Patient Assessment

[LovingPeds, MSN, APRN, NP]

I have been out of bedside care for 1 - 2 years now. I recently stayed with a relative during their hospital stay. In the 24 hours we were there, only once did anyone actually do a physical assessment using a stethoscope on a patient with respiratory illness and a history of cardiac complications. This includes providers, nurses, and respiratory staff. Vital signs, a quick radial pulse check, and dependent edema were assessed on admission. Vital sign assessment continued with the tech as routinely scheduled. IV was checked once with bag change. Other than that, nothing.

I always did a head to toe shift assessment and then a focused assessment on my rounds. I always auscultated heart and lung sounds on my rounds as well even if not admitted for a cardiac or respiratory problem. I always considered assessment a basic standard of care. I am concerned about this whole experience. How are you able to start the nursing process without assessment?

What have your experiences been? What do you consider to be the standard of care? This occurred over multiple departments and included providers so it's not an individual thing but systemic within their facility. The nurse to patient ratio was pretty standard for the clinical area for the shifts we were there. I'm curious as to what others do elsewhere because I've never encountered this type of behavior before in my own professional career and the systemic nature of it within the facility makes me wonder if this is normal in other places.

[JBMmom, MSN, NP]

Yes, you're not the only one who can relay experiences like this in healthcare lately. Is it right? No. Is it an acceptable standard of care? No. But it's definitely happening more than it should. There are some excuses but they're only that, excuses. Short staffing in floor nursing being what it is, some are skipping the basics unless someone appears to be in acute distress. For many people, after COVID made it that we couldn't use our stethoscopes in more than one room, people stopped carrying them. I know that for me I have a hearing impairment so the fisher price stethoscopes in precaution rooms are next to useless for me. And, some people are burnt out, lazy, and just shouldn't be working in healthcare. But they're still there. 

You could reach out to the patient advocate at your facility and relay the experience.  Perhaps some re-education or reminders on standard of care would help the people that cared for your family member. 

[JKL33]

On 8/10/2022 at 2:06 PM, LovingPeds said:

The nurse to patient ratio was pretty standard for the clinical area for the shifts we were there.

I don't think the care you describe is the right way to do things and I agree w/ above poster regarding the variety of reasons/factors that may be involved. But as for standards....I left because their priorities aren't mine as a nurse. Their standards are not sufficient. The "standard of care" doesn't mean jack to hospitals as long as they can write policies that say X is what people are supposed to be doing, staff however they want, and then point to an individual when things don't get done. If they can keep their business rolling, they do not care what your feelings are or my feelings are about how nursing should be.

An additional factor is the amount of turnover taking place and the lack of concern that nurses should have any expertise.

On 8/10/2022 at 2:06 PM, LovingPeds said:

I'm curious as to what others do elsewhere because I've never encountered this type of behavior before in my own professional career

Well, I do a lot more than what you're describing, but TBH I wouldn't consider myself the type to always listen to heart and lungs on every round. Frankly these days that could very well amount to mis-prioritization. That's the thing with prioritization...the more that gets piled on, the more frenzied things get, the less experience people have...it adds up. And things like going around listening to everyone's heart and lungs every two hours becomes a luxury. [Not to mention that there is a lot of respiratory information to be gleaned right from the doorway, in addition to the other modalities of monitoring].

Just a few thoughts; excuses aren't appropriate but reasons are still real.

Out of curiosity, did this have a negative impact on your mother's treatment/outcome?

If you reach out to discuss this with them I would focus on the idea that it seems like a system/facility/culture issue.

[CalicoKitty, BSN, MSN, RN]

Not excusing the behavior, but I honeslty dislike doing assessments with family in the room. In some settings (typically ICU), they would ask family to leave the room for assessment or change of shift. Did you never feel uncomfortable doing assessments on adults with other adults present in the room? I realize your specialties are pediatrics and mother-baby where families are typically in the room constantly, so perhaps you were used to this.

[RNperdiem, RN]

Over the past 25 or so years I have been working in hospitals, I have noticed a trend away from doctors listening to heart and lung sounds to looking at a combination of patient appearance, x-rays, EKGs, labs and other tests to tell the story. During rounds, the doctors do not listen to lung sounds, they pull up today's x-ray, compare it to yesterday's, look for trends in oxygen requirements then decide if diuresis is needed. 

