# Cardiac Output and Cardiac Index – What's the Difference?

Mastering hemodynamics can be tricky, but the first step is understanding the terminology. Let’s take a look at cardiac output and cardiac index – how to calculate them and why they’re important.

### Cardiac Output (CO)

Cardiac output is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate. Stroke volume is determined by preload, contractility, and afterload. The normal range for cardiac output is about 4 to 8 L/min, but it can vary depending on the body’s metabolic needs. Cardiac output is important because it predicts oxygen delivery to cells.

Here’s an example:
If a patient's stroke volume is 75 mL with each contraction and his heart rate is 60 beats/minute, his cardiac output is 4,500 mL/minute (or 4.5 L/minute).

### Cardiac Index (CI)

The cardiac index is an assessment of the cardiac output value based on the patient’s size. To find the cardiac index, divide the cardiac output by the person’s body surface area (BSA). The normal range for CI is 2.5 to 4 L/min/m2.

Here’s an example of how to calculate the cardiac index:
If a patient’s cardiac output is 4.5 L/minute and his BSA is 1.25 m2, his CI would be 3.6 L/min/m2. If another patient has a cardiac output of 4.5 L/minute, but he has a BSA of 2.5 m2, his CI would be 1.8 L/min/m2.

Both cardiac output and cardiac index are important to let us know if a patient’s heart is pumping enough blood and delivering enough oxygen to cells. We also use CO and CI values to manage certain drug therapy, such as inotropics and vasopressors.

##### References Gowda, C. (2008). Don't be puzzled by cardiovascular concepts. Nursing Made Incredibly Easy!, 27-30. Smeltzer, S. B. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Warise, L. (2015). Understanding Cardiogenic Shock: A Nursing Approach to Improve Outcomes. Dimensions of Critical Care Nursing, 67-77.

Posted: 12/13/2016 9:40:25 AM by Lisa Bonsall, MSN, RN, CRNP | with 5 comments

Categories: Diseases & Conditions

# ​Nursing Conferences and Events in 2017

It’s hard to believe that 2016 is coming to a close. We’ve had some amazing experiences at nursing conferences and events this year.

Our senior publisher, Bob Maroldo, and I attended the NSNA Annual Convention in the spring in Orlando, where I met many excited and eager nursing students about to start their careers. I also had the chance to go to Nursing2016 Symposium and National Conference for Nurse Practitioners (NCNP) in Orlando with our clinical editor, Lisa Bonsall, MSN, RN, CRNP. You can see a highlights video of all the fun we had on our Lippincott YouTube Channel.

Lisa also attended the NCNP’s fall conference in Chicago with our senior editor, Kim Fryling-Resare, as well as Nursing Management Congress (NMC) 2016 in Las Vegas.

Our team had a blast meeting and greeting nurses from all different practice areas and specialties -- we can’t wait for the upcoming nursing events in 2017! We compiled a variety of nursing conferences and events happening next year and here are a few to look out for.

Nursing Events 2017
• National Conference for Nurse Practitioners: The Conference for Primary and Acute Care Clinicians, April 19-22nd, Nashville, TN.
• Nursing Management Congress 2017, October 2-6th, Las Vegas, NV.
National Conference for Nurse Practitioners: The Conference for Primary and Acute Care Clinicians, October 9-12th, Las Vegas, NV.

To see all the nursing conferences in 2017, visit our Nursing Events Calendar.

Which conferences are you planning to attend?

Posted: 12/8/2016 8:02:11 AM by Cara Deming | with 5 comments

Categories: Continuing Education

# Lifelong Learning in Nursing: Macro Trends in Nursing 2016 [Infographic]

With the end of 2016 quickly approaching, it’s important to look ahead to the future trends happening in the nursing profession. More and more, nurses are going back to school to earn higher degrees, but why? "Life-long learning keeps nurses up-to-date on the advances in practice and can help them critically think more thoroughly because they have more evidence and information to inform their practice decisions,” explains our Chief Nurse, Anne Dabrow Woods DNP RN CRNP ANP-BC AGACNP-BC FAAN.

