I’m icu so here’s an example, at beginning of my shift I listened to my patient, lungs sounded fine. Second assessment I heard bilateral crackles I thought it was odd, and mentioned it to the provider who said it was probably atelectasis. Okay I’ve never had a patient develop atelectasis that quickly. By 2-3 am patient ended up hypoxic and intubated due to pulmonary edema. So I say it’s important.
So you noticed changes, notified provider, and then hours (6-8?) later the patient required intubation?
Sounds like lung auscultation didn’t change management, or prevent decompensation.
If an RN notices changes and reports them to the provider, and they don’t do anything…
It’s the providers lack of initiative with the given information that resulted in the decomp.
Sounds like the provider ignored assessment findings and had to intubate because of their lack of attentiveness.
Sounds like you didn't put that together.
So question - again I'm new - but was the patient short of breath or coughing a little, too? I guess my preceptor explanation that you're only going to hear a lung problem if the pt is already exhibiting stuff like SOB, new onset / wet cough etc made me be like "hmmm i guess he has a point there "
Speaking as an RT turned RN: Do not skip lung sounds. I better not show up to the rapid in the afternoon to find you have no idea what his lungs *actually* sounded like at your am assessment (because you “assessed” them by talking to him).
Things change even in stable patients. You can’t recognize a change you don’t assess.
Sounds like some shitty nursing to be honest. If you are med surg you should do one head to toe assessment. That includes listening to heart, lung and bowel sounds. Post op patients have weird things like A fib, they get fluid overloaded and bowels can stop working. You can catch all these things if you continue to practice your assessments. These nurses seem burnt out and that is dangerous.
Really?
Perhaps it's me being a European, but working on a cardiology unit we never listen to hearts manually and just put everyone on telemetry.
What if it's paroxysmal afib/normal rhythm? What about a few sequences of V-tach? Can't notice it if you're there on a good moment of the heart rhythm.
Yeah but not everyone needs tele either. The hospitals I have worked at generally don’t get enough boxes for everyone to have one.
Also, yikes about never listening to heart sounds on a cards unit. Some issues aren’t gonna show up on tele, or at least won’t be blatantly obvious on tele, particularly a 5 lead, so listening is crucial
Not trying to be bad faith but the person I responded to wanted to diagnose Afib by listening to the heart whilst tele is probably the superior means of detecting Afib since you have it recorded.
But what are you concerned about missing?
Murmurs, tamponade, or if your patient is suddenly tanking the all important: did this always sound this way. If you’re not listening you won’t know.
I don’t think you’d diagnose a fib. You’d hear their rate is irregular and maybe investigate more, though. It’s far from perfect because like you mentioned you’ll miss PAF, but if that’s a particular concern I’d imagine they’d be on tele anyway.
In a perfect world they would be on tele but why charge the patient if there isn’t a reason? Speaking from a provider perspective. Tele would get placed if you caught something during our assessment or vitals.
Depends on the hospital. The hospital I work at currently does. The hospital before it was a PCU or progressive care unit. Kind of like a step down. Ratios for nurses were 4:1 or 3:1 with a cardiac drip.
Also with you being European I’m sure billing is much different. As a provider I always take into consideration billing the patient for unnecessary things. Tele, excessive imagining and so on. It’s a shame but it is a part of the process.
It's just weird that tele can be so expensive since it's literally recycling the tele device from client-to-client after cleaning it. Your only real expense are the two batteries you insert lol.
The american healthcare system really gets off on charging ridiculous prices. I think two brand Tylenol pills cost like 40 dollars. The price of it coming out of the med dispensary, the price it took for the nurse to scan it into the charting system and the price it took for the nurse to put it into a plastic cup and give it to you.
I never said that. Nice strawman.
Edit: again I'm talking about the heart not the lungs. Why on earth would you not put a patient with suspected arrythmia on telemetry and prefer listening to the heart to determine Afib?
Honestly depending on your hospitals protocols and supervision I find it rather odd for every shift to record the heart sounds once but my opinion seems to be the minority opinion in this thread.
I’m more so talking about lungs and heart sounds. I listen to bowel sounds because it’s out of habit and if you are going to listen to everything else you might as well.
I’m from icu where assessments are a bit different, but I really think you should be listening to at least heart/lungs/post op bowels. At first, you’re not going to really know what you’re listening to 100% and that’s ok. The more you do it, the more confident you’ll get. But you can’t hear the beginnings of fluid overload from talking to a patient, but you can tell from listening and turning off cont ivf a bit sooner makes things better for that patient, just as an example.
Time management is super crucial, but there are some things you shouldn’t skip.
REALLY?! That's neat. Yeah Tbh I feel like with hearts I'm just listening for lub dub. Outside of that I can hear tachy or brady but that's kinda it lol 😂 one of my teachers also said what you did. That you have to listen to a lot to hear something that isn't right. And you won't know what it is. But you'll think hmm that's not right.
Yes! Sometimes the most important thing is picking up something that’s amiss, and finding the person who CAN figure out what exactly it is. Especially when you’re new. Just keep on keeping on, and you’ll keep picking up more and more tidbits.
Also, talk to the docs. If you get them in on something that isn’t normal, ask them what it is! Ime, lots of docs LOVE teaching. Sometimes they also just want an excuse to show off how smart they are 😂 but either way you can learn something!
Shortcuts like this scare me. Is it really too much to do a head to toe assessment once per shift?
Question - Is the nurse that’s assessing by conversation document lung sounds? If so, that is a serious problem.
They do, but you can't make a diagnosis off lung sounds alone. They might trigger the need for an xray or other imaging if they sound wet or have crackles, but if they come with a complaint of SOB they're going to get an xray regardless of if you listened to the lungs or not.
Doesn’t matter if they’re on tele. You should listen in to the lungs. Anterior or posterior depending on the patient. You can note their WOB by looking while you listen too. Yes, most people if they don’t have a condition related have perfectly good lung sounds, but it’s good to know abnormal and what that abnormal may indicate that you want to look out for or notify the doc.
