Final Project
Stethoscopy for Dummies Session
Bob Page
EDAE 639
12-13-2014
Introduction:
This class is designed to be a supplemental course that current paramedics,
EMT’s, and nurses can take for continuing education credit. Audience analysis
polling revealed that most providers do not have the fundamental knowledge
required to use a stethoscope properly. The basic assumption is that the learners
have had some introduction in the use of the stethoscope. The overall objectives for
the course is that the learner will be able to use their stethoscope in a clinical setting
and can correctly identify various normal and abnormal breath sounds.
Audience analysis:
The purpose of this audience analysis is to determine the knowledge level
and confidence level of prospective students to take a stethoscopy class. The first
section is a self-assessment (a 5 point Likert scale) to determine a baseline of how
they feel they grasp the skill. The second part is actual assessment of their
knowledge. I do it this way because some students will say they know something but
indeed they do not. By doing this I can gauge the level of interest and the genuine
knowledge gap and needs of the student.
The questions will be anonymous using an audience response system and the
students will have clickers to respond to the questions that appear on the screen.
This will allow for quick and measurable feedback. The Likert scale will appear on
the screen with each question to prevent confusion in answering.
The second set of questions featured a real breath sounds played aloud and
the participants hear them and select the correct answer. Here is an example of the
question that appeared on the screen.
Results
The audience was informed that the study was to determine their needs and
interest in a class on stethoscopy. I asked the participants to be honest and open
with their answers. I polled a total of 104 students in two separate venues:
Gunnison, Colorado and Panama City, Florida. Overall I was surprised that there was
a difference between their perceived knowledge and their actual knowledge of
procedures and performance in identifying sounds; A big difference.
The perception questions were presented first before the learners were
actually tested. I did this to gauge their perception of their own skills. When asked to
respond to the statement: “I feel I am completely competent is my skills in using a
stethoscope.” Only 20% disagreed with the statement meaning they did not feel
competent at all. However 80% thought they were confident. When asked about
their initial training on a stethoscope, 59% thought they didn’t receive sufficient
initial training. This was intriguing because it did not correspond with their
perception of their skill. They must have learned through experience.
I asked a pure clinical question that was used to gauge the perceived value of
breath sounds. “I listen to breath sounds on every patient.” 92% disagreed, which
tells me that the providers are only listening when they think the patient has a
condition that the need to listen.
The questions about their perceived need for more training was very telling
as most agreed they needed more training. That was also apparent because a large
majority voiced they did not have a way to train on this themselves.
Then when put to the test to actually identify sounds that were played aloud,
the results were very clear that more training in sound identification was needed.
When all sounds that were played, less than 30% correctly identify any one sound.
The raw results from all of the questions are in appendix B.
Conclusions
Based on the data in this audience analysis, there is strong evidence that the
class is not only needed but is also desired but the audiences polled. I also learned
the students may not value the information gained by the stethoscope as they do not
listen on every patient. This is not promising as experience is only gained by
practice and valuable information is being lost. In developing this course, I will
include several cases where routine breath sound assessment reveals unexpected
results. I also think that the lack of doing lung sounds assessments may also be due
to their not being at all confident on how to use a stethoscope. Although I did not
poll the learners after they were assessed on their ability to identify the sounds. It
was apparent to me that they struggled to identify the sounds. This class is going to
be a real success and a much-needed offering that should fill in a learning gap that
exists.
Appendix A: Question List
Section 1
Audience instructions. After carefully considering the following statements, please
respond with your clicker with the number that corresponds with your answer.
1. Strongly Agree
2. Agree
3. Neither agree or disagree
4. Disagree
5. Strongly disagree
Statements
1. I feel I am completely competent is my skill in using a stethoscope.
2. I received sufficient training in using a stethoscope in my primary EMS
course.
3. I listen to breath sounds on every patient.
4. I can easily recognize normal breath sounds by location heard
5. I can easily recognize and name adventitious breath sounds.
6. I am aware of the proper procedure for auscultating breath sounds.
7. I have access to a lab that I practice listening to breath sounds.
8. I need more practice in using a stethoscope.
9. I need more practice in identifying the various breath sounds.
10. I would take a class on stethoscopy if one were offered.
Assessment:
1. When auscultating breath sounds, which of the following statements are
true?
