Embarrassing question from new nursing student

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Hello all! I am in my first semester of nursing school, we just started clinicals, and I have kind of an embarrassing, probably stupid question/issue...I am way too embarrassed to ask my instructors about this (or frankly, even the other students) so hopefully someone here can give me some advice.

When you are auscultating a woman's chest, and she has larger breasts, how exactly are you supposed to do it? Do you just kind of move them out of the way? Do you tell the patient that you need to move it? Also, are you supposed to auscultate through their shirt/hospital gown/bra, or ask them to remove it? Same goes for bowel sounds...I had one of my first patients get mad at me because I tried to pull her pants down a little for bowel sounds (they were so high I couldn't see her belly button, which I use as the landmark for my quadrants), and she yelled at me that I didn't need to do that to listen for bowel sounds...I thought you did because it might be hard to hear through clothing...I apologized profusely to her and she seemed to be ok, but I still feel really bad about it...I mean I certainly wasn't going to pull them all the way down, only far enough to expose her lower belly, but I probably should have at least explained to her what I was doing and why.

Anyway, I'm sorry if this is a dumb or weird question...I've never worked in the medical field at all before and I feel seriously nervous and out of my league in clinicals, and it doesn't help that I'm a pretty introverted person and have never been very touchy-feely. I don't consider myself a squeamish or conservative person (e.g. I really don't care if I'm out in public and see a woman breast feeding or something, nudity doesn't bother me, etc.), so I thought I'd be fine with the more "sensitive" parts of being a nurse, but when it comes to actually doing this to real live patients, I just feel completely lost as to what the right approach is, what you should say to the patient, what's appropriate, etc. I don't feel it's something I can really ask my instructors about and nobody else in my class seems to have a problem with this like I do, and the textbooks say zilch about it....somebody please help!

Thanks for "listening" and I appreciate any advice!!

I think this is a great q. My teachers have actually yelled at students who auscultate through shirts or gowns. If its a larger breasted woman, just kindly tell her "I'm gonna listen to your heart or lungs" and proceed. Most people don't have an issue with you touching them after you warn them nicely... Good luck

Specializes in Med-Surg, Ortho, Subacute, Homecare, LTC.

I think maybe if I were to listen to bowel sounds that required pulling down someone's pants I may begin by saying, "Hi, I have to listen to your bowel sounds, would you mind moving your pants down a little so I can hear them better?"

I am always suspicious of someone who listens to hearts, lungs, guts, and BPs through clothing of any kind. That tells me s/he doesn't know what to listen for in case of any abnormal or subtle findings (or doesn't care), and I don't want anyone that careless taking care of people. Yes, I know you see it done all the time; yes, I know you see physicians and PAs do it. Still wrong. Even a routine exam can have unexpected findings like a new murmur or funny lung sound, and better to find it than to miss it.

Specializes in Cardiology.

No ? is too embarrassing or "dumb". In general, you should not have any clothing between the stethoscope and what you are trying to auscultate because the fabric can create artifact sounds.

Also, I would suggest explaining what you are doing to a pt and gaining their permission to proceed prior to pulling the waist of their pants down. example: "Ms. smith, I am going to lower your pants a little and listen to your abdomen, is that OK?"

good luck

I agree that telling people what you're going to do as you go and explaining why is the best way to avoid this kind of thing. Say, "now I'm going to listen to your heart - in order to properly auscultate your apical heartbeat, which is located in the 5th intercostal space just below your breast, we will need to displace some of your breast tissue. Do you mind?" (Using technical language might give the patient more confidence in you, which will then allow you to proceed as you need to proceed - and maybe she'll offer to move the breast herself.) If she doesn't volunteer to move the breast, then yes, do it with the back of your hand, and before you do it, say, "Okay, I'm going to displace your breast now, so you will feel me displacing the tissue. Ready?"

As for the abdominal stuff, you might say, "In order to properly hear the sounds in your small intestine, I will need to auscultate in the lower quadrant, which means I will be moving my stethoscope further down. Will that be okay?" If the patient claims that this is not necessary, just tell her that it sounds like she's not comfortable with the procedure, so you will stop (she does have the right to refuse). But if she's mainly saying that you can hear through her pants, just tell her that based on evidence-based research, it's not really possible to detect peristalsis through fabric, and for her safety you need to be as precise as possible so that the doctor/NP can determine whether there is a problem, because if you don't hear anything for 15-30 seconds, this could be an indication that (blah blah blah)."

I understand the stuff about being introverted, and it's REALLY tough when your patients challenge you. My instructor told us that no matter what, as long as you're not doing something that you really shouldn't be doing yet, just act like you've done it a million times already, and make yourself pretend that you know exactly what you're doing. A patient like this can make you second guess yourself unnecessarily. Just put on your nurse's costume and tell yourself that you're being the nurse - then maybe the patients will be easier on you, and you'll realize that you can do this!

I hope that helps. It's tough, I know. I'm right there with you.

