Download RET 1024 Introduction to Respiratory Therapy

RET 1024
Introduction to Respiratory Therapy
Module 4.4
Bedside Assessment of the Patient
— Heart Sounds
Bedside Assessment of the Patient

Heart Sounds

The purpose of
cardiac auscultation is
to identify the
presence and
characteristics of
normal and abnormal
heart sounds
Bedside Assessment of the Patient

Heart Sounds

The normal beating heart
has a basic first and second
heart sound with each
cardiac cycle

S1 Best heard
over the apex with
the diaphragm

S2 Best heard over
the base with the
diaphragm
The initial sound is called S1

Closure of the atrialventricular valves
 mitral and tricuspid
The second sound is S2

Closure of the semilunar
valves
 Aortic and pulmonic
Bedside Assessment of the Patient

Heart Sounds

The normal beating heart (S1, S2)

Animated Heart (systole and diastole)

Animated Heart (heart sounds)
Bedside Assessment of the Patient

Heart Sounds

In some healthy people and
in many with heart disease,
a third (S3) and/or forth (S4)
may be present
Bedside Assessment of the Patient

Heart Sounds

S3, an early diastolic sound produced by blood
passively entering the ventricles and contacting the
ventricle walls, causing them to vibrate

Most often occurs with heart disease when ventricular
wall is abnormal , as occurs after an MI and is
commonly indicative of CHF.
S3 Best heard
over the apex
with the bell
Bedside Assessment of the Patient

Heart Sounds

S4 occurs late in diastole – just before S1, when
the atria contracts and sends a bolus of blood into
the ventricles just before systole

Most often heard in patients with an abnormal left
ventricle, e.g., when left ventricle has become
hypertrophied in order to compensate for ischemia or
excessive pressure load
S4 Best heard
over the apex
with the bell
Bedside Assessment of the Patient

Heart Sounds

S3 and S4

Animated Heart (systole and diastole)
Bedside Assessment of the Patient

Heart Sounds

Areas on the
precordium for best
listening to each of
the four heart valves




A – Aortic (2RICS)
P – Pulmonic (2LICS)
T – Tricuspid (LLSB)
M – Mitral (Apex)
Bedside Assessment of the Patient

Heart Sounds

Areas on the
precordium for
best listening to
each of the four
heart valves
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Alterations in loudness of either S1 or S2 may
occur

Decreased Intensity (loudness)

Extracardiac
 Pulmonary hyperinflation
 Pleural effusion
 Pneumothorax
 Obesity
 Muscular
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Alterations in Loudness of S1 or S2

Decreased Intensity (loudness)

Cardiac
 Heart failure – poor ventricular contraction
(common following myocardial infarction)
 Valvular abnormalities (rigid leaflets)
 Hypovolemia
 Systemic hypotension
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Alterations in Loudness

Increased Intensity of S1


Faster heart rates
Increased contractility, e.g., exercise, anemia, high
fever
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Alterations in Loudness

Increased Intensity of S2

Loud P2 (pulmonic valve)
 Pulmonary hypertension
. Caused by the forceful closure of the
pulmonic valve
. Best auscultated over the
pulmonic valve (2LICS) using diaphragm
. Chronic lung disease
. Chronic LV dysfunction
. Pulmonary emboli
. Primary pulmonary hypertension
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Alterations in Loudness

Increased Intensity of S2

Increased intensity of A2 (aortic valve)
 Systemic hypertension
. Caused by the forceful closure of the
aortic valve
. Best auscultated over the
aortic valve (2RICS) using diaphragm
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Presence of S3 and S4

Gallop Rhythm




Volume overload – CHF
Noncompliant ventricle – myocardial infarction,
ventricular hypertrophy
Advanced mitral or tricuspid valve regurgitation
Chronic drug or alcohol abuse can lead to
cardiomyopathy and ventricular hypertrophy
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Murmurs

Produced by the following:




Rapid blood flow over a normal valve (physiologic
murmur)
Blood flow over a narrowed valve (stenosis)
Backflow of blood through an incompetent valve (not
seating properly when they close)
Blood flow through an abnormal opening (e.g.,
ventricular septal defect)
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Murmurs

Systolic murmur


Stenosis (narrowing) of a semilunar valve
Incompetent A-V valve
Animated Heart (heart sounds)
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Murmurs

Aortic stenosis
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Murmurs

Diastolic murmus


Stenosis of an A-V valve
 Tricuspid or Mitral valve
Incompetent semilunar valve
 Pulmonic or Aortic valve
Bedside Assessment of the Patient

Interpretation of Heart Sounds

Pericardial Friction Rub

Heard when the percardial sac becomes inflamed


Producing a grating sound due to the friction of the
visceral and parietal pericardial layers rubbing against
each other as the heart beats inside the pericardial sac
Best heard over the apex of the heart