#KYJ- knowing your jargon
Breath sounds, part 1.
Rattles, rales, crackles n creeps, Wheezes, and Rhonchi.
When I teach nurses about breath sounds, I always ask who does them, and who does them confident in the knowledge that they can name them. In an average class of 25 nurses, 5-7 put up their hand indicating they auscultate chests, but only 1-2 of these (about 5-8% of all nurses) attending my nursing assessment classes, or respiratory nursing classes, agree they can identify different breath sounds.
Here is my simplified version of the terminology (our biggest hurdle).
Pitch (highs and lows)
Let's start with a beautiful pipe organ in a cathedral. You know the ones I mean, huge gilded pipes arranged artistically around a dual layered keyboard and foot pedal system. When a low note is struck, deep, chocolate vibrating sound emanates from the largest pipes. When a high note is played, the tone bursts from the smallest pipes.
Lungs are similar. As air rushes through them, the pipes (bronchi and bronchioles) vibrate producing noise audible with the diaphragm (flat surface) of the stethoscope. Large airways towards the centre of the chest produce low pitch deep notes, and fine tubes on the outer periphery of the lung fields produce a higher pitch sound.... It's just like the pipe organ.
The first concept is this one of pitch. Low pitched sounds over the middle of a chest, high sounds in the outer reaches of the respiratory tree.
Next to master is the two major categories of abnormal sounds produced by diseased lungs. Abnormal lung sounds are often called "Adventitious sounds". They are lumped into two types.
Wet and squeezed.
1. Wet sounds (crackles)
Wet sounds are produced as air moves through pipes filled with water and thin mucus. Typically heard in pulmonary oedema, wet sounds resemble that bubbly noise you made as a kid, sucking the last dregs of a milkshake through a straw. Don't lie, I know you did.
Wet sounds are collectively called crackles, and depending on where in the lungs they are, they will produce a different pitch.
In smaller peripheral airways, the sounds are high pitched, so these crackles are called creps or fine crackles. Typical in pulmonary oedema, pneumonia, and chest infections.
In larger bronchioles and bronchi, the sound is lower pitch. Still wet bubbling sounds, but lower in tone. These crackles are commonly called Rales, or simply coarse crackles. Typical of bronchitis.
If the wet sound is audible with no stethoscope, the gurgling sounds like comes from the back of the throat, it is fluid in the main bronchi, or trachea. These sounds are called Rattles. The gurgling death rattle common in an frail dying patient is a classic example.
Next episode we look at squeezy wheezes.
Stay tuned. "F" to follow or comment to stay in the feed.
Monday, 29 February 2016
Friday, 19 February 2016
#KYJ - Wound care series- Hydrogel dressings
Hydrocolloids.
These dressings have been around for 30 years. They are generally a thin film that has a thick rubbery adhesive which , when contacting a moist wound, creates a gel against the wound surface.
Some hydrocolloids contain an alginate (seaweed base) to help with wound exudate absorption. Different hydrocolloids dressings come with many shapes for "difficult to attach" areas, and different thicknesses so the nurse can tailor the dressing to the amount of exudate. The hydrocolloids dressings often stick to the wound's healthy skin margin with a water resistant film type adhesive.
So how do they work?
Being water occlusive, they provide a moist healing environment and heat insulation. In episode one we discussed the need for a moist and warm wound bed.
These dressings also encourage a process called autolytic debridement. This is where the gel from the hydrocolloids attract moisture from the wound like a sponge, and in doing so, promote the release of protein and debris dissolving enzymes from tissues. These dressings clean the wound, not just cover it.
Pros
• Water resistant keeps bugs out.
• non stick to the moist painful wound surface, so gentle when being removed.
• non stick to the moist painful wound surface, so gentle when being removed.
• Easy peel and stick application that can be used under compression stockings or lymphoedema bandages.
• Can and should stay on for days. Many products report 3-7 days with the familiar mantra "leave it a week or till there's a leak"
Cons
• Never on infected wounds, and they are not great on heavily exuding wounds. Venous ulcers and some diabetic ulcers are notoriously oozy.
• extreme caution on diabetic feet!! Only safe if the wound is superficial with no signs of infection, there is low to moderate exudate, there are no signs or symptoms of ischemia, and dressings are changed frequently. This last point negates the value of a dressing that is designed to stay on for days.
