Sienna Rhodes
Documenting heart sounds is an essential skill for nurses to master. It involves listening to the heart at specific locations on the chest, known as cardiac auscultatory areas, to identify any potential signs of dysfunction. Nurses must be vigilant in collecting comprehensive information, including subjective statements and objective findings, to make informed clinical judgments when providing patient care. The heart produces a lub-dub sound, with the dub (S2) usually louder than the lub (S1). Nurses should auscultate for these heart sounds, noting any extra sounds, irregular rhythms, gallops, murmurs, or rubs. They should also identify the Point of Maximum Impulse (PMI), typically found in the fifth intercostal space, and document the capillary refill time. This paragraph provides an introduction to the topic of how to document heart sounds in nursing, highlighting the key aspects that nurses should consider during cardiovascular assessments.
| Characteristics | Values |
|---|---|
| Observation | Look for jugular venous distention. Note any obvious chest deformities |
| Palpation | Place your hand on the patient's chest to feel for the point of maximum impulse |
| Auscultation | Listen for heart sounds at different points in the cardiac cycle, noting any extra sounds, gallops, murmurs, or rubs |
| Medical History | Obtain a thorough medical history related to the heart and peripheral vascular systems |
| Physical Assessment | Perform a physical assessment of the heart and peripheral vascular system, including examinations of color, temperature, edema, capillary refills, and peripheral pulses |
| Blood Tests | Check cholesterol levels and other relevant blood tests, such as Electrocardiogram (ECG) and Echocardiogram |
| Vital Signs | Check if vital signs are within normal limits |
| Heart Sounds | Identify S1 and S2 sounds and follow up on any unexpected findings, such as irregular rhythm or extra sounds |
| Capillary Refill | Document the capillary refill time as less than or greater than 2 seconds |
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What You'll Learn
Auscultate for S1 and S2 heart sounds
To auscultate for S1 and S2 heart sounds, begin by asking the patient to breathe quietly, and then a bit more deeply. Use the diaphragm of the stethoscope to listen to the intensity of each sound, noting if each is a single or split sound, and any respiratory variation. The S1 heart sound corresponds to the closing of the mitral and tricuspid valves during systole, and the S2 heart sound corresponds to the closing of the aortic and pulmonary valves at the beginning of diastole.
The aortic area is the second intercostal space to the right of the sternum, and the pulmonic area is the second intercostal space to the left of the sternum. When listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1). Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and the tricuspid area (fourth intercostal space).
The rate of ventricular contraction affects the intensity of S1. The faster the heart rate and the faster the rise in ventricular pressure, the louder the S1. Thus, high-flow states such as anaemia, thyrotoxicosis, or sepsis would result in an accentuated S1. The second heart sound is produced by the closure of the aortic and pulmonic valves. The sound produced by the closure of the aortic valve is termed A2, and the sound produced by the closure of the pulmonic valve is termed P2. The A2 sound is normally much louder than the P2 due to higher pressures on the left side of the heart.
S2 is physiologically split in about 90% of people. The S2 heart sound can exhibit persistent (widened) splitting, fixed splitting, paradoxical (reversed) splitting, or the absence of splitting. The splitting between A2 and P2 can be exaggerated by inspiration, particularly in young individuals. During inspiration, you should hear the inspiratory splitting of S2 into A2 and P2. To the untrained ear, this sounds more like a prolongation of sound rather than two distinct sounds.
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Identify abnormal heart sounds
To identify abnormal heart sounds, nurses must be vigilant in collecting comprehensive information and using their best clinical judgment. A normal heartbeat has two sounds, "lub" (S1) and "dub" (S2), caused by the closing of valves inside the heart. However, problems with the heart may result in additional abnormal sounds, such as heart murmurs, gallops, clicks, or rubs.
Heart murmurs are the most common abnormal heart sound and can be described as blowing, whooshing, swishing, or rasping sounds that occur during the heartbeat. They can be present at birth (congenital) or develop later in life (acquired). While some heart murmurs are harmless and do not require treatment, others may indicate a serious heart condition. Nurses should listen for these extra heart sounds using a stethoscope at the five specific auscultation sites: Aortic, Pulmonic, Erb's point, Tricuspid, and Mitral areas.
Gallops, also known as extra heart sounds, can indicate an abnormality. These are sounds that occur in addition to the normal S1 and S2 heart sounds and may suggest an underlying heart condition. Clicks are another type of abnormal heart sound that can indicate issues with the heart valves. Rubs, also known as pericardial friction rubs, are creaky, scratchy noises heard upon cardiac auscultation, indicating inflammation of the pericardium.
When performing a cardiovascular assessment, nurses should follow these steps:
- Observation: Look for jugular venous distention and any obvious chest deformities.
- Palpation: Place the hand on the patient's chest to feel for the Point of Maximum Impulse (PMI), which is typically visible in the fifth intercostal space. Any displacement of the impulse can signal underlying pathology.
- Auscultation: Listen for heart sounds at different points in the cardiac cycle, noting any extra sounds or irregular rhythms.
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Palpate the chest for Point of Maximum Impulse (PMI)
Palpating the chest for Point of Maximum Impulse (PMI) is a crucial step in a cardiovascular assessment. The PMI is the area on the chest where the cardiac impulse can be felt most strongly, typically visible in the fifth intercostal space near the mid-clavicular line. This area usually corresponds to the apical or left ventricular area, which is the tip of the heart pointing downward on the left side of the chest. However, in certain conditions, such as severe right ventricular dilation, the PMI may be displaced.