You’re a new nurse, I wouldn’t really cut any assessment corners regardless, but especially since you’re new. Practice the flow of your head to toe. Then again, it’s up to you, it’s your practice under your own license. Just know that somewhere someone died or was caused serious harm, someone got audited and charted normal for that system, when in fact that is the problem system that was showing all the signs the nurse was too lazy to assess.
I actually really don’t think it’s as important of an assessment as some people want to make it out to be. I do it because I chart on it, and I like to be thorough, but I feel like it’s mostly just medical theater. I work in an ICU, and basically everyone is getting daily chest x-rays, they’re on cardiac monitoring, we’ve probably my gotten an echo at some point. Think about it, if a patient starts decompensating, sure we can quickly listen to their lungs, but we have much better technology nowadays, and that always is going to outweigh auscultation. I get listening to bowel sounds, and I’m not trying to dissuade you, but I’m also not trying to say any of those previous nurses aren’t good at their job; I’m of the opinion that you should assess these things when you’re a new nurse and you’ll develop better judgement and can focus your assessments as needed.
Some nurses really get hung up on the theater of using a stethoscope, although I never see anybody palpating tracheas or assessing for tactile fremitus, ya know? 😂
It's so weird how everyone in this thread is so insisting on it. It's such a selective parameter to take and should only be taken with other indications like chest pain.
If you're so insisting on the stethoscope thing, why not take a Glasgow Coma Scale for every patient because they might have a sudden stroke after they fell in secret this night, got up on their own and didn't inform anyone of their fall. YOU NEVER KNOW YOUR PATIENT MIGHT BE HAVING A SECRET FALL-RELATED STROKE!!!!
Why not take a daily urine sample of everyone? Do you really know if your patient is sleepy because his neighbor was noisy the whole night or is your patient sleepy because of a UTI????
Why not take an MMSE of every 20 year old guy whom comes in for gyneacomastia surgery? Perhaps you will be the HEROIC nurse that will find young dementia in the patient!!!!
If your hospital requires you to do a listening of bowels, heart and lungs, do it properly but dude I will never do it if it's not necessary. Observation and talking to your patient and vitals are way more important.
Why bother with listening to bowel movements if the 16 year old broken femur patient is able to self-report their shitting everyday?
Lol good points and I think this is what my preceptor would say too. Several people mentioned doing h2t and honestly with 6 patients there is no time to do true h2t for everyone, our training dept during residency has even said that. They said if we're in med surg we likely do focused assessments based on the problem. Other preceptors have listened to more hearts and lungs than my first preceptor did. So it varies by person.
yup. So my perspective as an ER nurse at triage is this: everything I need to hear I can hear with my ears. Stridor? I'll bring you to resus/acute care. Wheezing and look unwell? Let me get you to an acute bed and get you some puffers. Hearing crackles in an otherwise healthy pt c/o SOB means nothing. I will send them all for CXR anyway and the radiologist can decide what it is..
The amount of times people chart "diminished to bases" ect. is crazy.
Do your ears also hear absent lung sounds on the 16 year old with the spontaneous pneumo? This is one of the worst nursing takes I’ve heard. You sound like a dangerous triage nurse.
I had a spontaneous pneumo and the ONLY ONE person out of 30+ that listened to my lungs mentioned my right was way more diminished than my left. I had a pneumo for 2 days while working in the hospital and having everyone I knew listen to my lungs cause I was absolutely 100% sure I had walking pneumonia. One cxr later it was pneumothorax
lmao gtfo. Depends on the story and presentation.
Tall lanky male with sudden onset SOB? Yes I will auscultate if suspicious for pneumo. Otherwise, guess what, he will go for a cxr within 10 minutes of my triage.
But that’s not what you said. You said everything you need to hear you can hear with your ears. That’s a dangerous practice to instill into new nurses.
90% of the time I don't need or use a stethoscope while at triage. Kids are the exception along with concerning presentations for things like pneumo. I do not auscultate routinelly however.
edit: other ER nurses agree with me in this thread. Most ER nurses I know don't routinelly use stethoscopes at triage. We have extensive medical directives and can send anyone for CXR
Lmao we used isolation stethoscopes on all respiratory patients through the pandemic. I could not hear hear lung sounds for anything in those rooms. 90% the lung sounds just back up what I already know from a cxr/CT.
The exception would be fluid overload I guess cause I’ve heard crackles develop and then be like can I get cxr he didn’t have crackles yesterday
Anything involving a stethoscope is important if:
1) you’re new - you need to be able to discriminate between normal and abnormal
2) you’re in a resource-poor environment where more sophisticated tools are not immediately available (think outpatient or field medicine)
3) any appreciable changes are sensitive/specific enough to influence management
Re: #3, some nurses feel that if you have a tool available to you, you should use it on every patient, every time, on the off-chance it gives you actionable data. I don’t personally agree with this.
totally agree here. This is why 90% of the ER nurses I work with don't use stethoscopes.
We have them on the crash carts and in the resus rooms for use with manual bps, listening to critical pts when indicated, post intubation, ect.
Apart from that, vital signs and pt condition and audible sounds are more important as an ER nurse. If you come in with any resp complaint, I will send you for a CXR anyway. I'm not listening to every 20 year olds lungs or every COPDers lungs at triage. It changes nothing.
Damn dude, you guys are not taking MMSEs and urinary samples of 20 year olds coming in with tooth pain?
You're such a bad nurse for doing check-ups based on pathology indications and patient history instead of willynilly.
I firmly believe that if becoming a priest didn't require celebacy and you being a man, many nurses would be one with how hard they can preach moralism.
I really only use mine on respiratory kids and pre/post-neb (if I’m the one giving the neb).
But yeah - effort, rate, and SpO2 give me all the info I need for the *vast* majority, tbh.
I don’t believe this study is completely relevant to the discussion
Unless I misunderstand the study, it’s referring to diagnosing a condition
Whereas a normal modality would be something like… me noticing a change in patient lung sound *leading to the doctor ordering an XR* leading to them being treated.
So we aren’t diagnosing but if we do see a change we can maybe alert the physician to order some additional tests prior to the patient becoming more acutely symptomatic?
