I've been a nurse for four years and now while generally I feel pretty good with lung auscultation, sometimes my confidence gets shaken. Like the other night...
ER sent me up a patient who was "COPD exacerbation" and ER said that the first blood gas on arrival was ph of 7.2 but that was a on NRB that she came in on from a care facility. She was also full code and Hospice... They said drew another blood gas on 2 liters. She had no results on those. Long story, patient came up, I look at her after transfer her and I'm just like, this lady is gonna die. She could hardly talk from what I assumed was C02 narcosis.
Anyway, I got help right away, called Rapid Response, called family and she was transfered to the unit for possible Bipap/intubation. ER is gonna be majorly in trouble on this one.
When I initially listened to her, she I heard very little posteriorly but anteriorly she was moving air but with horrid rhonchi. We later NT suctioned her. And then later on in ICU on Bipap, she sounded fine but maybe Bipap distorts true breath sounds? The ICU nurses were saying that she was "tight." I always thought that word meant they had poor aeration and needed a resp tx for example. But what exactly does tight sound like.?
I'm just glad she got to the unit and family was called and DNR status was clarified. I can't believe ER did that to me... Oh well, maybe I should have been more questioning by their telling me her Ph was 7.2...
May 14, '07
how "tight" sounds depends on the severity:
Little tight: Expiratory wheezing
Moderate tight: Inspiratory and expiratory wheezing
Really tight: poor or no air movement as evidenced by significantly dimished or absent lung sounds.
when you listen to someones lungs anteriorly you are mostly listening to air movement in the mainstem bronchi and in the upper lobes. In her case you were more than likely hearing air movement in her large airways. When you listen posteriorly you are listening to the smaller airways that are effected by COPD which is why you heard hardly any air movement which does indeed mean this person was pretty tight and need bronchodilation a assistance with her breathing as she was probably approaching respiratory failure if not already in that state.
Hope this helps