a. They are high pitched sounds heard with a bell
b. They are high pitched sounds heard with a diaphragm
c. They are low pitched sounds heard with a bell
d. They are low pitched sounds heard with a diaphragm
2. Blood pressures should be taken with
a. The bell of the stethoscope
b. The diaphragm of the stethoscope
Listen to the following sounds and select the correct answer to these questions
3. Identify the following breath sound.
a. Normal vesicular
b. Normal broncho-vesicular
c. Normal tracheal
d. Normal bronchial
4. Identify the following breath sound
a. Monophonic wheeze
b. Polyphonic wheezes
c. Stridor
d. Crackles
5. Identify the following breath sound
a.
b.
c. Normal vesicular
d. Course crackles
e. Fine crackles
f. Rales
6. In using a stethoscope with a tunable diaphragm, which of the following
techniques will result in the user hearing low frequency sounds.
a. Diaphragm lightly held
b. Diaphragm firmly held
c. Bell lightly held
d. Bell firmly held
With this information in mind, I have developed the following course designed to
address the needs and requests of EMS medical professionals
Course Proposal:
“Stethoscopy for Dummies”
Time Frame: 60-75 minutes or
2 hour hands on Skills Session
Audience: All, BLS, ALS
CEU category: Assessment
Web Page Link:
http://www.multileadmedics.com/www.multileadmedics.com/Stethoscopy.html
How much did you pay for your stethoscope? How much training did you get on
how to use it? This will fill the gap. In this session, participants are provided
down to earth “for dummies” information on various types of stethoscopes and
how to use them to get the most out of patient assessment. In this “Ear Opening”
session, new and improved methods and techniques are presented and you will
get the chance to practice this on others. Breath sounds are also played aloud so
all participants can hear the sounds rather than hear a “description” of the sound.
Stethoscopy with Skills Session: 2 hours
In this session, participants must bring heir own stethoscopes with them. Bob brings
simulators for all participants to use their own stethoscopes to hear the various
sounds. There is even a test at the end of class to see who earns the right to wear the
stethoscope!
Objectives
By the end of this session, the participant will be able to
1.
Describe the parts of the stethoscope and the proper way to wear it
2.
Describe the difference in the bell vs the diaphragm and the use for each
3.
Identify by sound, common normal and abnormal breath sounds
4.
Describe a technique for identifying consolidated lung tissue
5.
Value the use of a stethoscope as a primary assessment tool on every
patient contact.
Sub-objectives:
1. Given a stethoscope, correctly identify the bell, diaphragm, tubing, earpiece
and yolk with 100% accuracy
2. Describe the difference between the bell and the diaphragm.
3. Demonstrate on another person or simulator, each of the proper locations
for a 6 point breath sound assessment.
4. Demonstrate the proper use of a tunable diaphragm stethoscope on another
person for both high frequency and low frequency sounds.
5. Correctly identify by sound all of the following: normal tracheal, bronchial,
broncho-vesicular, and vesicular breath sounds.
6. Correctly identify by sound all of the following adventitious breath sounds
of narrowed airways such as wheezes and stridor.
7. Describe the difference between polyphonic and monophonic wheezes.
8. Correctly identify by sound all of the following adventitious breath sounds
of mechanical obstruction: course and fine crackles and consolidated tissue.
Lesson Plan: Stethoscopy for Dummies
Materials needed: Stethoscope, sounder, handout/course syllabus, clicker, alcohol wipes
Time needed for lesson: 2 hours
Time Index
Prior to start
Objective
Baseline
assessment
History and why
use a stethoscope
0 -15 minutes
15 – 30 minutes
Describe the
parts of the
stethoscope and
the proper way to
wear it
SO - 1
Describe the
Content
On screen poll
Sounds overhead
Brief history
How a
stethoscope
works
Methods
Clickers, Q and A
The parts of the
scope
Hands on wearing
and seating the
scope in your ears
Lecture
Powerpoints
Photos and old
stethoscope
tacticle
Photos of proper
ways to wear in a
PowerPoint. In
seat practice in
small groups
How to adjust the
Students pair up
Instructor
B. Page
B. Page
B. Page
30 – 40 minutes
40-50 minutes
50-60 minutes
60-75 minutes
75 – 90 minutes
90 -100 minutes
100-110 minutes
110–120 minutes
difference in the
bell vs the
diaphragm and
the use for each
SO 2,4
SO 3
Demonstrate on
another person or
simulator, each of
the proper
locations for a 6
point breath
sound
assessment.
touch to hear
different
frequency sounds
Respite
Ears on Lab,
Normal Breath
Sounds
OB - 3
SO - 5
Respite
Normal Tracheal
Bronchial
Bronchovescicular
Vesicular sounds
Ears on Lab
Abnormal breath
sounds-
Abnormal Sounds
Stridor
Monophonic and
polyphonic
sounds
OB 3
SO – 6 -7
Ears on Lab
Abnormal Sounds
OB 3 SO 8
Review game
show assessment
Reflection and
evaluations
OB 5
How to do a
methodical
assessment of
breath sounds
using correct
anatomical
landmarks
Abnormal sounds
Crackles
Consolidation
All sounds
Class discussion
after a period of
processing
and practice.