Whether you’re a nurse with a diploma or associate’s degree contemplating achieving your BSN, or you’re looking to pursue an advanced degree in nursing, you’re not alone. According to a 2014 survey by the American Association of Colleges of Nursing (AACN), there’s been a “4.2% increase in students in entry-level baccalaureate programs (BSN) and a 10.4% increase in ‘RN-to-BSN’ programs for registered nurses looking to build on their initial education at the associate degree or diploma level. In graduate schools, student enrollment increased by 6.6% in master’s programs and by 3.2% and 26.2% in research-focused and practice-focused doctoral programs, respectively.”

With this new shift to lifelong learning in nursing, educators are adapting the way to they teach their students. “When we were [originally] taught how to educate students,” Woods says, “we were taught to sit them in a classroom and to lecture to them. That is not reality anymore today. What we’ve seen is a whole flip of the classroom so that the students or nurses…read, learn, and then come together and they discuss how to actually apply the principles that they’ve learned. That’s called the ‘flipped classroom,’ and that is what we are going to be using from now on.”

To discover more about the flipped classroom and other changes in lifelong learning in nursing, utilize this handy infographic.

Remember to bookmark our blog and look out for the next three trends in nursing. Our Chief Nurse also gave a presentation on the six key trends in nursing. To see Woods’ full Macro Trends in Nursing 2016 presentation, go to the Lippincott NursingCenter YouTube channel

Add this first infographic to your website by copying and pasting the following embed code:

 Lifelong Learning in Nursing By Lippincott NursingCenter

Posted: 11/28/2016 8:34:54 AM by Cara Deming | with 1 comments

Categories: Inspiration

# Nursing Management Congress (NMC) 2016

Nurse leaders + Las Vegas + a Presidential election = a busy conference week! Whew…it certainly was an eventful week as nurse leaders from around the world got together in Las Vegas for Nursing Management Congress 2016!

#### Preconference workshops

For two days, preconference workshops were in action. The New Manager Intensive provided fundamentals for success for those new to the role, including calculations – staffing, supplies, and equipment – to effectively and safely run a unit. In addition, new managers brushed up on relationship and communication skills, as well as handling the pressures of leadership through a period of health care reform. The Experienced Nurse Leader Intensive covered topics related to the business of health care, such as aligning with organizational goals, team development, and improving performance. Other sessions during these two days included a Certification Prep Course, Creating a World-Class Culture, and Improving the Patient Experience.

#### An opening session to remember

This was my first real exposure to Zubin Damania, MD, aka ZDoggMD, and I am now a big fan! His humor, talent, and passion for improving the patient experience were inspiring. He encouraged us to “reshuffle our deck” and embrace a new era of health care – Health 3.0 – re-personalized medicine with a focus on building relationships.  Here’s a brief video clip from his keynote address:

You can find ZDoggMD on YouTube, Facebook, and twitter. His “membership-based primary care and wellness ecosystem”, Turntable Health, is truly breaking down barriers.

#### So much learning

While I’ve never held a role in nursing management, the knowledge and advice from the experts at NMC are beneficial to all nurses. Here are some of the pearls and tips I learned:
“To be a successful leader, you must be flexible and move quickly in decision making.’”
Opening Session
Jeffrey Doucette, DNP, RN, FACHE, CENP, LNHA

“Until you change people’s minds about their work habits, they’re not going to change their work habits.”
Changing the Culture of Fatigue: A Nurse AND Patient Safety Problem
Mary Lawson Carney, DNP, RN-BC, CCRN, CNE

“Understanding quality across the continuum will lead to improved outcomes across the continuum.”
Reducing Readmissions Across the Care Continuum
Leonard L. Parisi, RN, MA, CPHG, FNAHQ

“Nurses should prepare for the future by keeping their eyes on how nursing care helps patients become and stay healthy and allows the health care system to work smoothly.”
Nursing Workforce Predictions: What’s Really Happening?
Sean Clarke, PhD, RN, FAAN

“It’s the simple solutions that get us where we need to be.”
Getting the Most from People Around You
Andrea Mazzoccoli, MSN, MBA, PhD, FAAN

“The curse of knowledge…We forget what it was like to not know what we know now.”
Talkin’ Bout My Generation: Generations in the Workplace should be Your GREATEST Strength, Not Your Biggest Headache!
Libby Spears

As next year’s planning gets underway, we invite you to look at our 2016 NMC photo album, see social media highlights, and submit an abstract!