I like history, especially the history of medicine. Before CT scans, echocardiograms and most of the diagnostics we have today, the only way for a doctor to get a diagnosis was a very thorough hands-on physical exam and a detailed list of questions about symptoms. The stethescope was a useful tool for listening in. Many of the obscure techniques can still be found in assessment textbooks. 

I still do a head to toe, and I do listen to heart and lung sounds, but the EKG monitor will tell me if a patient is in atrial fib much more clearly than my listening for irregular beats. 

[JBMmom, MSN, NP]

3 hours ago, RNperdiem said:

I still do a head to toe, and I do listen to heart and lung sounds, but the EKG monitor will tell me if a patient is in atrial fib much more clearly than my listening for irregular beats. 

In my ICU clinical rotation I showed up and the intensivist saw my stethoscope on my neck and said "get rid of that piece of crap". He explained his rationale was that if I listen to a patient that just needs to cough, I'm going to chart coorifice lung sounds, even rhonchi- then 10 minutes later the patient coughs and the next person charts "clear". So what was the value in that? He said it's just waste of important time. I didn't really agree with his philosophy entirely, but he has 20 years of experience and said he hasn't put a stethoscope on a patient in 10 years. 

 I agree that for many situations, like afib, the monitor will pick it up just as well. I still listen because it makes me feel more confident in the whole picture, but I realize an acute change in condition will probably be signaled by other aspects than a change in lung sounds. Increased work of breathing, decreased oxygen saturation, increased frequency in cough, etc. We have many tools these days, but our most important are still our eyes, it's interesting to hear how people approach patient care and difficult to correlate with outcomes when there are so many differences.

To the OP I hope your family member is doing better!

[vintagegal, BSN, DNP, RN, NP]

Umm, assess every patient every time. I’m not giving up my license because I miss lungs filling up with fluid or a change in cardiac status. I don’t care what anyone says with any amount of knowledge- you have to assess your patient to know what’s going on with them. That’s like the plumber saying he knows what’s up with your pipes when he never laid an eye on them. 

[HiddenAngels]

No this is not the NEW standard of care. This is called laziness and I bet you they are charting that they did a whole freaking assessment. 
so weird to me that people do this I mean how are you going to be able to distinguish a line of deviation.  
pull  those blankets back and check out your peeps. It takes less than 5 minutes

[HiddenAngels]

On 8/11/2022 at 12:36 AM, CalicoKitty said:

Not excusing the behavior, but I honeslty dislike doing assessments with family in the room. In some settings (typically ICU), they would ask family to leave the room for assessment or change of shift. Did you never feel uncomfortable doing assessments on adults with other adults present in the room? I realize your specialties are pediatrics and mother-baby where families are typically in the room constantly, so perhaps you were used to this.

I do the same in this instance if I’m on nights. I’ll circle back once visiting hours are over,  or if their hubby or wife is staying over I just let them know what I’m going to do and they usually hang out in the room, spouses usually don’t mind 

[HiddenAngels]

On 8/11/2022 at 10:35 AM, JBMmom said:

In my ICU clinical rotation I showed up and the intensivist saw my stethoscope on my neck and said "get rid of that piece of crap". He explained his rationale was that if I listen to a patient that just needs to cough, I'm going to chart coorifice lung sounds, even rhonchi- then 10 minutes later the patient coughs and the next person charts "clear". So what was the value in that? He said it's just waste of important time. I didn't really agree with his philosophy entirely, but he has 20 years of experience and said he hasn't put a stethoscope on a patient I

What a crock!  Do You know how many people I stopped from drowning in fluids with that ‘piece of crap” as he said.

Do you know how many hypoactive bowel sounds .. trying to dodge SBO’s.

Just WOW

On 8/14/2022 at 5:51 PM, vintagegal said:

Umm, assess every patient every time. I’m not giving up my license because I miss lungs filling up with fluid or a change in cardiac status. I don’t care what anyone says with any amount of knowledge- you have to assess your patient to know what’s going on with them. That’s like the plumber saying he knows what’s up with your pipes when he never laid an eye on them. 

Amen!

[JBMmom, MSN, NP]

On 8/18/2022 at 1:12 PM, HiddenAngels said:

What a crock!  Do You know how many people I stopped from drowning in fluids with that ‘piece of crap” as he said.

Do you know how many hypoactive bowel sounds .. trying to dodge SBO’s.

I agree. But I think it's easy for the provider to say that, knowing that there's a nurse behind him doing the actual assessing!!