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Transcript of Assessments heart & neck vessel
Assessment of the Heart and
Peripheral vessels
Maria Carmela L. Domocmat, MSN, RN
Associate Professor, College of Nursing
Manila Adventist College
Anatomy
Heart
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Heart
extends vertically
L, 2nd to 5th
horizontally
R edge sternum to L MCL
inverted cone
o base – upper portion – near L 2nd ICS
o apex – lower portion – near L 5th ICs and L MCL
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precordium
anterior chest that overlies the heart and great
vessels
great vessels
large veins and arteries leading directly to and away
from heart
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great vessels includes:
o sup and inf vena cava
o pulmo artery, pulmo veins (2 from each lung)
o Aorta
septum – separates the R and L sides of heart
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Valves
o AV
o at entrance into ventricles
tricuspid – R; bet R atrium and R ventricle
bicuspid (mitral) – L ; bet L atrium and ventricle
chordae tendinae- anchor AV valve flaps to papillary
muscles within ventricles; prevent reverse open of
AV valves
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Valves
o semilunar valves – at exit of each
ventricle at beginning of great vessels
has 3 cusps or flaps that looks like half-
moons
open - during ventricular contraction
close – from pressure of ventricle when
ventricles relax
prevent blood from flowing
backward into relaxed ventricles
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Valves
o semilunar valves – at exit of each ventricle at
beginning of great vessels
pulmonic valve – at entrance of pulmo artery as it
exits the R ventricle
aortic valve - at beginning of ascending aorta as it
exists L ventricle
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Covering and Walls
pericardium – tough, inextensible, loose-fitting,
fibroserous sac that attaches to great vessels and
surrounds heart
parietal pericardium – serous membrane lining
o secretes small amount of pericardial fluid that allows
for smooth, friction-free movement of heart
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Covering and Walls
epicardium – covers outer surface; also has
serous membrane lining
myocardium – thickest layer; made up of
contractile cardiac muscle cells
endocardium – thin layer of endothelial tissue;
forms innermost layer; continuous with
endothelial lining of blood vessels
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Electrical Conduction
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The Cardiac Cycle
refers to filling and emptying of heart’s
chambers
two phases: diastole & systole
o diastole – filling; relaxation of ventricles
2/3 of cardiac cycle
o systole – emptying; contraction of ventricles
1/3 of cardiac cycle
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The Cardiac Cycle
Diastole
Systole
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Diastole
early or protodiastolic filling
presystole or atrial systole
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Diastole
o early or protodiastolic filling – early, rapid.
passive filling
AV valves open
ventricles relaxed
this causes higher pressure in atria than in ventricles
therefore – blood rushes thru atria into ventricles
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Diastole
o followed by period of slow passive filling
o presystole or atrial systole – ―atrial kick‖ – final
active filing phase
atria contract— near the end of ventricular diastole
this complete emptying of blood out of upper
chambers by propelling into ventricles
this raises L ventricular pressure
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Systole
o filling phases during diastole –result in large amt
of blood in ventricles
this causes the pressure in ventricles to be higher
than in atria
this causes the valves (mitral & tricuspid) to shut
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Systole
o closure of AV valves
produces 1st heart sound (S1); beginning of systole
prevents blood from flowing backward
(regurgitation) into atria during ventricular
contraction
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o isometric contraction
at this point – all 4 valves are closed and ventricles
contract
there is now high pressure inside ventricles
causing (1) aortic valve to open on L side of heart;
(2) pulmonic valve to open on R side
blood is ejected rapidly thru these valves
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o with ventricular emptying – the ventricular
pressure falls and semilunar valves close
this closure produces the 2nd heart sound (S2); end of systole
o after closure semilunar valves – ventricles relax
o atrial pressure is now higher than ventricular
pressure
causing AV valves to open and diastolic filing to
being again
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HEART SOUNDS
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Heart Sounds
produced by valve closure
opening of valve is silent
normal heart sounds
o ―lub dubb‖
o occasionally – extra heart sounds and murmurs are
auscultated
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Heart Sounds
Heart Valves
Act as one-way doors, making sure that blood flows
in the correct direction through the heart.
