ret 1024 introduction to respiratory therapy module 4.4 bedside assessment of the patient — heart...

RET 1024RET 1024Introduction to Respiratory Introduction to Respiratory TherapyTherapy

Module 4.4Module 4.4

Bedside Assessment of the PatientBedside Assessment of the Patient— Heart SoundsHeart Sounds

Bedside Assessment of the PatientBedside Assessment of the Patient

Heart SoundsHeart Sounds The purpose of The purpose of

cardiac auscultation is cardiac auscultation is to identify the to identify the presence and presence and characteristics of characteristics of normal and abnormal normal and abnormal heart soundsheart sounds


Heart SoundsHeart Sounds The normal beating heart The normal beating heart

has a basic first and second has a basic first and second heart sound with each heart sound with each cardiac cyclecardiac cycle The initial sound is called The initial sound is called S1S1

Closure of the atrial-Closure of the atrial-ventricular valves ventricular valves mitral and tricuspidmitral and tricuspid

The second sound is The second sound is S2S2 Closure of the semilunar Closure of the semilunar

valvesvalves Aortic and pulmonicAortic and pulmonic

S1 Best heard S1 Best heard over the apex with over the apex with the diaphragmthe diaphragm

S2 Best heard over S2 Best heard over the base with the the base with the diaphragmdiaphragm


Heart SoundsHeart Sounds The normal beating heart (S1, S2)The normal beating heart (S1, S2)

Animated Heart (systole and diastole)Animated Heart (systole and diastole)

Animated Heart (heart sounds)Animated Heart (heart sounds)


Heart SoundsHeart Sounds In some healthy people and In some healthy people and

in many with heart disease, in many with heart disease, a third (S3) and/or forth (S4) a third (S3) and/or forth (S4) may be presentmay be present


Heart SoundsHeart Sounds S3, an early diastolic sound produced by blood S3, an early diastolic sound produced by blood

passively entering the ventricles and contacting the passively entering the ventricles and contacting the ventricle walls, causing them to vibrateventricle walls, causing them to vibrate Most often occurs with heart disease when ventricular Most often occurs with heart disease when ventricular

wall is abnormal , as occurs after an MI and is wall is abnormal , as occurs after an MI and is commonly indicative of CHF. commonly indicative of CHF.

S3 Best heard S3 Best heard over the apex over the apex with the bellwith the bell


Heart SoundsHeart Sounds S4 occurs late in diastole – just before S1, when S4 occurs late in diastole – just before S1, when

the atria contracts and sends a bolus of blood into the atria contracts and sends a bolus of blood into the ventricles just before systolethe ventricles just before systole Most often heard in patients with an abnormal left Most often heard in patients with an abnormal left

ventricle, e.g., when left ventricle has become ventricle, e.g., when left ventricle has become hypertrophied in order to compensate for ischemia or hypertrophied in order to compensate for ischemia or excessive pressure loadexcessive pressure load

S4 Best heard S4 Best heard over the apex over the apex with the bellwith the bell


Heart SoundsHeart Sounds S3 and S4S3 and S4

Animated Heart (systole and diastole)Animated Heart (systole and diastole)


Heart SoundsHeart Sounds Areas on the Areas on the

precordium for best precordium for best listening to each of listening to each of the four heart valvesthe four heart valves A – Aortic (2RICS)A – Aortic (2RICS) P – Pulmonic (2LICS)P – Pulmonic (2LICS) T – Tricuspid (LLSB)T – Tricuspid (LLSB) M – Mitral (Apex)M – Mitral (Apex)


Heart SoundsHeart Sounds Areas on the Areas on the

precordium for precordium for best listening to best listening to each of the four each of the four heart valvesheart valves


Interpretation of Heart SoundsInterpretation of Heart Sounds Alterations in loudness of either S1 or S2 may Alterations in loudness of either S1 or S2 may

occuroccur Decreased Intensity (loudness)Decreased Intensity (loudness)

ExtracardiacExtracardiac Pulmonary hyperinflationPulmonary hyperinflation Pleural effusionPleural effusion PneumothoraxPneumothorax ObesityObesity MuscularMuscular


Interpretation of Heart SoundsInterpretation of Heart Sounds Alterations in Loudness of S1 or S2Alterations in Loudness of S1 or S2