Diabetic wounds crash in hours when they crash, and you want to be there when that starts. You don't want to pull off a dressing to find 2 weeks of healing undone overnight!
• unlike film dressings which are clear and transparent, hydrocolloids are opaque. So you can't watch the wound.
• notorious for dislodgement if wound is too wet, and they curl or roll at the edges, potentially trapping bacteria.
• some patients (and nurses) complain that they are a bit on the nose.
• can cause wet maceration to healthy skin (all those trapped enzymes in the Slough )
• May cause trauma/injury to fragile skin upon removal... That prednisone abused nana skin is so paper thin!
• hypergranulation can be a problem leading to scaring
• notorious for dislodgement if wound is too wet, and they curl or roll at the edges, potentially trapping bacteria.
• some patients (and nurses) complain that they are a bit on the nose.
• can cause wet maceration to healthy skin (all those trapped enzymes in the Slough )
• May cause trauma/injury to fragile skin upon removal... That prednisone abused nana skin is so paper thin!
• hypergranulation can be a problem leading to scaring
When to use
A hydrocolloid dressing is appropriate for these situations:
• necrotic or hard capped eschar covered wounds (lifts the dry nastiness)
• dry wounds
• partial- or full-thickness wound
• protection of intact skin ( but watch for maceration ) or a newly healed wound.
• necrotic or hard capped eschar covered wounds (lifts the dry nastiness)
• dry wounds
• partial- or full-thickness wound
• protection of intact skin ( but watch for maceration ) or a newly healed wound.
Frequency of dressing changes
• depending on the product specifications, dressings should be changed every 3 to 7 days. This of course depends also on exudate.
How to apply a hydrocolloid dressing .
Gloves on and remove the soiled dressing (noting the date it was applied) - contaminated bin is wise, irrespective of colonisation.
Deglove, hand wash, reglove
Clean the wound with warm normal saline or warm tap water.
There is no evidence that chlorhexidine or other antiseptics are safe, or necessary or helpful.
Use gauze to pat dry the foot edges of the wound margin where the adhesive should stick.
Apply liquid barrier film or moisture barrier to the periwound area.
For deep wounds, apply wound filler or packing materials as indicated/ordered ( a whole other post).
Deglove, hand wash, reglove
Clean the wound with warm normal saline or warm tap water.
There is no evidence that chlorhexidine or other antiseptics are safe, or necessary or helpful.
Use gauze to pat dry the foot edges of the wound margin where the adhesive should stick.
Apply liquid barrier film or moisture barrier to the periwound area.
For deep wounds, apply wound filler or packing materials as indicated/ordered ( a whole other post).
Warm it by holding it between your hands to increase molding and adhesive ability.
Remove the paper backing from the dressing.
Bend the dressing (sticky side out) and apply it from the center of the wound, smoothing it outwardly like putting contact on the kids books.
Hold the dressing in place for a few seconds, warming it with your hands to improve molding and adhesion.
The dressing should be at least 2cm larger than the wound.
Remove the paper backing from the dressing.
Bend the dressing (sticky side out) and apply it from the center of the wound, smoothing it outwardly like putting contact on the kids books.
Hold the dressing in place for a few seconds, warming it with your hands to improve molding and adhesion.
The dressing should be at least 2cm larger than the wound.
Our next instalment will take a look at hydrogels.
Check out our Webpage for education opportunities.
#KYJ - Wound care series- Hydrocolloids dressings
Hydrocolloids.
These dressings have been around for 30 years. They are generally a thin film that has a thick rubbery adhesive which , when contacting a moist wound, creates a gel against the wound surface.
Some hydrocolloids contain an alginate (seaweed base) to help with wound exudate absorption. Different hydrocolloids dressings come with many shapes for "difficult to attach" areas, and different thicknesses so the nurse can tailor the dressing to the amount of exudate. The hydrocolloids dressings often stick to the wound's healthy skin margin with a water resistant film type adhesive.
So how do they work?
Being water occlusive, they provide a moist healing environment and heat insulation. In episode one we discussed the need for a moist and warm wound bed.