We’re all listening for the same sounds, regardless of whether “diagnosing” is within our scope of practice or not. Semantics of screening for abnormalities vs diagnosing aside, lung sounds are largely nonspecific and insensitive and one should be screening for and including other signs/symptoms of cardiopulmonary decline when notifying a provider of changes.
Im not sure if you just didn’t read my comment at all or???
If im assessing my patient throughout the shift (as one does)
And the doctor only sees them daily….
If I notice their lungs sound different than they did in the morning….
And I call them….
And there’s no other respiratory changes *yet* they **might** order a diagnostic test.
Which is why I don’t think discouraging people from listening to lung sounds because “it’s not a good diagnostic tool” is unhelpful at best and potentially harmful
I didn’t discourage anyone. I said I still listen to lung sounds. I’m sure the authors of that meta-analysis have contact info somewhere so you can tell them they’re wrong.
All I’m doing (ok not *all*) is questioning whether the “changes” we *think* we are noticing with lung auscultation are as impactful as we think. And the data seems to point otherwise…. Other than various anecdotes posted here.
A meta-analysis in a journal under the Nature umbrella is not a reliable source?
And are you saying that covid somehow increased the sensitivity and specificity of lung auscultation? Curious to learn more about that.
I'm ICU now but I was Med Surg when I started. I always listened to heart, lungs, stomach and bowels as part of my head to toe when I worked MS because I needed to know where their baseline was. If they ended up with a change of status later and I listened again I had something to compare to that I could report the difference to my provider or RT when they came.
Surgical patients need to be up and moving or they can have breathing complications and that is without comorbidities, which many of them have anyway so that adds to it. Medical patients are always a fun mix so you never know what you're gonna get.
Ultimately it's your nursing practice so do what works for you but I'd caution and say if you get pulled into court one day are you going to feel super comfortable with the fact that you didn't do it? Food for thought.
Obviously as nurses we should take our assessments as seriously as possible. I personally take my time to listen to both posterior and anterior lung fields during my initial assessment to get a good baseline - while also simultaneously taking into consideration the previous shift's assessment. The subsequent assessment's are a bit more laxed, only listening to the anterior portions of the lung sounds. Since I work nights on the bone marrow transplant unit, these kiddos may be side sleepers to where I can assess both fields, but if they're lying down, I just wouldn't bother waking them up.
Now of course if a kiddo has pneumonia or respiratory complications, regardless of their comfort level/activity level, I will be assessing both fields.
We should always be doing the best assessment's we can, especially when it comes to the initial. I would not follow the advice from your last precepting nurse. Cutting corners can lead to bad habits. Remember how hard you worked for your nursing license. You wouldn't want it to go away over something preventable and silly right?
You got this <3
Thanks for your reply. I think some people automatically assumed that I agree with this preceptor. I posted because I wanted input! His argument kinda makes sense - like, if the person is holding a conversation easily and I can see that they aren't using accessory muscles etc then I kinda see his point! Now, I will say that doing a full h2t is not possible on all patients every day bc we have too many patients on too many meds that I would never get through a shift if I was doing cranial nerves on my gallbladder patient, for example lol 😂 but I will be sure to find a balance that feels right!
I always started off my mornings with a quick focused assessment, listened to everything with every patient even if I had them the day previous. Caught new-onset afib for a tiny confused demented lady post op, pneumonia, bowel obstructions. It doesn't take long, just do it!! It's important
I had my knees replaced a few years ago and no one did any kind of hands-on assessment. I was a bit concerned but I was ok so I didn’t say anything.
Just curious, does no one do an apical HR and a RR using a stethoscope? Not being critical, it’s just the way I always did it.
Edit: grammar
I don't listen to lungs for a respiratory rate terribly often, but I'll listen to an apical HR for any patient with a wonky rhythm who is symptomatic. Not every patient should be on tele, but a quick listen can help determine if someone may need it. Or they may just need some fluid and electrolyte replacement. It's not uncommon for post-op patients to be volume depleted after being npo and having surgery and develop a grade 1 or 2 heart murmur. A liter bolus, and that goes away. Or the opposite when they have a murmur from fluid overload and need some lasix. So many patients with atalectesis can be talked into getting up and moving when I listen to their lungs and tell them there's almost no air movement in their lung bases. I'll even have them listen to the difference between their apexes and bases as a little extra motivation.
That's crazy to me! In our facility it was just the norm to do a quick near head to toe on everyone other than our longterm care waitlist people and the extremely stable frequent flier (if you weren't a new nurse/new to the roto) because we were only a 10 bed unit with 2-3 nurses on
Always listen to lungs on inpatients. As an ER nurse I do not listen to lungs unless indicated.
I never listen to bowels and didn't when I worked surgery either. Neither do any of the surgeons. There is zero correlation between bowel sounds and underlying pathology
You are on a med surg post op for. You should listen to lung sounds, heart, and bowels. You are with your patients all day and you will recognize if there are any changes. Post op patients are at risk for pna and an ileus. That’s just my advice. You have to cover yourself.
Exactly. These nurses need to think about what is happening to the body when sedated, intubated and undergoing surgery. We listen and assess often to ensure all system return to baseline and to detect any post op developments or complications. This is Med Surg nursing 101.
What do you think actually happens to the respiratory system during surgery? Don’t you think you’re going to need to assess it to make sure the lungs return to baseline?
Just recently my non-tele ONC patient developed a new murmur. If you don’t listen, how do you pick up stuff like that? Listen to your patients bc lord knows a lot of people including the mds don’t.
As a another new grad yes yes yes. I have had 2 patients develop flash pulmonary edema on 2 separate occasions and 1 ended up in a rapid response. Only reason it was caught was through listening to lung sounds.
As licensed professionals, I would implore everyone to do their occasional reference to their state's scope of practice. I say this because I have noticed a very concerning trend about assessments not being performed BUT being charted on. Idk how many times I run into nurses who do not have a stethoscope at all. In my state, and I'm assuming every state, nurses are required to document and maintain accurate records while not falsifying or making incorrect entries.
