Crackles in lower lobes?

[brdavis17]

Hi, I am a new nurse. During last night's shift (I work nights), I auscultated fine inspiratory crackles in my pt's lungs in their bilateral lower lobes. My pt was there for something totally unrelated-colitis, and has no heart/lung history besides HTN. She was gettting fluids at 100 mL/hr. Her vitals were stable and she wasn't short of breath. My charge nurse also heard them (I asked her to verify) and then a few hours later I checked again and they were still there. I asked my charge nurse if this is something concerning, and she said since the patient's vitals were stable, she wasn't SOB, and as long as the crackles didn't "increase" over night, it's okay and I can pass it on in report and possibly the next nurse can tell the rounding MD who could possibly decrease fluids. Also the crackles didn't clear when I asked her to cough.

So I am wondering, were the crackles concerning? They were a new finding but I'm not sure physiologically how that could have happened besides the pt maybe being fluid overloaded. I guess I'm just confused about why my charge nurse was not that concerned. Maybe I should've text paged the MD to possibly turn down the fluid rate? Can I just say that it is challenging as a new nurse that so many things are gray, and it's hard to transfer what I learned in school to real life. :)

[AlwaysLearning247, BSN]

It's good you asked her to cough, however if she was drinking/eating okay I would probably have stopped the fluids and told the MD I heard crackles and ask if they'd want to stop the fluids all together or lower the rate. Also I'd make sure she wasn't spiking a temp, look at WBC, O2 sat, etc and see if they'd want a chest xray. Good luck!

[brdavis17]

Okay, so I had her as a pt again last night and the crackles were gone. She also was saline locked. So perhaps the crackles resolved since they stopped the fluids? Also, that first night that she had crackles, her O2 sat was fine, as were her other vitals and she wasn't on any oxygen. So you still would've texted the MD with those considerations? It makes sense, since it was a new finding, but it was literally the only thing abnormal so possibly the crackles were the atelectatic crackles that are not pathologic?

[AlwaysLearning247, BSN]

I would've given a heads up, yes. Because she may not have been short of breath at the time but the crackles could have gotten worse and caused her to desatt, need lasix, etc. At my work we use text paging, I would just write it as an FYI and they usually put the orders in from their end.

[iluvivt, BSN, RN]

Any new abnormals need to be reported to the provider along with your assessment.If you follow that rule you will be in good shape!

[PeekabooICU77]

I believe this should have warranted notification to the MD for sure. Even without a (known) history of heart failure or lung problems, acute issues can always arise. She could have gone in the other direction with crackles in her lungs and IV fluids going at 100/hr. Not to scare you, but flash pulmonary edema is fast and bad.

As a new nurse, try to stick to the recommendations of notifying provider for any changes, no matter how small it might seem. Over time, you'll acquire your own judgment and be able to decide how to intervene. For now, don't EVER worry about feeling dumb or asking silly questions. The providers will increasingly trust you and value your diligence.

Something I do frequently when starting a shift is think of as many unexpected or undesired things that could happen with the patient, depending on what the patient is in for and their history, and then play out what I would do if anything were to happen. I have found this helpful in situations like yours, where I have thought of possible causes and effects, and I am more comfortable sharing the gathered info with the team. For example, a call to the doc could have included: your SBAR-blah, blah, blah as follows) patient xyz admitted for colitis with new onset crackles, No known cardiac or respiratory history. Sats wnl, O2 demands unchanged, patient breathing comfortably and denies SOB. receiving IV fluids at 100/hr - do you want her to continue receiving these? any other orders or suggestions? of course this is wordy and best done over the phone or in person, so if you text page at your facility I would send a short and sweet "pt with new crackles, no SOB, in NAD. DC IV fluids? -peekaboo x12838"

More often than not, I'd have residents that would receive that page and decide nothing is needed, but wouldn't let me know. So don't hesitate to page again if you don't hear back. Maybe pages not getting through actually does happen? (Haha)

I probably gave way more than you needed or wanted but hopefully there's something in this post that can be helpful to you :)

[brdavis17]

Thank you all! Extremely helpful!