Quote from tarotale
Haha no one is starting controversy. I'm not talking about trauma situation, I'm talking about your everyday sob, cp, abd pain, etc etc. I get what you are saying. But so what if pt wheezes or has rales? Does you knowing this or charting it really have an outcome or any effect? I'm not talking about stridors or intubation, just regular situations. Ya I can tell the doc the pt is wheezing but he probably already knows that and ordered bd. Please do tell, what does it change? That I know what the lung sounds like? So what, are you going to prescribe antibiotics?
I am going to indulge you and engage in a brief conversation for I get the feeling you are tweeking my nose.....
Please do tell, what does it change? That I know what the lung sounds like? So what, are you going to prescribe antibiotics?
but no matter I''ll bite.
For SOB...I listen for breath sounds. Are they equal? Are there any adventitious sounds? Are they wheezing? How bad? Fo they have rales? Are they jut at the bases or do they sound like a washing machine? Are they having a high drama asthma attack? or are they in trouble. Do I need to think about preparing the patient for and admission for ICU to the floor?...or will this be a treat and street.
For abd pain...are there bowel sounds? What do they sound like...as I am listening...is the abdomen distended? Is it tender? Is there any evidence of trauma of surgeries?
For chest pain...is there a rub? Is there a murmur? Do they have a gallop? Are the heart tones good or are they muffled? A development of a new murmur in the presence of EKG changes is an acute finding and an indicator of a blown papillary muscle and impending cardiogenic shock.
Please do tell, what does it change? That I know what the lung sounds like?
It can change plenty....Is the patient getting better after treatment or do I need to badger the EDMD for further more aggressive intervention? I don't know about you...but I feel having this information I can affect change and help the patient. Do I actually order the meds? No....if I wanted to do that I would have become a physician.
Does you knowing this or charting it really have an outcome or any effect?
I think it does...is the EDMD able to keep up with all the patients on a busy night or is it up to the nurse to let the MD know the patient isn't getting better and requires additional intervention/assessment before they go down the tubes. How do you document whether a neb or lasix has been effective treatment in your documentation (not just for liability but for reimbursement purposes) if you have no baseline to compare.
I know you have not been a nurse for very long.....It is standard of care to document assessment that applies to the patient presentation. Do I listen to the lung sounds of a finger lac? No...I don't. However....you have a patient come in with SOB/Chest pain and the shoot the crapper and they or the family sues....you bet your sweet patooty your behind will be in a sling for delay of treatment/failure to rescue and failure to follow standards of care. If that is okay for you (never mind the responsibility to treat appropriately) the BON and your malpractice carrier...all the power to you.
We all make practice decisions. I happen to believe that assessment is imperative to the quality of care my patient receives and the timeliness of interventions.
But that is just me and my opinion...and my opinion is only important to me.