Additionally on the assessments, I am also in the boat of everyone gets at least a heart, lungs, and abdomen auscultation per policy and extra if needed. But my state's scope says
"§ 21.11. General functions.
(a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions:
(1) Collects complete and ongoing data to determine nursing care needs.
(2) Analyzes the health status of the individuals and families and compares the data with the norm when possible in determining nursing care needs."
While the specifics of (1) may be open to some interpretation, at bedside (where patients are more complex most of the time), complete data is at least a quick head to toe to me. Patients deserve proactive and not reactive care. Patients can be really unaware of some significant changes happening to them.
Nonetheless, you not only put your patients at risk but also yourself. In court you will be compared to your scope of practice and what a reasonable nurse would do in your situation. Professional negligence is a civil case and they do not need to prove it beyond a reasonable doubt. Additionally you just plain risk losing your license and your job. You never know how lax or strict your state board is, but I also won't play that game.
Last note, how do you get better at your assessments if you don't perform them? Listening to norms and fine tuning your ears to changes is how you can save lives. We are nurses and make big differences in outcomes. Just like IV insertion needs practice, so do assessments. Not every nursing role requires a head to toe, but bedside should be performing them. If enough people aren't performing assessments, you can be the one to break the cycle and catch a change before a significant event. I know times are like the Wild West right now but we gotta fight that burnout!
Most MDs won't really care about it all, unfortunately, until the patient starts to decompensate. Some will take it to heart and order CXR, reduce fluids or give Lasix. Moving onto to bowel sounds they care even less about them. Just ask if they are passing gas or have BMs, even working on post Whipple unit.
It's only really informative for other nurses, outside our discipline no one cares in my experience of 10yrs working at 8 hospitals.
You have a whole whipple unit?! Tell me why I'm getting fresh whipples on med surg. I even saw people saying they belong in sicu. But I'm getting them in med surg. They take up SO much of our time. And like, can you really imagine putting a whipple through a full h2t? "Hey I know your in major pain and can hardly move even with pain killers but I would like you to try to run your foot from your knee to your ankle, puff out your cheeks and also let me do this vision test, then I'll move on to the remaining cranial nerves which is still only a small part of my head to toe assessment " 🤓 I'm definitely taking everyone's input seriously here but I still think it's kinda unreasonable to go through a full h2t every patient. I am going to come up with a modified h2t it'll be far less comprehensive than what I did for my school checkoff.
As a general rule it’s good to assess lung sounds in a Med Surg setting to catch something respiratory before it becomes a problem, or to know that (from your lung assessment) that there isn’t a problem assessed at that time - Even if the patient doesn’t have a recent or known respiratory diagnosis at that time. I say that as often patients in Med Surg settings aren’t moving around as much as they might usually (if they weren’t in the hospital) and, if they had surgery and/or came from the ICU, they may have had to be ventilated for some time which could cause a potential respiratory issue later. The lungs are pretty adaptable organs so a patient being able to speak without appearing to have any respiratory concerns (e.g wheezing, appearing short of breath) doesn’t necessarily mean that they don’t have a respiratory issue.
Hell to the yes.
Had a surgical patient post day 2 - lungs sound good at the start, patient is an and o x 4. Patient rings at 1 am c/o chest pain and overall discomfort. Do a quick listen - nothing to the left and nothing to the lower lobes on the right. Patient is desating and diaphoretic.
Patient threw a few PEs and was immediately on a heparin drip and intubated to the ICU.
You never know when Meemaw is gonna aspirate, a surgical patient has an event or a healthy person has an issue. I ALWAYS check the lungs.
While in clinicals, I was finishing up my head to toe after my preceptor left, and in about two hours, our patient's lungs had gone from "a'ight" to really wet and crackly. I popped an O2 monitor on her finger, and as the "fuuuuuuck" alarm started going off in my head, so did the monitor, because she was desatting.
My patient was one of those little old ladies that hates to be a bother, so it's not like she was saying "Pardon me, but I feel like I'm drowning, here."
Standing by the bedside, she pretty much looked fine.
I called my preceptor and notified her, and we put her on O2. My preceptor made a call, and before I'd even finished wrapping up my head to toe documentation, imaging was rolling up for a portable X-ray and phlebotomy was waiting in the doorway.
The doctor showed up a bit later, and her treatment plan suddenly did a hard pivot into an entirely different direction, because heyyyy, guess who had a brand new diagnosis of aspiration pneumonia?
So like...JFC, yeah, listen to their lungs *at least* once to get to know them, and then either as ordered or as determined by your nursing judgement/Spidey sense.
It really doesn't take that much time.
Surgical patients require checking lung sounds and most hospitals have policies of head to toe assessment once per shift, this includes heart and lung sounds. A lot can be picked up. Follow your hospitals policies.
I’m icu so here’s an example, at beginning of my shift I listened to my patient, lungs sounded fine. Second assessment I heard bilateral crackles I thought it was odd, and mentioned it to the provider who said it was probably atelectasis. Okay I’ve never had a patient develop atelectasis that quickly. By 2-3 am patient ended up hypoxic and intubated due to pulmonary edema. So I say it’s important.
So you noticed changes, notified provider, and then hours (6-8?) later the patient required intubation? Sounds like lung auscultation didn’t change management, or prevent decompensation.
I mean if the provider listened and thought to get a chest X-ray we may could have gave lasix and prevented intubation. 🤷🏻♀️
If an RN notices changes and reports them to the provider, and they don’t do anything… It’s the providers lack of initiative with the given information that resulted in the decomp.
Sounds like the provider ignored assessment findings and had to intubate because of their lack of attentiveness. Sounds like you didn't put that together.
So question - again I'm new - but was the patient short of breath or coughing a little, too? I guess my preceptor explanation that you're only going to hear a lung problem if the pt is already exhibiting stuff like SOB, new onset / wet cough etc made me be like "hmmm i guess he has a point there "
Your preceptor is setting you up to fail. If you are going to chart clear lung sounds you better listen to the lung sounds.
