Global Medical TrainingWorkshop

www.gmtonline.org http://studentorgs.utexas.edu/gmt

October 19, 2006

Parts of the Stethoscope

Basic Terminology • Bell

– The bell of the stethoscope is the cup shaped part at the end of the tubing, usually opposite to the diaphragm. Not all stethoscopes have a bell. The bell is used to listen to low pitch sounds.

• Diaphragm – The diaphragm of the stethoscope is the flat part at the

end of the tubing, with the thin plastic "drum-like" covering. The diaphragm is used to listen to high pitch sounds. Some stethoscopes have a diaphragm but no bell.

Basic Terminology Cont.

• Earpieces – Earpieces fit into the ears. They should

angle slightly forward for the best fit. Earpieces made of soft rubber are more comfortable and may prevent outside sounds from interfering with your listening.

How to Use the Stethoscope

• STEP 1: Clean off the earpieces before placing the stethoscope into your ears, especially if others share it

or you seldom use it. In the hospital, earpieces are wiped with alcohol prep swabs.

• STEP 2: Hold the chest piece between your palms to warm it before placing it on a person's chest. Thirty seconds is usually long enough to remove the chill.

• STEP 3: Place the stethoscope into your ears.

• STEP 4: Hold the chest piece in your hand. With the other hand, tap a finger against the chest piece and listen. Many stethoscopes have reversible heads, which can be

incompletely swiveled and block sound.

• STEP 5: Grip the chest piece between your middle and index fingers to provide firm contact with the skin.

• STEP 6: To minimize extraneous noises, avoid touching or rubbing the tubing or chest piece against clothing, bedcovers or hair.

• STEP 7: Place the chest piece onto the part of the body you want to listen to. For the heart, this is a few

inches above the left nipple. You should hear a steady "lub dub." This is known as the apical pulse.

• STEP 8: Store your stethoscope so that the tubing isn't kinked when you put it away.

• Although the "gold standard" clearly is that the chest piece should be applied to the bare skin, a rough screening of both heart and lung sounds can be done through a thin T-shirt. Button-up or polo shirts can be a problem because of buttons, pockets and heavy weaves near listening areas. However, unbuttoning a few buttons at the top shirt often allows sufficient access to the area without unbuttoning and removing the entire shirt. Further, decent screening of the lungs can often be done over the shirt from the back without taking it off---if the shirt is fairly thin and not furry; like a plaid or suede.

Taking Vital Signs

• Blood Pressure• Pulse Rate

Used to assess the immediate health of a heart

Blood Pressure• Blood pressure is taken using

a Sphygmomanometer.

1. Place the cuff around the upper arm2. Hold a stethoscope over the artery just below

the cuff.3. Pump air into the cuff to stop the flow of

blood through the artery. Pump the air until it reaches to about 140-150 mmHg.

4. Slowly let out the air in the cuff to let the blood flow again.

5. The first beat you hear is the systolic phase. 6. The last beat you hear is the diastolic phase.

Systolic vs. Diastolic *Systolic: The pressure of the heart's contraction. This is the first

number, which is higher, that is taken to measure the blood pressure.

*Diastolic: The pressure of the heart’s relaxation. This is the second number that is taken to measure the blood pressure.

-Average Blood Pressure Rates (Systolic/Diastolic)*Systolic - 110 to 150*Diastolic – 60 to 80

Hypertension: High blood pressure. Patients that exceed these ranges need to be treated.

Hypotension: Low blood pressure. Patients that are below these ranges usually does not require treatment.

Pulse Rate• The rate of the pulse as observed in an artery,

expressed as beats per minute.

Average Pulse RatesAdult Males: about 72Adult Females: 76 to 80Newborns: up to 140Children: about 90Elderly: 50 to 65

1. Place your first two fingers over the radial artery below the wrist on the palm side of your arm.

2. Count the beats per minute OR the beats per 15 seconds and multiply this number by 4.

Listening…http://www.med.ucla.edu/wilkes/inex.htm

• You will need to differentiate between normal and abnormal sounds of the heart and lungs.

• This site will help you recognize the different sounds you will hear.

• You do not need to know all the different types of abnormality. Just make sure you can distinguish between the sounds of a normal heart/lung and an abnormal heart/lung

Listening…• Abdominal sounds are the noises that are made by the

intestines.• The sounds are usually harmless and they usually mean

that the Gastrointestinal tract is working.• To listen to these sounds, you should use the bell of the

stethoscope.• Absence of these sounds can often mean intestinal

obstruction.• Increased (hyperactive) bowel sounds reflect an increase in

intestinal activity. This can be seen in diarrhea and after eating.

• Abdominal sounds are always evaluated in conjunction with symptoms such as nausea, vomiting, presence or absence of bowel movements or gas.

Pulmonary Auscultation

http://sprojects.mmi.mcgill.ca/mvs/MVSTETH.HTM

1. Environment

2. Proper position

3. Stethoscope touching the patient’s bare skin

Assess the posteriorchest

1. Ask the patient not to speak and to breathe deeply

2. Listen to locations, move from side to side and compare sounds. Start from the apex until you approach the bases.

Normal Breath Sounds• How are breath sounds

created?a) Inspiration – air moves

to alveoli – air hits the walls of these small airways – turbulence is created – produces sound

b) Expiration – air moves in the opposite direction – air hits walls of large airways – less turbulence is created – quieter breath sounds

Most common sounds

a) Vesicular Breath sounds: clear lungsb) Diminished vesicular sounds: variation of

normal vesicular breath sounds. Can occur in obese patients (so much tissue mass), the elderly, or patients who don’t take deep breaths

c) Harsh vesicular: children, someone who just exercised

Abnormal Breath Soundsa) Absent or decreased breath

soundsi. Asthmaii. Emphysema

b) Adventitious Breath Sounds1. Crackles: Small airways open during inspiration and collapse during expiration

i. Asthmaii. Chronic Bronchitisiii. Pulmonary edema

Abnormal Breath Soundsb) Adventitious Breath Sounds

2. Wheeze: High pitched, hissing sounds heard normally on expiration. They are produced when air flows through airways narrowed by secretions, foreign bodies, etc. i. Asthmaii. Chronic Bronchitisiii. Pulmonary edema

3. Rhonchi: low pitched, continuous sounds similar to wheezes (like a snore). Obstruction of a large airway by secretions i. Asthmaii. Bronchospasmiii. Bronchitis

Bowel sounds• Abdominal sounds are the noises

that are made by the intestines (assess gastric motility)

• The sounds are usually harmless and they usually mean that the Gastrointestinal tract is working.

• Listen for gurgling sounds for at least a minute in each quadrant, starting with the right lower quadrant (near the appendix)

• Abdominal sounds are always evaluated in conjunction with symptoms such as nausea, vomiting, presence or absence of bowel movements or gas.

Abnormal bowel sounds

• Hyperactive: bowel sounds reflect an increase in intestinal activitya) diarrheab) emotional stressc) infectious enteritisd) parasites

Abnormal bowl sounds

• Hypoactive: decrease in intestinal activitya) intestinal obstructionb) constipation