Breath sounds-advice please

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    I am a fairly new RN working in Geriatrics and have to admit Breath sounds are a problem area for me. My residents are mostly no transfers. I have been working with a man who is failing quickly. I just have a hard time understanding and describing what I hear in his lungs. Am I right to assume that anything that sounds like a crackle, bubble, gurgle generally means fluid in some amount?? I hear so many different terms like crackles, rales, rhonchi, I am very confused by it all. What is the difference in crackles if it's heard on inspiration or expiration. We have always been told to just document it as we hear it. This guy had espiratory "crackles" to his lower left lung and expiratory "crackles" throughtout his right lung. (Sounds like bubbles to me) No transfer. So would Lasix and oxygen be warranted? I am usually the only RN in this facility per shift so there isn't anyone around for advice. I'd appreciate it if anyone could give me their course of action on situations like this and also describe these sounds to me.
  2. 4 Comments so far...

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    stprdi_01,
    Lung sounds are a tricky thing to get the hang of until you have actually heard the abnormals with another nurse who tells you the lable that goes with the sound.
    I can give you the definitions I have been taught,

    crackles: are the sounds made by the aveoli as they pop open or closed when made sticky by fluid or exudate as in CHF or consolidations of pnuemonias. The thickening of the bronchi as in bronchitis. crackles may be heard on insiration or experation. ( crackle and rale are the same thing) The sound of crackles is like the sound of hair being rubbed between fingers or a large amount of bubble wrap being twisted. They do not usually clear with a cough. May be positional.

    Wheezes: are the sounds made by the narrowing of the internal diameter of bronchi and smaller branches of air passages. They may be on insiration or expiration. They sound like a sigh, sick whistle or musical tone. They usually clear with coughing. Wheezes are auscultated in ashma and COPD. Also known as rhonchi in some regions, in others rhonchi are wet gurguly to course sounding wheezes.

    Lasix would be prudent if the Resident is in distress, has CHF, does not have pnuemonia. Oxygen should be applied for o2 sats below 90% and is symptomatic for hypoxia; confusion, SOB, cyanotic lips/nail beds, etc. Also for comfort, sometimes just the O2 and cannula on a distressed Resident is enough to calm them to normal breathing patterns, increase comfort.

    I hope this helped some.
    peter
    nurseme3 likes this.
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    Thanks Peter that does help some. I guess everyone has their own names for different sounds and basically there are just a couple of them. I guess he had expiratory crackles throughout his right lung. I did find though that when he did manage to cough(when we turned him side to side) the cough more or less cleared the upper airways. Moaned with each expiration too. Afebrile. Mid eighties with probable prostate cancer. The doctor did say if his lungs were filling up we could give Lasix. Now the question, you say not to give Lasix with pneumonia. Not always a temp with pneumonia so ...... how do we know?????? Hope you don't mind. It's nice to troubleshoot.
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    Thanks Peter,I did so need a refresher in that. Love the BB
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    You can know for sure with a CXR showing changes to the density of the lung tissues, esp the lower lobes or left lobe in the case of aspiration, elevated WBC is also a good clue, also, the character of the sputum if any may lead you to an idea if it is pnuemonia or CHF. Sputum C&S can be done but is difficult in elderly pts. due to frequent difficulties with cough/deep breathing. Often you must suction for a good sample and this causes increased secretions and can make resps more difficult, I try to aviod this unless MRSA or VRE is suspected. Some Docs also order blood culture. The s/s of pnumonia are often atypical in the elderly but once you see it alot, you can pick up on the differences found on assessment in CHF and pnumonia rather quickly. If further tests are not ordered, the MD is relying totally on your assessment info for the DX or going with her/his best guess. No CXR = No confirmation of pnuemonia. If you are just flying on S/S I would look for cough, fever, purulent sputum first, but, these may all be absent. Next would be change in mental state, chills, chest pain, dyspnea, tachypenia, lethargy and loss of appetite or vomiting. Other conditions may exhibit exacerbation in major infection also, ie- blood glucose goes through the roof. Any or all vital signs may change form base line. It is not uncommon for a resident with a normal temp of 97-98 degrees drop to 95, or have funky B/P and/or pulse.


    peter


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