Heart Sounds: Recognizing the “Four” Which are Possible
Pearls of Knowledge © BrainyNurses.com
In listening to the heart, a systematic approach is important. And remember, the more you listen, the better your skills will become. In acute conditions, listening to heart sounds is very important on presentation, and then with subsequent assessments. If heart sounds change, it generally signifies a deterioration in condition.
Be sure to determine the following with assessment.
As the valves close, S1 and S2 are produced.
We often see anion gap reported on patient charts. The gap defines the type and cause of acidosis. Normal is 8-16 mEq/L. The formula is Na+ + K+ - (Cl- + HCO3-) and luckily the computer generates the reading for us!
Only in select clinical situations, does the reading have significance from a nursing perspective. We will discuss two of the most common in this “Pearls of Knowledge”, utilizing our Memory Hint.
#1 When to give sodium bicarbonate based on the anion gap.
#2 The implication the anion gap has in a patient in diabetic ketoacidosis and insulin administration.
When a patient presents in metabolic acidosis, nurses are anticipating the administration of sodium bicarbonate. However, this may or may not be appropriate. When the anion gap is normal, sodium bicarbonate is the appropriate treatment. When the anion gap is high, the underlying condition needs to be treated, such as insulin administration in diabetic ketoacidosis.
You are invited to check out a quick review of Breath Sounds to incorporate in the assessments you make as a professional.
Check out the simplest ABG interpretation ever!
There is a lot of information available about ABG analysis. It is all important, but as a nurse at the bedside, you may be looking for a “quick and dirty” way to get to the interpretation. As I have presented this method in numerous seminars throughout the years, I frequently hear…”where have you been all my career? I have always struggled with interpretation…and this makes sense!”
Your memory hint for ABG interpretation is “If the pH and Bicarbonate are Both in the same direction, it is a metabolic disturbance”. This is similar to “R-O-M-E” which you may have learned in nursing school. But, as a practicing nurse, you may have learned it a long time ago.
As you click on the image below, check out the three examples using this method. Note the way the arrows are going with the pH and HCO3 to lead you to the correct interpretation. Patient example #3 is a septic patient....