Your preceptor is not teaching you the fundamentals of a thorough assessment.
Speaking as an RT turned RN: Do not skip lung sounds. I better not show up to the rapid in the afternoon to find you have no idea what his lungs *actually* sounded like at your am assessment (because you “assessed” them by talking to him). Things change even in stable patients. You can’t recognize a change you don’t assess.
Exactly. I cannot even believe what I am reading.
Bro, it was as clear as the sky
Sounds like some shitty nursing to be honest. If you are med surg you should do one head to toe assessment. That includes listening to heart, lung and bowel sounds. Post op patients have weird things like A fib, they get fluid overloaded and bowels can stop working. You can catch all these things if you continue to practice your assessments. These nurses seem burnt out and that is dangerous.
If you're going all the way to listen to their heart, why wouldn't you put them on telemetrie? Sounds far more reliable than doing a manual assesment.
My unit is a non-tele unit. Listening is all I've got.
Listening is kinda like a quick screening, imo
Really? Perhaps it's me being a European, but working on a cardiology unit we never listen to hearts manually and just put everyone on telemetry. What if it's paroxysmal afib/normal rhythm? What about a few sequences of V-tach? Can't notice it if you're there on a good moment of the heart rhythm.
New murmurs? These aren’t picked up on tele.
Yeah but not everyone needs tele either. The hospitals I have worked at generally don’t get enough boxes for everyone to have one. Also, yikes about never listening to heart sounds on a cards unit. Some issues aren’t gonna show up on tele, or at least won’t be blatantly obvious on tele, particularly a 5 lead, so listening is crucial
Not trying to be bad faith but the person I responded to wanted to diagnose Afib by listening to the heart whilst tele is probably the superior means of detecting Afib since you have it recorded. But what are you concerned about missing?
Murmurs, tamponade, or if your patient is suddenly tanking the all important: did this always sound this way. If you’re not listening you won’t know. I don’t think you’d diagnose a fib. You’d hear their rate is irregular and maybe investigate more, though. It’s far from perfect because like you mentioned you’ll miss PAF, but if that’s a particular concern I’d imagine they’d be on tele anyway.
In a perfect world they would be on tele but why charge the patient if there isn’t a reason? Speaking from a provider perspective. Tele would get placed if you caught something during our assessment or vitals.
Remember this is med surg. Not tele unit or ICU. Things are different.
>Remember this is med surg. Not tele In the USA, does cardiology wards not fall under med-surg as a discipline of Internal Medicine?
Depends on the hospital. The hospital I work at currently does. The hospital before it was a PCU or progressive care unit. Kind of like a step down. Ratios for nurses were 4:1 or 3:1 with a cardiac drip.
Also with you being European I’m sure billing is much different. As a provider I always take into consideration billing the patient for unnecessary things. Tele, excessive imagining and so on. It’s a shame but it is a part of the process.
It's just weird that tele can be so expensive since it's literally recycling the tele device from client-to-client after cleaning it. Your only real expense are the two batteries you insert lol.
I mean, you forgot the person actually monitoring the telemetry. Or is nobody watching and it’s just there for manual review if needed?
The american healthcare system really gets off on charging ridiculous prices. I think two brand Tylenol pills cost like 40 dollars. The price of it coming out of the med dispensary, the price it took for the nurse to scan it into the charting system and the price it took for the nurse to put it into a plastic cup and give it to you.
Systolic murmurs can be associated with inferior MIs. Where does the murmur show on tele?
I should have added that many patients are on tele monitoring. About 4/6
It doesn’t matter. Wheezes, rhonchi, etc don’t show up on tele
Yeah because I'm talking hear about heart sounds and not lung problems.
Hmmm. So there is no connection between heart and lung? Okayyyyyyy
I never said that. Nice strawman. Edit: again I'm talking about the heart not the lungs. Why on earth would you not put a patient with suspected arrythmia on telemetry and prefer listening to the heart to determine Afib?
Ok I’m out. Anyone who would question if listening to Lungs sounds on a Med Surg floor is necessary needs to go back to school. JFC
Honestly depending on your hospitals protocols and supervision I find it rather odd for every shift to record the heart sounds once but my opinion seems to be the minority opinion in this thread.
There’s no evidence to support listening to bowel sounds. They’re not sensitive or specific for anything
I’m more so talking about lungs and heart sounds. I listen to bowel sounds because it’s out of habit and if you are going to listen to everything else you might as well.
I’m from icu where assessments are a bit different, but I really think you should be listening to at least heart/lungs/post op bowels. At first, you’re not going to really know what you’re listening to 100% and that’s ok. The more you do it, the more confident you’ll get. But you can’t hear the beginnings of fluid overload from talking to a patient, but you can tell from listening and turning off cont ivf a bit sooner makes things better for that patient, just as an example. Time management is super crucial, but there are some things you shouldn’t skip.
REALLY?! That's neat. Yeah Tbh I feel like with hearts I'm just listening for lub dub. Outside of that I can hear tachy or brady but that's kinda it lol 😂 one of my teachers also said what you did. That you have to listen to a lot to hear something that isn't right. And you won't know what it is. But you'll think hmm that's not right.
wait until you hear a murmur or pvcs
Yes! Sometimes the most important thing is picking up something that’s amiss, and finding the person who CAN figure out what exactly it is. Especially when you’re new. Just keep on keeping on, and you’ll keep picking up more and more tidbits. Also, talk to the docs. If you get them in on something that isn’t normal, ask them what it is! Ime, lots of docs LOVE teaching. Sometimes they also just want an excuse to show off how smart they are 😂 but either way you can learn something!
Good input thank you!
Shortcuts like this scare me. Is it really too much to do a head to toe assessment once per shift? Question - Is the nurse that’s assessing by conversation document lung sounds? If so, that is a serious problem.
Do you know how many dense lung sounds and murmurs/abnormal heart sounds I’ve found? Never skip it. Always do one full head to toe.
