Hey people, first time poster here. I'm also a first year student and tomorrow I begin acute care clinicals. This will be my second bunch of clinicals, my first being at an extended care facility with elderly patients.
Overall my first experiences with clinicals was good. I had the opportunity to change briefs, give baths/showers, watch a dressing change, assess stage 2 pressure ulcers, perform baseline assessments, etc. Unfortunately there was one part of my experience that I feel I need to improve: lung sounds. I'm a drummer and my ears are pretty crappy as it is. My patient had dementia so communication was a bit tricky and I could never get her to take deep breaths. My patient was also female so naturally I felt awkward trying work around her breasts--What is the best way to listen to lung sounds in a way that makes the patient as comfortable as possible?
I tried to reach down the front of her gown but then my elbow/arm is right up in her face. I was thinking perhaps I could simply untie the gown from her neck and lower it gradually as I work my way down, but then if she's got an IV that could get in the way...and my patient couldn't really straighten her arms so that would have been tricky too.
Any response would greatly appreciated! (Also--I get the impression that people under 30 are thought of as somewhat burdensome...any general wisdom on how I can fight that stereotype?)
Specializes in MPH Student Fall/14, Emergency, Research.
JMO, but women are usually a lot more comfortable with their breasts being moved around than you might think. A male friend of mine was trying to listen to cardiac sounds on an older woman with pendulous breasts. He was very gingerly poking around and not getting a good assessment. Eventually the patient said "here, let me grab that for you," and gave her breast a serious heave-ho out of the way. It was hilarious :)
I know for myself, it's not a huge deal at all when an HCP needs to rearrange as necessary. Use the back of your hand to avoid any uncomfortable squeezing - but truly, women routinely have their breasts and reproductive organs poked and prodded and palpated. Unless she is very confused, she probably won't mind. I certainly have never run into anyone who did, and haven't heard of any stories from my peers other than the above.
I, myself, would find it odd that my nurse would wear gloves when moving my breast out of the way, unless there were fluids present.
EVERYONE IS SAYING DIFFERENT THINGS AM I ON CRAZY PILLS OR SOMETHING!?
Okay--all better. I'm just going to go with what my instructors told and listen to all the sides with my steth on the skin. Any advice to make that go smoothly is cool. Really, I'm probably just over-thinking this stuff. It's just skin and I have a job to do.
On a personal note...I don't think I'll be able sleep tonight. Ugh. Stupid anxiety.
What? A heart/lung assessment should never ever be done over gowns or clothing of any kind IMO.
This only really matters if you cannot hear anything or if the gown is making excess noise right?... because I do lung assessments in surgical with people's gowns on all of the time. I only have to remove clothing etc, if i cannot hear anything at all to do a sufficient lung assessment. Same as posterior, a lot of post op. patients I will not make them sit up when doing my assessment if they are freshly post operative, unless a really extensive and good lung assessment needs to be done. Usually if i can hear clear equal breath sounds anteriorly and laterally I do not make them move.... unless its decreased a/e to bases then unfortunatly they have to sit up. However I am seeing now this is not necessarily the best lung assessment.... nor good habits to be picking up...
Specializes in Tele Step Down, Oncology, ICU, Med/Surg.
You don't need to wear gloves when just touching intact skin--in fact, touching skin is one of the ways I assess my pts.
I to have had a hard time with larger breasts and getting good lung sounds. I usually strive for skin to bell contact but I've learned over time how to use my steth thru the gown when I need to. Not optimal, and def not the "proper" way, but it can be done. And I find it less awkward with the larger breasted gals.
Most of the time I go digging under the gown and usually hit a good spot to listen just a hands breath down from the arm pit, so if I follow that route I pretty much skirt around to the underside of the boob without actually touching it.
But what bothers me more than boob issues is when I can't get to their back to get a good listen. Especially when a pt that is so out they cannot move, and they are hard to turn and nobody is around to help. Sometimes I can get them sideways enough SQUEEZE my steth under them....but am always worried I may hurt them.
Sometimes when I just can't get a good listen I come back later when another staff member is in the room to help me move them, but that is not the best use of time given the pressure we are under to do assessments, pass meds, do treatments, chart, and follow up on care issues.
You will figure out what works for you--good luck.
What? A heart/lung assessment should never ever be done over gowns or clothing of any kind IMO. I can't imagine an environment where that would be ok.
ICU nurse huh? With 2 patients you might have time and maybe even need to strip all your patients naked. Imagine 9 or 10 patients. You'd still be stripping them down for your first assessment when it's time to clock out.
EVERYONE IS SAYING DIFFERENT THINGS AM I ON CRAZY PILLS OR SOMETHING!?
Okay--all better. I'm just going to go with what my instructors told and listen to all the sides with my steth on the skin. Any advice to make that go smoothly is cool. Really, I'm probably just over-thinking this stuff. It's just skin and I have a job to do.
