1. Cardiac Assessment

2. Comprehensive Cardiac Assessment Health History Inspection Normal/abnormal Palpation-4 landmark areas Normal/abnormal Technique Auscultation

3. Normal Rate Rhythm Regular Irregular Strength (intensity) Extra Sounds

4. Chest Landmarks

5. Anatomical Landmarks Heart Sounds Aortic Area: 2 nd intercostal space (ICS), right sternal border Pulmonic Area: 2 nd ICS, left sternal border Tricuspid Area: 5 th ICS, left sternal border Mitral or Apical Area: 5 th ICS, medial to the midclavicular line AP TO MAN

6. S1: Systole First heart sound Closure of the AV valves – loudest at the tricuspid and mitral landmarks “lub” Dull, low pitched Longer than S2 Carotid pulse

7. S2: Diastole “dub” High pitch Shorter Semilunar valves close –loudest at the pulmonic or aortic valves landmarks S1 and S2 within 1 second or less

8. S3 Beginning of diastole Position on L side Mitral area Bell Low pitched “Kentucky” Too rapid of filling of the venticules HF

9. S4 Before S1 Position on L side Mitral area Bell Low pitched “Tennessee” Abnormal flow Elderly, MI, HTN

10. Murmur Turbulence of blood flow Increased blood flow Incomplete valve closure Stenosis Regurgitation Blood flow through: a dilated chamber abnormal opening between chambers Anywhere in the cycle Pathology Benign Abnormal

11. Classification of Murmurs Location Intensity (I-VI) Pitch Quality Timing Position

12. Other Abnormal Heart Sounds Pericardial Friction Rub a scratching high pitched sound caused by friction between the pericardial and epicardial surfaces (pericarditis)

13. Cardiac Assessment Auscultation Quiet environment Consistent /Systematic Method– with bell and diaphragm Listen for 1 full minute Listen with stethoscope and feel for radial Louder sounding valves at different locations Positioning Sitting up and leaning forward Left lateral recumbent Supine

14. Auscultation Tips Diaphragm high-pitched sounds such as S1, S2, murmurs, pericardial friction rubs. Bell low-pitched sounds such as S3, S4, and murmurs. S3 and S4 best position is the Left lateral using the bell