See you next year!
#NMCongress

Posted: 11/25/2016 6:47:52 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

# Three more gift ideas for nurses

Last year, during the holiday season, we shared Three inspirational gifts for nurses. This year, we’ve got some more gift ideas to share with you! Explore the products below and consider which nurse you’d like to surprise this year with a special gift. You may even want to pick up one of these for yourself, or leave some hints for your family and friends!

### Reflections on Nursing

Offering life- and career-changing moments in nurses’ lives, the 80 true stories in Reflections on Nursing, from the American Journal of Nursing, reveal nursing at its most demanding and fulfilling. These inspiring, true stories—written by nurses in numerous care settings—show nursing as both professional and life experience, and often, as an inspired journey. Here’s a look at some of the stories that caught my eye: In the Hand of Dad: Preemie's struggle becomes one nurse's journey with a father; At Her Mercy: A nursing instructor finds herself in the hands of a challenging former student; and Nurse, Heal Thyself: Walking in the patient's shoes.

### Inspired Nurses Calendar

I picked up my copy of the Inspired Nurses Calendar earlier this month and have already put it to use! This is the gift that keeps on giving all year! Each month showcases a different story from a nurse that demonstrates our hard work and dedication. You will be reminded daily of what it means to be a nurse. By reading these stories, such as that of a NICU mom who went on to become a NICU nurse or a church missionary nurse now pursuing her DNP, you’re sure to be reminded of your own journey in nursing and your past experiences, and probably ponder, as I do, what the future holds.

Based on the same content used by hospitals and brought to you by the most trusted source in nursing, the Lippincott Advisor app is an expanding collection of over 2,000 evidence-based, clinical decision support entries on diseases, treatments, signs and symptoms, and diagnostic tests that are updated quarterly. You can take all that you learned in school with you and be able to make clinical decisions at the bedside – safely and confidently.

Have a wonderful holiday season!

Posted: 11/21/2016 8:43:54 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Inspiration

# The role of nurses, APNs, and healthcare reform in a changing political climate

This week has demonstrated that the political climate in the United States is not fixed in a stationary position but, is dynamic. Many of you will be asking yourselves what does this mean for healthcare reform, the Affordable Care Act, and for nurses and advanced practice nurses (APNs) in the United States. The bottom line is we just don't know. However, one thing we are sure of is, healthcare needs to be reformed and we must be present at the table when options are being discussed.

So, what can you do?

First, you need to understand your scope of practice and if you live in a state with restricted practice, you need to continue to lobby your congressmen and senators about the value nurses and APNs bring to patients and healthcare delivery.

Secondly, be the voice of reason. There are many things about the Affordable Care Act that have improved access to care and quality of care; we must be able to articulate why those things are important and why they need to stay from a cost-benefit and cost-effectiveness perspective.

Thirdly, educate our healthcare colleagues and healthcare consumers about who we are as a profession and why having a nurse and an APN as part of the healthcare team improves quality, patient-centered care.

And finally, remember our history and the great strides we have made as a profession. The profession of nursing is growing and changing based on the needs of those we serve. We are all Americans and our goal is to improve patient care and outcomes regardless of who is in power.

