Jump to content

Difficulty with respiratory issues as a new grad?

Posted

Specializes in Tele. Has 2 years experience.

I'm a new grad on a med surg/tele unit. I'm on week 3 on my own and I've noticed I'm having a hard time with lung sounds, and with determining if my SOB pt needs intervention or not. Today I pissed off one of the RTs, because I had a CHF pt who I felt had loud, extremely textbook wheezing and was satting at 93% on room air so I put him on oxygen and requested a PRN neb treatment. I was very confident he was wheezing! RT came and did the treatment. Later, I told him my COPD pt was short of breath, but he was satting at 97% on room air. I also told him he sounded slightly wheezy but overall I thought the he was stable, but could benefit from a treatment. When the RT came to do my second pts treatment, he told me "I'm wasting my time here, you keep telling me everyone is wheezing and EVERYONE IS FINE!" He said it in front of the pt and then left the room and said it again at the nurses station where all my coworkers could hear him. I felt so humiliated. I know I am still green and need more experience, but I listened to my lung sounds on Youtube on the way home and I still feel my pts had wheezing! But this RT has years of experience and I trust his judgment over mine. Maybe my ears are just broken. 😔 I understand RTs are very busy people also, but I'm not sure what to take from this experience.

tldr; overly concerned new grad, I keep hearing wheezing but every time I call RT I'm told the pt lungs are clear. Does anyone have any suggestions to get better at differentiating lung sounds? And just suggestions with interventions for my pts who have subjective shortness of breath but have stable vital signs.

Perhaps getting a colleague to take a listen would help before you summon the RT. Also consider that the RT may be pushing his weight around to get you to stop bothering him. He wants you to leave him alone.

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

The RT's behavior was unprofessional for sure, but I agree with @caliotter3 that it may be helpful if you ask another nurse to assess lung sounds prior to notifying RT until you become more comfortable. Even then, there will be times when a provider or RT will disagree with your assessement...better to have the patient to be checked out than to be sorry.

Audacioustank

Specializes in Tele. Has 2 years experience.

1 minute ago, caliotter3 said:

Perhaps getting a colleague to take a listen would help before you summon the RT. Also consider that the RT may be pushing his weight around to get you to stop bothering him. He wants you to leave him alone.

It was my first experience with this RT. After he stormed off on me, I talked to my charge about it and he said "that's how he is." But also told me he handled the situation wrong. I had my charge listen to my pts lungs (the COPD one) and he also heard faint wheezing, but in his opinion not audible enough to warrant intervention.

Audacioustank

Specializes in Tele. Has 2 years experience.

7 minutes ago, SilverBells said:

The RT's behavior was unprofessional for sure, but I agree with @caliotter3 that it may be helpful if you ask another nurse to assess lung sounds prior to notifying RT until you become more comfortable. Even then, there will be times when a provider or RT will disagree with your assessement...better to have the patient to be checked out than to be sorry.

Yeah, I think I will do that from now on before calling RT! I mentioned in my other comment that I had the charge listen to one of them after the fact, and he agreed he heard faint wheezing but not necessarily audible enough to warrant an intervention. I told the RT my assessment- 97% on RA and (at least to me) faint wheezing. I can't wait to have more nursing judgment to know when I should call (text in this case) about these things. It didn't help my anxiety that my pt was also verbally and physically aggressive and was getting angry about not getting his treatment.

Edited by Audacioustank

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

13 minutes ago, Audacioustank said:

It was my first experience with this RT. After he stormed off on me, I talked to my charge about it and he said "that's how he is." But also told me he handled the situation wrong. I had my charge listen to my pts lungs (the COPD one) and he also heard faint wheezing, but in his opinion not audible enough to warrant intervention.

I think it is great that you had the charge nurse there to help back you up. While it really isn't acceptable that it is "just how the RT is," at least you know he is like that with other people and can hopefully not take it personally. It's also great that the charge nurse was able to validate your findings; I feel like it probably takes time to decide whether or not an abnormal lung sound requires immediate intervention. Perhaps you could ask your charge nurse why he felt, in this instance, he wouldn't have notified RT? For example, was it due to him expecting to find these lung sounds, the fact that vitals were stable, or that it is not uncommon for COPD patients to feel short of breath, etc? I've always found it helpful to ask someone with more experience why they chose to make the decisions they did so I can learn from them.