Show them quick,
Show them slow,
Let them practice,
Let them go!
Students pair up
and practice.
Show them quick,
Show them slow,
Let them practice,
Let them go!
Respite
Live use of
stethoscope on
sounder. Play
sounds three
times for 15
seconds each
Live use of
stethoscope on
sounder. Play
sounds three
times for 15
seconds each
Live use of
stethoscope and
sounder
Use stethoscopy
final challenge
game with
clickers, scope
and sounders
Final evaluations
with clickers and
on screen
questions
B.Page
B. Page
B. Page
B. Page
B. Page
B. Page
B. Page
When practicing the hands on skills with the stethoscopes, make sure
participants wipe down their stethoscope before touching the volunteer. Emphasize
the importance of direct skin contact to prevent extraneous sounds. Make gloves
available for those that request it. Allow time for reflection after each task is done.
Rubric for Assessment of Stethoscopy Skills
This rubric is an assessment that can be used throughout a module by the
instructor and the student for self-evaluation and for feedback on their progress
towards skill mastery.
Scoring
Mastery - 4
Competent - 3
Progressing - 2
Beginning - 1
Identifies parts of
the stethoscope
Uses stethoscope
properly
Can easily identify
all the parts of the
stethoscope and
can elaborate on
the differences
between scopes
Can identify all the
parts of the
stethoscope
without prompting
Easily uses the
stethoscope
correctly and with
confidence
Can correctly
identify all breath
sounds correctly
on one breath
every time
Wears and uses
properly with
some hesitation
and deliberate
movements
Knows how to
wear it properly,
but need more
practice to use
properly
Does not know
how to wear a
stethoscope or
how to use it
Can correctly
identify all breath
sounds correctly
after a few breaths
Can identify some
of the parts of the
stethoscope with
some prompting
Cannot identify an
of the parts of the
stethoscope
Correctly Identifies
breath sounds
Can identify many
but not all of the
breath sounds
correctly
Cannot correctly
identify any breath
sounds
I chose mastery at the top and beginning at the bottom. As a minimum, I want
providers to achieve the competent level. To be considered competent, the student
has to meet the objectives. Some will achieve the mastery level, the highest rating.
Those that achieve mastery are expected to perform easily and with confidence, on
their own without help. I tried to select the scoring based on a student’s progress
towards mastery. The progressing phase is the students that has learned the skill
but is in need of further practice. The beginning section is the student that has just
started learning the skill as a baseline.
Sounder Skills Practice
When practicing the sounds with the sounder device, play the sounds for at
least 15 seconds each. Allow time for a self-description and reflection of the sounds.
Mention the correct name of the sound played before, during and after the sound.
During the sounds practice, have the students assess each other using the
rubric provided. The can get feedback from each other and help each other to obtain
the minimum level of competency.
The review assessment will be done using the clickers, their stethoscopes,
and the sounders. Sounds will be played, the students will have 15 seconds to
correctly identify the sounds they hear.
Evaluation Plan:
Pre-course Evaluation
At the beginning of the class, I will use audience polling to determine the
baseline attitude of my students towards their knowledge of stethoscopy skills and
training in general. This will be done with clickers that each student will have.
Questions will appear on the screen and students will answer with their devices.
This type of polling is anonymous to the students but I can see the results via a bar
graph on my screen giving me instant knowledge and feedback as to their
responses.
The questions will be general opinion questions based on the objectives I
plan to cover in the course. The information gained from this polling will allow me
to improve my delivery and content based on the feelings of the group. I will know
what areas to emphasize and which do not need that much time spent it. Covering
things the audience already knows well will not benefit the learner and will
diminish the overall impact of the course. This also will help me to evaluate the
success of the course design by spotting opinion changes in the pre and post course
evaluation.
