Assessment Blues

  1. Feeling more like a nurse everyday! Doing things with more efficiency and knowledge under my belt. Being more educated in my decisions, following through with my actions, trying to educate my teammates, making goals and taking initiative (I am spearheading our "new fistula protection program", trying to get ppl buttonholing and making sure our new accesses are taken care of with love and tenderness!)
    I just feel like I am still lacking in the basics. We're talking lung and heart sounds. I know it sounds silly, but I just feel really stupid for not getting it. I mean, I listen for apical pulse, sometimes I have a hard time finding it. I listen to see if it's regular, right? I'm not counting, because the BP cuff does it auto. Now, if it's tachy or brady or something similar, I check the radial pulse to confirm findings.
    Then I listen to the lungs. Here comes my anxiety. I am afraid that I am going to miss something, my patient is going to go to the ER with his CHF. Sometimes I can't hear anything! Or they always sound clear! CTA! I don't think I am doing it wrong, per se, I just wouldn't know crackles if I heard it on an actual person. Is that my fingers creaking ever-so-slightly on the stethoscope, or it that some coarse crackles? I can't tell! ( I love the Auscultation Assistant, btw. Google it.)
    And I do have some common sense; don't get me wrong. If someone has 2+ ankle edema, the BP is 241/128 (actually happened today!) I would know to listen extra careful and maybe get a 2nd opinion if I thought I heard something. I just hope that I am doing a good job, that's all I guess. I don't want somebody to suffer because I didn't recognize a sign!
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    About GeauxNursing

    Joined: Nov '06; Posts: 808; Likes: 248
    LVN, Dialysis
    Specialty: Dialysis

    8 Comments

  3. by   traumaRUs
    Go easy on yourself. You seem like you are being very conscientious about this. You will become a pro soon enough because you get to do this so often! If I have any doubt anteriorly, I will have them lean forward and listen posteriorly.
  4. by   corky1272RN
    Quote from geauxnursing
    i just feel like i am still lacking in the basics. we're talking lung and heart sounds. i know it sounds silly, but i just feel really stupid for not getting it. i mean, i listen for apical pulse, sometimes i have a hard time finding it. i listen to see if it's regular, right? make sure that you are listening in the best spot (b/tw the 5th and 6th intercostal space) if you can't hear it anywhere else. also make sure your stethoscope is a good one (cheapies are hard to hear from sometimes). listen for regular rhythm, but also listen for abnormal sounds. you may not know what it is but you probably know if it sounds different than "normal".i'm not counting, because the bp cuff does it auto. now, if it's tachy or brady or something similar, i check the radial pulse to confirm findings.

    then i listen to the lungs. here comes my anxiety. i am afraid that i am going to miss something, my patient is going to go to the er with his chf. sometimes i can't hear anything! or they always sound clear! cta! i don't think i am doing it wrong, per se, i just wouldn't know crackles if i heard it on an actual person. is that my fingers creaking ever-so-slightly on the stethoscope, or it that some coarse crackles? i can't tell! ( i love the auscultation assistant, btw. google it.) lung sounds are a mystery to some nurses. i always wonder if i am hearing everything correctly as well. sometimes i hear something but wonder if it is just a slight movement over their shirt. or truely adventitious breath sounds. until you know what the pts normal sound is you might get second opinions.
    and i do have some common sense; don't get me wrong. if someone has 2+ ankle edema, the bp is 241/128 (actually happened today!) i would know to listen extra careful and maybe get a 2nd opinion if i thought i heard something. i just hope that i am doing a good job, that's all i guess. i don't want somebody to suffer because i didn't recognize a sign!
    . remember that nursing is continuous and it does not solely rely on you. confer with other nurses to learn, that is how you will get more confident with you assessment skills.
  5. by   traumaRUs
    I want to add too that many dialysis pts are vasculopaths - they have poor, poor, poor circulation - the auto BP and pulse machines don't work on many of our patients. Always check a manual BP and take an apical pulse when in doubt.

    Also - make sure you have a working set of BP cuffs - putting one on someone's ankle, wrist, etc., does not afford you accuracy. Also - make sure you have appropriately sized cuffs and in the right place - not upside down!

    Can you tell this is a pet peeve of mine?? I have a set of manual BP cuffs that I keep with me so that I can take a manual BP.
  6. by   GeauxNursing
    You know what? There are some pts that I have a b#### of a time with, finding an accurate BP! Huge upper arm doesn't support the cuff. (we have large cuffs as well as regular.) So we go lower arm. Re-take, re-take, re-take. Machine just doesnt like her arm!
    One of the PCTS "likes the reading better" when she puts the cuff on one man's thigh. I say t isn't accurate. On his arm, its 110's/50s. On the leg, 160/60. SHe likes that better. But I just don't! I've told the charge nurse, but she doesn't seem to think it's that important. He is consistently in the 100s and 90s, I know that. Therefore I know when he is going to start feeling bad. If the cuff is on the leg and the reading is wrong, how can you know when he'll start going downhill?? It really bugs me.
    Or, am I completely wrong--what if the accurate one IS the thigh reading?
    I went on youtube and found some great assessment videos.
  7. by   traumaRUs
    Again since many of our patients have peripheral vascular disease, calcified vessels, etc., probably the only accurate BP is invasive - lol! I've always thought the dialysis lines should have a transducer in them so that BP would be accurate, get rid of the cuff completely.
  8. by   workingmomRN
    I try to listen to the heart & lung sounds while they are either standing or still sitting upright in the chair. Once they are recllined in the chair, it is really difficult to listen well. Once you hear crackles or rales in someone's lungs, you will probably know it. What worries me most is when I don't hear any air movement in the lungs. It could be pneumonia starting, or CHF.
    When you have to put on your own patients as well, it's impossible to get around to all of the patients before their treatments start.
  9. by   GeauxNursing
    Quote from workingmomRN
    When you have to put on your own patients as well, it's impossible to get around to all of the patients before their treatments start.
    I know! In the morning, I'm pretty good about assessing before I put on my patients. Once turnaround hits, I tend to do a quick lookover as I am getting them ready, then once they are put on and I have a quick minute, I listen.
    Davita says something like, If the nurse doesn't get to the pt before put-on, then the PCT better be doing the pre-tx "data collection" before putting them on, then the nurse has 1 hour to assess.
    Davita's computer charting has "data collections" as well as "assessments." The PCT does the post-tx data collection on their pts, unless something went wrong during tx, then the nurse will do post-tx assessment. Nurses do pre-tx assessments on everybody.
  10. by   blondeamazonRN
    BP measurements directly from the dialysis line. What a great idea maybe we could get some engineering person to check into the feasibility of it.

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