Should you use stethoscope in front of clients?

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Thu, 17 Nov 2016 16:41:05 GMT

That's spot on to my own findings and thoughts Robyn! Aaaaaaand breathe...

RE: Should you use stethoscope in front of clients?

Robyn — Thu, 17 Nov 2016 15:54:02 GMT

I was about to have a minor heart attack about my legal ability to be doing pre-op checks the morning of the sx when the vet isn't on site yet on reading the RCVS' response! Sounds like we should just be doing what we should be doing regardless however: have a listen, if you hear anything funky get a vet to check without declaring in so many words that you've diagnosed something ("I'm not totally happy with that, just gonna get the vet to check" as opposed to "I think he has a heart murmur, I'll get the vet to have a listen too"), and be upfront about not being able to diagnose things.

RE: Should you use stethoscope in front of clients?

Helen Tottey — Sat, 12 Nov 2016 10:37:18 GMT

[quote user="Alison Clare Hickman"]

Okay, to summarise everything so far (in my understanding). Please shout if I've misunderstood or missed anything. Ta!

1. Always report information to a vet so they can check the animal; this catches animals that might otherwise leave the practice without having had a health check of any kind and (possibly) result in a disease diagnosis that would have been missed.

2. Always state to my client that for a full and diagnostic health check a vet check is an absolute requirement. If the client decides NOT to proceed with that, then the onus is on them and not me as an RVN if the unfortunate occurs where the animal subsequently suffers a problem, (in the example given, a collapse 2 weeks later). Notes on the client record that a vet check was offered and declined would seem to be a hugely sensible record of the event.

This is what I already do. So, panic over. My backside is covered. Carry on consulting!

Yes?

Ali h

P.s. I reflect that the way nursing is heading, (has already arrived, in many ways), in the 21st century appears very much to be on an extreme "mind your P&Q's" basis. This, to protect yourself against litigation/prosecution/discipline. But, as it has ever been, with Regulation comes red-tape, responsibilities and (I would hope, sensible) adherence to rules. We wanted it, We've got it. So be it!

Thanks Helen for raising the subject matter. It has really made me think and reflect. More please!

Ali h

[/quote]

Sounds good advice to me

RE: Should you use stethoscope in front of clients?

Arlo Guthrie — Sat, 12 Nov 2016 09:13:18 GMT

[quote user="kkatkatk"]guys if you arent sure, never be afraid to ask. Ask your friendly peers on this site.

Without fear of being judged.[/quote]

Hear hear. If I could have given 10 stars for that one, I would.

kkatkatk - I second that, and just to be very clear that I have zero tolerance for unkind posts. Fair to disagree. Fair to disagree robustly. But as on vetsurgeon, I don't tolerate posts that are personally unkind, belittling or judgmental.

RE: Should you use stethoscope in front of clients?

kkatkatk — Sat, 12 Nov 2016 09:04:48 GMT

My opinion. i feel as a profession nurses have moved forward alot over the years and are a pivitol member of the veterinary team. We use our own common sense and initiative alot with the aim of doing good. but we need to protect ourselves and our practices from litigation by being aware of our limitations both as an individual and those set out by governing bodies. anyone that has a feeling they might be doing something at work that puts them outside these limitations should speak up and ask the question, as you have.

Ignorance is no excuse.

guys if you arent sure, never be afraid to ask. Ask your friendly peers on this site.

Without fear of being judged.

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 22:55:33 GMT

Okay, to summarise everything so far (in my understanding). Please shout if I've misunderstood or missed anything. Ta!

This is what I already do. So, panic over. My backside is covered. Carry on consulting!

Yes?

Ali h

Thanks Helen for raising the subject matter. It has really made me think and reflect. More please!

Ali h

RE: Should you use stethoscope in front of clients?

Helen Tottey — Fri, 11 Nov 2016 20:04:19 GMT

[quote user="Sal the 1st"]

ever think some people just have too much time on their hands to overthink stuff? and ever think this job is just becoming unworkable because of it?