Tricuspid valve
Mitral valve
Pulmonary valve
Aortic valve
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atrio-ventricular valves (A-V valves)
openings leading to the right and left ventricles
first heart sound that we hear on the chest wall
occurs when these A-V valves close;
this heart sound is called S1.
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Heart Valves
Tricuspid Valve
• right A-V valve
• between right atrium
& right ventricle
Bicuspid Valve
• left A-V valve
• between left atrium &
left ventricle
Pulmonary Valve
• semilunar valve
• between right
ventricle & pulmonary
trunk
Aortic Valve
• semilunar valve
• between left
ventricle & aorta
15-7
Skeleton of Heart
• fibrous rings to which the heart valves are attached
15-10
Heart Valves
Pulmonary and Aortic Valve
semilunar valves
openings leading to the pulmonary trunk and aorta
pulmonic valve and the aortic valve
second heart sound occurs when these semilunar
valves close:
these heart sounds is called S2.
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S1 – ―lub‖
o result of closure of AV valves (mitral and tricuspid)
o correlates with beginning of systole
o heard over entire precordium – heard best at apex (L
MCL, 5th ICS)
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S2 – ―dub‖
o result from closure of semilunar valves (aortic and
pulmonic)
o correlates with beginning of diastole
o heard over base
o splitting of S2 – may be exaggerated during
inspiration and disappear during expiration
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Extra heart sounds
o S3 and S4 - referred as diastolic filing sounds or extra
heart sounds
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Extra heart sounds
o S3
can be heard early in diastole, after S2
often termed ventricular gallop
results from ventricular vibration secondary to rapid
ventricular filling
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Extra heart sounds
o S4 -
heard late in diastole, just before S1
often termed atrial gallop
results from ventricular vibration secondary to rapid
ventricular resistance (noncompliance) during atrial
contraction
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Murmurs
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Murmurs
o blood normally flows silently through heart
o there are conditions that can create turbulent
blood flow in which swooshing or blowing
sound may be auscultated over precordium
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Murmurs
o conditions that contribute to turbulent blood
flow include
increased blood velocity
structural valve defects
valve malfunction
abnormal chamber openings (e.g., septal defect)
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Cardiac Output (CO)
8/14/2017 38 Maria Carmela L. Domocmat, RN, MSN
Cardiac Output (CO)
the amount of blood pumped by ventricles
during a given period of time (usually 1 min)
determined by stroke volume (SV) multiplied by
heart rate (HR): SV x HR = CO
normal adult CO is 5 to 6 L/min
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SV
o amount of blood pumped from heart with each
contraction
o SV from L ventricle is usually 70 ml
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Factors that influence SV
degree of stretch of the heart muscle up to a
critical length before contraction (preload)
the greater the preload – the greater the SV
unless heart muscle is stretched so much that is
cannot contract effectively
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Factors that influence SV
pressure against which heart muscle has to eject
blood during contraction (afterload)
increased afterload results in decreased SV
synergy of contraction
i.e, uniform, synchronized contraction of
myocardium
conditions that cause an asynchronous contraction
decrease SV
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Factors that influence SV
compliance or distensibility of ventricles
decreased compliance decreased SV
contractility or force of contraction of
myocardium under loading conditions
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HEALTH HISTORY
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Present Health History
Q: Do you experience chest pain?
When did it start?
Describe the type of pain, location,
radiation, duration, and how
often you experience the pain.
Rate the pain on a scale 0 to 10,
with being the worst possible
pain.
Does activity make the pain worse?
Did you have perspiration
(diaphoresis) with the chest
pain?
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Present Health History
R: Chest pain can be cardiac, pulmonary,
muscular, or GIT in origin. Angina (cardiac
chest pain) is usually described as a sensation of
squeezing around the heart; a steady, severe
pain; and a sense of pressure. It may radiate to
the left shoulder and down the left arm or to the
jaw. Diaphoresis and pain worsened by activity
are usually related to cardiac chest pain.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 49
Q: Do you experience
palpitations?