The purpose of this type of formative evaluation is to try to measure the
learner’s pre and post course opinions on their understanding of the information
presented. I will use the following questions to measure their opinions before the
class begins as a baseline for a comparative evaluation
Audience instructions. After carefully considering the following statements, please
respond with your clicker with the number that corresponds with your answer.
1. Strongly Agree
2 Agree
3 Neither agree or disagree
4 Disagree
5 Strongly disagree
Statements
1 I feel I am completely competent is my skill in using a stethoscope.
2 I received sufficient training in using a stethoscope in my primary EMS
course.
3 I listen to breath sounds on every patient.
4 I can easily recognize normal breath sounds by location heard
5 I can easily recognize and name adventitious breath sounds.
6 I am aware of the proper procedure for auscultating breath sounds.
7 I have access to a lab that I practice listening to breath sounds.
8 I need more practice in using a stethoscope.
9 I need more practice in identifying the various breath sounds.
These questions are a baseline because I really want to see their response to the
statements after having the opportunity for hands on and “ears” on learning
sessions.
Overall Summative Post-Course Evaluation
The overall summative course evaluation will query anonymously the
learner’s opinions of the instructor’s effectiveness and their thoughts on the
learning techniques used and their desire to continue to learn. I really want to see
how they will process the session and get to the “now what” phase. I will use the
following questions in the post- course summative evaluation.
Audience instructions. After carefully considering the following statements, please
respond with your clicker with the number that corresponds with your answer.
1. Strongly Agree
2. Agree
3. Neither agree or disagree
4. Disagree
5. Strongly disagree
1. The instructor covered the stated objectives adequately.
2. The instructor encouraged questions
3. The instructor provided adequate feedback
4. The instructor used effective teaching techniques
5. The hands on use of the stethoscope drill was helpful to me
6. The ears on simulator experience was helpful to me
7. I would like more practice listening to the breath sounds
8. This class will change my practice using a stethoscope
9. After the class, I feel more confident using a stethoscope
Using the Data from the Evaluation
I will use the data from this post course evaluation to alter the methodology
and delivery style of the material until the learning objectives and the behavioral
objectives are met. Since this is relatively new or infrequently assessed skills,
Questions 1-4 are designed to evaluate the instructor’s ability to establish a great
learning environment. One that is conducive to learner’s engagement in the course.
Since a course like this may seem to make the learner feel like they are ill prepared
or hesitant to divulge their own weaknesses to the material, an open and honest
approach to feedback and questioning is essential. This part of the evaluation should
help to improve this important part for future classes by exposing weakness or
areas for improvement. It is equally important to provide feedback to instructors
doing a great job as well.
The heart of the program is the “hands and ears” on approach to this skill. A
considerable amount of time and practice goes into skill mastery of any given skill.
Although this is not a very long course, the time spent should be based upon the
learner’s feedback. Question 7 evaluates the learner’s need for more practice in a lab
like this. When compared with pre-course evaluation on whether this training is
actually available to the student, a new business opportunity for self run program
similar to the lab can be explored. Another outcome is adding to the time for the
course. How long is too long? The learner feedback here is vital.
The practice labs should be of value to the learner. Questions 5-6 evaluate
the effectiveness of the two main labs. Feedback from this will directly impact how
future courses are tweaked. A simulator has the ability to make things easy or
difficult for the learner. The feedback will allow the instructor to customize their
delivery of this station to suit the learner’s needs. Many times in skill stations,
advanced learners may indicate that it wasted their time. This evaluation should
gauge that and changes be put into the course to accommodate advanced learners.
The data gathered in the pre-course evaluation can help identify these learners at
the start of the class.
Final Analysis
I want the learner to be able to value the importance of using the stethoscope
correctly. It is through the knowledge gained and skill mastery that this goal will be
achieved. Questions 8-9 evaluate the overall effectiveness of the course based upon
a self-assessment of their confidence level in performing the skill. The impact of this
course overall is increase the learner’s confidence and make the student reflect and
process the information which will lead to future changes in their practice. I am also
hoping that it will lead to different instruction design and techniques in teaching
this skill on a larger scale.
Web Page Link:
http://www.multileadmedics.com/www.multileadmedics.com/Stethoscopy.html
Follow this link to learn more and to download the handout for the course.
NEW! In response to learner feedback and polls, Bob has developed a tool called a
Lung Sounds Tutorial for the learner to continue practicing the skill after class in
over, designed to take them to mastery level. More details are found on this web
site:
https://www.pinnacletec.com/medical-products-catalog/shop/breath-sounds/