[/quote]

If this is directed at me - i can assure you I don;t have too much time on my hands. It was a genuine question based on information i was told years ago and i wanted to check if others had heard the same and if so where it came from.

The point is non of us diagnose CHF/DCM or other heart conditions when faced with the scenario you mention, we listen to gather facts to pass on to the vet to diagnose.

The point is in the "healthy" 2 year old dog that a has its heart listened too by an RVN who doesn't hear anything abnormal and then the dog collapses 2 weeks later - the owner could perceive the RVN missed something and that is the issue as it was explained to me.

Please do not think i am undermining RVNs. In 2008 i spoke at BVA conference to say i thought RVNs should be allowed to give booster vaccinations for pets that owners say have no health concerns and with our skill at asking right questions I believed this would improve the number of pets that are vaccinated.

RE: Should you use stethoscope in front of clients?

Denise Mayne — Fri, 11 Nov 2016 17:35:27 GMT

In my practice I'm told to take a pulse and to not use a stephoscope or if I do to state that I can not diagnose.

RE: Should you use stethoscope in front of clients?

molladog — Fri, 11 Nov 2016 14:09:45 GMT

[quote user="Sal the 1st"]

ever think some people just have too much time on their hands to overthink stuff? and ever think this job is just becoming unworkable because of it?

I was checking my blue dog with a stethoscope in front of the client ( so slap my wrist somebody) to establish the heart was actually still beating! whilst somebody else was on the phone already getting the vet back - the dog was collapsed to the extent I wasn't entirely sure that the breaths I was seeing wasn't an agonal last gasp. By using a stethoscope I could hear that the heart was still beating ineffectually and irregularly and could report this to the vet prior to their arrival and proceed as advised to give the dog a chance.(take note the VET not the owner - the owner didn't need to be told there was something wrong with their dog because it was painfully bloody obvious)

For 2 1/2 years with a previous employer my job was 100% nurse consults - did I use a stethoscope? yes. Did I pick up problems? - yes. Did I ever say to a client as a result of what I heard, saw, felt, found - 'oh thats interesting lets just ask the vet to have a quick look'? - yes. Did I ever make a diagnosis? No

I give up - maybe I shouldn't bother at all in future.

[/quote]

Totally agree with all you say Sal, fed up with constantly having to worry about pointless rules when only trying to do my job, makes you wonder why we bothered to qualify really.

RE: Should you use stethoscope in front of clients?

Sal the 1st — Fri, 11 Nov 2016 13:33:22 GMT

ever think some people just have too much time on their hands to overthink stuff? and ever think this job is just becoming unworkable because of it?

I give up - maybe I shouldn't bother at all in future.

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 13:21:08 GMT

Cool. St long as I say I am information gathering then I am fine!

Ali h

RE: Should you use stethoscope in front of clients?

Helen Tottey — Fri, 11 Nov 2016 12:48:50 GMT

[quote user="Alison Clare Hickman"]

This probably means that a lot of animals may go un-referred to a vet, when they could've been... I wonder what Helen does to try and avoid this? Helen?

Just another thought...how does this jive with my professional observation of the Animal Welfare Act 2006? Am I not to assist clients to understand and deal with their pet's health? How do I do this in this particular respect? Does it mean an end to a nurse consult / admission checks as a back-up to the vet check as I know it?

Can of worms! Am really interested in this discussion!

Ali h

[/quote]

Where to start!

As we all know, listening to hearts is not the only way to check on health with mucous membrane colour, asking questions about any coughing, shortness of breath, exercise intolerance are all information gathering. For all nurse consults, we never listened to hearts after being told (by someone) not too and I didn't feel this undermined me in any way.

First vaccinations had seen a vet 2/3 weeks ago and the vet advised in notes if they wanted to come and check anything at 2nd vacc.

For admits - the vet is always going to listen again anyway so just questions were asked

For triage - in the case of the blue ckcs someone mentioned (sorry forgotten your name) the blue really tells you there is circulation issue and if you want to take RATE then that is information gathering.

