Heart Sounds – Advanced Assessment

The cardiac exam always starts when you walk in the room, long before you start putting this on your
patient, and essentially when you look at your patient and decide whether or not they really are in
distress. You know, a patient is complaining of chest pain could just be from some sort of
musculoskeletal injury and they could be quite comfortable sitting there and not have any other
evidence of any systemic or cardiovascular badness happening at the time. In contrast, a person
who's in acute coronary syndrome, it shouldn't be that subtle, if they have a significant coronary
event happening. They may have diaphoresis on their forehead with evidence of just sweating. They
may look really anxious and uncomfortable. Certainly, they may be in respiratory distress, which we'll
talk a little bit more about in the pulmonary section. And hey, they may even be clutching their chest
right before your eyes as evidence of the source of this crushing chest pain that they're
experiencing.

So having done that our patient, at least at the moment, looks fairly calm, doesn't look like he's
having a lot of anxiety, is not clutching his chest, and he's not diaphoretic. So that's a good sign, we
can take our time by examining this patient. With that, let's talk about the cardiovascular exam. So
when you know the cardiac exam, many things are possible. Now, what do I mean by that? Many
things are possible is actually not just a statement of fact, it's also an acronym. It's a useful way to
remember the heart valves. Many Things Are Possible is M-T-A-P. Those letters represent the
sequence of closing of the four heart valves in the heart, the mitral, the tricuspid, the aortic and the
pulmonic. You'll remember which sequence those valves are closing. You'll also remember where
they're located. This is a circle, M-T-A-P.

M-T-A-P, which helps us to keep track of where we are when we're listening for particular
murmurs and trying to find the etiology of a particular murmur that we hear based on the location on
the anterior chest wall. The next thing to talk about is once we lay our stethoscopes on his
chest, we're going to be listening in particular to three phases of the cardiac cycle. You're going to
listen first to heart sounds, that is your S1 and S2, also known as your "lub-dub, lub-dub, lub-dub".
We're going to listen to the S3 and S4 parts of the heart sounds. Those are your gallops, which can
accompany your "lub-dub and lub-dub".

The second part is systole. So we're going to focus very deliberately on listening to the space
between S1 and S2. And then we're going to listen to diastole, the space between S2 and S1. And I
found that really important when you're auscultating the chest to make sure you really very
deliberately listen to one thing at a time. First, the heart sounds, then systole then diastole. That
helps you to avoid the common mistake of getting so sucked into a very loud systolic murmur that
you neglect to hear that more subtle diastolic murmur that's happening afterwards. So with that,
opening outline, heart sounds, systole, diastole, let's start off by talking about the heart sounds.

So S1 and S2, "lub-dub lub-dub", as we said before, many things are possible so M and T are the
first heart sounds, so that must represent S1, and then A-P represent the second heart sound, S2.
These are paired together because they're so closely occurring in space, all we hear is a "lub", not
two different sounds just the "lub", and then the "dub" is the A and the P. Importantly, the S1 and S2
heart sounds are higher in pitch than some other sounds that you might hear. And this leads me to
our important quick brief on your stethoscope. The stethoscope has two heads on it, you've got a
bell, you've got a diaphragm. These are useful in different circumstances. In particular, the bell of
your stethoscope is most useful for low-pitched sounds. It actually, by putting the bell on the chest
and creating a seal, you are filtering out a lot of the higher pitched sounds.

In contrast, the diaphragm is useful for hearing all of the different pitches within the heart, though
with potentially a little bit of a focus on some of the higher pitched sounds. So when you're using the
diaphragm - you're thinking higher pitch, the bell - you're thinking lower pitch. So I just said that the
S1 and S2 heart sounds, we know that there, we're going to best hear S2 up here, we're going to
best hear S1 down here. And typically you're listening with the diaphragm because they're both
higher pitch sounds, like so. Now in some patients, you may find that rather than just hearing this
simple "lub-dub, lub-dub, lub-dub", maybe you hear an extra sound, something like the "buh-lub-dub,
buh-lub-dub, buh-lub-dub". That is an extra heart sound, in this case a "buh" occurring before the
"lub" and that's called an S4. It immediately proceeds systole and it's called a fourth heart sound. It's
part of the atrial kick.

