Breath sounds..experienced nurse

[zacarias, ASN, RN]

Hey all,

Haven't posted here in a long time. Anyway, I'm a nurse with over five years now of experience who feels good about my nursing ability but occasionally I feel unsure. There's just so many things unknown in medicine and healthcare.

I believe myself good at listening and interpreting breath sounds, above average actually but encounter frustrations.

Frustration #1. I had a patient the other night, paraplegic from spina bifida and physically and mentally sick. In most patients, upper anterior lung fields will always sounds normal. In this pt, she was normal on the right side but on the left anterior, she had some "crackles" but there was no reason. X-ray was clear. And occasionally I wouldn't hear it. She had messed up thorax, but still I don't where these seemingly adventitious sounds come from.

Frustration #2. How many times are my patients old sick patients who don't sit up or help move for you to listen their lungs. I break my back trying to move them just a little to listen to their posterior lung field and then even I don't trust it because it's not like the patient is nicely sitting up and breathing deeply on command like it should be. If I can find someone or a CNA to help me move the patient, that does help but it's not always available. Also, anyone notice that most old people sick enough to be in the hospital will have dependent crackles in bases?

Anyone have any comments of understanding, and shared frustration on this? Also, any comments on what's going on on my Frustration # 1 above?

Thanks!!

Zman

[Medic/Nurse, BSN, RN]

It sure sounds as though you are very good at respiratory assessment.

I think that you work with a difficult population as it relates to "textbook" ability to fully and accurately assess breath sounds.

Just keep on doing what you can - chart what you hear and any limitations in patient participation in the assessment.

And YES - I think that patients that are bed dependent almost always have some degree of diminished breath sounds - crackles, etc. Hard to "clear" secretions when pt is not ambulatory.

Heck, my world of breath sounds is usually "simple" compared to others practices.

Got 'em? - Yeah!!!

Equal? - No? Only 1 lung? No. Well, now I gotta fix that!

Good Even Excursion? Flail chests always squeam me. SubQ air - yikes! Increased AP dimension? I like symmetry (and normal).

Work of Breathing? Are these folks pooping out - I'll be RSI'ing and getting 'em on the vent right away.

Wet vs. Dry? - Are we dealing with flash pulmonary edema, pneumonia, I even had a dude with a fulminate fungal infection that I managed to "tap" after placing the ET tube - got several hundred ml's of funky stuff and then had to extubate him - I got lucky and he got quite a bit better. No way could I have predicted that...

Just noting that it is hard to fully assess uncooperative, limited patients. Sounds like you are doing great. Just like everything else document any exam limitations - now, get back to being a great nurse. Unless it is something that will need an immediate fix - just work through it.

I'm hoping to add a little smile to your day. Actually I can't hear much after we load/lift over the jet engines in a helicopter - doppler, palpate breath sounds (now, that is a trick )

Practice SAFE!

Deep Breath - now, doesn't that feel better??? :) :) :)

[leslie :-D]

sometimes the sounds we hear are actually transmitted, or bronchial in nature.

i have the pt db & c, which often clears the area when i reauscultate.

and yes, elderly who are pretty much immobilized, will have baseline bibasilar fine crackles.

so anything that progresses to coorifice or up from bases, would be considered adventitious.:)

leslie

[zacarias, ASN, RN]

Thanks guys for your encouraging (understanding) comments, they made me feel normal LOL. I haven't been to allnurses.com for a long time...I miss the group!NREMT-P/RN, sounds like you have an exciting job!!

Zach