R: Palpitations may occur
with an abnormality of
the heart’s conduction
system or during the
heart’s attempt to
increase cardiac output
by increasing the heart
rate. Palpitations may
cause the client to feel
anxious.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 50
Q: DO you tire easily? Do you
experience fatigue? Describe
when the fatigue started. Was
it sudden or gradual? Do you
notice it at any particular
time day?
R: Fatigue may result from
compromised cardiac
output. Fatigue related to
decrease cardiac output
is worse than the evening
or as the day progresses.
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Q: Do you have difficulty
breathing or shortness of
breath (dyspnea)?
R: Dyspnea may result
from congestive heart
failure pulmonary
disorders, coronary
artery disease, myocardial
ischemia, and myocardial
infarction. Dyspnea may
occur at rest, during
sleep, or with mild,
moderate or extreme
exertion. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 52
Q: Do you wake up at night
with an urgent need to
urinate (nocturia)? How
many times a night?
R: Increase renal perfusion
during periods at rest or
recumbency may cause
nocturia. Decreased
frequency may be related
to decrease cardiac
output.
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Q: Do you experience
dizziness? R: Dizziness may indicate
decreased blood flow to
the brain due to
myocardial damage;
however, there are
several other causes for
dizziness such as inner
ear syndromes, decreased
cerebral circulation and
hypotension. Dizziness
may put the client at risk
for falls.
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Q: Do you experience swelling
(edema) in your feet, ankles
or legs?
R: Edema of the lower
extremities may occur as
a result of heart failure.
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Q: Do you have frequent heart
burn? When does it occur?
What relieves it? How often
do you experience it?
R: Cardiac pain may be
overlooked or
misinterpreted as GIT
problems. GIT pain may
occur after meals, and is
relieved with antacids,
whereas cardiac pain may
occur anytime, is not
relieved with antacids
and worsens with activity
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Family health History
Q: Is there a history of
hypertension, myocardial
infarction, coronary heart
disease, elevated cholesterol
levels, or diabetes mellitus in
your family?
R: A genetic
predispositions to these
risk factors increases a
client’s chance for
development of heart
disease.
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Lifestyle and Health Practices
Q: Do you smoke? How many
packs of cigarettes per day
and how many years?
R: Cigarette smoking
greatly increases the risk
of heart disease.
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Q: What type of stress do you
have in your life? How do
you cope with it?
R: Stress has been
identified as a possible
risk factor for heart
disease.
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Q: Describe what you usually
eat in a 24-hour period.
R: An elevated cholesterol
level increases the chance
of fatty plaque formation
in the coronary vessels.
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Q: How much alcohol do you
consume each day/week?
R: Excessive intake of
alcohol has been linked
to hypertension.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 61
Q: Do you exercise? What type
of exercise and how often?
R: A sedentary lifestyle is
known modifiable risk
factor contributing to
heart disease. Aerobic
exercise three times per
week for 30 minutes is
more beneficial than
anaerobic exercise or
sporadic exercise in
preventing heart disease.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 62
Q: Describe your daily
activities. How are they
different from your routine
5 or 10 years ago? Does
fatigue, chest pain, or
shortness of breath limit
your ability to perform daily
activities? Describe. Are you
able to care for yourself?
R: Heart disease may
impede the ability to
perform daily activities.
Exertional dyspnea or
fatigue may indicate
heart failure. An
inability to complete
activities of daily living
may necessitate a
referral for home care.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 63
Q: Has your heart disease had
any effect on your sexual
activity?
R: Many clients with heart disease are
afraid that sexual activity will
precipitate chest pain. If the client
can walk one block or climb two
flights of stairs without
experiencing symptoms, it is
generally acceptable client to
engage in sexual intercourse.
Nitroglycerin can be taken before
intercourse as prophylactic for
chest pain. In addition, the side-
lying position for sexual
intercourse may reduce the
workload on the heart.