What's happening when you hear an S4 is that the left ventricle has fully filled during diastole, you
have diastolic filling, and at the end of diastole, the left atrium is contracting and spitting out that last
volume of blood from the atrium, but it's hitting against a stiff left ventricular wall. And this is
something that you'll hear in patients with left ventricular hypertrophy, potentially hypertrophic
obstructive cardiomyopathy. And it's a very characteristic feature that you'll find in a lot of folks, and
it does portend or suggest that a patient does have one of those conditions. Importantly, that "buh-
lub-dub", the "buh" is a lower pitched sound. And as I said before, that means you're going to best
catch it with the bell of your stethoscope. Before we find it, though, let's just quickly talk about the
other kind of abnormal gallop that you might hear.

Rather than "lub-dub, lub-dub lub-dub", you might hear a lub-duh-bub, lub-duh-bub, lub-duh-bub,
lub-duh-bub, essentially, that is a sound happening right after S2. So rather than "lub-dub", it's "lub-
duh-bub, lub-duh-bub". And you can tell that that "bub" is coming right after the "duh", which would
have been a "dub", and that is an indication of an S3, a third heart sound. Now our third heart sound
is also emanating from the left ventricle down here at the apex of the heart. And rather than being
associated with left ventricular hypertrophy, it's typically found in acute systolic heart failure, with left
ventricular dilation, potentially increased filling pressures and almost always some evidence of
systolic heart failure, whether it's in the setting of ischemic cardiomyopathy, or potentially if
somebody has aortic regurgitation with a surplus of blood backfilling into the heart, then has to be
ejected.

So that sound is also heard at the apex, which is where of course the left ventricle is going to be best
heard. And it's also a low pitch sound just like the S4. So the ideal way to bring about that sound, it's
going to be with the bell. And since we really want to try and accentuate that sound, because it can
be very subtle to hear We're also going to reposition our patient and lie him in the left lateral
decubitus position to really bring out that heart sound. Alright, so now that we have Shawn in the left
lateral decubitus position, this is the ideal place for us to try to pick up a third or fourth heart sound.
I've got the bell of my stethoscope lightly applied to his chest, simply to provide a seal if I push too
hard, I'm actually just creating a diaphragm out of the skin. So you just want to have light pressure at
the apex and that's it.

Now, there's a couple different positions that you may see over the course of this next few minutes.
Depending upon what you're looking for, you may have him lying in the left lateral decubitus
position, you may have him sitting upright, you may have him lying flat. In general, you don't want to
have to repeat the entire cardiac exam in all three positions. So as we go through each murmur,
each type of valvular disease, I'll talk about which positions may be most appropriate.
 Nursing Assessment of the Heart

Now, anytime you listen to the heart, take your stethoscope get your ears placed into your heart, you
always hear that lub dub, lub dub. So a lub dub is one, lub dub is two,  that's how you're going to
count you're listening to your heart or auscultate. So this is what we call your S1 and S2 heart
sounds. Now this is going to correlate with the blood pumping out of the ventricles, and then you're
going to hear the closing of valves. So the first sound that you hear, that lub, this is what we call our
S1. Now, at the bottom of this image of the heart, the ventricles are really important here. Here's
where they can tract and they're going to pump blood out of the body. And we're going to hear that
little bit of closing of that tricuspid and that mitral valve. Now that's where we're going to hear the S1
from the closing of these valves. So there's our lub.

Now for moving on to our S2, which is our dub. This is after we've received that blood, and then we
start hearing the diastole phase. So this is where we hear the aortic and that pulmonic valve
close, causing a little bit of that vibration causing the S2. So don't forget, you hear a lub dub  S1, S2,
and that is 1B. Now just know the increase in intensity of the sound can main mean that there's
certain conditions. And again, there's various of sound such as clicks or something else that you
may hear whooshes. Just note these and make sure you talk to your patient and also make sure that
you check with your health care provider.