Decreased Intensity (loudness)Decreased Intensity (loudness) CardiacCardiac

Heart failure – poor ventricular contraction Heart failure – poor ventricular contraction (common following myocardial infarction)(common following myocardial infarction)

Valvular abnormalities (rigid leaflets)Valvular abnormalities (rigid leaflets) HypovolemiaHypovolemia Systemic hypotensionSystemic hypotension


Interpretation of Heart SoundsInterpretation of Heart Sounds Alterations in Loudness Alterations in Loudness

Increased Intensity of S1Increased Intensity of S1 Faster heart ratesFaster heart rates Increased contractility, e.g., exercise, anemia, high Increased contractility, e.g., exercise, anemia, high

feverfever



Increased Intensity of S2Increased Intensity of S2 Loud Loud P2 (pulmonic valve)P2 (pulmonic valve)

Pulmonary hypertension Pulmonary hypertension . Caused by the forceful . Caused by the forceful

closure of the closure of the pulmonic valve pulmonic valve . Best auscultated over the . Best auscultated over the pulmonic pulmonic

valve (2LICS) using diaphragmvalve (2LICS) using diaphragm. Chronic lung . Chronic lung

diseasedisease. Chronic LV . Chronic LV

dysfunctiondysfunction. Pulmonary emboli. Pulmonary emboli. Primary pulmonary . Primary pulmonary

hypertensionhypertension



Increased Intensity of S2Increased Intensity of S2 Increased intensity of Increased intensity of A2 (aortic valve)A2 (aortic valve)

Systemic hypertensionSystemic hypertension

. Caused by the . Caused by the forceful closure of the forceful closure of the aortic valve aortic valve

. Best auscultated over . Best auscultated over the the aortic valve (2RICS) using diaphragmaortic valve (2RICS) using diaphragm


Interpretation of Heart SoundsInterpretation of Heart Sounds Presence of S3 and S4Presence of S3 and S4

Gallop RhythmGallop Rhythm Volume overload – CHFVolume overload – CHF Noncompliant ventricle – myocardial infarction, Noncompliant ventricle – myocardial infarction,

ventricular hypertrophyventricular hypertrophy Advanced mitral or tricuspid valve regurgitationAdvanced mitral or tricuspid valve regurgitation Chronic drug or alcohol abuse can lead to Chronic drug or alcohol abuse can lead to

cardiomyopathy and ventricular hypertrophycardiomyopathy and ventricular hypertrophy


Interpretation of Heart SoundsInterpretation of Heart Sounds MurmursMurmurs

Produced by the following:Produced by the following: Rapid blood flow over a normal valve (physiologic Rapid blood flow over a normal valve (physiologic

murmur)murmur) Blood flow over a narrowed valve (stenosis)Blood flow over a narrowed valve (stenosis) Backflow of blood through an incompetent valve (not Backflow of blood through an incompetent valve (not

seating properly when they close)seating properly when they close) Blood flow through an abnormal opening (e.g., Blood flow through an abnormal opening (e.g.,

ventricular septal defect)ventricular septal defect)



Systolic murmurSystolic murmur Stenosis (narrowing) of a semilunar valveStenosis (narrowing) of a semilunar valve Incompetent A-V valveIncompetent A-V valve

Animated Heart (heart sounds)Animated Heart (heart sounds)



Aortic stenosisAortic stenosis



Diastolic murmusDiastolic murmus Stenosis of an A-V valve Stenosis of an A-V valve

Tricuspid or Mitral valveTricuspid or Mitral valve Incompetent semilunar valveIncompetent semilunar valve

Pulmonic or Aortic valvePulmonic or Aortic valve


Interpretation of Heart SoundsInterpretation of Heart Sounds Pericardial Friction RubPericardial Friction Rub

Heard when the percardial sac becomes inflamedHeard when the percardial sac becomes inflamed Producing a grating sound due to the friction of the Producing a grating sound due to the friction of the

visceral and parietal pericardial layers rubbing against visceral and parietal pericardial layers rubbing against each other as the heart beats inside the pericardial saceach other as the heart beats inside the pericardial sac

Best heard over the apex of the heartBest heard over the apex of the heart

ret 1024 introduction to respiratory therapy module 4.4 bedside assessment of the patient — heart...

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