Sienna Rhodes
Documenting normal heart sounds is a critical aspect of cardiovascular assessment, requiring a combination of subjective statements and objective findings. A thorough medical history, including symptoms like fatigue, indigestion, and leg swelling, guides potential diagnoses. The physical examination focuses on the heart and peripheral vascular system, encompassing inspection of the chest area, palpation of pulses, and auscultation of heart sounds with a stethoscope. Normal heart sounds, often described as lub-dub, involve identifying S1 and S2 sounds with regular rhythm and no murmurs or extra sounds, indicating a healthy cardiovascular system. This introduction sets the stage for understanding the process of documenting normal heart sounds as a vital tool in clinical practice.
| Characteristics | Values |
|---|---|
| Heart rate | 60-100 for adults |
| Rhythm | Regular |
| S1 and S2 sounds | Heard and of normal intensity |
| S1 and S2 sounds | "Lub-dub" or "lub and a dub" |
| S1 sound | Heard when listening over the area of the aortic and pulmonic valves |
| S2 sound | Louder than S1 when listening over the aortic and pulmonic valves |
| S3 sound | May indicate abnormality |
| Murmurs | May indicate abnormality |
| Gallops | May indicate abnormality |
| Rubs | May indicate abnormality |
| Extra sounds | May indicate abnormality |
| Irregular rhythm | May indicate abnormality |
| Capillary refill time | Less than 2 seconds is normal |
| Peripheral pulses | Present and equal bilaterally |
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What You'll Learn
Listen for the 'lub-dub' sound
To document normal heart sounds, you must listen for the "lub-dub" sound. This is the sound of the valves closing, with the first "lub" composed of the mitral and tricuspid valves closing, and the second "dub" composed of the aortic and pulmonary valves closing.
The "lub-dub" sound is produced by the closing of the atrioventricular valves and semilunar valves, respectively. The first heart sound, or S1, is the "lub", and the second heart sound, or S2, is the "dub". Normally, the aortic valve closure (A2) precedes pulmonary valve closure (P2), especially during inspiration where a split of S2 can be heard.
When listening over the aortic and pulmonic valves, the "dub" (S2) will sound louder than the "lub" (S1). To listen for these sounds, a stethoscope is placed over five auscultation areas of the heart: the apical pulse at the fifth intercostal space, midclavicular line for one minute, 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 apical pulse should be counted over a 60-second period, with a rate of 60-100 beats per minute considered within the normal range for adults. The "lub-dub" sound can also be recorded via direct output to an external recording device, such as a laptop or MP3 recorder, using electronic stethoscopes.
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Identify S1 and S2 sounds
To identify S1 and S2 sounds, you must auscultate with both the bell and the diaphragm of the stethoscope over five auscultation areas of the heart. The apical pulse should be counted over a 60-second period. For an adult, a heart rate of between 60 and 100 with a regular rhythm is considered within the normal range.
The first heart sound, S1, corresponds to the closure of the mitral and tricuspid valves during systole. The mitral and tricuspid valves close almost simultaneously, so only a single heart sound is usually heard. However, in some cases, a "split S1" sound can be heard, where the mitral valve closes significantly before the tricuspid valve, allowing each valve to make a separate audible sound. 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.
The second heart sound, S2, corresponds to the closing of the aortic and pulmonary valves at the beginning of diastole. S2 is normally split because the aortic valve closes before the pulmonary valve. The aortic component of S2 (A2) is normally much louder than the pulmonary component (P2) due to higher pressures on the left side of the heart. S2 may be subdivided into aortic (A2) and pulmonary (P2) sounds, and the splitting between these two sounds can be exaggerated by inspiration, particularly in young individuals.
S3 and S4 are extra heart sounds that can occur after S2. S3 occurs during ventricular filling and can be a normal finding in some cases, although it can also be a sign of systolic heart failure. S4 arises when the atria contract against a stiff ventricle and is usually abnormal.
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Check for murmurs
To check for murmurs, a stethoscope is required. Heart murmurs are extra, unusual sounds in the heartbeat, which can sound like a whooshing or swishing noise. This occurs when blood does not flow smoothly through the heart. Murmurs are graded by intensity from 1 to 6, with 1 being barely audible even with a stethoscope, and 6 being clearly audible without the stethoscope touching the skin.
