A thorough assessment of your patient is like an adventure in hunting, and it enables you to make sense of the clues to your patient’s current health status. But in order to find and understand those clues, one must have a strong foundation in their assessment skills. Although each area of assessment has its own art and mystery, many report struggling the most with cardiac assessment. When teaching assessment programs, I repeatedly hear some common questions. Here are three of those questions and their answers.Q. What does it mean when I hear an S3 heart sound, and where can it be heard the clearest?
An S3 is the most commonly heard extra heart sound in adults and is heard with fluid volume overload, such as that related to heart failure. Left-sided heart failure is heard best at the mitral valve location. Remember, S3 heart sounds are soft and subtle, so a quiet environment is necessary when listening for one. Frequently, S3 sounds are heard best in the left lying position, shifting the heart towards that part of the chest wall. This extra heart sound is heard right after lub (S1) and dub (S2), leading to pneumonic Kentucky—a short extra sound tagged on to the end of S1 and S2. One last reminder - after the fluid volume overload is resolved, an S3 heart sound will no longer be heard, and we go back to just hearing S1 and S2.Q. Are there clues on auscultation to whether a heart murmur is systolic or diastolic?
In reality, the distinction between systolic and diastolic is not hard to tell. First, identify the swooshing sound of a murmur being present. Then listen again to identify where in the cycle you hear it. Is it between S1 and S2? If so, that is a systolic murmur. If you hear it between S2 and S1, then that is a diastolic murmur. Ironically, even though systolic murmurs are often benign or functional (medically managed unless severely symptomatic), they are often the louder of the two.Q. How do I tell the difference in my cardiac assessment findings between right- or left-sided failure?
Visualizing blood’s journey through the body may help us see clues to right- or left-sided failure. Before the blood hits the right side of the heart, it comes from the body. Blood makes its journey to the tissues dropping off oxygen and picking up carbon dioxide (CO2), and then journeys up the superior vena cava to the right side of the pump. If the patient is having right-sided heart dysfunction, blood backs up to the body causing systemic symptoms, such as lower extremity edema, jugular vein distention, and engorgement of the liver. If the liver engorges enough, the patient may start to develop ascites.
From the right side, blood goes to the lungs and then to the left side of the pump. If a patient is having left-sided pump dysfunction, blood backs up the lungs and the patient experiences pulmonary symptoms. These may include dyspnea, hypoxia, the development of rales (crackles in the bases), and orthopnea (when patient lies flat, they feel they can’t breathe).
Now that being said, I need to remind you: The most common cause of right-sided failure is severe left-sided failure, where blood finally backs up to the right side of the heart. Those patients have both pulmonary and systemic symptoms. Many of the patients you work with may have this mixed failure.
Were you able to answer these questions? Has it lead you to pondering more cardiac questions? Or perhaps you have questions about other aspects of the physical assessment. To give the best care to our patients we need to understand how to find the clues and decipher what they are telling us.
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This post was brought to life by PESI speaker Cyndi Zarbano
, MSN, BSN, CCRN, CMSRN, CLNC, NLCP. Cyndi is an intensive care nurse with over 20 years of nursing experience who is currently practicing in the Twin Cities area of Minnesota. She is a nationally-recognized seminar speaker who has opened multiple national symposiums and speaks on several topics for PESI, as well as a variety of other companies in the US and Canada. Her national acclaim is well deserved for her ability to make knowledge practical, as well as encouraging knowledge retention by her frequent use of stories, humor and case studies.