Now let's take a little bit deeper look of how we perform a cardiovascular assessment and some key
considerations. Now we're going to use our diaphragm of our stethoscope here and we're going to
auscultate or listen. For 30 beats three really big things. So we need to number one see, is the
rhythm regular? So if you recall, we're going to listen to that lub dub, S1, and it should be very
regular and on time. So it may sound like lub dub, lub dub, lub dub, lub dub, and as you can hear
very regular and on time. Now sometimes you may hear some irregularity. Now this could be mean
that the patient has a irregular rhythm such as atrial fibrillation, and that's important to know. So it
may sound like lub dub, lub dub, lub dub, lub dub, lub dub lub dub, so you can see that's not
regular and that's important to know and communicate with the healthcare provider. And of course,
don't forget about the heart rate of your patient.

As you recall, 60 to 100 is what we consider normal,  but your patient's resting heart rate may be a
little bit different. So it's important for you to assess it and note that first. You may listen to the heart
rate, and it may be really fast, like tachycardia, or really slow. So this is important to know based on
medications and other treatments that the patient may have. And of course, if you hear any
whooshes or clicks, you want to note these as well. You might hear something like an artificial heart
valve when you're listening to your patient. An important note as well, if you're given some certain
cardiac medications like digoxin, for example. It's really important that you listen to the heart or
auscultate for one full minute and get a true apical pulse. Now this is important for that particular
med because with digoxin, if the patient's heart rate is less than 60, we will hold that med. So here to
get the truest and most accurate assessment, we listen for an apical pulse.

So when we're talking about auscultation with a cardiovascular assessment, if you take a look at
these images, and you see all these little red circles or hotspots, these are all different areas of the
thorax or the chest that you can listen to, to auscultate the heart. However, the erbs point that you
see pointed out here is the auscultation location for heart sounds and heart murmurs and this is
really preferred. Now as you can see, this is located between about the third intercostal space in the
left lower sternal border. And now here at this erbs point, you should be listening for the S1 and S2
here. Now again, nice thing if you think about you put your stethoscope to the patient's chest at any
of these points, even maybe down to the apex, that horde is going to radiate and that sound can
radiate. So you want to make sure you listen to the spot that you can pick up and listen to that lub
dub. But again, for heart sounds or heart murmurs, that erbs point is definitely preferred.

Nursing Assessment of the Vascular System

Now, let's talk about when we talk about cardiac, It is more than just your heart rate, your heart
rhythm. We've got to think about that heart perfuses all the rest of our body. And this is going to be
an assessment details that are important to include. Now, this is going to include your pulses, your
jugular vein distension. And we'll get into that a little bit more. Capillary refill, and also checking the
edema. So again, your vascular system tells us a lot about the cardiovascular and circulatory status
of your patient.

So we're talking about pulses. so palpating pulses, if you remember palpating the feeling that are
central and distal. Now, it's important here that you're going to compare sides. We want to check the
rate, we want to check the rhythm, and how regular it is just like that lub-dub. We want to check the
tension. So if we talk about compressing an artery if you push on it, you should feel some like
rebound, some flexibility. And there should be a certain amount of resistance. And also when we talk
about strength or volume, we're looking here: Is it strong? Is it bounding? Is it weak? Can we barely
feel it? These are all important things to note when we're talking about pulses.

So if you take a look at this image here on our guy, you see there's pulses all over the place. We've
got lots of pulse points starting in the neck with carotids, your brachial artery for blood pressure, your
radial which is in the wrist, and your radial artery is very easy to find. So many times you're gonna
gain a pulse rate from the radial artery. Your femoral artery, the popliteal behind the knee, and of
course, those in the feet. All of these are really important, circulatory points.