In conclusion; step up, have a voice, be able to articulate the message, and speak from a position of knowing what you do in practice does make a difference.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Health Learning, Research & Practice

Posted: 11/11/2016 9:03:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Inspiration

# Trauma-informed care

I stood in the doorway of room 630 and observed her staring out the window, consumed by thought. She was a 20-year old young woman who had been admitted to the medical unit due to gastrointestinal bleeding. I walked into the room, introduced myself and told her that I needed to perform my initial physical assessment. I put on my stethoscope and motioned closer, then she raised her hands and said “Please, don’t.” I stepped back, confused, and informed her that I needed to check on her bleeding and to make sure everything was ok. She shook her head as tears filled her eyes. I asked her why she was crying and she stated “because I don’t feel comfortable having a stranger touch me.” I assured her that I wouldn’t hurt her and after several more minutes of silence she stated, “I was sexually abused as a teenager.” I thanked her for sharing that very personal and painful information and asked how I could make her more comfortable. She was grateful and just asked for more time. It was early in my nursing career, and I didn’t have any specific training or experience dealing with trauma victims.

Traumatic events, such as sexual abuse, domestic violence, elder abuse, and combat trauma, can have serious long-term detrimental effects on the physical, emotional, and mental well-being of an individual. These life events may lead to depression, distrust, smoking, substance abuse, shame, and low self-esteem. Traumatic events can also shape an individual’s comfort level and attitude toward health care.1 Routine preventative health care visits that involve invasive physical exams and close contact with a health care provider could trigger fear and anxiety in the patient.

Trauma-informed care (TIC) is a term that has been used in recent years in a variety of areas, including social services, education, mental health, and corrections to address the needs of people who have experienced traumatic life events. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a methodology to respond to those who are at risk or have experienced trauma.2 There are four essential approaches and six principles of trauma-informed care.

The four essential approaches of trauma-informed care can be found in a program, organization, or system that2:
1. Realizes the widespread impact of trauma and understands potential paths for recovery.
2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
4. Seeks to actively resist retraumatization.
The six key principles of trauma-informed care include2:
1. Safety – make sure your patient and family members feel safe, both physically and psychologically.
2. Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
3. Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
4. Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
5. Empowerment, voice, and choice – identify individual strengths and differences and utilize them as the foundation for recovery and healing. Provide the patient with choices and an opportunity to share in the decision-making process, which results in a sense of control.
6. Recognition of cultural, historical, and gender issues – set aside cultural stereotypes and biases.
How do we put these principles into every day practice? For patients who openly share their trauma history, clinicians should be careful when delving into their psychological histories, unless they have specific training in trauma.1 Many patients, however, feel ashamed and are not comfortable exposing their past. Every member of the health care team should be trained on universal trauma precautions, which is the idea that every person potentially has a history of trauma.2 There are several strategies that clinicians can utilize to implement the TIC approach in general patient care. 1

1. Patient-centered communication:
1. Ask every patient what can be done to make them more comfortable during their appointment.
2. Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
3. Give the patient the option to shift their clothing out of the way instead of putting on a gown.
4. Provide a pillow for back support for patients who are anxious in the supine position.
5. Offer a mirror to see procedures or examinations that a patient cannot see.
6. If a patient seems moderately to highly anxious, offer ways for patients to signal distress either verbally or by raising their hand during a procedure.
2. Understanding the health effects of trauma:
1. Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
2. Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.
3. Multidisciplinary collaboration:
1. Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
2. Keep referral and educational material on trauma available in waiting rooms.
3. Engage in inter-professional collaboration to ensure continuity of care.
4. Understanding your own history and reactions:
1. Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
2. Learn the signs of professional burnout and prioritize good self-care.
5. Screening:
1. Decide if your organization will screen for current trauma or a history of traumatic events.
2. Consider if screenings will be face-to-face or self-reported by the patient.
3. Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
4. Ensure your organization has the resources available to properly care for the patient, or have processes in place to refer patients to other resources.
Unfortunately, traumatic events occur more often in our society than we think. Caring for patients with a history of traumatic life events requires a high level of sensitivity and compassion. Health care organizations can assist their staff in navigating delicate and difficult situations by providing educational training, tools and resources on the trauma-informed care approach.