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Q: How many pillows do you
use to sleep at night? Do
you get up to urinate during
the night? Do you feel
rested in the morning?
R: If heart function is
compromised, cardiac output
to the kidneys is reduced
during episodes of activity. At
rest, cardiac output increases,
as does glomerular filtration
and urinary output. Orthopnea
(the inability to breathe while
supine) and nocturia may
indicate heart failure. In
addition, these two conditions
may also impede the ability to
get adequate rest. 8/14/2017 65
Q: How important is having a
healthy heart to your ability
to feel good about yourself
and your appearance? What
fears about heart disease do
you have?
R: A person’s feeling of
self-worth may depend
on his or her ability to
perform usual daily
activities and fulfill his or
her usual roles.
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 66
PREPARING THE CLIENT
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• explain - need to expose the
anterior chest
• Female clients may keep their
breast covered and may
simply hold the left breast
out of the way when
necessary
Explain need to assume
several different
positions for the
examination.
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• supine position with the head
elevated to about 30 degrees..
• Auscultation and palpation of
the neck vessels and
• inspection, palpation and
auscultation of the pericordium
• left lateral position
• palpation of the apical
impulse
• if the examiner is having
trouble locating the pulse
with the client in the
supine position.
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• left lateral and sitting-up and
leaning-forward position
• auscultate for the presence of
any abnormal heart sounds.
• These positions may bring
out an abnormal sound not
detected with the client in the
supine position.
• Make sure you explain to
the client that you will be
listening to a heart in a
number of places and that
this does not necessarily
mean that any thing is
wrong.
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• Help ease any anxiety
• Provide with such modesty as
possible during the
examination
• describe the steps of the
examination
• and answer any questions the
client may have.
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EQUIPMENTS
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Steth with bell and diaphragm
Sml pillow
Penlight or movable exam light
Watch with second hand
Cm rulers (2)
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PHYSICAL ASSESSMENT
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ASSESSMENT OF THE HEART
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Overview
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Assessment of the Heart
Inspect pulsations
Palpate apical impulse
Palpate abnormal pulsations
Auscultate heart rate and rhythm
Auscultate heart sounds
Auscultate : pulse rate deficit
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Assessment of the Heart
Auscultate heart sounds
Auscultate heart rate and rhythm
If detect an irregular rhythm, auscultate for pulse
rate deficit
Auscultate to identify S1 and S2
Auscultate for extra heart sounds
Auscultate for murmurs
Auscultate in with the client assuming other
position
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Inspect pulsations
Client supine position with the head of the bed
elevated between 30 and 45 degrees
stand on client’s right side and look for the
apical impulse and any abnormal pulsation
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Inspect pulsations
o Note: apical pulse – originally called PMI (point
of maximal impulse)
not used anymore – bcoz maximal impulse may
occur in other areas of precordium as result of
abnormalities
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Inspect pulsations
o normal findings:
apical impulse – may or may not be visible
if visible – in mitral area (Left MCL, 4th or 5th ICS)
result of left ventricle moving outward during systole
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8/14/2017 Maria Carmela L. Domocmat, RN, MSN 82
Inspect pulsations
o abnormal findings:
pulsations – or heaves or lifts –other than the apical
pulsation
may occur as result of enlarged ventricle from an
overload of work.
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Abnormal ventricular impulses
Lift
Thrill
Accentuated Apical Impulse
Laterally displaced apical impulse
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PALPATION
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Palpate the apical impulse
Remain on the client’s right side
Client remain supine
Use palmar surfaces of hand
palpate the apical impulse in the mitral area
(fourth or fifth intercostals space at the
midclavicular line).
After locating the pulse, use one finger pad for
more accurate palpation.