To accurately palpate for the PMI, the patient should be positioned lying flat, allowing for better observation of the pulsations from the PMI from the side. Using your finger pads, which are more sensitive than fingertips, cover the patient's chest with your hand and feel for the PMI. In adults, the PMI is typically located between the fifth and sixth ribs, while in children under seven, it is found in the fourth intercostal space.
It is important to note that in some cases, such as extreme tachycardia or shock, palpating the PMI may be challenging. Additionally, the PMI may exhibit different characteristics depending on the underlying cardiac condition. For example, in conditions like hypertrophic cardiomyopathy, a double impulse may be felt, indicating a second impulse after the first one due to the filling of the enlarged ventricle during diastole.
After palpating the PMI, it is essential to document your findings comprehensively. Note the location of the PMI, any displacement, and characteristics such as a single or double impulse. Also, observe if there is a parasternal heave, which could indicate right ventricular hypertrophy. Your documentation should include both subjective statements and objective findings to provide a holistic understanding of the patient's cardiovascular health.
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Observe the jugular venous distention
To observe jugular venous distention, the patient should be positioned supine on a bed that is bent at the hip, so that the head, neck, and thorax are on a similar plane. The examiner should stand at the right side of the table, as the right-sided internal jugular vein connecting to the right brachiocephalic vein is in direct line with the superior vena cava. The left brachiocephalic vein, which connects the left internal jugular vein, can be used if the right-sided internal jugular vein is not visible.
The patient's neck should be positioned for the best view. A well-lit room negates the need for a direct light to be shone on the patient's neck. The goal is to observe a pulsation and then decide if it is arterial or venous. A venous wave is bifid, flicking like a snake's tongue. It rises when the head of the bed is lowered and sinks when the head of the bed is raised. The height of the pulsation is then measured relative to the sternal angle, which is approximately 5 cm above the right atrium. A JVP of 0 to 4 cm above the sternal angle is considered normal, whereas a JVP of more than 4 cm indicates jugular venous distension.
The JVP can be assessed on either the right or left side. On occasion, the pulsations can only be visualized on one side due to musculoskeletal anatomy or venous clots. If the JVP cannot be determined, the exam should be reported as ""JVP not visualized" rather than "no JVD".
The JVP can provide an estimate of central venous pressure (CVP) and, when distended, can provide prognostic implications in patients with heart failure exacerbation.
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Examine the peripheral vascular system
To examine the peripheral vascular system, it is important to understand its anatomy and function. The peripheral vascular system (PVS) is a network of blood vessels that carry oxygenated blood away from the heart to the periphery and deoxygenated blood back to the heart and lungs. This system is crucial for tissue perfusion and oxygenation in the periphery.
When examining the PVS, nurses should follow a systematic approach, starting with the upper limb and moving downwards, unless instructed otherwise. Here is a step-by-step guide:
- Introduce yourself to the patient, wash your hands, and explain the examination procedure in simple terms. Gain the patient's consent to proceed.
- Expose the patient's limbs and abdomen, offering a blanket to maintain privacy and comfort.
- Inspect the patient's limbs for any signs of vascular compromise, such as missing limbs or digits, scars, or discolouration.
- Position the patient supine and raise both feet to 45 degrees for 1-2 minutes.
- Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses bilaterally. Also, palpate the carotid pulse one side at a time, noting the presence and amplitude of the pulse.
- Assess capillary refill time by palpating the nail beds. A refill time of less than two seconds is considered normal.
- Auscultate for heart sounds using a stethoscope, focusing on the aortic, pulmonic, Erb's point, tricuspid, and mitral areas. Listen for extra sounds, irregular rhythms, gallops, murmurs, or rubs.
- Document your findings, including any subjective statements and objective observations. Note any unexpected findings that may require further investigation.
By following these steps, nurses can effectively examine the peripheral vascular system, identify potential signs of dysfunction, and provide comprehensive care to their patients.
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Frequently asked questions
The heart assessment points are specific locations on the chest where nurses can listen to heart sounds. These areas correspond to optimal spots to hear specific valves and the flow of blood through the heart. The main assessment points are:
- Aortic area: 2nd intercostal space at the right sternal border
- Pulmonic area: 2nd intercostal space at the left sternal border
- Erb’s point: 3rd intercostal space at the left sternal border
- Tricuspid area: 4th or 5th intercostal space at the left sternal border
- Mitral area: at the apex of the heart, usually in the 5th intercostal space at the midclavicular line
The different heart sounds are often referred to by the mnemonic "lub-dub". The "dub" (S2) will sound louder than the "lub" (S1) when listening over the aortic and pulmonic valves.
Listen for extra heart sounds, gallops, murmurs, or rubs.
The PMI is the area on the chest where the cardiac impulse can be best felt. It is typically visible in the fifth intercostal space. Displacement of the impulse can signal underlying pathology.
Some related diagnostic procedures include:
- Electrocardiogram (ECG or EKG)
- Holter Monitoring (or Ambulatory ECG)
- Chest X-ray
- Echocardiogram
- Exercise stress test (or Treadmill test)