Now, when we're talking about palpating pulses, here's something to keep in mind, like, especially if
you're teaching or learning how to assess a radial pulse. Now, when we're talking about palpating
pulses, here's something to keep in mind, like, especially if you're teaching or learning how to assess
a radial pulse. So if I'm finding my radial, for example, if I go down my thumb side, use my thumbs.
And you notice I'm not here pushing down, I'm more flat, I can easily find my radial pulse. Now, one
key note, don't use your thumb, your thumb has a pulsating in itself and this can give you an
inaccurate reading and assessment.

So next, let's talk about something we call JVD or Jugular Vein Distension. So this is a sign of
increased venous pressure inside of our body. Now this can be a sign of a lot of issues. So this is
really showing when we're talking about central venous pressure. It just tells us how much blood is
flowing back into the heart, how well that heart can move into your body or through your body into
your lungs and back into the rest of your body. But if you see this JVD, if you take a look at this
image, you see we're here in the jugular, meaning the neck, you see this vein is all engorge and it's
here to the surface, that indeed is jugular vein distension. That means we've got too much fluid in
our circulatory system on board. And this can cause lots of issues. So if we assess that, we need to
examine the client with the head of bed about 45 degrees. And so when we're looking at that vein in
the neck, is it distended, engorge, and popping out like you see in this image, or is that
pulsating? This is all something you want to report to the health care provider. Now another really
easy and important vascular system assessment is capillary refill. So this is really helpful on
diabetics and specially on feet and toes of a diabetic patient. Capillary refill is really simple and it's
effective. Here we're just checking peripheral perfusion or blood flow to our extremities. So all we do
here like you see in the image is take a finger, push down on the patient's fingernail.

Now we should see normal color come back within three seconds. If it's any longer than three
seconds, this is abnormal. And clearly if the patient has fingernail polish, you may have to remove
this. Now, in next thing to talk about when you're talking about the vascular system, if you see any
signs of what we call cyanosis, cyanosis is a bad thing. So if you see this bluish color, like you see in
the image here, if you see it in the hands, the feet, the lips or the face, any of this have signs of
cyanosis or this bluish color, we have low oxygenation. We are not perfusing, meaning we're not
getting good blood flow to tissues and this is an emergency. You can lose tissues and this is a
problem. And this is emergency we've got to report.

Now next off, let's talk about something called edema. Now, edema can sometimes be a less serious
issue. But again, this is going to vary depending on the reason why the edema is there. So if we take
a look at this image, you see this patient's leg. So on the forside of the image, you see pretty normal
sided L size leg, and then you see the other one that's large, and engorge. You can even see the
skin maybe coming around the ankle, that is a edema. So just by assessing the patient on both
sides, you can tell if one leg is larger than the other. Same thing here on the image of the feet.
Notice one foot looks relatively normal. The other one, you see the little wrinkling almost around the
ankle and the size of the foot? This is also noting edema. So we talk about edema, a lot of reasons.
So fluid volume excess, and you could because there's a blood clot, it could be a lot of reasons or an
infection that the patient's got edema.

Now, we classify this in two different ways. One is called pitting edema, meaning when we push on
it, it almost develops a little pit. And non-pitting, which is like, let's say you cut your finger  and it gets
red hot swollen and really tight. That's what we call non-pitting edema. So just to discuss how we
rate edema, or discuss non-pitting edema, if you take a look at this image, you see how the nurse
simply just takes their finger and pushes down into the edematous area. Now, this is kind of
subjective, but we really just kind of count one, 1002, 1003, 1004, 1000. And let's say it takes up to
one, 1002, 1000. to get back to normal, then we'll call it +2 pitting edema.

So again, remember we only grade pitting edema, because you can push on it, make that pit like you
see in the image. We're gonna count, and then see what we grade that and that is only on pitting
edema. Now, other edema can be caused again from like DVTs, where it's red, hot, and swollen.
This is called non-pitting, and you can't push down on that type of edema.