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Palpate the apical impulse
If cannot be palpated
Have client assume left
lateral position
This displaces heart toward left
chest wall and relocates apical
impulse farther to left
Elderly
May be difficult to palpate
Bcoz of increased AP chest
diameter
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Normal findings:
Palpation apical impulse
apical impulse – palpated in mitral area; size –
nickel (1-2 cm)
amplitude – small – like gentle tap
duration – brief; lasting thru first 2/3 of systole
and often less
obese or large breasts – may not be palpable
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Normal findings:
Palpation apical impulse
o abnormal findings:
not palpable – pulmonary emphysema
suspect cardiac enlargement
If larger than 1 to 2cm,
displaced more forceful, or
of longer duration
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 89
Palpate: abnormal pulsations
Use palmar surfaces to palpate the
apex,
left sternal border, and
base
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Palpate abnormal pulsations
o normal findings:
oNo pulsations or vibrations in the areas of the apex,
left sternal border, or base
o abnormal findings:
thrill – feels similar to purring cat
is usually associated with Grave IV or higher
murmur
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AUSCULTATION
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Auscultate heart rate and rhythm
Place the diaphragm of the stethoscope at the
apex and listen closely to the rate and rhythm of
the apical impulse.
Concentrate on systematically moving the steth
from left to right across entire heart area from
base to apex (top to bottom) or from apex to
base (bottom to top)
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Auscultate heart sounds
o Traditional 5 areas
aortic area : 2nd ICS, R sternal border (base of heart)
pulmonic area : 2nd or 3rd ICS, L sternal border
(base of heart)
Erb’s point : 3rd to 5th ICS, L sternal border
tricuspid area : 4th or 5th ICS, L lower sternal border
mitral or apical area : 5th ICS, L lower sternal border
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Heart Sounds
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1. 2.
3.
4.
5.
Auscultate heart sounds
o Alternative areas
o (by chamber)
aortic area
pulmonic area
left atrial area
right atrial area
left ventricular area
right ventricular area
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 100
Auscultation of heart sounds
Auscultate heart rate and rhythm
Traditional areas of
auscultation
Aortic area
Pulmonic area
Erb’s point
Mitral (apical) area
Tricuspid area
“Alternative” areas
Aortic area
Pulmonic area
Left atrial area
Right atrial area
Left ventricular area
Right ventricular area
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Systematically auscultate in each of the five areas
while the patient is breathing regularly and holding
breath for the following: Rate, rhythm S1 ,S2
Splitting
S3 and S4
Extra heart sound snaps, clicks, friction rubs, or murmurs
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Normal findings:
Heart rate and rhythm
60-100 bpm
regular rhythm
regularly irregular rhythm – sinus arrhythmia
when HR increases with inspiration and
decreased with expiration
female – 5 to 10 beats faster than male
do not differ by race or age in adults
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Abnormal findings:
Heart rate and rhythm
bradycardia (‹60 bpm)
tachycardia (›100 bpm)
regular irregular rhythms (i.e., premature
atrial contraction or PVC)
irregular rhythms (i.e., atrial fibrillation,
atrial flutter) – may predispose client to
decreased CO, heart failure, emboli
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If detect irregular rhythm,
auscultate for a pulse rate deficit.
Palpate radial pulse while auscultate apical pulse
Count for a full minute.
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Auscultate : pulse rate deficit
Normal findings
radial and apical pulse rates –
identical
Abnormal findings
pulse deficits
difference between apical
and peripheral/radial
pulse
indicate atrial fibrillation,
atrial flutter, PVC, varying
degrees of heart block
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S1 AND S2
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Auscultate to define S1 and S2
Auscultate the first heart sound (S1 or ―lub‖)
and the second heart sound (S2 or ―dub‖).
Remember these two sounds make up the
cardiac cycle of systole and diastole.
S1 starts systole
S2 starts diastole.
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Auscultate to identify S1 and S2
o S1- first heart sound
―lub‖
the result of closure of AV valves – indicate start of
systole
best heard – apex of heart; where S1 is louder than
S2
lower in pitch and a bit longer than S2
occurs immediately after diastole
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Auscultate to identify S1 and S2
o S2 – second heart sound
―dubb‖
result of closure of semilunar valves- indicate end of
systole, starts diastole
higher in pitch, shorter duration than S1
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Normal findings:
Auscultation : S1 and S2
o S1 corresponds with each
carotid pulsation and is
loudest at the apex of the
heart
o Note: if have difficulty
differentiating S1 from S2
– palpate carotid pulse
o S1 – harsh sound that
occurs with carotid pulse
.
