What is heart auscultation?Auscultation of the heart is not synonymous with examination of the heart. That is not to diminish the importance or difficulty of acquiring the necessary skills. Show
Examination of the heart starts with general inspection for cyanosis, dyspnoea, oedema or cachexia. It is followed by assessment of jugular venous pressure (JVP), examining the pulse and checking blood pressure. This includes checking the fingers for clubbing or splinter haemorrhages. Only then is it time to move to the chest and even then it is still not yet time to produce the stethoscope. The interpretation of heart murmurs in children can be especially difficult and it is discussed elsewhere in the separate Heart Murmurs in Children article. Mechanism of heart soundsHeart sounds (normal or pathological) are caused by turbulent blood flow. They include the sound of the closing heart valves. Laminar flow is silent. Turbulent flow makes a sound. A thrill is turbulence or a murmur that is so marked that it is palpable. Inspection and palpationLook at the chest.
Feel for the apex and note its character and position.
Sites for heart auscultationThe bell of the stethoscope is better for detecting lower-frequency sounds whilst the diaphragm is better for higher frequencies. The bell is usually used to listen to the mitral valve and the diaphragm at all other sites. Heart auscultation is usually performed with the patient sitting up or reclined at about 45°. Where variations are required, they will be described. Mitral area
Tricuspid area
Pulmonary area
Aortic area
The best place to hear the heart valves is not necessarily directly over the anatomical site. Heart soundsThe intensity of heart sounds and murmurs is graded as follows on Levine's scale:
Listen first for the heart sounds. They are called S1 and S2 and are traditionally described as 'lub' and 'dub' respectively. The first sound (S1) is caused by closure of the mitral and tricuspid valves and the two sounds tend to merge as one. When considered separately, the closure of the mitral and tricuspid valves is called M1 and T1 respectively. The second sound (S2) is caused by closure of the aortic and pulmonary valves. They are slightly apart with the aortic component, also called A2, slightly after the pulmonary closure called P2.
Additional heart soundsThe differentiation of 3rd sounds, 4th sounds, opening snaps and widely split S1 or S2 can be daunting.
Heart murmursNote the timing of murmurs. Establish whether systolic or diastolic. First listen to the lub dub and then get the timing. Some murmurs may obscure the heard sounds. Systolic murmurs can be innocent but are rarely so unless the patient is a child or pregnant[2]. Diastolic murmurs are always pathological. Mitral murmurs
Tricuspid murmurs
Pulmonary and aortic murmursThe pulmonary and aortic valves are both best heard in the 2nd intercostal space, to the left and right respectively. This can make differentiation quite difficult. Sound from the aortic valve is often transmitted to the carotid and can be heard by placing a stethoscope over the carotid bifurcation.
Septal defects
Other heart murmurs
Heart murmurs in children
Differential diagnosisThe following is a very simple approach to the differentiation of some of the more common and simpler problems of identifying murmurs on heart auscultation:
Referral[5]The National Institute for Health and Care Excellence (NICE) recommends referral for any adult with a heart murmur as follows: Referral for echocardiographyConsider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on:
Offer an echocardiogram to adults with a murmur if valve disease is suspected (based on the nature of the murmur, family history, age or medical history) and they have:
Referral for urgent specialist assessment or urgent echocardiographyIf valve disease is suspected (based on the nature of the murmur, family history, age or medical history):
For guidance on referral and assessment for adults with murmur and non-exertional syncope, follow the recommendations in the NICE guideline on transient loss of consciousness ('blackouts') in over-16s. For guidance on referral and assessment for adults with breathlessness but no murmur, follow the recommendations in the NICE guideline on chronic heart failure in adults. Referral to a specialist after echocardiographyMild valve disease is common and rarely progresses to become clinically significant. Offer referral to a specialist to:
For pregnant women and women considering pregnancy
ConclusionIn these days of ready access to echocardiography and even cardiac catheterisation, it is easy to forget the simple techniques of heart auscultation. Rheumatic heart disease is becoming rare these days and surgery corrects very many congenital cardiac defects, leaving no murmurs. Nevertheless the ability to use the traditional methods in the surgery is cheap, effective and very satisfying. Not all systolic murmurs need assessment by echocardiography[6]. Listening to recordings of heart sounds can be a very effective way to learn to recognise them[7]. The ability to recognise sounds is said to be low but can be improved with training[8]. Where should the nurse expect the first heart sound S1 the loudest when Auscultating a client's heart?Auscultate the heart at various sites
The 1st heart sound, S1 (lub), marks the beginning of systole (end of systole). Related to the closure of the mitral and tricuspid valves. Loudest at the apex.
Which location would the nurse expect the first heart sound to be heard the loudest?During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest? The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart.
When Auscultating heart sounds the nurse hears a whooshing sound this would be documented as?When your heart beats, valves open and close, allowing blood to flow. When the valves close, they produce two sounds: a “lub” and a “dub.” If your heart makes a whooshing or swishing sound instead, that's called a heart murmur.
When Auscultating heart sounds which technique should the nurse use?For best results, the nurse would use the diaphragm of the stethoscope and have the client sit up, lean forward, exhale, and hold his or her breath. The left lateral position may be used to hear an S3 or S4 heart sound or a murmur of mitral stenosis that was not detected in the supine position.
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