Complex Medical Lab/Practical

Heart/lung sounds, EKG reading, etc.

You are evaluating a patient with COPD, what do you expect to find when observing them sitting in a chair breathing?

• barrel chest

• less use of diaphragm, more use of scalenes

• hypoxic drive to breathe

Normal lung sounds that are heard peripherally sound _____ while sounds closer to the trachea sound more _______

peripheral: softer

trachea: tubular

Crackling/rales lung sounds are associated with…

• pneumonia

• edema

• fibrosis (fine crackles)

Rhonchi is another term for…

wheezing

_______ is a harsh, high-pitched breathing sound caused by a blocked or narrowed upper airway

stridor

Normal lung sounds when a person speaks sound muffled at the edges of the lungs. But with a person with __________ the sound will be loud and clear which signals _________

• bronchophony

• dense lung tissue

How do you confirm bronchophony in a patient? What are you expecting with a positive result?

• have the patient say 99 (or another easy word) repeatedly as you listen to different points on the lung

• positive result: increased sound in area of tissue consolidation

How does whispered pectoriloquy sound different in a patient with healthy lungs vs. abnormal lungs?

• healthy: whisper sounds faint and unclear

• abnormal: whisper sounds loud and clear

When a patient’s lung tissue is filled with fluid or solid matter instead of air, what will it sound like when they say the letter “E”? What is this called?

• it will sound like an “A” in the area of consolidation

• this is called egophony

You ask a patient to say the words “99” while palpating their upper back. You notice increased vibrations (more than usual) what does this mean and what is this called? What could be a cause of this?

• there is solid or dense tissue in the lungs (sound travels better through solids/fluids than air)

• this is called tactile fremitus

• cause: pneumonia or lung tumor

_______ breath sounds are normal respiratory sounds with a medium pitch and intermediate intensity where inspiration and expiration last for equal amounts of time (1:1 ratio). Where are these breath sounds heard?

• bronchovesicular

• mid-chest area

• posteriorly between the shoulder blades

Patient presents with the following symptoms:

• chest pain when taking a deep breath or cough

• abnormal sounds heard during both inspiration and expiration that are low-pitched and harsh grating

What sound is being heard and what is the likely condition?

• pleurisy

• pleural rub

A patient presents with pneumonia. What abnormal lung sounds do you expect to hear and why?

• diminished breath sounds

• this is due to lots of fluid in the lungs

• the fluid is not allowing for proper gas exchange, so you won’t hear the air moving in and out

When performing a mediate percussion assessment on a patient with COPD, what would you expect and why?

• dullness or higher resonance

• due to barrel chest

_________ is a partial or total collapse of a lung or lobe of a lung

atelectasis

You are listening to the bases of the lungs on a patient with heart failure and here this: (listen to audio). What sound did you hear? What other conditions might this sound be associated with?

• fine crackles (firewood on a campfire)

  • high pitched sound toward the end of inspiration

  • brief, short, discontinuous

  • won’t clear with coughing

  • location: bases of the lungs

• conditions

  • CHF

  • atelectasis

  • pnemonia

  • pulmonary fibrosis

What is the reason for hearing fine crackles when a patient breathes (toward the end of inspiration)?

• fine crackles occur as the deflated alveoli begin to pop open

• when air rushes into the alveoli, it causes them to explode open or “crack” open which is why you hear that popping sound (at the end of inspiration)

What can you do for a patient who has congestive heart failure who is having trouble breathing (you hear the fine crackles upon auscultation)

• Better breathing position with fowler’s position: head of the bed at 45-60 degrees

  • also helps to reduce venous return which helps to reduce fluid that is accumulating in their lungs

• encourage coughing and deep breathing techniques

• educate patient on monitoring daily weight for potential fluid accumulation

A patient presents with the following signs/symptoms:

• fever: 102.2F

• pain when breathing in deeply or coughing

• SOB and dry cough

• this lung sound (listen to audio)

What sound did you hear? What other conditions might this sound be associated with?