S2 immediately follows
after S1 and is loudest
at the base of the
heart.
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Auscultate to identify S1 and S2
• abnormal findings:
– ventricular impulses
• lift
• thrills
• accentuated apical impulse
• laterally displaced apical impulse
– abnormal heart rhythms
• premature atrial or junctional contractions
• premature ventricular contractions
• sinus arrhythmia
• atrial fibrillation and atrial flutter with varying ventricular response
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S1
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 117
Listen to S1
Use the diaphragm of the stethoscope to best
hear S1.
Intensity of S1 depends on
position of mitral valve at start of systole
Structure of valve leaflets
How quickly pressure rises in the ventricles
All these factors influence speed and amount of
closure of the valve
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S1
o Normal finding
distinct sound heard in each area
loudest – apex
may become softer with inspiration
split S1 – young adults; left lateral sternal
border
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S1
Normal variations
Softer at base and louder at apex of heart
May be split along the lower left sternal border,
where tricuspid component of sound, usually too
faint to be heard, can be auscultated
Split S1 heard over apex – may be an S4
8/14/2017 Maria Carmela L. Domocmat, RN, MSN 120
S1
o abnormal finding
Accentuated S1
Diminished S1
Varying S1
Split S1
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S2
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Listen to S2
o use diaphragm of steth
o breathe regularly
o Note: do not ask to hold breath –
breath holding may cause any normal or
abnormal split to subside
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Listen to S2
o normal finding
distinct sound heard in each area
loudest – base
physiologic split
split S2 – two distinct sounds of its
components – A2 and P2
heard at in late inspiration at 2nd or 3rd left
ICS
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Listen to S2
o abnormal finding
Any split S2 heard in expiration is abnormal.
The abnormal split can be one of these three types:
Wide
Fixed
Reversed
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EXTRA HEART SOUNDS
Snaps
Clicks
Friction rubs
Murmurs
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Auscultate for extra heart sounds
o 1st - use diaphragm then bell of steth
o to auscultate over entire heart area
o (1) auscultate during systolic pause
o (2) auscultate during diastolic pause
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Auscultate for extra heart sounds
o systolic pause
space between S1 and S2
short duration
that’s why occur S1 and S2occur very close together
o diastolic pause
space between end of S2 and next S1
longer duration
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Auscultate during the systolic
pause
Auscultate during the systolic pause
space between S1 and S2
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Normal findings:
Auscultation systolic pause
o systolic pause
o no extra heart sounds
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Abnormal findings:
Auscultation systolic pause
extra heart sounds
ejection sounds or clicks
e.g., midsystolic click associated with mitral valve prolapse
friction rub – heard during systolic pause
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Auscultate during the diastolic
pause
Auscultate during the diastolic pause
space heard between end of S2 and S1
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Normal findings:
Auscultation diastolic pause
Normally no sounds are heard.