These dressings also encourage a process called autolytic debridement. This is where the gel from the hydrocolloids attract moisture from the wound like a sponge, and in doing so, promote the release of protein and debris dissolving enzymes from tissues. These dressings clean the wound, not just cover it.
Pros
• Water resistant keeps bugs out.
• non stick to the moist painful wound surface, so gentle when being removed.
• non stick to the moist painful wound surface, so gentle when being removed.
• Easy peel and stick application that can be used under compression stockings or lymphoedema bandages.
• Can and should stay on for days. Many products report 3-7 days with the familiar mantra "leave it a week or till there's a leak"
Cons
• Never on infected wounds, and they are not great on heavily exuding wounds. Venous ulcers and some diabetic ulcers are notoriously oozy.
• extreme caution on diabetic feet!! Only safe if the wound is superficial with no signs of infection, there is low to moderate exudate, there are no signs or symptoms of ischemia, and dressings are changed frequently. This last point negates the value of a dressing that is designed to stay on for days.
Diabetic wounds crash in hours when they crash, and you want to be there when that starts. You don't want to pull off a dressing to find 2 weeks of healing undone overnight!
• unlike film dressings which are clear and transparent, hydrocolloids are opaque. So you can't watch the wound.
• notorious for dislodgement if wound is too wet, and they curl or roll at the edges, potentially trapping bacteria.
• some patients (and nurses) complain that they are a bit on the nose.
• can cause wet maceration to healthy skin (all those trapped enzymes in the Slough )
• May cause trauma/injury to fragile skin upon removal... That prednisone abused nana skin is so paper thin!
• hypergranulation can be a problem leading to scaring
• notorious for dislodgement if wound is too wet, and they curl or roll at the edges, potentially trapping bacteria.
• some patients (and nurses) complain that they are a bit on the nose.
• can cause wet maceration to healthy skin (all those trapped enzymes in the Slough )
• May cause trauma/injury to fragile skin upon removal... That prednisone abused nana skin is so paper thin!
• hypergranulation can be a problem leading to scaring
When to use
A hydrocolloid dressing is appropriate for these situations:
• necrotic or hard capped eschar covered wounds (lifts the dry nastiness)
• dry wounds
• partial- or full-thickness wound
• protection of intact skin ( but watch for maceration ) or a newly healed wound.
• necrotic or hard capped eschar covered wounds (lifts the dry nastiness)
• dry wounds
• partial- or full-thickness wound
• protection of intact skin ( but watch for maceration ) or a newly healed wound.
Frequency of dressing changes
• depending on the product specifications, dressings should be changed every 3 to 7 days. This of course depends also on exudate.
How to apply a hydrocolloid dressing .
Gloves on and remove the soiled dressing (noting the date it was applied) - contaminated bin is wise, irrespective of colonisation.
Deglove, hand wash, reglove
Clean the wound with warm normal saline or warm tap water.
There is no evidence that chlorhexidine or other antiseptics are safe, or necessary or helpful.
Use gauze to pat dry the foot edges of the wound margin where the adhesive should stick.
Apply liquid barrier film or moisture barrier to the periwound area.
For deep wounds, apply wound filler or packing materials as indicated/ordered ( a whole other post).
Deglove, hand wash, reglove
Clean the wound with warm normal saline or warm tap water.
There is no evidence that chlorhexidine or other antiseptics are safe, or necessary or helpful.
Use gauze to pat dry the foot edges of the wound margin where the adhesive should stick.
Apply liquid barrier film or moisture barrier to the periwound area.
For deep wounds, apply wound filler or packing materials as indicated/ordered ( a whole other post).
Warm it by holding it between your hands to increase molding and adhesive ability.
Remove the paper backing from the dressing.
Bend the dressing (sticky side out) and apply it from the center of the wound, smoothing it outwardly like putting contact on the kids books.
Hold the dressing in place for a few seconds, warming it with your hands to improve molding and adhesion.
The dressing should be at least 2cm larger than the wound.
Remove the paper backing from the dressing.
Bend the dressing (sticky side out) and apply it from the center of the wound, smoothing it outwardly like putting contact on the kids books.
Hold the dressing in place for a few seconds, warming it with your hands to improve molding and adhesion.
The dressing should be at least 2cm larger than the wound.
