Difficulty with respiratory issues as a new grad?

caliotter3 · Jun 13, 2020

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 · Jun 13, 2020

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 · Jun 13, 2020

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 · Jun 13, 2020

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.

SilverBells, BSN · Jun 13, 2020

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 · Jun 13, 2020

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 · Jun 13, 2020

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.

Closed Account 12345 · Jun 13, 2020

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 · Jun 13, 2020

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 · Jun 13, 2020

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 · Jun 13, 2020

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.