Resources for Health Care Providers:
Child Welfare Information Gateway
National Council for Behavioral Health
Substance Abuse and Mental Health Services Administration
The Trauma Informed Care Project

2. ##### Koetting, C. (2016). Trauma-Informed Care: Helping Patients with a Painful Past.Journal of Christian Nursing, 33 (4), 206-213.
Myrna B. Schnur, RN, MSN

Posted: 11/10/2016 2:29:07 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Patient Safety

# 10 Ways to Make the Most of Your Holiday Nursing Shift

As October comes to a close, we can feel the excitement and, at times, stress of the holidays approaching. While many people are out buying their last-minute Halloween costumes or planning their Thanksgiving menu, or even setting up their Christmas decorations (we know, early!), nurses are preparing for working their holiday shifts.

Working over the holidays is a reality check for nurses. While other professionals get this time off to be with their loved ones, nurses are caring for their patients and working to ensure the safety of other people’s friends and family members. While it is an honor at any time to care for the sick or injured, we understand it can be especially difficult at the celebratory times of the year.

To make these occurrences a tad easier, and even fun, here are 10 ways to make the most of your holiday nursing shift.

Start planning your holiday shifts way ahead of time. Coordinate with your loved ones on days to celebrate that work around your schedule. For instance, if you are working over Thanksgiving, plan to celebrate a day or two later. Speak with your manager about the best way to ensure you are there to cover your shift, but that you also have time built in for those holidays that are important to you.

Do you normally do the bulk of the Christmas or Hanukkah cooking? Ask your family members to pitch in or organize a pot luck so everyone shares the labor. If you know you are scheduled to work over a holiday, know your limits and time constraints and ask those around you to assist in the holiday preparations.

3. Be prepared
If you are scheduled to work over certain holidays, be prepared to meet any holiday-related needs of patients. Be on the lookout for complications of diabetes and dehydration over Halloween and be sensitive to how costumes may interfere with your ability to care for a patient or how they may affect a patient, especially those with a mental illness. Be ready for cooking-related injuries, such as burns or cuts, around Thanksgiving. Pay extra attention to patients suffering from depression around Christmas and New Year’s Eve. If you know what to look for, you will feel more prepared when encountering these situations.

4. Make your work space feel like home
With permission from your manager, decorate your work station over the holidays. Put up paper pumpkins and turkeys. String twinkle lights and set up a holiday tree or bush. Just be sure to be sensitive and inclusive of everyone’s holidays, not just your own.

5. Organize a work party
Many times, your co-workers can feel like family. Take some time during a shift to celebrate with your team. Have everyone bring in their favorite holiday treat or consider exchanging small gifts. You may also consider planning a holiday party outside of your work setting. It’s nice to take the time out to blow off steam and enjoy your co-workers’ company.

6. Celebrate when you can
Working over New Year’s Eve? Celebrate at a time that works for you. Start the countdown at 5am with the other nurses working alongside you. If you want to celebrate with family and friends, you can do the same – pick another day and/or time, adjust your clocks and watches and ring in the New Year accordingly.

7. Be resourceful
Make the most of your breaks during your shift. If able, Skype with friends and family, follow their photos on Facebook or Instagram, or ask someone to share videos of the holiday gatherings with you. Utilize available technology to stay as connected as possible.

8. Be mindful
Be mindful that the patients are there for the holidays too. Try to lift their spirits by asking if they would like their room decorated or try speaking with them about happy holiday memories. You may be able to help accommodate visitors or help patients get in touch with family and friends.

Too busy to decorate for your favorite holiday? Not enough time to go to the mall to buy gifts? Too stressed to cook your traditional holiday meals? Cut corners where you can; shop online, skip the decorating all together, order take-out or pick up prepared food from a local store. Determine what you can do without and compromise where you can.

10. Focus on the positive
Depending on your work place, there may be benefits to working a holiday shift, such as extra pay or the next holiday off. During the holidays, you may also get to enjoy a slower work pace and a shorter commute. On top of that, you are in it together with your fellow nurses and your patients, who all are there to share the holiday with you.

