ascultating the lungs of a female patient

[srleslie]

As a new male nurse, I am finding this more challenging than it should be. First is the issue of technique. Breasts often seem to "get in the way" and I'm not sure about the best technique to go about listening to the lungs on a female patient, partcicularly when they have the larger variety.

Then there's the issue of modesty. We are taught in nursing school to listen directly on the skin and not through a gown (though I see nurses doin this all the time). I am afraid of making my female patients uncomfortable by listening to them underneath their gown. So I'm not sure how to go about this. I'm afraid this is going to affect the quality of my assessments and don't want that to happen. I might discuss this with my preceptor but she is also female. Any advice you have would be appreciated...thanks!

[trauma_lama, BSN]

Aaahahaha the first time I did an assessment on a busty lady I completely forgot about the back of my hand- I scooped up her boob the same way I scoop my own into my bra (I'm busty too)- I cupped it with my palm. It didn't feel weird at all to me because I'm used to handling my own breasts that way but WOW you shoulda seen my instructor's face (she was observing since it was my first assessment ever). I thought I was gonna have to call a code on her, lol. But you can bet that seeing that horrendous face she made burned "back of hand" into my mind for all eternity... I still chuckle thinking back on that day. Hahaha...

[Meriwhen, ASN, BSN, MSN, RN]

You need to perform your assessment regardless of what gender the patient is. So if/when it's necessary to work around a patient's breasts, you can tell her that you need to move her breast so you can listen, or you can ask her if she will move them for you. But tell her that you have to move the breast before you touch her. Also, if she is truly uncomfortable, she can request a female nurse.

Also, be as professional as possible. That will make her more comfortable if you go in hesitant and embarrassed, and if she's more comfortable you'll be more comfortable. With time and practice, you'll become more adept.

[nerdtonurse?, BSN, RN]

If I've just finished washing my hands (as opposed to having one a few thing first) I also try to rub my hands together discretely to warm them up -- I normally have cold hands. Same if I'm heading to the "basement." I know I've had a GYN put a hand on my thigh during my exam and I about jumped off the table because his hands were like ice.

If the pt's large busted, I will often fold a washcloth and place under each one so air can get under there and to keep the breast from rubbing on the top of the telemetry wires as she breathes if the pt's out -- I work in ICU, so a lot of our patients are sedated. I'm still looking for a good option to prevent shear injuries to the bottom breast fold. We can't exactly wrestle them into a bra when we're doing external pacing, 12 leads, etc.

[merlee]

A very simple "I need to listen to your lungs, can we loosen your gown?" is appropriate. And posterior is usually easier to hear most areas. And should be practical in most cases.

I had a LUL pneumonia which wasn't quickly caught, probably because it is the hardest area to hear. And I now have somewhat pendulous breasts, so I try to move them when I can.

It is also appropriate to ask you instructor these things.

Much more in the way of 'modesty' issues to come - get used to it, and find your way around them!

Best wishes!

[DixieRedHead, ASN, RN]

Auscultation is pretty important. That breathing stuff is not nearly as overrated as some would have you think.

[Morainey, BSN, RN]

If I listen on the lateral side, I usually say to the patient "I'm going to listen down here, ok?" and then pat the area on my own self. No surprises that way. Then if I have to lift or move anything, I say "'Scuse me!" It'll get easier after you do it 100 times :)

[merlee]

To Nerdtonurse - - I often use a thin (old) washcloth under each breast, and sometimes under my panniculum, in the summer, to prevent yeast infections. The skin-on-skin contact is sweaty and uncomfortable, and I hate that feeling.

And I have always hated bras!!!

[Ted]

First, as others have pointed out, communicating what you're about to do goes a long way toward alleviating the patient's (and hopefully your) anxiety. This is true for any procedure as well as listening to anterior breath sounds. Apologies if this has already been pointed out, but in addition to instructive communication, I do the old "towel over boob" trick. I simply place a clean bath towel over the breast to help keep the patient's modesty and proceed to listen where I need to listen. The towel can be used to help lift up those larger breasts as needed during the ascultation process. The "towel over the breast" technique is also good when doing EKGs for the very same reasons. Works like a charm.

