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.

image1_optTom 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

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10 Responses to This is My Stethoscope!

  1. I feel that undergraduate nurse training these days doesn’t equip nurses with the right practical skills for appropriate patient assessment and initial management. Taking blood pressures and giving drugs does not equate to good clinical practice that advocates for the patient and identifies deterioration in clinical conditions. In the UK we have a long way to go with UG nurse training and there is a big gap between UG and PG education where the majority of nurses struggle to educate themselves in acute skills. This is also hampered by the pressure of less staff and more patients and more paperwork!

  2. Tom Hreben says:

    Dear Sam,

    In some ways you are hitting the nail head on. I only speak of my own experiences as an undergraduate and felt that it was rather lacking in physical assessment and other elements eg teaching on pathophysiology etc. I definitely felt under prepared in some aspects. Sadly so much was left to placement areas, the expertise of lack there of in those areas. This was also hampered by an absolute lottery as regards placement allocation. Sadly post graduate education for nurses is very hit and miss. We seem to be expected to know it all. Paper work is a separate debate for another occasion as is safe staffing.

    Tom

    • Gav says:

      The blur between roles is difficult to make tangible. I’ve don’t know what I am now. I can look after most critically ill patients, near independently now, the limit of the care I can provide is largely down to the number of hands I have. When it comes to what my patient needs, I think to myself do I have the knowledge, skills and credentials too meet that need, not, should a nurse meet that need or a doctor.

      • Tom Hreben says:

        Ultimately what it needs to boil down it is knowledge, skills and competence. Sadly nursing in the UK seems to be to obsessed with saying “because we are nurses” and then saying we should or shouldn’t be doing something based on that. Can we assess our interventions and adequately plan interventions based upon an incomplete assessment? If you’re able, competent and qualified to do something then go for it. You are the person most capabale of providing what that patient needs at the time.

    • scott says:

      I think UG training has come a long way. Physiology, Pathophysiology and aetiology is taught. What i don’t see is UG and post grad Nurses using the transferable skills and applying them to different processes.

      While i agree nurses can take advance practice roles and deliver them with care and to a high standard. Making a huge impact on patient outcome. We need to stop rewarded task orientated nursing which unfortunately doesn’t allow nurses to develop these skills.

      Scott

  3. Gav says:

    The really blurry part is where Dr’s ask me to supervise a procedure conducted by them.

  4. Heather Baid says:

    Interesting and thought-provoking read about implications for nurses using a stethoscope. I did my pre-reg nursing education in Canada in the early 1990’s where we were taught to listen to auscultate lung and heart sounds as part of daily nursing practice. It wasn’t considered an ‘advanced’ or ‘extra’ skill added into post-registration nursing education but something all nurses do. When I moved to the UK in 1999, I remember working on a ward with a patient that I was worried may be going into heart failure who had an IV infusion running in quite quickly when I came on shift……so I started listening to his breath sounds thinking this was an obvious thing to do and I was stopped by the Ward Sister who quite clearly (and sternly!) told me that was not my job and using a stethoscope for breath sounds was a Doctor’s job.

    But things have moved on and many University pre-reg nursing programmes in the UK now have physical assessment integrated in and physical assessment modules within post-reg courses are increasingly popular. When nurses first started using stethoscopes, it was only to take a Blood Pressure – this explains why there is the term ‘Nurse Scopes’ for these types which are so basic and not good for anything much except for taking BPs:
    https://www.normed.com/products/shopexd.asp?id=432

    I can’t seem to remember or find the reference but I’m sure I read an editorial by an A&E consultant a few years ago who said he never had an expensive stethoscope because firstly they tend to get easily stolen or lost in an A&E environment. But also, he pointed out if auscultation findings are that severe/abnormal, they are likely to be picked up by a really cheap stethocope……and if they are that subtle / hard to hear, then he didn’t really want to know because these type of auscultation findings could likely be left as followed up by somebody else after patient leaves A&E if they were clinically significant at all.

    It’s hard to imagine the kind of practice existing now which is described here about the role of the nurse in the 1950’s and 1960’s in relation to auscultation and the traditional nurse-physician relationship:

    https://books.google.co.uk/books?id=DflC25GsVkAC&pg=PA109&lpg=PA109&dq=nurse+scope+stethoscope+1960%27s&source=bl&ots=GluDi_dpNU&sig=eLV_hyzmZfY0_DdHuO_HtN0jPZM&hl=en&sa=X&ved=0CCwQ6AEwAmoVChMI8NLLsePsyAIVhlQUCh0G6wo_#v=onepage&q=nurse%20scope%20stethoscope%201960%27s&f=false

  5. Jonathan Harris says:

    Hi, thanks for this article. Really interesting and enjoyable read. Currently I am coming to the end of a pre-reg masters in Adult Nursing and am looking forward to starting a new job in a busy A&E. Personally I agree with your approach to physical assessment and have been trying hard the past few months (since an ICU placement) to utilise a more rigorous respiratory assessment on patients including chest auscultation. Like you I have used books to develop these skills along with YouTube having had very limited training in physical assessment in university. I am not great at hearing the sounds yet but feel like I can only improve through practice! However, I must say that I am almost ashamed that I utilise these skills and hide my stethoscope in my pocket knowing that I’d get stick from other nurses for using it. Do you find that you get this (almost aggressive) attitude from other nurses? How do doctors respond to you when you provide them with a more detailed assessment? Also, I see you work in A&E from your bio, when do you utilise auscultation in this practice environment? Triage? Resus? Would be interested to know! Thank you!

    • Jonathan Downham says:

      Hi Jonathan and thanks for your comments. I don’t work in A7E anymore (and must update my bio!) but when I did it was as an advanced practitioner and I needed to use my stethoscope a lot! I have never had a problem fro other nurses and it’s a shame you feel the need to hide it in your pocket. As you say if you practice you will only become more competent and perhaps you are an Advanced Practitioner of the future.

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