Audacioustank

Specializes in Tele. Has 2 years experience.

11 minutes ago, SilverBells said:

I think it is great that you had the charge nurse there to help back you up. While it really isn't acceptable that it is "just how the RT is," at least you know he is like that with other people and can hopefully not take it personally. It's also great that the charge nurse was able to validate your findings; I feel like it probably takes time to decide whether or not an abnormal lung sound requires immediate intervention. Perhaps you could ask your charge nurse why he felt, in this instance, he wouldn't have notified RT? For example, was it due to him expecting to find these lung sounds, the fact that vitals were stable, or that it is not uncommon for COPD patients to feel short of breath, etc? I've always found it helpful to ask someone with more experience why they chose to make the decisions they did so I can learn from them.

That's a good idea too!! I didn't think to ask those questions at the time, but I should have! It's a relief that I wasn't just hearing nothing, but now I have to start learning the critical thinking aspect. On that note, I'm so glad I work on a floor where the other nurses are so supportive and always encourage the new grads to ask questions and ask for help. I was very upset for a bit of my shift after that event, and was in tears in the break room, but I had a great pep talk from one of the more experienced nurses who told me it would come with time, and to always ask for help when I need it! I felt so much better after that.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

The thing is, people with COPD and some other pathologies can wheeze all the time. It doesn't mean they need "respiratory treatment" every time you hear wheezing.

Your job at this point is to learn how to treat patient, not wheezings, crackles, SaO2 or anything else. Assuming you heard wheeze and one more experienced nurse heard it too. Is patient comfortable? Is he struggles to breathe? How does he breathe? Can he cough? Vitals are fine? (know the baseline!) Did the patient just do something that could make him short of breath (ambulating, PT, etc)?

Give yourself 30 sec every time to think and answer these questions and "see the picture". If patient on this picture looks OK, he likely won't need any treatments, he is fine the way he is, wheezing or not. Or, if your patient has SOB because of CHF, "breathing treatment" may be even contraindicated (think why it can be so).

Learning this is not a weeklong project. Assessment is the finest of the nursing (and medical) skill and it takes a long time to develop, so be patient, get a good quality stetoscope (yes, they are expensive but one will serve you for a decade or longer) and try to find an experienced colleague, RT or provider who likes teaching.

Edited by KatieMI

Closed Account 12345

Has 14 years experience.

I love the advicd you've received above about seeking a second nursing opinion, but I want to add that you should not let this RT run you down.

If he gives you a hard time in the future, you follow him out of the room, and say "Excuse me, but do not speak to me like that in front of a patient again. You were really unprofessional in there. I'm a new nurse and still learning, so sometimes I might call when you don't think treatment is necessary. It's my duty to keep my patient safe, which includes making a referral to RT if I'm concerned about my patient's respiratory status. I'm going to continue calling when I think it's necessary, even if it turns out I'm wrong. It's OK if you disagree with my judgment once you evaluate the patient, but I expect you to treat me with professionalism and respect in front of the patient and my peers. Now, can you explain to me why this patient doesn't warrant a treatment at this time, and what would need to change with his status for me to call you again? I'd like to learn from you and improve my clinical judgment, but I can only do that if we work together as the team we're supposed to be."

In my opinion, it's OK for people to be jerks in their personal lives. It's not OK for people to be jerks at work, so "That's just how he is" should never fly. Speak up for yourself. You'd be surprised how that will earn respect from some people with jerk personalities who just need to be called out.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 42 years experience.

5 minutes ago, FacultyRN said:

If he gives you a hard time in the future, you follow him out of the room, and say "Excuse me, but do not speak to me like that in front of a patient again. You were really unprofessional in there. I'm a new nurse and still learning, so sometimes I might call when you don't think treatment is necessary. It's my duty to keep my patient safe, which includes making a referral to RT if I'm concerned about my patient's respiratory status. I'm going to continue calling when I think it's necessary, even if it turns out I'm wrong. It's OK if you disagree with my judgment once you evaluate the patient, but I expect you to treat me with professionalism and respect in front of the patient and my peers. Now, can you explain to me why this patient doesn't warrant a treatment at this time, and what would need to change with his status for me to call you again? I'd like to learn from you and improve my clinical judgment, but I can only do that if we work together as the team we're supposed to be."