• pleural friction rub (harsh grating noise)

  • can occur on inspiration and expiration

  • low pitch

  • continuous or discontinus depending on severity and cause

  • location: pleura layers

• conditions

  • pleurisy

    • layers of pleura (parietal and visceral) are no longer gliding, but rubbing because they are inflamed which is why there is pain with breathing

  • pneumonia

  • pulmonary embolism

  • tuberculosis

  • lung cancer

With ________ the layers of the pleura are no longer gliding during breathing but are rubbing against one another due to being inflammed. This will likely cause what two things in a patient during breathing?

• pleural friction rub

• chest pain/pain with breathing on inspiration and expiration

You are seeing a patient in a hospital who was admitted with bronchitis. You ask the nurse to listen in to their lung sounds to get better with identifying different ones. This is what it sounds like (listen to audio). What did you hear? What other conditions might you hear this sound?

• rhonchi (snoring, snorting sound)

  • heard on expiration

  • continuous

  • low pitch but loud

  • improves with coughing

  • this sound occurs because when air is leaving the trachea and bronchi, it hits secretions (mucus and fluid)

• conditions

  • bronchitis

  • pneumonia

  • COPD

A _______ sound occurs in patients with bronchitis during ______ because when air is leaving the trachea and bronchi, it hits secretions such as mucus and fluid

• rhonchi (wheezing)

• expiration

A patient presents with the following signs/symptoms:

• low-grade fever

• increased respiratory rate

• voice hoarseness

• this lung sound (listen to audio)

What did you hear? What conditions might you hear this sound? What should you do if you hear this sound coming from a patient’s room?

• stridor (screeching, squawking from throat area)

  • don’t even need stethoscope to hear

  • occurs with inspiration or expiration

  • high pitched sound

  • location: upper respiratory system

  • this sound occurs due to narrowing of the larynx and trachea from swelling or blockage (usually from an infection)

• conditions

  • infection (epiglottitis)

  • anaphylaxis (allergic reaction)

  • object/obstruction

MEDICAL EMERGENCY

• get nurse

A _______ sound might occur when a patient inhales and exhales due to narrowing of the larynx and trachea from swelling or a blockage

stridor

During a head to toe assessment you listen to the patient’s peripheral lung fields and hear the following sound (listen to audio)

What did you hear?

• normal lung sound (vesicular lung sound)

  • heard at peripheral lung fields

  • soft, low-pitched

  • tends to be longer and louder on inspiration than expiration

A normal lung sound is also called a _________ sound

vesicular

A patient has SOB and a Hx of asthma. You hear the following sound upon auscultation (listen to audio)

What sound did you hear? What conditions might you hear this sound?

• high-pitched wheezing (squeaky, whistling, musical sound)

  • mainly expiration (but can also occur in inspiration)

  • high pitch

  • continuous

  • location: throughout respiratory system but mainly lower

  • this occurs due to narrowing of the airways in the respiratory system

• conditions

  • asthma

  • COPD

  • lung infections

A patient is receiving treatment for pneumonia. When auscultating the lungs, you hear this (listen to audio; it is hard to hear but focus on the inspiration part)

What sound did you hear? What conditions might you hear this sound?

• coarse crackles (gurgling, bubbling)

  • start of inspiration (can extend into expiration)

  • low pitch

  • discontinuous (gurgling)

  • location: large airways (bronchi)

  • coughing doesn’t clear it

  • this occurs when the patient breathes through thick mucus/fluid in the larger airways

• conditions

  • pneumonia

  • bronchiectasis

  • infections

  • heart failure due to pulmonary edema

You may hear __________ in a patient with CHF, pneumonia, or bronchiectasis during auscultation due to them breathing through thick mucus/fluid in the bronchi

course crackles

On an EKG, every big box is equal to _____ seconds

0.2

When reading an EKG, what are the 6 things you want to look at?