Other normal findings
Physiologic S3 heart sound
Physiologic S4 heart sound
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Normal findings:
Auscultation diastolic pause
Physiologic S3 benign finding
quiet sound heard during diastole - as ventricle fill form
atria
resembles rhythm of ―Tenn-es-see‖
heard at beginning of diastolic pause
Normal among: children, adolescence, young adults
rare after age 40
usually subsides upon standing or sitting up
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Normal findings:
Auscultation diastolic pause
Physiologic S4 o quiet sound
o sound like ―Ken-tuc-ky‖
o occur in second phase of ventricle filling from atria
o heard near the end of diastole
oNormally heard among:
owell-conditioned athletes
o adults older than 40 or 50 with no evidence of heart dse, esp
after exercise
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Abnormal findings:
Auscultation diastolic pause
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pathologic S3 – (ventricular gallop)
pathologic S4 – (atrial gallop)
summation gallop
snaps
friction rub
Abnormal findings:
Auscultation diastolic pause
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pathologic S3 – (ventricular gallop)
ischemic heart dse, hyperkinetic states (e.g., anemia),
restrictive myocardial dse
Abnormal findings:
Auscultation
pathologic S4 – (atrial gallop)
toward left side of precordium
o coronary artery dse (CAD), hypertensive heart dse,
cardiomyopathy , aortic stenosis
toward right side of precordium
opulmonary HTN, pulmo stenosis
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Abnormal findings:
Auscultation
summation gallop
S3 and S4 pathologic sounds together - creates
quadruple rhythm
friction rub Harsh, grating sound that can be heard in both systole and
diastole
caused by abrasion of inflamed pericardial surfaces
(pericarditis)
Heard best with diaphragm of steth, patient sit and
leaning forward
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Abnormal findings:
Auscultation
Note: normally no sound produced when valves
open
Opening snaps: abnormal diastolic sounds heard
during opening of AV valve (mitral stenosis)
Systolic click: result of opening of a rigid and
calcified aortic or pulmonic valve during ventricular
contraction
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MURMURS
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Murmur
o swishing sound caused by turbulent blood flow
thru heart valves or great vessels
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Heart Murmurs
Auscultate for murmurs
o use diaphragm and bell
o bcoz murmurs have diff pitches
o different positions & across entire heart area
o bcoz murmurs occur or subside according to
client’s position
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Auscultate for murmurs
o normal findings:
no murmurs
innocent and physiologic midsystolic murmurs –may
be present
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Auscultate for murmurs
o abnormal findings:
pathologic midsystolic, pansystolic, diastolic
murmurs (p.382)
types of murmur:
systolic: early, mid, late, pansystolic
diastolic: early, mid, late, pandiastolic
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AUSCULTATE : DIFFERENT
POSITION
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Auscultate in with the client
assuming other position
o (1) client assume left lateral position
use bell – apex of heart
o (2) client sit up, lean forward, and exhale
use diaphragm – apex, along left sternal border
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Auscultation: Other position
o Normal findings:
S1 and S2 heart sounds present
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Auscultate in with the client assuming
other position
o Abnormal findings:
heard when client assume left lateral position
S3 and S4 or murmur
not detected on supine – indicate mitral stenosis
murmur from aortic regurgitation
May be heard sit up, lean forward, and exhale
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CLINICAL PEARLS
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Heart sounds
It is a common to try to hear all of the sounds in the cardiac
cycle at one time. Take the time to isolate each sound and each
pause in the cardiac cycle, listening separately and selectively for
as many beats as necessary to evaluate the sounds. It takes time
to tune in, so you must not rush. Avoid jumping the stethoscope
from one site to another; instead, inch the endpiece along the
route. This maneuver prevents missing important sounds,
particularly more widely transmitted abnormal sounds, and it
allows tracking of a sound from its loudest point to its farthest
reach (e.g. into the axilla or the back).
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The infant heart and liver
If heart failure is suspected, note that the infants
liver may enlarged before there is any of
moisture in the lungs, and that the left lobe of
the liver may be more distinctly enlarged than
the right.
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Chest wall thickness
The heart of an infant or child, particularly a
preschool child, is very close to the chest wall;
thus it is much easier to hear the innocent
sounds cause by the necessary rush of the
cardiovascular system.
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DOCUMENTATION
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Sample of subjective data:
No chest pain, dyspnea, dizziness or palpitations. No
previous history of cardiovascular diseases. Denies
rheumatic fever, no current medications or treatment.
Denies family history of hypertension, myocardial
infarction, CAD, high cholesterol levels, or diabetes
mellitus. Has never had an ECG, states he needs to
exercise more and consume less fat. Client does not
monitor own pulse or blood pressure. Denies the use
of tobacco. Sleeps 6-8 hours per night. Feels rested
after sleep. States that job can be somewhat stressful.