As others have also stated - it is communication that is key and being clear that it is information you are gathering for the diagnosis to be made by the vet.

We never took temperatures either for routines as most will have increase with stress but in triage we would gather the info for the vet (that is how our protocols worked anyway).

I hope that helps clarify what i did and why.

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 12:13:33 GMT

Arlo, in answer to your 'how many' question... nearly ALL pets registered with my latest practice, at some stage in their life...

Depends on the practice protocol's but at my last one, RVN's and SVN's did the following: all with on the spot health checks as requested by the vets with referral to a vet on any suspicions.

Admits

New pet (from pup to 'tribal elder')

1st vac appointments; vet called in to conduct a health check & give vac / KC. 2nd vac's.

2nd vacc's

Preventative checks/admin.

Dietary

Behavioural

Diabetic

Weight (loss and gain)

Geriatric

Annual health-checks (clients on a healthcare plan)

and so on...

Ali h

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 12:04:23 GMT

... maybe the easiest answer is to be Sneaky McNurse and whisk the pet out to Prep, do the stethoscope thing and alert the vet if I suspect they are needed, then whisk them back to my consult room as though nothing has happened if there is nowt to report. Or chuck the client out of my room? Offer of a free coffee in the Waiting Room...

This, all so the client can't SEE me doing anything (or thinking, come to that ) and therefore avoid the potential for them to conclude erroneously that I have diagnosed something...

Diagnosis: the act of identifying a disease, illness, or problem by examining someone or something. : a statement or conclusion that describes the reason for a disease, ...

Suspect: to believe to be the case or to be likely or probable; surmise

What do the vets' think Arlo?

Ali h

RE: Should you use stethoscope in front of clients?

Arlo Guthrie — Fri, 11 Nov 2016 11:58:00 GMT

[quote user="Alison Clare Hickman"]This probably means that a lot of animals may go un-referred to a vet, when they could've been[/quote]

That's the nub of it, really.

How many animals per day are seen at your practice ONLY by a nurse (presumably for nurse consults for nutrition, parasite control etc.).

How many of those do you think might have a heart condition that, if the nurse DOES NOT get the stethoscope out, would remain undiagnosed (or not diagnosed till later, at the next appt with the vet, or when symptoms became more obvious). In other words, what percentage of the time do you reckon you hear something that needs reporting to the vet?

If enough people answer that question, maybe we could extrapolate to the vet-visiting dog population as a whole and estimate how many animals benefit from a check by the nurse.

[quote user="Alison Clare Hickman"]Does it mean an end to a nurse consult / admission checks as a back-up to the vet check as I know it? [/quote]

Again, looking at human medicine, one has to think 'surely not'.

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 11:42:14 GMT

Yup, that's an idea...but the client STILL knows I went to get the vet in the first place don't they? What for? Um, oh yes, I identified a potential problem.

If I don't SAY anything I can report that I've not SAID anything - but I did THINK it. I have still (silently) identified a potential problem. The ONLY way to be 100% would be, as Helen Totty identifies, is to NEVER do it in the first place.

This probably means that a lot of animals may go un-referred to a vet, when they could've been... I wonder what Helen does to try and avoid this? Helen?

Can of worms! Am really interested in this discussion!

Ali h

RE: Should you use stethoscope in front of clients?

Arlo Guthrie — Fri, 11 Nov 2016 11:19:58 GMT

Well, you could just say nothing at all, except: 'could you hang on a second', and just get the vet?

RE: Should you use stethoscope in front of clients?

Alison Clare Hickman — Fri, 11 Nov 2016 11:16:04 GMT

Ach, if I say I need to get a vet (without any clarification or qualification as to WHY), then the client KNOWS I've detected something... . #rock&ahardplace

just sayin....

Ali h

RE: Should you use stethoscope in front of clients?

