Assessment – Auscultation Skills

NU2ICU V3 logoASSESSMENT – AUSCULTATION SKILLS

Listen in the order shown above comparing 1 with 1, 2 with 2 and onwards front and then back

 

AUSCULTATIO

Listening for inherent noises over body cavities used to determine presence and quality of heart, lung, and bowel sounds


Low-pitched tones are best heard with the stethoscope’s bell (“bell-low” to remember). The bell should be placed lightly on the skin

 

Quality – normal breath sounds heard over the lung fields are referred to as vesicular. They are usually louder and longer on inspiration and there is no gap between inspiratory and expiratory sounds

Bronchial breath sounds are caused by turbulence in the large airways. They are higher in pitch, hollow, tubular sounds. They are louder and longer on inspiration than expiration, and there is often a gap between inspiration and expiration (auscultate over your trachea or manubrium to get an idea of what they sound like)

If you can hear bronchial breath sounds when auscultating your patient’s chest it is because the sounds are being conducted to the peripheral lung fields from the large airways by consolidation (fluid or lung tissue)

Intensity: Some assessors recommend documenting intensity rather than air entry. Reduced intensity on one side of the chest may be due to pleural effusion, pneumothorax pneumonia etc.  The audible noises of normal air entry are not from gases within the lung fields but reflected from the attenuation of flow as gases move from the large bronchioles through the hilum into the smaller airways

Adventitious sounds (added sounds)

There is often much confusion about documenting these sounds, to make it simple use the following 2.

  • Wheeze – Resulting from distal airflow obstruction. They are continuous, high pitched almost hissing sounds caused when air flows through airways narrowed by secretions, spasm, lesions or foreign bodies

                Beware the silent chest. If present with other signs of respiratory distress, it may signify total peripheral airway obstruction.  Seek immediate assessment by senior nurse / MO or RRS

  • Crackles – described as interrupted, non-musical sounds, they are caused by the distal airways opening during inspiration and collapsing during expiration

Further described as:

Fine: sound of hair being rubbed between the fingers

Medium: sound of dreadlocks being rubbed between the fingers

Coarse: characteristic unpleasant cackling, gurgling quality

 

Pleural rub – a continuous or intermittent grating sound as thickened pleural surfaces rub together during breathing.  Indicative sound of pleurisy usually secondary to pneumonia or pulmonary infarction

Stridor – Stridor is a loud strangulating sound during inspiration indicating obstruction of the trachea or larynx (unless proved otherwise). Stridor is an upper airways obstruction and can be clearly auscultated over the patient’s trachea  Seek immediate assessment by senior nurse / MO or RRS/MET

 


 

HEART VALVE ASSESSMENT

True knowledge of hearts sounds and their interpretation may take many years to master, the sounds we hear are reflections of physical changes to the heart as part of the electrical cycle

N.B. The best places to auscultate the valves do not quite correlate with their anatomical location

To remember the valves in order across the chest from right to left we use the saying “Toilet Paper My Ass” crude but effective!

We are listening for a defined regular clear “Lub-Dub” sound that accompanies the feeling of an apical pulse

Systole = ventricular pressure increase

  • Increase in pressure causes mitral and tricuspid valves to close
  • Ventricles contract
  • LV ejects blood to body
  • RV ejects blood to lungs
  • Known as S1
    • “lub” sound

 Diastole = resting phase

  • Ventricles relax while atria contract
  • Pressure in ventricles is less than in aorta and pulmonary artery
  • Causes the aortic and pulmonic valves to close
  • Known as S2
    • “dub” sound

Sometimes you hear a third sound while ventricles fill

  • Known as S3
  • Pressure in L side of heart is greater than R
  • Sometimes can hear aortic valves close before pulmonic
    • referred to as a split S2 sound

 


 

ABDOMINAL QUADRANTS

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

Divide the abdomen in four quadrants

  • Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement
  • Peristaltic sounds are quite irregular so it is recommended listening for at least 3 – 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present
  • Normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. Varying numbers of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound

Adapted from  http://nursinglink.monster.com/training/articles/238-physical-assessment—chapter-9-gastrointestinal-system  accessed online 12 / 03 / 2015

Time to think about whats where…

 

 So we have learnt to listen to the lungs, the bowel and most importantly, the patient!   Well done and keep up the great work!

NU2ICU

 

REFERENCES

Clinical Examination : a systematic guide to physical diagnosis 6th Edition 2010 by Nicholas J. Talley, Simon O’Connor.

Oxford Handbook of Clinical Examination and Practical Skills, 1st Edition 2007 by James Thomas, Tanya Monaghan

More reading

NU2ICU GENERAL ASSESSMENT

NU2ICU PRIMARY ASSESSMENT

NU2ICU SECONDARY ASSESSMENT

NU2ICU KNOWLEDGE ADJUNCTS

NU2ICU NORMAL VALUES

NU2ICU RRS / MET VALUES

NU2ICU ASSESSMENT PRACTICE TOOL