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Home , Heart murmur, Split S2

peak technique

Cardiac assessment: A sensory experience

MARJAANA MEHTA, RN, APN,C, MSN Adult Nurse Practitioner • Hackensack University Medical Center • Hackensack, N.J.

Evaluating your patient’s requires measure from this Chest X-ray you to call on your senses—sight, sound, point to the sternal did you has replaced and touch—to find out what’s going on angle with a centime- know? percussion beneath the surface. In this article, I’ll help ter ruler. A measure- An irregular heart to detect you brush up on your inspection, palpa- ment of more than 3 sound may be changes in tion, and skills. cm signals elevated caused by atrial heart size. venous pressure. If fibrillation, prema- Take a look around you don’t see venous ture or delayed Your first step is inspection. Start by sim- pulsation, the highest ventricular contrac- tions, premature ply looking at the anterior chest wall. point may be below atrial contractions, Note any scars that indicate the level of the ster- or heart block. An cardiac surgery or an nal angle, indicating absent or muffled implantable device, that the pressure isn’t heart sound may like a pacemaker. You elevated. If pulsa- result from fluid or might see pulsations at tions on both sides blood collected the fourth or fifth inter- are comparable, you around the heart. costal space (ICS) at the need to measure only midclavicular line, indi- one side. cating an apical impulse. Or you might see heaves Hands-on work or lifts, which are forceful Now you’re ready to palpate. You’ll find thrustings of the left and the apical impulse by placing one finger at right ventricles during sys- the fourth or fifth ICS at the midclavicular tole. A right ventricular line, and asking the patient to exhale and heave would be visible at stop breathing for a few seconds. Feel for the sternal border; a left ven- the pulsation, assessing its location, diam- tricular heave, at the apex. eter (width), amplitude (strength), and du- Next, check the jugular . With the ration. patient supine, turn his head slightly away Sometimes that’s easier said than done. from you and shine a light obliquely onto For example, the apical impulse may be dis- the neck. This will highlight pulsations of the placed down and to the left by ventricular internal jugular . dilatation. So you may have to move your To visualize the external jugular veins, fingers around a bit to find it. If the patient is raise the head of the bed 30 degrees. The obese or has a thick chest wall, you may be external jugular veins should flatten once he unable to palpate an apical impulse. gets to 30 degrees. If they’re fully distended On the other hand, you may feel nothing above 30 degrees, you’re seeing evidence of but apical impulse: Patients who are anx- increased central venous pressure related to ious, anemic, or feverish, for example, may . Unilateral distension of the have a bounding apical impulse from high external jugular veins may have a local cardiac output. cause, such as an aneurysm. Palpate across the precordium, placing the Identify the highest point of pulsation and palmar aspect of your four fingers over the

6 Nursing made Incredibly Easy! September/October 2003 left sternal border, you hear can help in diagnosing serious listen up! apex, and base. You cardiac abnormalities. When you auscul- shouldn’t feel any Help your patient sit up straight or raise tate, you’ll listen other pulsations, the head of the bed 45 degrees. Use the throughout the pre- unless the patient diaphragm of the to listen in cordium—first with has a , four areas: aortic, pulmonic, tricuspid, and the diaphragm of which will feel like mitral. The area is located at your stethoscope, the throat of a the second right ICS, the pulmonic valve then the bell. The purring cat. More on area at the second left ICS, the tricuspid diaphragm is better murmurs later. valve area at the fourth to fifth ICS at the at picking up high- pitched sounds like Finally, move left sternal border, and the back to the neck and area at the fourth to fifth ICS at the mid- S1 and S2, pericar- dial friction rubs, gently palpate the clavicular line. and aortic and carotid , one mitral regurgitation at a time to prevent The beat goes on murmurs. The bell vagal stimulation or Start by listening for 1 full minute for the is better for low- compromised blood heart rate in beats per minute (bpm). Also pitched sounds flow to the brain, note whether the heart rate is regular or such as S and S 3 4 which could cause irregular. and the murmur of syncope. To palpate, A normal heart rate is 60 to 100 bpm. mitral . place your index and Anything less than 60 bpm is defined as middle fingers on , and anything more than 100 first one, then the bpm is defined as . other carotid , in the lower third of the patient’s neck. You’re assessing both sides Sounds like… for amplitude and contour (upstroke Next, concentrate on identifying S1 and S2, speed, duration of summit, and downstroke which sound like “lub-dub.” speed). The normal carotid pulse is 2+ (mod- S1, the “lub,” or first heart sound, is erate) in strength. Decreased stroke volume caused by the closure of the atrioventricular may weaken the carotid pulse. (mitral and tricuspid) valves and is the

beginning of . It’s louder than S2 at Now hear this! the apex. The period between S1 and S2— The most important part of cardiovascular systole—corresponds to the pulse and the R assessment is auscultating the heart. What wave in the .

