurse who attends to affect as clinical data is attending to something the patient's vital signs do not capture.

What Using These Observations Would Change

A medical training that taught gait, breathing, color, and affect as formal observational skills — not just as signs to recognize in the framework of pathology, but as continuous variables that change across context and provide moment-to-moment clinical data — would produce physicians who see patients differently.

The physician who rounds on a patient in bed would ask the patient to walk, not because walking is part of the neurologic exam, but because the walk itself contains information. The physician who examines a patient would attend to the breathing across contexts, not just during the examination. The physician who interviews a patient would attend to the affective arc of the interview, not just the final affect state.

These are not hard skills. They require time and attention and training to do systematically. Most physicians have some intuitive sense of gait and affect and breathing. The difference is that nursing training makes them systematic, makes them nameable, makes them part of what the clinician is explicitly taught to look for.

The nurse who is continuously at the bedside and the physician who rounds briefly on the same patient are looking at the same patient. What they see is different because what they have been trained to see is different.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.