My guess is that an RT who is a jerk would be walking away from you before you finished the third sentence. In the hall, you might want to shorten it a bit.

"Excuse me, but do not speak to me like that in front of a patient again. That was very unprofessional. I'm a new nurse and still learning. Now, can you explain to me why this patient doesn't warrant a treatment at this time, and what would need to change with his status for me to call you again?

Audacioustank

Specializes in Tele. Has 2 years experience.

2 hours ago, KatieMI said:

The thing is, people with COPD and some other pathologies can wheeze all the time. It doesn't mean they need "respiratory treatment" every time you hear wheezing.

Your job at this point is to learn how to treat patient, not wheezings, crackles, SaO2 or anything else. Assuming you heard wheeze and one more experienced nurse heard it too. Is patient comfortable? Is he struggles to breathe? How does he breathe? Can he cough? Vitals are fine? (know the baseline!) Did the patient just do something that could make him short of breath (ambulating, PT, etc)?

Give yourself 30 sec every time to think and answer these questions and "see the picture". If patient on this picture looks OK, he likely won't need any treatments, he is fine the way he is, wheezing or not. Or, if your patient has SOB because of CHF, "breathing treatment" may be even contraindicated (think why it can be so).

Learning this is not a weeklong project. Assessment is the finest of the nursing (and medical) skill and it takes a long time to develop, so be patient, get a good quality stetoscope (yes, they are expensive but one will serve you for a decade or longer) and try to find an experienced colleague, RT or provider who likes teaching.

I agree with you, but one concern is my nursing critical thinking skills, my other concern is that the RT specifically told me both patient's lungs sounded clear when I really heard otherwise- so I'm questioning my simple assessment skills. ☹

In hindsight, I do think the COPD pt was pretty stable. He was just sitting in bed and had done nothing that had aggravated his SOB, so I sat him up in bed but he was getting verbally aggressive, too (aggressive psych hx), while huffing at me demanding a breathing treatment. Not that it makes my lack of critical thinking okay, but it contributed to my panicking and going straight for RT as a resource.

As for giving a CHF pt a breathing treatment, I'm not too sure of the contraindication- I did consider the side effect of tachycardia which I brought up to the RT earlier as my hesitancy to give my pt albuterol, and he had suggested xopenex instead which the provider agreed on. If not that, what else am I missing?

Audacioustank

Specializes in Tele. Has 2 years experience.

58 minutes ago, Kitiger said:

My guess is that an RT who is a jerk would be walking away from you before you finished the third sentence. In the hall, you might want to shorten it a bit.

"Excuse me, but do not speak to me like that in front of a patient again. That was very unprofessional. I'm a new nurse and still learning. Now, can you explain to me why this patient doesn't warrant a treatment at this time, and what would need to change with his status for me to call you again?

I like that. The extended version was nice too in a perfect world, but I agree I doubt he'd listen to the whole thing LOL. I was trying to explain to him my thinking and ask questions but he was already out the door.

amoLucia

Specializes in LTC.

Am just another one here to play Devil's Advocate in that NOT everyone is in distress with slight wheezing.

Also, sometimes even some deep breathing can help. And better positioning. I will make this caveat statement - I am often skeptical about pOx readings. Too many folk overly RELY on them as a measure of pt stability.

Re documentation - if you believe what you heard is correct, then you chart what YOU heard. No need for concern about the RT's assessment. You intervened and the pt response should be followed. RT will document own actions.

Know also, that as resp pts start to experience some distress, EVEN minimal, it really is an uncomfortable awareness and it does become anxiety provoking. Which then can escalate.

So to OP - just for the future, STAY CALM. Like other skills, proficiency & competency comes with practice. And you ARE heading that way in the right direction.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

3 hours ago, Audacioustank said:

I agree with you, but one concern is my nursing critical thinking skills, my other concern is that the RT specifically told me both patient's lungs sounded clear when I really heard otherwise- so I'm questioning my simple assessment skills. ☹

In hindsight, I do think the COPD pt was pretty stable. He was just sitting in bed and had done nothing that had aggravated his SOB, so I sat him up in bed but he was getting verbally aggressive, too (aggressive psych hx), while huffing at me demanding a breathing treatment. Not that it makes my lack of critical thinking okay, but it contributed to my panicking and going straight for RT as a resource.

