Auscultating Through a Patient Gown

Purpose: Students are traditionally taught to auscultate with a stethoscope on bare chest. While, in practice many healthcare providers auscultate through clothing. Only two studies evaluated the ability to hear sounds when auscultating through fabric. The aim of this study was to determine if advanced practice nursing students could accurately assess heart and lung sounds through a patient gown using a stethoscope. Theoretical Model: Sociocultural Theory states that human activities take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when investigated in their historical development. Based on this theory, nurses learn procedures by modeling instructor’s behaviors and improve their skills under guided participation. Participants: Advanced Practice students in Health Assessment, Primary Care I and Adult/Gero Healthcare I were invited to participate in this study. Methods: This was a quantitative study evaluating the accuracy of advanced practice nursing students’ assessments of recorded heart and lung sounds heard through a hospital gown compared to that heard directly on the chest wall of a manikin. During data collection, subjects were asked to identify three different heart sounds and three different lung sounds repeated randomly for a total of 5 assessments under each condition. The number of correct responses compared to incorrect assessments were calculated to determine if there was a significant difference with and without a gown. Results: A total of 7 participants completed the study. There were a few errors, but most of the time subjects were accurate in their identification with both abnormal and normal heart and lung sounds both with and without the hospital gown. Some subjects stated that it was easier to hear without the gown, especially the heart sounds. Some also complained of the noise of the manikin motor. Conclusions: Further study of this issue should be done with a larger sample size using heart and lung sounds from actual people. Maldonado, A. Auscultating Through a Patient Gown. Spring 2016 INTRODUCTION Nursing students have traditionally been taught to always auscultate heart and lung sounds with a stethoscope applied to the patient’s bare skin. In practice however, healthcare providers are often observed auscultating through the patient’s gown. The assessment is done in this manner, often times due to its convenience. Very few studies have been done to determine if performing this vital procedure in this manner has a detrimental effect on practice and patient outcomes. The aim of this study was to determine if students in an advance practice nursing program taking Advanced Health Assessment and Clinical Reasoning, Primary Care I, and Adult/Gero Healthcare I could accurately assess lung and heart sounds though a patient gown using a stethoscope. REVIEW OF LITERATURE A review of the literature revealed where and how to perform a pulmonary and cardiac auscultation. Many authors gave a detailed description of how to perform these assessments. While others identified the errors made by students and professionals and ways to correct these errors. The authors looked at how to improve teaching methods for healthcare professionals, but little is mentioned in literature about performing an auscultation assessment over clothing. Of the literature reviewed, only Jarvis (2012) and Reiner-Kent (2013) mention performing this assessment on bare skin. Only two studies were found that examined auscultation on fabric (Rankin, Rankin, & Rankin, 2015) (Kraman, 2008). In an editorial, Sherman (2009) scolds providers who auscultate over the patient’s fabric. The author proceeded to state that even though there is little evidence to prove fabric does not interfere with cardiac or lung sounds, there is an increase in the number of providers auscultating through fabric. Maldonado, A. Auscultating Through a Patient Gown. Spring 2016 A two-part series by Reimer-Kent (2013a) was designed to inform of different techniques providers can use to help improve the auscultating sound. One of the techniques listed focused on adequate exposure to the pericardium without interference from clothing and body hair. The first article part of this series also focused on demonstrating the basics of heart sounds and the heart’s cycle in relation to the sound heard when auscultating. The author mentioned the importance of being able to master the understanding of cardiac anatomy and both its physiology and pathophysiology in order to fully differentiate the heart sounds and then recognize any abnormalities. Nurses that have not mastered this ability tend to have less confidence when it comes to stating their findings related to cardiac auscultation. Reimer-Kent (2013a) concluded that the lack in confidence these nurses’ possess could lead to inaccurately performed examinations and inaccurate findings of cardiac abnormalities. The second part to this series by Reimer-Kent (2013b) was designed to provide an overview of the anatomy and pathophysiology related to heart disease and the description of the heart sounds associated with different valve conditions. The author gave a short review of the anatomy of the aortic and mitral valves, followed by a short summary of systolic and diastolic murmurs. The author then focused on stenotic and regurgitant valvular heart disease. The author included a description of the pathophysiology of each one, followed by a description of the heart sounds associated with each valvular heart disease as well (2013b). Nielsen, Mølgaard, Ringsted, & Eika (2010) designed an instrument for assessing cardiac auscultation skills of medical students and physicians that provided a high degree Maldonado, A. Auscultating Through a Patient Gown. Spring 2016 of accuracy in the reproduction of normal heart sounds and murmurs, while also mimicking clinical situations. A goal for the instrument was to allow for convenient and cost effective standardized testing which would avoid the difficulties that using an actual patient may present. The study addressed the participants’ ability to identify patients with cardiac murmurs among a group of persons with normal and abnormal heart sounds. The two-part test instrument used in this study was designed containing heart sound recordings from patients with common murmurs as well as patients with healthy cardiac sounds. The results showed there was a correlation between clinical experience and diagnostic ability. However, being able to distinguish abnormal murmurs from normal heart sounds seemed to be independent of clinical experience. Germanakis, Petridou, Varlamis, Matsoukis, Papadopoulou-Legbelou, & Kalmanti, (2013) examined the performance of pediatricians in pediatric auscultation and the impact of a multimedia-based teaching intervention. The study included four multimedia-based pediatric cardiac auscultation teaching courses offered to 106 primary healthcare physicians within a two year period. The physicians were of different specialties and training levels, but all cared for pediatric patients either exclusively or partially. The courses were based on virtual patients’ presentation and the participants’ performance was evaluated at the beginning and the end of each course. At the end of the study it was noted that multimedia-based teaching was associated with a significant improvement in the detection of abnormal murmurs and additional sounds by the providers. However, the study showed the rate of innocent murmurs interpreted as abnormal did not change after the multimedia-based courses were offered. This study supported the use of multimediaMaldonado, A. Auscultating Through a Patient Gown. Spring 2016 based teaching interventions as an effective way to improve cardiac auscultation skills in pediatrics. Kraman (2008) explored the assessment of artificial lung sounds through t-shirt material and through flannel. This study found flannel to be thicker, to have a greater negative effect on auscultation quality, and that low frequency sounds were harder to accurately assess. The author went on to warn of extraneous sounds mimicking crackles. He concluded that “[t]his study show[ed] that lung sounds are well transmitted through indoor clothing provided that extra force is applied to the stethoscope head” (Kraman, 2008, p. 88). This study, however, did not investigate auscultation of heart sounds through t-shirt material and flannel. Only one research study (Rankin et al, 2015) explored the assessment of both lung and normal heart sounds through fabric. The aim of this study was to determine the impact on quality of the sounds this method had as well as how often physicians performed their assessment using this method. This study found that physicians were more “likely to listen to breath sounds than heart sounds through patients’ gowns” (Rankin et al, 2015). The main reason physicians gave for performing auscultation over fabric was for compassion. Patient privacy was the first reason followed by patient immobility. Most physicians were not able to distinguish between sounds heard through a gown or skin (Rankin et al, 2015). THEORETICAL MODEL Sociocultural Theory states that human activities take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when Maldonado, A. Auscultating Through a Patient Gown. Spring 2016 investigated in their historical development. Based on this theory, nurses learn procedures by modeling instructor’s behaviors and improve their skills under guided participation.