Quick story. . . quick aside. . .

Back when I was furthing my education and working towards my happy Bachelors in Science (Major: Nursing), I took the obligatory Advanced Assessment class. Mind you, I was the ONLY male in that class for that semester. We had to know our lung fields and know them well. We had to know where to "locate" the different lobes of each lung based on a person's anatomy both posteriorly and anteriorly. (Lots of "touchy and feely".) For the instructor, the only way to visually PROVE that we knew where the lobes of each lung were based on the body's anatomy was to literally mark them, on the skin, both back and front, using a magic marker.

That day, when we were to do the "Mark the Lung Fields" test on eachother. . . (cough, cough). . . I was the second to last person that walked into the classroom. All other classmates had quickly paired up with each other to take this test prior to my arrival. Not knowing how I would complete this exam, I sighed and felt a bit awkward. At the time, I didn't know that I was the second to last to enter the room. I thought I was the last. Well, thankfully the last classmate FINALLY walked in. THEN I felt even more awkward. This person who finally walked in was a retired Nurse Director, well into her 60s, who already had her Masters in Science (Major: Nursing) was only auditing this class just keep up her skills. Yes, for many reasons, I felt a bit more awkward! LOL!

She was cool-headed as a professional should be. She actually helped ME to calm down and do the tasks at hand. Needless to say, we both completed the tests on each other and both passed the exam with flying colors. . . literally on our bodies (both back and FRONT).

Just one word, though. . . and I say this with only the deepest respect towards that person: Perky!

Cheers. . . :)

[Nurse Leigh]

If the pt's large busted, I will often fold a washcloth and place under each one so air can get under there and to keep the breast from rubbing on the top of the telemetry wires as she breathes if the pt's out -- I work in ICU, so a lot of our patients are sedated. I'm still looking for a good option to prevent shear injuries to the bottom breast fold. We can't exactly wrestle them into a bra when we're doing external pacing, 12 leads, etc.

I found products from Monistat and Lanacane that are basically a slick smooth "gel" that dries to feel powdery. Great for applying anywhere that skin brushes against skin. Seems to keep it dry and reduces irritation by reducing the friction. Would love it if our hospital would use it to prevent these problems but do not know who to talk to about it. (also, I imagine some men who would benefit from it in various areas such as between abd folds, might now want to use the brand monistat, lol. Just something I've been thinking about.

http://www.lanacane.com/anti-chafing-gel

http://www.monistat.com/monistat-products (near bottom of page)

[RH-CC2011]

If I have to listen anteriorly for some reason, I listen high on the chest and then along the axillary line. My preference is for posterior lung sounds though. I know we were all taught to listen on bare skin, but honestly, unless the cloth is thick I don't have much of an issue listening through clothing.

You have a lot of med surg patients who can't sit up or roll to the side?

I agree. I'm also a new Guy on a med-surg floor. I can always hear better on the posterior anyway for both male and female patinets (when you account for tele leads, chest hair, breasts, or obesity). I try to be quick but thorough and professional, ask pertinent questions related to the admitting dx, and move on. I haven't had any modesty problems yet, but I'm not reaching way down the front of a gown to listen either. Our gowns are pretty thin and for the most part, I can hear just fine.

I've had a few patients with really bad lungs and RT is usually on top of them. I'm just listening to document my assessment and watch for changes. Most patients arent' there for respiratory issues and a basic assessment to check for clear bi-lateral breath sounds w/o wheezes or crackles (or other abnormalities) is sufficient.

[Ted]

Got to remember the right mid lobe. Anatomically, it's heard anteriorly. If there's ever a concern about that right mid lobe, especially patients with pneumonia, it's it seems prudent to ascultate the lungs anteriorly.

I lay awake at night worrying about these things. Can't miss that freakin' right mid lobe. Is it getting worse?? Is it getting better??

[groundedandrooted]

Yes, and you do well to be concerned, I know of one Tech who was in nursing school and on his 90 days of orient was accused by a female patient of assault. Ruined his nursing career, as well as requiring a jail visit and a jury trial.