STARES #1, TOPIC: ASSESSMENT

SITUATION

Auscultation is an assessment technique that I quickly realised needs to be finely tuned on a cardio practical. Auscultation has been used for every patient I have seen this past week with a variety of conditions, from pneumonia and post-surgical patients to suspected pulmonary embolism. It is essential that this technique is effective to determine the severity of a patient's condition, how best to focus a treatment as well as whether the treatment has been effective or not.

TASK

Prior to this placement my auscultation skills were probably not as good as they should have been and on my first day when I was asked to auscultate a 66yr old male with left lower lobe pneumonia patient I didn't feel adequately prepared. It was used in this circumstance as part of my initial objective assessment to then determine the most appropriate treatment technique.

ACTION

I began by instructing the patient to cough and clear any secretions and then disrobed the patient appropriately so I wasn't auscultating through clothing. As the patient was slightly short of breath I chose to auscultate posteriorly as it was more accessible with less soft tissue that may obstruct the technique in case the patient wasn't able to tolerate all of the deeper breaths. I began at the bases posteriorly as this is where he was likely to have abnormal sounds. I instructed the patient not to talk during the auscultation and to take slightly deeper breaths in than normal. I compared the left side to the right systematically as I went along, segment by segment to determine if there was any differences between sides, listening to two breaths at each point. As I had thought, my patient became increasingly short of breath with the auscultation so I completed the posterior assessment but felt it was unsafe and also would be uncomfortable for the patient to continue.

RESULTS

My patient had fair breath sounds and bilateral crackles at the bases with the left worse than the right. This suggested that there was some sputum retained within the lungs especially at the left base, confirming the results of the CXR and the diagnosis.

EVALUATION

My technique was certainly far from perfect. Although I had remembered and implemented most of the theoretical knowledge, my practical skills were lacking. I auscultated too many points posteriorly, which probably contributed to my patient becoming quite SOB. As well as this, I began my auscultation too inferior and so my interpretation was less accurate as what I thought was reduced breath sounds was as a result of no lung tissue being where I was auscultating. Despite a few mistakes I was able to auscultate and gain the correct findings when compared to what my supervisor had heard, apart from the breath sounds. Another area where I was unsure about was what the different sounds actually reflected. I knew that crackles could be from sputum or the reopening of collapsed lung tissue but I didn't know how to clearly differentiate between the two. I now am aware that it is the quality of the crackles, coarse or fine, as well as whether they were heard on inspiration or expiration that determines this. That is, despite reaching the desired outcome, my technique was inefficient, with much room for improvement.

STRATEGIES

With feedback from my supervisor on board I went home and revised surface anatomy of the chest, listing key landmarks to assist in orientating me to exactly which lobe I'm auscultating. I also re-read the information regarding interpretation of findings and what the different abnormal sounds. I have since gained more practice in auscultating and feel far more confident in my ability to assess and interpret the results. I have also asked my supervisor to watch me auscultate again and give me feedback which was very helpful and positive with great improvement after only a few days. I will continue to practice my auscultation daily to further develop and fine tune my ability and hopefully get to listen to some interesting chests with more than just a little consolidation!