This is my stethoscope. There are many like it but this one is mine. Without me it is useless. Without it I am less effective. For my first post here on Jonathan’s new project I am going to tackle an issue that is not only close to my heart but current in social media. Those nurses who use social media and have seen the fall out from The View’s hosts will know what I’m on about. So here goes.
Recognition of the sick patient
One of my pet interests is the recognition, assessment and then the management of the acutely ill or deteriorating patient. Now to my mind, a thorough physical assessment by the nurse, who often acts as the person to first notice or respond to deterioration is essential in arresting deterioration or charting it’s progress and ascertaining how severe it may well be. I prefer to use and then document my assessment using the A to E framework followed by subsequent systems examinations as appropriate. This works for me as it gives me a system I can rely upon and will prompt me when under stress. Usually, as the registered nurse, I act in a variety of functions in regard to the acutely unwell and deteriorating patient. I speak only of my own experiences, however I have often found myself acting in three distinct roles; those of recorder, recogniser and primary responder. [Adam et al 2010, Evans & Tippins 2007, NICE 2013] Poorly structured assessment and low quality physical assessment of patients by nursing staff contributes to deteriorations being missed, this was demonstrated by NCEPOD (2005) which showed the alarming figure of some 66% of patients showed signs of deterioration for more than twelve hours prior to it being recognised. Management of the acutely unwell or critically ill adult often revolves around the prompt recognition of this acute phase [Jevon & Singh Pooni 2007, Creed & Spiers 2010].
How I choose to learn this skill
Physical assessment and the teaching thereof is something that I feel is lacking to quite an extent in undergraduate nursing courses. In my own experience I found that this was left more to placement areas and what you got hugely varied upon placement areas. A friend who did ICU as a student came out leagues ahead of me in this area. My own teaching comprised of me and several textbooks. In text there seems to be a varied idea of how nurses should and should not assess patients. Some of my preferred texts for the management of the acutely ill and for physical assessment show that there are differing attitudes towards this. This will link back to stethoscopes and auscultation. Jevon (2009) advocates chest auscultation as an essential part of respiratory assessment, Adam et al (2010) and Jevon and Singh Pooni (2007) advocate this as well. Creed and Spiers (2010) are less clear on the matter. This is suggested only if the nurse’s practise area requires this. On the flipside, they recommend a strong familiarity with heart sounds. In my own experience, heart sounds have been of little use to me and of little relevance with the exception of an apex beat. Lung sounds are of eminently greater use and relevance to me. Sadly, as I suspect I have previously stated, my own learning in regards to physical assessment as an undergraduate was not sufficient. I believe there are good grounds to give undergraduate nursing students a thorough knowledge and skills base in physical assessment. This would allow us to assess our interventions more effectively. Secondly and more importantly, we could recognise and react to acutely ill patients earlier in their deterioration process. I feel that doing the simple things well and early on has a huge impact further down the line.
A stethoscope is not just an instrument for the doctor.
The idea that a stethoscope is solely the instrument of a doctor is quite absurd. For me it is an essential tool that aids me in the care of my patients. Working in an area when I am frequently exposed to the critically ill it would be daft to think that this should be so. For me to provide the best care, escalate concerns appropriately and do my best all round I need to be able to assess patients as much as I can. Take a fairly common presentation to ED/MAU, shortness of breath. Is this cardiac or respiratory in nature? As part of my assessment I’ll undertake a respiratory assessment and cardiac assessment. This will include chest auscultation, the findings of this when taken in context with the history will allow me to do the best for my patients. If I had a septic patient who I am aggressively resuscitating with large volumes of fluids and who has a cardiac history I want to be careful as I run the risk of overloading them and causing a pulmonary oedema on top of their sepsis. This allows me to assess the impacts of my interventions, were I to hear fine crackles then I’d escalate my concerns. I would be looking to reassess my patient at intervals. Also if they showed signs of improvement or further deterioration, for example if they became more short of breath following aggressive fluid resuscitation. [Adam et al 2010, Jevon & Singh Pooni 2007, Longmore et al 2014]
As much as pulse oximetry is a helpful tool, it cannot be as accurate as auscultating an apex beat which is what I prefer to do if I doubt the pulse oximetry and I am not using cardiac monitoring on my patients. For me, this is the limit in auscultating heart sounds as I am not comfortable in listening for S1 and S2, nor is it really relevant to me at this point in my career.
Additionally if someone’s presenting complaint is abdominal pain, I’ll be interested to know if they have bowel sounds or not. Again, coupled with the history this is most relevant. The nature of the bowel sounds is also most vital.
Outdated images persist.
Ultimately, what the hosts of The View have implied is an outdated image of nursing where nurses do not assess their patients. We are simply pill passers and provide what may be seen as traditional nursing care. We are not highly trained in the eyes of The View. Quite the opposite of this is true. The lines on what traditionally nurses and doctors do have been blurred for a while. We are a progressive profession which has taken on more skills in the name of providing better care. The image of the modern nurse is changing rapidly, despite this I feel that in the UK we are still stuck with an image of nursing very much somewhere between Florence Nightingale and Call The Midwife. This has been shown by The View. Sadly my own profession also seems to echo it at times, ie there are things that we should and shouldn’t be doing as nurses. Surely a basic assessment of your patient’s physical condition is essential and elemental to their care. In my mind it is as essential as the fundamental nursing care like providing pain relief, assisting in meeting hygiene needs etc?
Ultimately I do not possess a doctor’s stethoscope. It is my stethoscope, an instrument I use to help those who come into my care. This is because I want to do the best for my patients and to me this involves as in depth a physical examination as I can provide.
Tom is a registered nurse working in emergency care settings splitting his time between ED and EAU. His passions involve furthering nurse education in regards to physical assessment combined with the assessment and care of the rapidly deteriorating patient.
He also has a keen interest in simulation learning. Tom has an interest in massive transfusion in trauma, having written his undergraduate dissertation on the subject.
Stereotypically lacking in attention span, usually well natured when adequately caffeinated.
Tom studied and now works in Oxfordshire