As for giving a CHF pt a breathing treatment, I'm not too sure of the contraindication- I did consider the side effect of tachycardia which I brought up to the RT earlier as my hesitancy to give my pt albuterol, and he had suggested xopenex instead which the provider agreed on. If not that, what else am I missing?

You will question your "simple assessment skills" to the end of your professional life. I do it too, all the time 🙂

You do not have to hear, or feel, absolutely the same as another person. That another person can be everything from just lazy to having cold and poor hearing that day. What matters for real is your "total" assessment, the picture.

In the case you described (known COPD, yelling and demanding patient) I would probably just let it go and ask for treatment just for peace's sake, unless it would be too early. The patient was probably VERY stable (old and still true medical observation: really medically sick people do not argue, do not demand and do not make the world revolving around them).

You are right regarding tachycardia. It is not beneficial for patients with CHF and a whole row of other pathologies. Xopenex, actually, was never shown to be any better than good ol' albuterol in any sense except inflating cost of care. When you see patient with shortness of breath, your actions should be directed at the cause of it. For patient with CHF - does he get daily weights and what his weight is? Is he on salt-free diet? What about fluid restriction? Does he have crackles or rales? Does he feel better sitting?

Last but not least: while that RT was not nice with you and definitely less than "professional", people who know their stuff and love to teach quite frequently come as less than professional. Learning now is extremely important for you, so if you find someone who can be bloody sarcastic and downright unpleasant but knows and teaches stuff, do whatever to gain the trust of this person. RTs work in difficult area which requires high level of analytical skills and so many of them are very smart. I learned a heck lot from them, despite multiple whins and even complains of "getting nose too close into nothing of your business". It all came very handy later when I became a provider.

Edited by KatieMI

speedynurse, ADN, RN, EMT-P

Specializes in ER, Pre-Op, PACU.

1. Like anything else, lung sounds take time to learn. I know when I was a paramedic and learning lung sounds, it took awhile to truly become adept at this.

2. What type of stethoscope do you have? I invested in a cardiology type stethoscope and it has done wonders for me. (I am fairly useless with the cheapo stethoscopes like for isolation rooms).

HandsOffMySteth

Has 3 years experience.

I don't know if this was mentioned but document everything for your own protection. If that patient feels they were neglected and starts a complaint, that RT might try using YOU as the sacrificial lamb.

Audacioustank

Specializes in Tele. Has 2 years experience.

2 hours ago, speedynurse said:

1. Like anything else, lung sounds take time to learn. I know when I was a paramedic and learning lung sounds, it took awhile to truly become adept at this.

2. What type of stethoscope do you have? I invested in a cardiology type stethoscope and it has done wonders for me. (I am fairly useless with the cheapo stethoscopes like for isolation rooms).

I have a Littman cardiology iv! I hate those isolation stethoscopes, I can never hear anything LOL 😭 I feel like lung sounds are so much different sounding in real life than they are in videos/ sound clips 🥺

pmath_RRT

Specializes in Respiratory Care.

RT here,

A lot of new grads/med/surg nurses tend to always think just because they hear a CHF pt with audible wheezing requires a dose of ALLBETTERol. Not all wheezes are due to bronchospasm. Think about the pathology of the disease state. The pt has fluid in his lungs and needs to get the fluid out. Where the fluid backs up starts in the alveoli and begins to build up, thus making the already small airways smaller which creates that wheeze/crackle sound. We refer to it as a cardiac wheeze. The pt needs lasixs more than anything and maybe if they are still having a hard time maybe some nitro. Albuterol doesn't pull fluid out of the lungs nor will it relive the SOB in these particular cases.

I don't think this cranky RT acted right and yah they may have been very busy and or ,just like me, hate being told "the pt needs a tx". Maybe just say can you come assess my pt for me.

After I receive these calls and determine the pt does not need albuterol I will take the time to find the nurse and explain to her why they don't , not in a rude way just some education is all.

You have a whole career ahead of you and lots to learn. No one should be yelling or acting unprofessional to you or literally anyone else they work with. Hopefully you have a better experience with other RTs in your future. We aren't all cranky!