Vol. 14 •Issue 8 • Page 44
Treat the Patient, Not the Numbers
Elements You Need to Know When Conducting Assessments
Throughout respiratory therapists’ professional schooling, we’re taught the meaning of facts that we obtain from various tests and procedures — arterial blood gas results, pulmonary function test interpretations, electrolyte imbalances, etc., etc., etc.
We’re taught to glean the chart and computer for the various bits of data that will make a plan of care complete and set the therapeutic course. The acquisition of pertinent data is crucial to patient care.
Sometimes, though, practitioners may be blinded by the information that they’ve accumulated. If you work in a teaching hospital, you might recall the chronically hypoxic chronic obstructive pulmonary disease patient who gets placed on 100 percent oxygen because that’s what the lab results indicate.
You might remember the intubated COPD patient who’s ventilated to achieve normal blood gases because that’s what the pocket manual says. Recall, too, that these occurrences are generally “seasonal,” frequently seen immediately post-graduation for allied health practitioners or in July when the new residents arrive.
This article won’t be a review of ABGs, PFTs or any other test result. For that, review courses abound, and pocket guides are plentiful. Instead, we’ll take a look at how we can look directly at the patient and see how the other data fits into the clinical picture. In short, we’ll remember how to treat patients and not their numbers.
THE PATIENT ENCOUNTER
Do you want to know how the patient is doing? The chart has the various progress notes of different disciplines, but a wealth of information also can be learned by doing what we were taught as children when approaching train tracks: Stop. Look. Listen.
• Stop. Tasks are important to complete, but holster that neb for a moment and take the time to see what’s going on.
• Look. What IVs are hanging? Antibiotics? Cardiac drugs? Total parenteral nutrition? Are there chest tubes? How many? Is the water seal bubbling? Wound dressings? Clean or bloody drainage? Is the suction canister full? Of what? Any oxygen devices in use? What color is the patient? Lips dry? Nail beds? Is the patient restrained?
Look further around the room. Caregivers frequently overstock specific items that are needed in particular rooms to save time in having to get more. Is there a large stash of suction catheters? Yankauers? Trach sponges?
Now look at the patient. Is he restless? Fidgety? Passive? Resigned? Angry? Hopeful? Attentive? In distress?
• Listen. No, not breath sounds — not yet. Listen to the patient. If he can verbalize, is he coherent? Is he oriented? What’s the tone of his voice? Does it match his body language? Is speech slurred or clear? Halting or smooth? If no speech, is he moaning? Grunting? Gurgling?
That was a passive approach to assessment, but the clinician should come away with a reasonable picture of the patient’s overall condition. Now let’s take a more active approach and zero in on the elements an RT may want to know. Let’s assume that, if appropriate, introductions have already been made, as well as an explanation given to the patient as to why the RT is there.
• Look. Is the chest expanding equally and bilaterally? Is exhalation prolonged? Are accessory muscles being used? Pursed lip breathing? Is the respiratory pattern regular? Tidal volumes small or large? Respiratory rate slow, fast or normal? Are there apneic episodes? If so, how long do the periods last? Is the patient diaphoretic? Cyanosis present?
We’ve covered some clinical observations, but sometimes we need to look for demonstrations by patients that they also can follow some basic instructions. For instance, a bedside PFT is only as good as the patient effort. Was the effort optimal but the coordination poor? The results may be skewed if that determination isn’t made.
Similarly, the switch of a nebulizer to a metered dose inhaler may not be possible because the patient can’t correctly time when to inspire. Can he accomplish a breath hold? Can he actuate the canister? Has anyone ever had a patient who, when given an incentive spirometer, blows into it as hard as he can? All of these are also elements of a complete assessment.
• Listen. Now you can get out the stethoscope.
Do you hear rales or rhonchi? An old test to determine the difference was that rhonchi would clear with coughing while rales would not.
If you determine that there are rales, you might differentiate whether they’re a result of atelectasis or fluid. Atelectatic rales are always heard over the affected area. Rales related to fluid (whether fluid overload or heart failure) are dependent on position.
Let gravity help you decide. The upright patient may have bibasilar sounds. The patient lying on his side may have the rales on the side that’s down. Don’t be afraid of having the patient switch positions during the assessment.
Wheezing? If wheezes are heard, do you hear a single tone or many different ones? The single tone (monophonic) may indicate an obstruction in specific bronchi.
Possible causes may be an obstructing tumor or other partial blockage, a foreign body perhaps. Multiple tone (polyphonic or “musical”) wheezes indicate a more diffuse constriction and are most typically seen in the patient with reactive airway disease.
Patients who can vocalize will frequently do so when you’re trying to auscultate their lungs. Take advantage of this. Recall that sounds transmit better through consolidated areas: the more consolidation, the better the sound transmission.
In the normal lung, voice sounds are distant and unclear. In the consolidated lung, they’ll transmit quite clearly. If you find that you can understand what’s being said while listening to their chest, your stethoscope is over an area that’s consolidated. This is also referred to as vocal fremitus.
OBTAINING A HISTORY
Let’s hone in now on what the patient can actually tell us. Obtain a brief history from him as it pertains to his pulmonary problems. Include the obvious questions about smoking, family and occupations, but don’t forget questions about travel and other potential exposures.
Keep all of it in a conversational tone rather than that of an interview. Strive to be more like Barbara Walters than Dan Rather. The resultant friendliness can calm patients’ fears and establish a rapport that can only be beneficial to their overall care.
Listen also to any complaints of pain. Note the degree, characteristics and duration they provide, and then record and report it accordingly.
You might now question why should an RT do this? Isn’t that a nurse’s job? Actually, it’s all of our jobs.
Most patient surveys suggest (and the Joint Commission on Accreditation of Healthcare Organizations now looks at) how the alleviation of pain impacts the perception of a hospital’s quality of care. When that perception of quality care diminishes, patients are prone to visit the competitor down the road. It’s a lose-lose proposition.
CREATE A MENTAL PICTURE
An assessment is only truly complete when we’ve documented the information we’ve obtained. The documentation shouldn’t just be a recitation of facts or a table of data. It should be constructed in a manner such that the reader can create a mental picture of who’s lying in the bed and what the problems are, as well as the degree of success that any prescribed interventions are having.
Additionally, communication might need to be done orally. It may be necessary to tell the nurse or call the physician. Good patient care isn’t the result of multiple independent entities but rather the coordinated effort of a cohesive team.
The basis for good care also lies in a good patient assessment. For that we should first stop, look and listen.
Robert C. Kay, RRT, MBA, MJ, is the former director of respiratory, pulmonary and neurodiagnostic services at Hahnemann University Hospital in Philadelphia. He was recently named hospital compliance officer.