RET 1024 Introduction to Respiratory Therapy

1. RET 1024Introduction to Respiratory Therapy Module 4.4 Bedside Assessment of the Patient Heart Sounds

2. 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

3. Bedside Assessment of the Patient • Heart Sounds • The normal beating heart has a basic first and second heart sound with each cardiac cycle • The initial sound is called S1 • Closure of the atrial-ventricular valves • mitral and tricuspid • The second sound is S2 • Closure of the semilunar valves • Aortic and pulmonic S1 Best heard over the apex with the diaphragm S2 Best heard over the base with the diaphragm

4. Bedside Assessment of the Patient • Heart Sounds • The normal beating heart (S1, S2) • Animated Heart (systole and diastole) • Animated Heart (heart sounds)

5. 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

6. 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

7. 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

8. Bedside Assessment of the Patient • Heart Sounds • S3 and S4 • Animated Heart (systole and diastole)

9. 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)

10. Bedside Assessment of the Patient • Heart Sounds • Areas on the precordium for best listening to each of the four heart valves

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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)

19. Bedside Assessment of the Patient • Interpretation of Heart Sounds • Murmurs • Aortic stenosis

20. 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

21. 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