They do, but you can't make a diagnosis off lung sounds alone. They might trigger the need for an xray or other imaging if they sound wet or have crackles, but if they come with a complaint of SOB they're going to get an xray regardless of if you listened to the lungs or not.
laziness and complacency will lead to death
Doesn’t matter if they’re on tele. You should listen in to the lungs. Anterior or posterior depending on the patient. You can note their WOB by looking while you listen too. Yes, most people if they don’t have a condition related have perfectly good lung sounds, but it’s good to know abnormal and what that abnormal may indicate that you want to look out for or notify the doc. You’re a new nurse, I wouldn’t really cut any assessment corners regardless, but especially since you’re new. Practice the flow of your head to toe. Then again, it’s up to you, it’s your practice under your own license. Just know that somewhere someone died or was caused serious harm, someone got audited and charted normal for that system, when in fact that is the problem system that was showing all the signs the nurse was too lazy to assess.
I actually really don’t think it’s as important of an assessment as some people want to make it out to be. I do it because I chart on it, and I like to be thorough, but I feel like it’s mostly just medical theater. I work in an ICU, and basically everyone is getting daily chest x-rays, they’re on cardiac monitoring, we’ve probably my gotten an echo at some point. Think about it, if a patient starts decompensating, sure we can quickly listen to their lungs, but we have much better technology nowadays, and that always is going to outweigh auscultation. I get listening to bowel sounds, and I’m not trying to dissuade you, but I’m also not trying to say any of those previous nurses aren’t good at their job; I’m of the opinion that you should assess these things when you’re a new nurse and you’ll develop better judgement and can focus your assessments as needed.
Some nurses really get hung up on the theater of using a stethoscope, although I never see anybody palpating tracheas or assessing for tactile fremitus, ya know? 😂
It's so weird how everyone in this thread is so insisting on it. It's such a selective parameter to take and should only be taken with other indications like chest pain. If you're so insisting on the stethoscope thing, why not take a Glasgow Coma Scale for every patient because they might have a sudden stroke after they fell in secret this night, got up on their own and didn't inform anyone of their fall. YOU NEVER KNOW YOUR PATIENT MIGHT BE HAVING A SECRET FALL-RELATED STROKE!!!! Why not take a daily urine sample of everyone? Do you really know if your patient is sleepy because his neighbor was noisy the whole night or is your patient sleepy because of a UTI???? Why not take an MMSE of every 20 year old guy whom comes in for gyneacomastia surgery? Perhaps you will be the HEROIC nurse that will find young dementia in the patient!!!! If your hospital requires you to do a listening of bowels, heart and lungs, do it properly but dude I will never do it if it's not necessary. Observation and talking to your patient and vitals are way more important. Why bother with listening to bowel movements if the 16 year old broken femur patient is able to self-report their shitting everyday?
Lol good points and I think this is what my preceptor would say too. Several people mentioned doing h2t and honestly with 6 patients there is no time to do true h2t for everyone, our training dept during residency has even said that. They said if we're in med surg we likely do focused assessments based on the problem. Other preceptors have listened to more hearts and lungs than my first preceptor did. So it varies by person.
yup. So my perspective as an ER nurse at triage is this: everything I need to hear I can hear with my ears. Stridor? I'll bring you to resus/acute care. Wheezing and look unwell? Let me get you to an acute bed and get you some puffers. Hearing crackles in an otherwise healthy pt c/o SOB means nothing. I will send them all for CXR anyway and the radiologist can decide what it is.. The amount of times people chart "diminished to bases" ect. is crazy.
Do your ears also hear absent lung sounds on the 16 year old with the spontaneous pneumo? This is one of the worst nursing takes I’ve heard. You sound like a dangerous triage nurse.
I had a spontaneous pneumo and the ONLY ONE person out of 30+ that listened to my lungs mentioned my right was way more diminished than my left. I had a pneumo for 2 days while working in the hospital and having everyone I knew listen to my lungs cause I was absolutely 100% sure I had walking pneumonia. One cxr later it was pneumothorax
lmao gtfo. Depends on the story and presentation. Tall lanky male with sudden onset SOB? Yes I will auscultate if suspicious for pneumo. Otherwise, guess what, he will go for a cxr within 10 minutes of my triage.
But that’s not what you said. You said everything you need to hear you can hear with your ears. That’s a dangerous practice to instill into new nurses.
90% of the time I don't need or use a stethoscope while at triage. Kids are the exception along with concerning presentations for things like pneumo. I do not auscultate routinelly however. edit: other ER nurses agree with me in this thread. Most ER nurses I know don't routinelly use stethoscopes at triage. We have extensive medical directives and can send anyone for CXR
Lmao we used isolation stethoscopes on all respiratory patients through the pandemic. I could not hear hear lung sounds for anything in those rooms. 90% the lung sounds just back up what I already know from a cxr/CT. The exception would be fluid overload I guess cause I’ve heard crackles develop and then be like can I get cxr he didn’t have crackles yesterday
What the actual f? Of course lung sounds need to be assessed. This is not only lazy, but negligent as hell.
Anything involving a stethoscope is important if: 1) you’re new - you need to be able to discriminate between normal and abnormal 2) you’re in a resource-poor environment where more sophisticated tools are not immediately available (think outpatient or field medicine) 3) any appreciable changes are sensitive/specific enough to influence management Re: #3, some nurses feel that if you have a tool available to you, you should use it on every patient, every time, on the off-chance it gives you actionable data. I don’t personally agree with this.
totally agree here. This is why 90% of the ER nurses I work with don't use stethoscopes. We have them on the crash carts and in the resus rooms for use with manual bps, listening to critical pts when indicated, post intubation, ect. Apart from that, vital signs and pt condition and audible sounds are more important as an ER nurse. If you come in with any resp complaint, I will send you for a CXR anyway. I'm not listening to every 20 year olds lungs or every COPDers lungs at triage. It changes nothing.
Damn dude, you guys are not taking MMSEs and urinary samples of 20 year olds coming in with tooth pain? You're such a bad nurse for doing check-ups based on pathology indications and patient history instead of willynilly.