How do you make your nursing holiday shift work for you? For other ideas, check out this blog from Lippincott Solutions, Making the Best of Holiday Shifts

Posted: 10/25/2016 8:27:56 AM by Cara Deming | with 0 comments

Categories:

# National Conference for Nurse Practitioners (NCNP) 2016

The fall edition of the National Conference for Nurse Practitioners took place earlier this month in Chicago. It was yet another remarkable conference in a great city. Here’s a look at some highlights from the conference and what I learned.

#### Words from the Experts

My schedule was full with sessions related to dermatology, pain management, critical care, and more! Here are some of the pearls and tips I learned from the sessions I attended:

“Engage patients. Say ‘What matters to you?’ rather than ‘What is the matter with you?’”
Healing Health Care: The Nurse Practitioner Solution
Tom Bartol, NP, CDE

“The two most powerful tips to prevent premature aging are never smoke and limit UV exposure.”
Identifying and Treating Common and Benign Skin Conditions
Victor Czerkasij, MA, MS, FNP-BC

Acute Care: Recognizing and Managing Respiratory Failure
Anne Dabrow Woods, DNP, MSN, RN, CRNP, ANP-BC

“Things will speak through the skin that have nothing at all to do with the skin.”
Victor Czerkasij, MA, MS, FNP-BC

“When initiating opioid therapy, have an exit strategy from the very beginning.”
Opioid Prescribing: Safe Practice, Changing Lives
Barbara St. Marie, PhD

“Suboptimal nutrition is a main contributor to postoperative complications.”
Optimizing Outcomes with Pre-Op Evaluation
Monica N. Tombasco, MS, MSNA, FNP-BC, CRNA

“There is a strong placebo effect in treatment of IBS. Why? Because symptoms come and go.”
New Concepts in IBS
Christopher Chang, MD, PhD

“When evaluating pain treatment, go beyond the number...ask about functionality. ‘What can you do now that you couldn't do before?’”
Chronic Pain Management
Yvonne D’Arcy, MS, CRNP, CNS

“The outcome of heart failure is about as severe as most malignancies.”
Comprehensive Management of Heart Failure
Louis Kuritzky, MD

“Zika Virus – why now? It's a novel virus introduced to a population with virtually no immunity."
Emerging Infectious Disease Threats: Dengue Fever, Chikungunya, Enterovirus D65, Avian Flu, and Zika Virus
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC

#### New (to me) Resources

I enjoy when presenters include websites and tools that I can add to my own list of go-to resources. Here are some that I’ve added to my favorites: style type="text/css">ul{margin-left:16px;}
• Recreating Healthcare — an open and interactive site where visitors can share ideas about health care, and read and comment on the ideas of others.
• TheNNT — quick summaries of evidence-based medicine provided by a group of physicians.
• The Collaborative for REMS Education (CO*RE) — tools and resources for safe opioid prescribing.
• Trauma.org — image databank and other resources for professionals in trauma and critical care.

#### Posters

Poster presentations often pull me in because it’s great to see the work that others are doing. It’s so important to share and learn from one another and presenting one’s work at a national conference, such as NCNP, is impressive! While all of the posters were well done and informative, what struck me were two common themes that emerged; there were multiple posters related to pediatric care and still more about shared medical appointments. You can take a look at a selection of the posters (as well as other pictures from the conference) here in our Facebook photo album.

#### Technology and sharing

As an attendee myself, I found the conference app helpful to keep track of my sessions and fill out evaluations as part of the process for obtaining my continuing education credit. Other features allowed me to learn about exhibitors and even vote on the poster presentations.

Social media was strong at the conference with attendees, conference staff, and exhibitors using the hashtag, #NCNPconf. Attendees shared what they learned and even posted photos of themselves in our selfie booth! Exhibitors also tweeted and shared information about their products and contest winners.

Stay tuned for details for NCNP 2017 (#NCNPconf) next spring in Nashville, Tennessee!
Hope to see you there!

