Difficulty with respiratory issues as a new grad?

[Audacioustank]

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.

[amoLucia]

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]

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.

[speedynurse, ADN, BSN, RN, EMT-P]

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]

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]

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]

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!

[amoLucia]

To pmath-RRT - TY for taking the time to explain information as education. I always appreciated it when someone would take the time to explain things like you just did.

And I always breathed easier (no pun intended) when RT arrived on the scene of a crashing pt episode. A big collective TY to you folk.

[canoehead, BSN, RN]

I started my nursing career on a pediatric respiratory unit, and among the staff that worked there we were pretty consistent as far as what sounds were heard and when a child needed a breathing treatment. The docs gave us orders for nebs with about a 2 hour range, so we could increase them or space them out, per nursing assessment. I took a job on another pediatric unit. The RTs gave the nebs, and they were given on a schedule, whether or not the child needed them at the time, or earlier. If they were getting wheezy a bit early and their sats went down, we were told (by RT) to increase the O2 until the next scheduled treatment.

The RTs were covering more than our floor, and didn't have time to do the before and after breath sounds. They definitely didn't pop down thirty minutes before treatment to make sure the kids were holding their own. Not their fault, it wasn't the best system.

I wonder if nursing is allowed to add PRN treatments, while the RTs stick to their schedule?

I also agree that adult COPDers are just a mess to assess. They pop and wheeze all over, but that can be their normal. I'm more into assessing work of breathing in COPD when I'm deciding if they need more support.

[Audacioustank]

5 hours ago, pmath_RRT said:

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!

Thank you for taking the time to explain this!! I didn't know CHF and the fluid buildup would cause wheezing. Of course the pt was getting lasix as well, but it takes some time for them to pee everything out, so my thought process was that a treatment could help get them more comfortable until that could happen.

I also wanted to add, thank you to you and other RTs! I know you guys are a fantastic resource and a super important part of the team and I'm grateful to work with you guys! This was the first time I've had such a bad experience with someone.

[Crystal-Wings, LVN]

93% may very well be normal for a patient with COPD, so you should check what the patient's norms are from the chart. It should give you a range. Suplemental O2 should be used if they are having SOB, which it seems like you did and the nebulizer treatment.

[ljo28, BSN]

In my opinion, on a med-surg floor if you heard a wheeze, as a nurse it is your responsibility to address it. You cannot just document that the patient is wheezing and move on. And you are the licensed personnel. You have to follow it through either by notifying the RT or a resident or someone because ultimately it is you who is responsible for the patient. Because if something happens and the patient decompensated, you will not be at fault. Once you tell someone, you can document it, and you are covered. You continue to monitor and follow up and as your shift goes on.

Things are different in the ICU or step-down units because the patients are closely monitored, those nurses are trained and have a little bit more autonomy in practice based on their skills and experience. In the units as long as the patient is breathing and able to protect his airway, has a decent SaO2, and not SOB, a CHF or a COPD patient wheezing can be tolerated, but still has to be monitored for decompensation. Nebs may not be the only treatment option available.

As far as the rude behavior of the RT is concerned, you can talk to his supervisor. You did the right thing of involving the charge nurse, and it will also help to bring it up to your nurse manager as well. And if this behavior continues, it needs to be addressed. There is a lot of demeaning behavior that goes on in the healthcare setting, and by any means don't let it stop you from doing what is right.

[KatieMI, BSN, MSN, RN]

15 minutes ago, ljo28 said:

In my opinion, on a med-surg floor if you heard a wheeze, as a nurse it is your responsibility to address it. You cannot just document that the patient is wheezing and move on. And you are the licensed personnel. You have to follow it through either by notifying the RT or a resident or someone because ultimately it is you who is responsible for the patient. Because if something happens and the patient decompensated, you will not be at fault. Once you tell someone, you can document it, and you are covered. You continue to monitor and follow up and as your shift goes on.

What exactly "something" may happen if a nurse appropriately accesses and monitors the patient who has advanced COPD and has wheezing and shortness of breath at baseline all the time, and doesn't "tell someone" every 2 hours about these baseline symptoms?

If patient is going to decompensate, the deviation from baseline can be clearly seen at least an hour (in case of true and real flash pulmonary edema) from the point of last "norm". The OP needs to learn how to figure out that baseline and see when things start to go down from it, not how hang on phone for hours "updating" and "reporting" everyone.

"Telling something to someone" just because "imanurseandiamdoingmyjob" inevitably leads to "cry wolf" effect and, finally, lack of trust and attention to details between services and within treatment team. This is when truly bad things happen.

CYA is an inevitable tactic nowadays but in case of slight variations from baseline it is more than enough for a nurse to document just that and continue to access and educate the patient.