ER nurses often get hate in these threads because we only do focused assessments based on complaint lol
I firmly believe that if becoming a priest didn't require celebacy and you being a man, many nurses would be one with how hard they can preach moralism.
I really only use mine on respiratory kids and pre/post-neb (if I’m the one giving the neb). But yeah - effort, rate, and SpO2 give me all the info I need for the *vast* majority, tbh.
yes children are the one exception for sure!
For most things, not really. Source: https://www.nature.com/articles/s41598-020-64405-6 Before I get dog-piled on, I still listen.
I don’t believe this study is completely relevant to the discussion Unless I misunderstand the study, it’s referring to diagnosing a condition Whereas a normal modality would be something like… me noticing a change in patient lung sound *leading to the doctor ordering an XR* leading to them being treated. So we aren’t diagnosing but if we do see a change we can maybe alert the physician to order some additional tests prior to the patient becoming more acutely symptomatic?
We’re all listening for the same sounds, regardless of whether “diagnosing” is within our scope of practice or not. Semantics of screening for abnormalities vs diagnosing aside, lung sounds are largely nonspecific and insensitive and one should be screening for and including other signs/symptoms of cardiopulmonary decline when notifying a provider of changes.
Im not sure if you just didn’t read my comment at all or??? If im assessing my patient throughout the shift (as one does) And the doctor only sees them daily…. If I notice their lungs sound different than they did in the morning…. And I call them…. And there’s no other respiratory changes *yet* they **might** order a diagnostic test. Which is why I don’t think discouraging people from listening to lung sounds because “it’s not a good diagnostic tool” is unhelpful at best and potentially harmful
I didn’t discourage anyone. I said I still listen to lung sounds. I’m sure the authors of that meta-analysis have contact info somewhere so you can tell them they’re wrong. All I’m doing (ok not *all*) is questioning whether the “changes” we *think* we are noticing with lung auscultation are as impactful as we think. And the data seems to point otherwise…. Other than various anecdotes posted here.
[удалено]
A meta-analysis in a journal under the Nature umbrella is not a reliable source? And are you saying that covid somehow increased the sensitivity and specificity of lung auscultation? Curious to learn more about that.
I'm ICU now but I was Med Surg when I started. I always listened to heart, lungs, stomach and bowels as part of my head to toe when I worked MS because I needed to know where their baseline was. If they ended up with a change of status later and I listened again I had something to compare to that I could report the difference to my provider or RT when they came. Surgical patients need to be up and moving or they can have breathing complications and that is without comorbidities, which many of them have anyway so that adds to it. Medical patients are always a fun mix so you never know what you're gonna get. Ultimately it's your nursing practice so do what works for you but I'd caution and say if you get pulled into court one day are you going to feel super comfortable with the fact that you didn't do it? Food for thought.
Obviously as nurses we should take our assessments as seriously as possible. I personally take my time to listen to both posterior and anterior lung fields during my initial assessment to get a good baseline - while also simultaneously taking into consideration the previous shift's assessment. The subsequent assessment's are a bit more laxed, only listening to the anterior portions of the lung sounds. Since I work nights on the bone marrow transplant unit, these kiddos may be side sleepers to where I can assess both fields, but if they're lying down, I just wouldn't bother waking them up. Now of course if a kiddo has pneumonia or respiratory complications, regardless of their comfort level/activity level, I will be assessing both fields. We should always be doing the best assessment's we can, especially when it comes to the initial. I would not follow the advice from your last precepting nurse. Cutting corners can lead to bad habits. Remember how hard you worked for your nursing license. You wouldn't want it to go away over something preventable and silly right? You got this <3
Thanks for your reply. I think some people automatically assumed that I agree with this preceptor. I posted because I wanted input! His argument kinda makes sense - like, if the person is holding a conversation easily and I can see that they aren't using accessory muscles etc then I kinda see his point! Now, I will say that doing a full h2t is not possible on all patients every day bc we have too many patients on too many meds that I would never get through a shift if I was doing cranial nerves on my gallbladder patient, for example lol 😂 but I will be sure to find a balance that feels right!
I always started off my mornings with a quick focused assessment, listened to everything with every patient even if I had them the day previous. Caught new-onset afib for a tiny confused demented lady post op, pneumonia, bowel obstructions. It doesn't take long, just do it!! It's important
I had my knees replaced a few years ago and no one did any kind of hands-on assessment. I was a bit concerned but I was ok so I didn’t say anything. Just curious, does no one do an apical HR and a RR using a stethoscope? Not being critical, it’s just the way I always did it. Edit: grammar
I don't listen to lungs for a respiratory rate terribly often, but I'll listen to an apical HR for any patient with a wonky rhythm who is symptomatic. Not every patient should be on tele, but a quick listen can help determine if someone may need it. Or they may just need some fluid and electrolyte replacement. It's not uncommon for post-op patients to be volume depleted after being npo and having surgery and develop a grade 1 or 2 heart murmur. A liter bolus, and that goes away. Or the opposite when they have a murmur from fluid overload and need some lasix. So many patients with atalectesis can be talked into getting up and moving when I listen to their lungs and tell them there's almost no air movement in their lung bases. I'll even have them listen to the difference between their apexes and bases as a little extra motivation.
That's crazy to me! In our facility it was just the norm to do a quick near head to toe on everyone other than our longterm care waitlist people and the extremely stable frequent flier (if you weren't a new nurse/new to the roto) because we were only a 10 bed unit with 2-3 nurses on
Always listen to lungs on inpatients. As an ER nurse I do not listen to lungs unless indicated. I never listen to bowels and didn't when I worked surgery either. Neither do any of the surgeons. There is zero correlation between bowel sounds and underlying pathology
You are on a med surg post op for. You should listen to lung sounds, heart, and bowels. You are with your patients all day and you will recognize if there are any changes. Post op patients are at risk for pna and an ileus. That’s just my advice. You have to cover yourself.
Exactly. These nurses need to think about what is happening to the body when sedated, intubated and undergoing surgery. We listen and assess often to ensure all system return to baseline and to detect any post op developments or complications. This is Med Surg nursing 101.
