1. RET 1024 Introduction 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