On a personal note...I don't think I'll be able sleep tonight. Ugh. Stupid anxiety.
a.) Way to post an attention-getting topic.
b.) Anxiety is not stupid. How else are we to know when running in circles, screaming and waving our arms is the appropriate action?
c.) In one of my early clinicals, I was sweating bullets trying to ausculatate the apical pulse on a rather buxom, mature patient who had definitely spent most of her life in a gravitational field. All I could get were bowel sounds, but I kept trying, and might actually have caught a hint of a "lub" when I heard my instructor behind me as she looked in to ask, "How's it going?" To which my patient replied, "He's playing with my boob."
Had I been less horrified, I might have thought it remarkable that my instructor simply continued on her rounds, but when I finally regained consciousness, my patient pointed to the point on her chest where her heart still was and her breast used to be, and said, "Most people just listen about here, honey."
When preplanning, I had noticed that my patient's occupation was "Retired." Would you care to guess what noble and esteemed profession she was retired from?
Throughout clinicals, I noticed that a lot of my patients were nurses. For a time, I wondered if it was my instructors' subtle way of providing me extra help (which I desperately needed). Eventually, I began to suspect they were giving their ailing colleagues someone to play with. That which does not kill me makes me stronger.
Do what your instructors tell you. If you aren't sure, ask them. When you get your own license, use your best judgement. Don't forget to breathe.
EVERYONE IS SAYING DIFFERENT THINGS AM I ON CRAZY PILLS OR SOMETHING!?
Nursing is a giant world of grey, very little black or white. There's the get through nursing school way, and the "real life" way. And well, even in the "real life" way, everyone has their things that they think are particularly important. As you can see here, some do their assessments very by the book, some of us do focused ones. It depends on where you work what's important. If you're a CCU nurse, you need to do the whole deal of listening to the heart at every spot shown on the diagram in the textbook. Doing peds, I listen to as much as I can without getting my kid worked up. (It would be ridiculous for me to upset a kid into respiratory arrest just so I can say that I "thoroughly" listened to his lungs.) Of course, if it's a post op kid that I want to avoid atelectasis with, then getting the kid worked up can be a good thing.
No two nurses do things the same, and that's a good thing. Nursing is just as much an art as a science. And the great thing is when making an assignment, we can assign patients to suit the different nurses' strengths and then everyone wins.
So for now, do things the way your instructor says to do them, because they're the one grading you. As you start to learn that the important thing to know is "why" rather than "how," you'll come to understand why different nurses do things differently, and you'll learn how to shape your own nursing practice.
Throughout clinicals, I noticed that a lot of my patients were nurses. For a time, I wondered if it was my instructors' subtle way of providing me extra help (which I desperately needed). Eventually, I began to suspect they were giving their ailing colleagues someone to play with. That which does not kill me makes me stronger.
I'm now hoping to get some nursing students to play with when I retire.
What? A heart/lung assessment should never ever be done over gowns or clothing of any kind IMO. I can't imagine an environment where that would be ok.
Just wanted to add, if you're listening to my heart and lungs for a typical assessment, you'd better keep your hands on the outside of my gown. Chart that I refused to let you stick your stethoscope inside my gown if you wish, but your desire to feel more thorough doesn't trump my desire to not have people needlessly sticking their hands under my clothes.
So for OP, remember, there's respecting the patient's privacy. If I just had an appendectomy, I'll lift up my gown to see my incisions, and you can listen all you want, but there will be no reason for you to be playing around near my breasts. The risk is atelectasis and pneumonia. Listening to posterior bases, even through a gown, will give you the information you need.
Specializes in acute care med/surg, LTC, orthopedics.
ICU nurse huh? With 2 patients you might have time and maybe even need to strip all your patients naked. Imagine 9 or 10 patients. You'd still be stripping them down for your first assessment when it's time to clock out.
Strip all your patients NAKED to auscultate heart/lung sounds?
Now that would be sexually inappropriate so I'm assuming you're just exaggerating.
It takes mere seconds to lift a gown or shirt out of the way to stick your stethoscope under, no need to strip anybody and if you're finding this time consuming then you clearly have your priorities in the wrong place. If you're going to do such a half-a$$ed assessment on me, then you wouldn't be my nurse.
Specializes in acute care med/surg, LTC, orthopedics.
Also, do any of you wear gloves when doing the baseline? I don't mind touching someone's arm when I'm taking BP but touching a breast with my bare hand seems creepy.
If you find touching a bare breast creepy when performing an assessment then you are viewing them as sexual organs and behaving quite unprofessionally. Not only is this a huge disservice to your patients but yourself as well. You need to change your mindset if you want to improve as a health professional; it is a body part like any other human body part. Gloves are used for contact precautions when there is a risk of blood or bodily fluid exposure NONE of which is consistent with moving breasts out of the way to listen to lung sounds (unless there's open puss-filled sores on the breast) and besides... what difference does a flimsy vinyl barrier between your hand and the breast make anyway? You are STILL touching the breast and if this genuinely bothers you, then you seriously need to re-examine why and take measures to improve your professionalism.
AM I ON CRAZY PILLS OR SOMETHING!?
I'm now hoping to get some nursing students to play with when I retire. 
linearthinker, DNP, RN
1,688 Posts
What? A heart/lung assessment should never ever be done over gowns or clothing of any kind IMO. I can't imagine an environment where that would be ok.
I don't wear gloves unless there are body fluids or some contanimant.