Breath Sounds -Part 3- location

Breath Sounds -part 3

Continuing on with our series on breath sounds. Today we look at stethoscope position.

First, knowing your stethoscope. The  flat disk like part of your stethoscope is called the diaphragm, and is the surface that is used for high pitched sounds. Lung auscultation and bowel sounds are examples.

If your stethoscope is a dual head, with the cone shaped bell, then low pitched sounds are heard best through this part of the scope.  Heart sounds can usually be heard better with the bell.

Anatomic placement

Listening to breath sounds is as simple or as complex as you want to make it.

Start with anterior (front of chest) for a quick listen for normal.

Location 

2nd intercostal space in the mid clavicular line.  Listen left then right in a patient sitting upright.

Then 5th Intercostal space in the mid axillary line (same spot you place the V6 lead on an ECG).

Again listen left then right.

You are listening for equality between two anatomically opposite locations. Read that again.... It's important!

R=L at the 2nd ICSMCL

R=L at the 5th ICSMAL

Listen to a couple of breaths in and out with the patient breathing through their mouth.

Focus on the duty cycle (time taken to breathe in vs out, focus on the equality between left and right and listen for abnormal sounds like wheeze or crackles.

Record any adventitious sounds or inequality.

These two locations complete a basic respiratory auscultation.  If a comprehensive assessment is needed (usually not) then the patient should be propped forward and auscultation is performed on the back.

This allows you to hear the largest portion of lung fields.  The posterior chest is called the base, which is often erroneously confused with the inferior aspect of the anterior chest.  More alveolar area is in the base of the lung.

Now say out loud... "2,4,6,8,10"

Did you say it? Are people looking at you funny? 

2,4,6,8,10.

These are the intercostal spaces.  Either side of the vertebral column, you listen at the 2nd ICS left then right 

4th ICS left then right

6th ICS left then right

8th ICS left then right

8th ICS at the Axillary line .

10th ICS left then right

Then finish at the 10th ICS out on the widest part of their chest - the posterior axillary line.

Don't be daunted by these 6 sites.  You are only listening to compare Left to right at each spot. 

Practice these locations on your partner or kids. Listen to normal chests to get your ear in for the nuances of normal.

Know normal so you can recognise abnormal sounds as they arise.

Next episode we will discuss classic consolidation/pneumonia and the funky sounds you can experience to identify a pneumonia in your patient. 

#KYJ Wound care series - part 4 Venous Insufficiency

Wound care series part 4.
Venous insufficiency.

In this #KYJ episode we look at venous insufficiency as a cause of leg ulcers and as an inhibitor to healing.

To begin to grasp the impact that venous disease has, we must understand a few truths about leg circulation.  Arteries in legs transport oxygenated blood to the tissues of the legs and feet. Arteries deliver nutrients to the capillary beds that perfuse tissue.  I like to think of arteries as a garden hose, and the capillaries as that soaker-hose weaved around the garden bed.  There is a blood pressure gradient that is highest as blood leaves the heart, that reduces in arteries and almost zero by the time that blood reaches the legs capillaries.
To return that blood to the heart, the veins and muscles of the legs are structured to "pump" blood back.
Three types of veins are featured.
Superficial
Perforating
Deep veins

Superficial veins are often seen as swollen inflamed spiderweb like varicose veins on the feet and ankles of people with venous congestion.  They drain their blood into communicating veins called "Perforating veins" , that take blood from the superficial veins and direct blood flow into the deep veins located deep in the muscle fascia.

Blood is forced along the length of the vein by the action of leg muscle movement.  If there is no leg exercise, this blood pools and congestion occurs, forcing the pressure inside veins to rise.

To ensure blood travels in one direction through veins, veins have one way valves. As congestion and pooling occurs, these valves fatigue and fail.  Venous insufficiency is a combination of high venous pressures from congestion & pooling of blood, and the valves no longer being efficient at transporting blood in the Leg to Heart direction.