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Sample of objective data:
Carotid pulse equal bilaterally, 2+, elastic. No bruits
auscultated over carotids. Jugular venous pulsation
disappears when upright. Jugular venous pressure x 2
cm. no visible pulsations, heaves or lifts on
pericardium. Apical impulse palpated in the 5th ICS, at
the left MCL, approximately the size of a nickel, with
no thrill. Apical heart rate auscultated, 70 beats per
min,, regular rhythm, S1 heard best at apex, S2 heard
best at base. No S3 or S4 auscultated. No splitting of
heart sound, snaps, clicks, or murmurs noted
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NECK VESSEL ASSESSMENT
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Neck vessel
Observe for jugular venous pulse
Evaluate jugular venous pressure
Auscultate carotid arteries
Palpate carotid arteries
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Observe for jugular venous pulse
o normal findings:
o jugular venous pulse – not visible when sitting
upright; visible on supine
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Observe for jugular venous pulse
o abnormal findings:
o visible jugular venous pulse – right ventricular
failure, pulmo htn, pulmo emboli, cardiac
tamponade
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Evaluate jugular venous pressure
o normal findings:
jugular vein – not distended, bulging, or protruding
at 45 degrees or greater
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Evaluate jugular venous pressure
o abnormal findings:
distended, bulging, or protruding at 45 degrees or
greater – right sided heart failure
document at which positions you observe distention
elevated venous pressure on expiration – obstructive
pulmonary disease
elevated venous pressure on inspiration –
Kussmaul’s sign – severe constrivtive pericarditis
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AUSCULTATE & PALPATE
CAROTID ARTERIES
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Observing Jugular Venous Pulse &
Evaluating Jugular venous pressure
Auscultate carotid arteries
Note: always auscultate first before palpating – palpation
may increase or slow the HR, therefore, changing
strength of impulse
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Auscultate carotid arteries
o normal findings:
no blowing or swishing sound or other sounds
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Auscultate carotid arteries
o abnormal findings:
bruit
blowing or swishing sound; cause- turbulent blood flow
thru narrowed vessel
occlusive arterial disease
no bruit heard – if more than 2/3 artery occluded
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Palpate carotid arteries
o Note: if detect occlusion during auscultation –
palpate very lightly
to avoid blocking circulation or triggering vagal
stimulation and bradycardia, hypotension, or cardiac
arrest
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Palpate carotid arteries
o normal findings:
pulses – equally strong; 2+; no variation in strength
contour
smooth and rapid on upstroke
slower and less abrupt on down stroke
arteries – elastic and no thrills noted
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Pulse Amplitude Scale
0 = Absent
1+ = Weak
2+ = Normal
3+ = Increased
4+ = Bounding
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Palpate carotid arteries
o abnormal findings:
unequal pulse – arterial constriction or occlusion in 1
carotid
weak pulse – hypovolemia, shock, decreased CO
bounding, firm pulse – hypervolemia or increased CO
variations in strength from beat to beat
delayed upstroke – aortic stenosis
loss of elasticity – arteriosclerosis
thrills – narrowing of artery
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NURSING DIAGNOSES
Wellness
Readiness for enhanced cardiac output
Health seeking behavior: Desired information
on exercise and low fat diet
Risk Diagnoses
Risk for sexual dysfunction related to
misinformation or lack of knowledge regarding
sexual activity and heart disease
Risk for ineffective denial related to smoking
and obesity
Actual Diagnoses
Fatigue related to decreased cardiac output
Activity intolerance related to compromised
oxygen transport secondary to heart failure
Acute pain: Cardiac related to an inequality
between oxygen supply and demand
Ineffective tissue perfusion related to impaired
circulation.
References
Weber J; Kelly J. (2007). Health assessment in
nursing (3rd ed.) Philadelphia: Lippincott Williams
and Wilkins.
National Institute of Health. (n.d.). Heart
Diseases. Retrieved from
www.nlm.nih.gov/medlineplus/heartdiseases.ht
ml - Health Information-MedlinePlus
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