I agree that telling people what you're going to do as you go and explaining why is the best way to avoid this kind of thing. Say, "now I'm going to listen to your heart - in order to properly auscultate your apical heartbeat, which is located in the 5th intercostal space just below your breast, we will need to displace some of your breast tissue. Do you mind?" (Using technical language might give the patient more confidence in you, which will then allow you to proceed as you need to proceed - and maybe she'll offer to move the breast herself.) If she doesn't volunteer to move the breast, then yes, do it with the back of your hand, and before you do it, say, "Okay, I'm going to displace your breast now, so you will feel me displacing the tissue. Ready?"

As for the abdominal stuff, you might say, "In order to properly hear the sounds in your small intestine, I will need to auscultate in the lower quadrant, which means I will be moving my stethoscope further down. Will that be okay?" If the patient claims that this is not necessary, just tell her that it sounds like she's not comfortable with the procedure, so you will stop (she does have the right to refuse). But if she's mainly saying that you can hear through her pants, just tell her that based on evidence-based research, it's not really possible to detect peristalsis through fabric, and for her safety you need to be as precise as possible so that the doctor/NP can determine whether there is a problem, because if you don't hear anything for 15-30 seconds, this could be an indication that (blah blah blah)."

I must completely disagree with your assumption that "technical language" will make you seem more knowledgable and important to the patient. On the contrary, people who don't understand what you're saying (and we have nursing students come here who don't know what "auscultate" and "peristalsis" mean) get their anxiety ratcheted up a hair every time they think they are missing something important, and they feel separated from their caregivers, not more confident in them.

It is perfectly acceptable to say, "I need to be able to hear your heart and lungs clearly, and I can't hear as well through clothing." "I need to be able to hear whether your bowels are working-- they normally make a lot of squeaky, bubbly noises; you've probably heard that yourself." You don't need to go into the whole evidence-based practice, what quiet sounds mean, what might happen if the physician learns about that, blah, blah, unless she asks you. If she's postop and wants to know when she can have her Salem sump out, you tell her that's why you're listening for bowel sounds because when they return and she passes gas she won't need the tube anymore.

("Mommy! Mommy! Where did I come from?" [Mother takes a deep breath and begins the long-dreaded birds-and-the-bees talk] "No, Mommy, Sarah comes from Brooklyn, where do I come from?")

hello,im on my senior year in nursing. always remember that to give the best care to patients is to think of them as your family member or as you. So technically, you wouldnt let anyone touch your breast without consent. even a staff nurse can intimidate you,right? So first of all, you should establish RAPPORT. that's the first thing you should have in mind because in any setting establishing rapport is a key to establish trust and patient's cooperation. Aside from that, you will read in ANY nursing assessment or skills book that before doing any procedure it is an ought to inform the patient about the procedures you are performing. It is their right and also signifies that you respect their autonomy. With regards to the clothing, the best way to assess is of course with patient gown to provide privacy.what you can do is expose only the part you need to assess and also assess for other indications of problem such as skin lesions, peeling in the portion of the breasts which can be a manifestation of cancer. remember in assessing the abdominal sound use the diaphragm and for vascular sound use the bell. If the breast is large ask the patient to lift it a bit if possible plus review your health assessment for best vascular points such as the apex of the heart 5th intercostal space mid clavicular line

I agree, you must not use jargons or technical terms when dealing with patients..BIG NO NO. why? because the patient care isnt just about carrying out interventions but also involving them in the care. you must be holistic and using technical terms may cause the patient to be anxious.if i am not in the medical field and you would ask me, ill get your vital signs.what vital signs are you talking about? do you get the point? you shouldnt just consider your convenience, you are a nurse!

I agree, you must not use jargons or technical terms when dealing with patients..BIG NO NO. why? because the patient care isnt just about carrying out interventions but also involving them in the care. you must be holistic and using technical terms may cause the patient to be anxious.if i am not in the medical field and you would ask me, ill get your vital signs.what vital signs are you talking about? do you get the point? you shouldnt just consider your convenience, you are a nurse!

I must completely disagree with your assumption that "technical language" will make you seem more knowledgable and important to the patient. On the contrary, people who don't understand what you're saying (and we have nursing students come here who don't know what "auscultate" and "peristalsis" mean) get their anxiety ratcheted up a hair every time they think they are missing something important, and they feel separated from their caregivers, not more confident in them.

It is perfectly acceptable to say, "I need to be able to hear your heart and lungs clearly, and I can't hear as well through clothing." "I need to be able to hear whether your bowels are working-- they normally make a lot of squeaky, bubbly noises; you've probably heard that yourself." You don't need to go into the whole evidence-based practice, what quiet sounds mean, what might happen if the physician learns about that, blah, blah, unless she asks you. If she's postop and wants to know when she can have her Salem sump out, you tell her that's why you're listening for bowel sounds because when they return and she passes gas she won't need the tube anymore.

("Mommy! Mommy! Where did I come from?" [Mother takes a deep breath and begins the long-dreaded birds-and-the-bees talk] "No, Mommy, Sarah comes from Brooklyn, where do I come from?")

I agree, you must not use jargons or technical terms when dealing with patients..BIG NO NO. why? because the patient care isnt just about carrying out interventions but also involving them in the care. you must be holistic and using technical terms may cause the patient to be anxious.if i am not in the medical field and you would ask me, ill get your vital signs.what vital signs are you talking about? do you get the point? you shouldnt just consider your convenience, you are a nurse!

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