S2, the “dub,” is the second heart sound. It occurs with closure of the semilunar (aortic and pulmonic) valves. It’s louder

than S1 at the base. The period between

S2 and the next S1 is . Some patients have split . With a split

S1, you’re hearing the mitral and tri- Using a centimeter ruler, you can evaluate your patient for jugular vein cuspid components distension. separately. With a

September/October 2003 Nursing made Incredibly Easy! 7 peak technique

Gently palpate the patient’s radial pulse while listening to a murmur. If Making the grade you hear the murmur at the same time as you feel The intensity (loudness) of a murmur is classified from grade 1 through grade 6: the pulse, it’s a systolic, Grade 1—barely audible; difficult to hear even in a quiet room not diastolic, murmur. Grade 2—clearly audible but faint Grade 3—moderately loud and easy to hear Grade 4—loud; with a palpable thrill noted on the chest wall Grade 5—very loud; can be heard with one corner of the stethoscope lifted off the chest wall Grade 6—loudest murmur; can be heard with the entire stethoscope lifted just off the chest wall.

, the aortic valve closes before the low-pitched sound (“lub-dub-ah”; sounds pulmonic valve. like Ken-tuck-y) caused by early and rapid Listen for extra heart ventricular filling of blood at the beginning sounds. Turn the patient of diastole.

or have him roll partly S4 is called an atrial gallop, and it’s patho- onto his left side; then, logic with coronary artery disease and using the bell of your hypertension. This low-frequency sound

stethoscope, listen for S3 (“ta-lub-dub”; sounds like Ten-nes-see) is and S4 over the fifth ICS at the related to ventricular stiffness. It occurs late midclavicular line (apical impulse). in diastole or right before S1. S3 is called a ventricular gallop; it’s pathologic in patients with heart Turbulence ahead failure and volume overload. You’ll After you listen for S3 and S4 heart hear S3 right after S2. It’s a faint, sounds, listen with the diaphragm and

2nd right 2nd left intercostal space intercostal space murmurs aortic area aortic area of all shapes and sizes The shape of a mur- mur is determined by its intensity over time. There are four basic shapes: • crescendo—the murmur grows louder • decrescendo— the murmur grows softer • crescendo- decrescendo—the murmur rises in Apex- intensity, then falls mitral area • plateau—the murmur has the Lower left sternal same intensity border- tricspid area throughout.

8 Nursing made Incredibly Easy! September/October 2003 The ins and outs of murmurs

Midsystolic murmurs Pansystolic murmurs Diastolic murmurs PULMONIC STENOSIS MITRAL REGURGITATION AORTIC REGURGITATION • Location—second and third left inter- • Location—apex Heard best with the patient sitting, costal space (ICS) • Radiation—to the left axilla; less leaning forward, and holding his breath • Radiation—if loud, toward the left often, to the left sternal border on exhalation shoulder and neck • Intensity—soft to loud; if loud, asso- • Location—second to fourth left ICS • Intensity—soft to loud; if loud, asso- ciated with an apical thrill; unlike tricus- • Radiation—if loud, to the apex, per- ciated with a thrill pid regurgitation, doesn’t become haps to the right sternal border • Pitch—medium louder with inspiration • Intensity—grade 1 to 3 • Quality—often harsh • Pitch—medium to high • Pitch—high (use the diaphragm of • Quality—blowing the stethoscope to listen) • Quality—blowing; may be mistaken Heard best with the patient sitting and TRICUSPID REGURGITATION for breath sounds leaning forward • Location—lower left sternal border • Location—right second ICS • Radiation—to the right of the ster- MITRAL STENOSIS • Radiation—often to the neck and num, to the xiphoid area, and perhaps Placing the bell exactly on the apical down the left sternal border, even to to the left midclavicular line, but not impulse, turning the patient into a left the apex into the axilla lateral position, and exercising mildly • Intensity—sometimes soft but often • Intensity—variable; unlike mitral will make this murmur more audible. loud, with a thrill regurgitation, may increase slightly with It’s best heard on exhalation. • Pitch—medium; may be higher at the inspiration • Location—usually limited to the apex apex • Pitch—medium • Radiation—little or none • Quality—often harsh; may be more • Quality—blowing • Intensity—grade 1 to 4 musical at the apex • Pitch—low (use the bell of the stethoscope to listen)

Adapted from Bickley L., and Szilagyi P., editors: Bates’ Guide to and History Taking, 8th edition. Philadelphia: Lippincott Williams & Wilkins, 2003, pp. 291-294.

bell of your stethoscope for murmurs. To ■ radiation—transmission from the point hear them better, ask your patient to tem- of maximal intensity to surrounding areas porarily hold his breath. ■ quality—musical, blowing, harsh, or A murmur is a sound that occurs with rumbling turbulent blood flow through an incompe- ■ pitch—high, medium, or low tent valve or stiff vessel (see The Ins and ■ shape—determined by intensity over Outs of Murmurs). Most murmurs are time and described as crescendo, de- caused by valvular disease, such as stenosis crescendo, crescendo-decrescendo, or or insufficiency. Murmurs in healthy chil- plateau (see Murmurs of All Shapes and dren or adolescents are normal and are Sizes) called innocent or functional. Innocent mur- ■ loudness—the intensity of the murmur murs have no valvular or pathologic cause. (see Making the Grade).

Functional murmurs are due to decreased You’ll hear systolic murmurs between S1 blood flow to the heart, such as in anemia and S2.Diastolic murmurs occur after S2 and or pregnancy. before S1. When you document the murmur, be Assessing heart sounds takes a lot of sure to describe: practice, so use every opportunity you can. ■ timing—systolic (between S1 and S2) or Listening to your patient gives you the per- diastolic (between S2 and S1) fect chance to know what’s going on ■ location—where the murmur is loudest beneath the surface. ■

September/October 2003 Nursing made Incredibly Easy! 9