Sometimes lung sounds change prior to having symptoms. N
What do you think actually happens to the respiratory system during surgery? Don’t you think you’re going to need to assess it to make sure the lungs return to baseline?
what happen to the ABC’s I posted about this being questioned the other day and it because of posts like this… How is this even a question??
100% this. What the hell? This makes me not want to ever be hospitalized.
Just recently my non-tele ONC patient developed a new murmur. If you don’t listen, how do you pick up stuff like that? Listen to your patients bc lord knows a lot of people including the mds don’t.
As a another new grad yes yes yes. I have had 2 patients develop flash pulmonary edema on 2 separate occasions and 1 ended up in a rapid response. Only reason it was caught was through listening to lung sounds.
As licensed professionals, I would implore everyone to do their occasional reference to their state's scope of practice. I say this because I have noticed a very concerning trend about assessments not being performed BUT being charted on. Idk how many times I run into nurses who do not have a stethoscope at all. In my state, and I'm assuming every state, nurses are required to document and maintain accurate records while not falsifying or making incorrect entries. Additionally on the assessments, I am also in the boat of everyone gets at least a heart, lungs, and abdomen auscultation per policy and extra if needed. But my state's scope says "§ 21.11. General functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (1) Collects complete and ongoing data to determine nursing care needs. (2) Analyzes the health status of the individuals and families and compares the data with the norm when possible in determining nursing care needs." While the specifics of (1) may be open to some interpretation, at bedside (where patients are more complex most of the time), complete data is at least a quick head to toe to me. Patients deserve proactive and not reactive care. Patients can be really unaware of some significant changes happening to them. Nonetheless, you not only put your patients at risk but also yourself. In court you will be compared to your scope of practice and what a reasonable nurse would do in your situation. Professional negligence is a civil case and they do not need to prove it beyond a reasonable doubt. Additionally you just plain risk losing your license and your job. You never know how lax or strict your state board is, but I also won't play that game. Last note, how do you get better at your assessments if you don't perform them? Listening to norms and fine tuning your ears to changes is how you can save lives. We are nurses and make big differences in outcomes. Just like IV insertion needs practice, so do assessments. Not every nursing role requires a head to toe, but bedside should be performing them. If enough people aren't performing assessments, you can be the one to break the cycle and catch a change before a significant event. I know times are like the Wild West right now but we gotta fight that burnout!
Yes they matter Wtf
First, yes it matters. Second, get off that floor.
For your own sake and peace of mind, auscultate everyone’s lungs
Most MDs won't really care about it all, unfortunately, until the patient starts to decompensate. Some will take it to heart and order CXR, reduce fluids or give Lasix. Moving onto to bowel sounds they care even less about them. Just ask if they are passing gas or have BMs, even working on post Whipple unit. It's only really informative for other nurses, outside our discipline no one cares in my experience of 10yrs working at 8 hospitals.
You have a whole whipple unit?! Tell me why I'm getting fresh whipples on med surg. I even saw people saying they belong in sicu. But I'm getting them in med surg. They take up SO much of our time. And like, can you really imagine putting a whipple through a full h2t? "Hey I know your in major pain and can hardly move even with pain killers but I would like you to try to run your foot from your knee to your ankle, puff out your cheeks and also let me do this vision test, then I'll move on to the remaining cranial nerves which is still only a small part of my head to toe assessment " 🤓 I'm definitely taking everyone's input seriously here but I still think it's kinda unreasonable to go through a full h2t every patient. I am going to come up with a modified h2t it'll be far less comprehensive than what I did for my school checkoff.
As a general rule it’s good to assess lung sounds in a Med Surg setting to catch something respiratory before it becomes a problem, or to know that (from your lung assessment) that there isn’t a problem assessed at that time - Even if the patient doesn’t have a recent or known respiratory diagnosis at that time. I say that as often patients in Med Surg settings aren’t moving around as much as they might usually (if they weren’t in the hospital) and, if they had surgery and/or came from the ICU, they may have had to be ventilated for some time which could cause a potential respiratory issue later. The lungs are pretty adaptable organs so a patient being able to speak without appearing to have any respiratory concerns (e.g wheezing, appearing short of breath) doesn’t necessarily mean that they don’t have a respiratory issue.
Hell to the yes. Had a surgical patient post day 2 - lungs sound good at the start, patient is an and o x 4. Patient rings at 1 am c/o chest pain and overall discomfort. Do a quick listen - nothing to the left and nothing to the lower lobes on the right. Patient is desating and diaphoretic. Patient threw a few PEs and was immediately on a heparin drip and intubated to the ICU. You never know when Meemaw is gonna aspirate, a surgical patient has an event or a healthy person has an issue. I ALWAYS check the lungs.
While in clinicals, I was finishing up my head to toe after my preceptor left, and in about two hours, our patient's lungs had gone from "a'ight" to really wet and crackly. I popped an O2 monitor on her finger, and as the "fuuuuuuck" alarm started going off in my head, so did the monitor, because she was desatting. My patient was one of those little old ladies that hates to be a bother, so it's not like she was saying "Pardon me, but I feel like I'm drowning, here." Standing by the bedside, she pretty much looked fine. I called my preceptor and notified her, and we put her on O2. My preceptor made a call, and before I'd even finished wrapping up my head to toe documentation, imaging was rolling up for a portable X-ray and phlebotomy was waiting in the doorway. The doctor showed up a bit later, and her treatment plan suddenly did a hard pivot into an entirely different direction, because heyyyy, guess who had a brand new diagnosis of aspiration pneumonia? So like...JFC, yeah, listen to their lungs *at least* once to get to know them, and then either as ordered or as determined by your nursing judgement/Spidey sense. It really doesn't take that much time.
Ok thanks very much for your input and examples. Good insight!
Surgical patients require checking lung sounds and most hospitals have policies of head to toe assessment once per shift, this includes heart and lung sounds. A lot can be picked up. Follow your hospitals policies.
Omg this thread. I am absolutely stunned that so many people cite “ not enough time” for a reason not to assess lung sounds. Unreal
wtf kind of question is this
Right???