1. regularity

   1. is the rhythm regular or irregular

   2. look at R-R interval; top of one QRS to the next

   3. equal # of boxes before every R-R segment = regular rhythm

2. rate

3. P wave before every QRS?

4. QRS after every P wave?

   1. if no this means there is a conduction issue btw atria and ventricles

5. PR interval

   1. < 0.20 seconds (1 big box) = conduction delay or heart block

6. QRS complex

   1. duration/shape

   2. normal: 0.1 sec (2-3 little boxes)

How do you calculate heart rate with a regular rhythm?

1. find one QRS

2. count ahead to the next QRS

3. every line goes like this: 300, 150, 100, 75, 60, 50

How do you calculate heart rate with an irregular rhythm?

1. count the number of R waves in 6 sec strip and multiple by 10

2. this is about 30 boxes

_______ is a HR under 60bpm w/ normal rhythm; when is this rhythm type an issue?

sinus bradycardia

• an issue if cardiac output is low

• determine if CO is low through checking BP!

• HR 60 + hypooo tensive = issue!

______ is a HR above 100bpm w/ normal rhythm

sinus tachycardia

True or false: ALL sinus rhythms have normal P waves, PR interval (0.2 sec) and QRS duration (0.1 sec)

true

What is the following arrhythmia? How do you know?

Supraventricular tachycardia: SVT

• high rate: 150-250

• no P wave

• QRS < 0.12 sec

What is the following arrhythmia? How do you know?

Atrial flutter

• saw tooth P wave

• high rate: 250-450

What is the following arrhythmia? How do you know?

Atrial fibrillation

• irregular rhythm

• P waves chaotic

What is the following arrhythmia? How do you know?

Premature ventricular contraction

• no P waves

• wide, early, random QRS

• could be 1 for every beat (bigeminy) or 1 every third beat (trigeminy)

What is the following arrhythmia? How do you know?

ventricular tachycardia

• rate > 100 bpm

• 3 or more PVC

What is the following arrhythmia? How do you know?

Torsades de pointes

• prolonged QT interval

What is the following arrhythmia? How do you know?

Ventricular fibrillation

• no organized rhythm

What type of heart block is this? How do you know?

1st degree

• PR > 0.2 seconds

What type of heart block is this? How do you know?

Mobitz Type I

• PR interval progressively gets longer

• then QRS drops

What type of heart block is this? How do you know?

Mobitz Type II

• regular dropped QRS every 2nd, 3rd, or 4th P wave

What type of heart block is this? How do you know?

Third degree heart block

• Ps can be hidden in QRS

• PVC

• QRS > 1 sec

What is the following condition? How do you know?

• ST segment elevation

• likely due to MI (myocardial infarction)

What is the following condition?

• ST segment depression

• myocardial ischemia

What is the following condition?

• myocardial ischemia

• inverted T waves

• could also indicate old MI

systolic heart failure will typically be associated with which heart sound?

S3

diastolic heart failure will typically be associated with which heart sound?

S4

What are some breathing interventions for cardiopulm patients?

• active cycle of breathing

  • normal 5-10 sec, deep inspr/relaxed expir 3-4 times, normal 5-10 sec, deep 3-4 times, forced expiratory to cough

• pursed lip breathing

  • smell the flowers, blow out the birthday candles

What are some cough assistance interventions for cardiopulm patients?

• butterfly technique

  • hands behind head

  • inhalation: elbows back, patient looks up

  • exhalation: elbows together, patient looks down

  • 3x, then on 4th patient coughs during exhalation

Explain how you would instruct a patient to use an incentive spirometer

• Purpose: the purpose of this intervention is to help increase lung volume and capacity

• steps:

  • take a full deep breath through the mouth piece and keep the ball between the markers

  • repeat 10x every hour; repetitions don’t need to be back to back

  • if patient is unable to keep ball between marked numbers, see what the patient can do on the first attempt and then slowly progress