Arlo Guthrie — Fri, 11 Nov 2016 11:06:35 GMT

actually ... for clarity ... I think these might be viewed as edging on diagnostic, just by saying: "I am not completely happy"

[quote user="rebecca wright"]I am not completely happy with how heart sounds and would like a vet to listen to see if we need to be concerned about anything[/quote]

[quote user="Alana Dent"]Same here. I will listen, ensure the rate is within normal range. If there is a arrythmia, heart murmur or abnormal rate then I will tell the clients that I am not happy with what I have found, and a Vet needs to check[/quote]

and this seems to me to be the safer approach (provided you don't even say you think something might be wrong!):

[quote user="Dreamcatcher"]Having said that, if I detect a problem, I never say what I think is wrong, just that I'm going to get a vet to double check.[/quote]

But that's just a personal opinion.

RE: Should you use stethoscope in front of clients?

Arlo Guthrie — Fri, 11 Nov 2016 10:59:36 GMT

[quote user="Helen Tottey"]I can't have made it up and would never seek to add to the limitations of RVN's so I hope no-one is upset with me for asking this question.[/quote]

Well, I think important to emphasise that this part of the response:

[quote user="Helen Tottey"]We have concluded that there is no specific guidance about an RVN listening to hearts of patients in front of clients.[/quote]

is the bottom line.

It's an interesting point, though.

As far as I know, 'human' nurses use stethoscopes (I've been in hospital a few times, and I am trying to remember!). In that situation, I wouldn't assume the nurse is 'diagnosing above their station', so to speak. I would assume they are reporting to the Dr.

Doesn't it all come down to common sense? In other words, if you use a stethoscope and then tell the client that you can hear a heart murmur (or tell them anything, in fact), you are overstepping the mark.

If you say nothing - just report your finding to the vet and make sure they check it too (regardless of whether or not you heard anything), then I struggle to imagine how (as a client), I would think you've been diagnosing anything.

And of course there is the emergency situation when the vet isn't immediately to hand.

RE: Should you use stethoscope in front of clients?

Helen Tottey — Fri, 11 Nov 2016 08:33:01 GMT

I received this from the RCVS the other day - sorry not posted before but have been busy!

Thank you for your email. Sorry that my reply is slightly delayed, I was conferring with colleagues about your question.

We have concluded that there is no specific guidance about an RVN listening to hearts of patients in front of clients.

However we agree that there may be a possibility of clients misinterpreting the situation and believing that the RVN is making a diagnosis ect, and therefore it is best that this is avoided altogether.

All I can say is that if it wasn't RCVS that said it that stopped me years ago then maybe it was BVNA or VDS but as others have heard of it - I can't have made it up and would never seek to add to the limitations of RVN's so I hope no-one is upset with me for asking this question.

RE: Should you use stethoscope in front of clients?

KizzieB — Thu, 10 Nov 2016 22:03:35 GMT

I've never heard of this either!!

I regularly listen to hearts in front of clients especially 2nd vaccs and oldies.

Like everyone else if I hear anything I will always say something like "best get the vet to listen."

It would be interesting to hear what the RCVS says about it.

RE: Should you use stethoscope in front of clients?

Sal the 1st — Wed, 09 Nov 2016 21:33:55 GMT

[quote user="Helen Tottey"]

Hi. I have contacted RCVS to ask them, I hope I am wrong but I'm convinced I read it somewhere which is why I stopped doing it. Hope I haven't opened a can of worms

[/quote]

and the RCVS response?

RE: Should you use stethoscope in front of clients?

molladog — Wed, 02 Nov 2016 09:30:36 GMT

so the ckcs that arrived in the back of a car last week, grey/blue mucous membranes, no vet on site I should have got the owners out of the way before listening to its heart to make sure it was actually still ticking and calling the vet? Kind of turns the stethoscope into a fashion accessory for nurses then - for pity's sake who comes up with this stuff!

Totally agree Sal, utter madness, what the hell did we qualify for ??

RE: Should you use stethoscope in front of clients?

Sal the 1st — Wed, 02 Nov 2016 09:15:26 GMT