Pooling of blood is called 'stasis'. In veins it is referred to as venoustasis.  If there is one thing that pooled blood loves to do, it's coagulate...Badness!

Venous pressures are strongly influenced by gravity.  Standing and sitting for long periods are the leading cause. Once we walk or contract leg muscles, the pump like action promotes momentum of pooled blood and the congestion eases.  This is true for healthy legs, but in patients with long term valve failure walking does little to alleviate pressure.

So what is the link between this venous disease and wounds?  Wounds need a constant clean flow of blood delivering nutrients to the wound bed.  Congestion seen in patients with valve disease or venoustasis slows or stops momentum, stops removal of waste and hence; stops healing.

In many patients with venous insufficiency, their disease actually causes ulceration.  Always on the lower leg and almost always on the medial ankle (malleolus) or anterior shin.

Patients with venous disease often have classic tell tale symptoms.
Ankle swelling
Superficial varicose veins
Spider veins on the inside of their ankle.
Discolouration to their skin ranging from red to rust to purple.
Occasionally slow healing wounds

As congestion increases, red blood cells are forced out of capillaries and fracture in the superficial skin.  The iron in red blood cells oxidises to iron oxide (rust).  It is called haemosiderin and is a permanent rusty discolouration of patients with advanced venous insufficiency .  Sometimes this is called venous eczema .

Next wound care episode we will look at compression as a treatment.

Stay tuned...
Comment or F for follow to stay in the feed.

Breath Sounds part 2 - Wheezes

#KYJ -Knowing your Jargon

Breath sounds part 2. 

Wheezes.

In part one http://knowingyourjargon.blogspot.com.au/2016/02/breath-sounds-part-1.html?m=1

We looked at the concept of pitch in breath sounds. In that episode we discussed the two major groups of abnormal (adventitious) lung sounds. We focused on crackles.

In this episode we look at the other group, the Wheezes.

Wheezes are a sound produced by air being squeezed through narrow swollen oedematous bronchi/bronchioles.  They can occur during inspiration (stridors) or expiration (wheezes).

Like crackles, wheezes are pitched differently, depending on the area of lung affected.  High pitched wheezes are heard in the periphery of the lung, whereas low pitched wheeze come from larger airways.  Like crackles, wheezes are termed differently depending on the area they originate.

High pitched wheeze is called a sibilant wheeze.   Sibilant is a whistle like sound of high frequency (high pitch). It is characteristically heard in asthmatic flare-ups.

Low pitched wheezes originate from bronchi and trachea, and sound like snoring.  In fact this is exactly what they are called, "snorous wheezes".  In older texts, you may hear these called Rhonchi (pronounced 'Ronk-Eye').

Typically these wheezes are heard in multiple areas of the lung field.  For this reason it is not uncommon to hear multiple different pitches.  Wheezes of this nature that demonstrate both snorous and sibilant qualities are frequently documented as widespread polyphonic (many voices) wheezes.  Asthma is a classic presentation.

Listen carefully to a wheeze; especially if the patient has cardiac or hepatic history, and after any rapid IV fluid infusion.  If crackles can be heard along side a sibilant wheeze, then a diagnosis of acute pulmonary oedema (APO) needs to be excluded.

So similar is an acute asthma wheeze and an acute pulmonary oedema wheeze, that at one time APO was called "Cardiac Asthma".

So that is it for this short episode. Next edition we look at where a stethoscope is placed.

Check out our blog site for all the KYJs you've missed. Www.knowingyourjargon.blogspot.com

Don't forget to place a comment or an F for following in the comments section, and share the post on your news feeds and nursing pages.

Breath sounds part 1- crackles

#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.

#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.

• 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

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.

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).

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. 

Our next instalment will take a look at hydrogels.

Check out our Webpage for education opportunities.

Www.ect4health.com.au

#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.

• 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

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.

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).

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. 

Our next instalment will take a look at hydrogels.

For ECT4Health information and courses
Www.ect4health.com.au

#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

Hydrogels, and gel based dressings.

For ECT4Health information and courses
Www.ect4health.com.au