Our next instalment will take a look at hydrogels.
For ECT4Health information and courses
Www.ect4health.com.au
For ECT4Health information and courses
Www.ect4health.com.au
Tuesday, 16 February 2016
#KYJ -Wound healing Series. Part 1
What do I put on that wound?
Part 1
In this knowing your Jargon #KYJ series we look at the options for wound dressings.
Everywhere I nurse, treatment rooms and clinics have a poster helping nurses recognise different stages of wound healing and usually offering a suggestion of what dressing to use. It's a confusing choice and often we come on shift to see that another nurse has changed to a different product.
So in this mini-series, we look at the different styles of dressing, and when they are indicated.
To get the ball rolling we must understand that wounds need 5 important things to heal.
*oxygen delivery
*nutrition (nutrients)
*moist wound bed
*warmth
*absence of infection
Oxygen / Nutrient
Oxygen and nutrients for cell growth need to be delivered to the wound systemically via the vascular network. Arteries and arterioles deliver to the micro fine capillary beds to diffuse in to the wound. This supports the proliferation of new tissue growth, and feeds hungry immune cells acting watch over the construction zone, preventing bacteria from colonising and initiating infection. In diabetics and other people with poor vascular flow, there exists a chronic reduction in tissue oxygen delivery. If the wound bed oxygen concentration should drop below an oxygen tension of 40mmHg, then wound stop healing. They become indolent and dormant.
For oxygen to get into a wound, blood needs to be adequately drained from the wound. In patients with heart failure (especially right heart), there is often venous engorgement/congestion. This venous congestion (particularly in lower limbs) usually decreases the ability of blood the cycle through the wound. Venous blood is notoriously hypoxic (without oxygen), so venous congested wounds will swell, hold and produce lots of exudate, and healing grinds to a halt. These patients need compression bandaging or stockings to promote venous return. We have to get the oxygen right.
Moist wound bed.
Within 24-48 hours of tissue injury, fibroblast cells commence work to create a protein base to the wound bed. It is called collagen and you could think of it as the frame or foundation of a deck verandah. On top of the frame work, eventually the decking timber will be attached. In wounds this construction is called granulation.
Granulation needs to take place in a moist/warm environment. Ultimately the skin cells that form the decking need to slide (migrate) across the collagen frame to complete the surface of the wound bed (epithelialisation). The process can take weeks, but in small wounds with close edges, the seal in just 48 hours. The wound bed needs to be slippery. This is where moisture comes into play.
As nurses we need to choose a cover that maintains wound warmth (>30 deg), and traps moisture to maintain the slippery environment fibroblasts (builders) need.
Too wet and the healthy tissues in the wound swell and cease to function. Too dry and the migration, and epithelialisation can't happen.
In our next part of the series, we will look at the dressings that do this task.
Absence of infection
If a wound is colonised by pathogenic (disease causing) bacteria, it won't start repairing. In infections, the immune system is activated to search and destroy bacteria, and using many signalling chemicals (cytokines) to aid communication between white blood cells (chemotaxis), the process of tissue repatriation ceases while active infection fighting occurs. Infection is the enemy of wound healing.
When assessing wounds, especially chronic wounds like leg ulcers, and decubitus ulcers, get into the practice of taking a baseline bacterial culture swab. If colonisation is present then the patient should be started on antibiotics for reduction in bacterial numbers. A colonised wound is not an infected wound, but given moisture, time and warmth (all things a healing wound needs), that little bacterial colony becomes a rampant infection. When wound bacteria do the dirty, they secrete toxins into the wound bed that destroys the fresh new growth, causes Vasoconstriction which reduces oxygen to the wound, and fills up the wound with excessive toxic exudate.
Wound cleaning
Warm water/saline irrigation under pressure of a 20ml syringe, and a blunt 18g needle is needed to irrigate /clean the wound. An uninflected wound often needs very little cleaning if it is healing well (every 3-7 days). But in infected wounds, healing is not our goal, cleaning is. Refrain from swabbing with gauze. This cleaning of the wound bed 1-2 times daily during active infection inhibits pus, exudate, and aids in reducing bacterial numbers.
Ok that is it for the first instalment. A primer as it were.
Next episode we will look at the start of our wound dressing list starting with
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