Posted: 10/19/2016 9:00:44 AM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Continuing EducationEducation & Career

# Breath sounds: Test your knowledge

Below are the results of a recent nursing quiz about lung auscultation posted on our Twitter page. This revealed a need for clarification of common adventitious lung sounds and the commonly associated clinical conditions.
Answer: B. Crackles are heard when collapsed or stiff alveoli snap open, as in pulmonary fibrosis. Wheezes are commonly associated with asthma and diminished breath sounds with neuromuscular disease. Breath sounds will be decreased or absent over the area of a pneumothorax.

First, let’s review the most common adventitious lung sounds.
A wheeze is high-pitched continuous musical sound, which may occur during inspiration and/or expiration, due to an obstructive process. The classic wheeze may be referred to as “sibilant wheeze.” This refers to the high-pitched whistle-like sound heard during expiration, typically in the setting of asthma, as air moves through a narrow or obstructed airway.

Alternately, what we often refer to as rhonchi is the “sonorous wheeze,” which refers to a deep, low-pitched rumbling or coarse sound as air moves through tracheal-bronchial passages in the presence of mucous or respiratory secretions.

In stridor, you’ll hear high-pitched, monophonic inspiratory wheezing. It’s typically loudest over the anterior neck, as air moves turbulently over a partially-obstructed upper airway.

Crackles, or rales, are short, high pitched, discontinuous, intermittent, popping sounds created by air being forced through an airway or alveoli narrowed by fluid, pus, or mucous. These sounds may also be heard when there is delayed opening of collapsed alveoli.

Crackles are typically heard during inspiration and can be further defined as coarse or fine. Coarse crackles are heard during early inspiration and sound harsh or moist. They are caused by mucous in larger bronchioles, as heard in COPD. Fine crackles are heard during late inspiration and may sound like hair rubbing together. These sounds originate in the small airways/alveoli and may be heard in interstitial pneumonia or pulmonary fibrosis.

Now, let’s think about test-taking strategies. In this instance, it would be helpful to go through each clinical condition separately and predict what you may hear on auscultation.

The first choice was asthma. Asthma is a condition mediated by inflammation. The resulting physiologic response in the airways is bronchoconstriction and airway edema. This response is triggered by an irritant, allergen, or infection. As air moves through these narrowed airways, the primary lung sound is high-pitched wheeze. Initially the wheezes are expiratory but depending on confounding factors or worsening clinical symptoms, there may be inspiratory wheezes, rhonchi or crackles. For testing purposes, however, expiratory wheezes are associated with asthma.

The second choice was pulmonary fibrosis. This is a form of interstitial lung disease in which scarring (or fibrosis) is the hallmark clinical feature. This scarring leads to thickness and stiffness in the lungs. The most common adventitious sound associated with pulmonary fibrosis is fine bibasilar crackles. This may be hard to distinguish from congestive heart failure. The crackles are the result of the snapping open of collapsed, stiff alveoli.

Neuromuscular disease was the third choice. Neuromuscular disorders can cause respiratory problems through several pathways as the muscles responsible for breathing are affected. Diaphragmatic weakness can lead to hypoventilation; chest wall muscle weakness can lead to ineffective cough; and upper airway muscle weakness can lead to difficult swallowing and ineffective clearing of upper airway secretions. In general, there are not specific adventitious sounds associated with neuromuscular disorders.

Lastly, a pneumothorax is a collapsed lung. There would be loss of breath sounds over the area of a pneumothorax as there is no air movement in the area of auscultation.

So, this leads us to the correct answer. During lung auscultation, crackles are heard in pulmonary fibrosis, which is choice B.

Reviewing what you know and thinking about each response choice can help you focus in on the correct answer. Do you have an easy acronym or pearl for remembering breath sounds, or some test-taking strategies to share?

##### Reference: Hinkle, J. & Cheever, K.  (2013). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

Megan Doble, MSN, RN, CRNP

Posted: 10/11/2016 7:54:17 AM by Lisa Bonsall, MSN, RN, CRNP | with 7 comments

Categories: Diseases & Conditions

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