To check for murmurs, the stethoscope should be placed over five auscultation areas of the heart. The apical pulse should be counted for one minute at the fifth intercostal space, midclavicular line. The rate and rhythm should be noted. The stethoscope should then be moved 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). When assessing female patients, it is helpful to ask them to lift their breast tissue so the stethoscope can be placed directly on the chest wall.
Murmurs can be innocent or abnormal. Innocent murmurs are harmless and are caused by blood flowing through the heart faster than usual. They are common in children and can be caused by an overactive thyroid or anaemia. Abnormal murmurs are caused by a problem with the heart, such as defective heart valves, and can be dangerous if untreated, although this is rare.
When checking for murmurs, it is important to note any other symptoms that may indicate a heart problem or other health issue. These can include fatigue, indigestion, leg swelling, unexplained weight loss, belly pain, diarrhoea, low blood pressure, chest pain, heart palpitations, or shortness of breath.
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Assess capillary refill
To assess capillary refill, start by removing any nail polish and finger rings. Elevate the patient's hand or foot above their heart. Apply pressure to the nail bed for up to 10 seconds, or until it turns white/pale. Release the pressure and record the time it takes for the colour to return to the nail bed. This colour change is due to oxygen-rich blood filling the capillaries. A refill time of less than 2-3 seconds is considered normal.
Capillary refill time is a rapid test used to assess blood circulation in the arms and legs (peripheral perfusion). It can be used to detect shock in people with life-threatening illnesses or injuries. If the refill time is longer than 3 seconds, arterial insufficiency is suspected, and further testing may be required.
The test can be performed on the fingers or toes, but in some cases, it may be necessary to use the skin near the breastbone (sternum). This alternative test site is used for people with hypothermia or those who arrive at the hospital cold due to cold weather.
Capillary refill time is a simple, quick, and reliable method for assessing peripheral perfusion in adults and children. It provides valuable information about the patient's circulatory system and can help healthcare providers determine the appropriate course of treatment.
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Inspect the chest area
Inspecting the chest area, also called the precordium, is an important step in documenting normal heart sounds. This involves examining the area over the heart for any visible abnormalities. Here are the key steps to follow when inspecting the chest area:
Check for Deformities and Scars: Inspect the precordium for any deformities, scars, or unusual markings. This includes looking for any signs of previous surgical procedures or injuries that may have left visible marks on the chest.
Assess Pulsations: Pay close attention to any abnormal pulsations that may be present. These pulsations can provide important clues about the underlying cardiac chambers and great vessels. Feel for any lifts, heaves, or thrills, which are vibratory sensations that indicate turbulence and can be felt in loud murmurs.
Inspect the Upper Extremities: Bilaterally inspect the fingers, arms, and hands. Note the Color, Warmth, Movement, and Sensation (CWMS) of these extremities. Any alterations or inconsistencies in CWMS between the left and right sides could indicate an underlying condition or injury.
Evaluate Capillary Refill: Assess capillary refill in the upper extremities by compressing the nail bed until it turns white or blanched. Time how long it takes for the colour to return to the nail bed. Normal capillary refill should take less than 2 to 3 seconds.
Examine the Skin: Observe the skin of the chest area for any visible signs. Note the temperature, colour, and texture of the skin. Look for any signs of cyanosis, pallor, or abnormal pigmentation. Additionally, check for the presence of hair distribution, as changes in hair growth patterns can be indicative of certain medical conditions.
By following these steps and closely examining the chest area, healthcare professionals can gather valuable information about the patient's heart health and document normal heart sounds accurately.
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Frequently asked questions
Normal heart sounds are often described as a "lub-dub" sound, with the "'dub' (S2) louder than the 'lub' (S1). These sounds are made by the closing of the heart valves.
You will need a stethoscope to listen to the heart sounds. You will also need a sphygmomanometer, a cuff with an inflatable balloon, and a manometer to measure blood pressure.
To document normal heart sounds, you must first identify the S1 and S2 sounds and ensure there are no extra sounds or irregular rhythms. Note the rate and rhythm of the heart rate, ensuring it is within the normal range for the patient's age and condition. You should also check for any unexpected findings, such as murmurs or gallops, and document the patient's medical history and any physical exam findings.
