The process of aging affects all body organs and systems, and their function can become less competent. Cardiac function is no exception. In fact, half of all adults over age 65 have heart disease. In general, we see reduced cardiac output in geriatric clients, with a resultant decrease in their ability to perform activities of daily living. The myocardium loses elasticity, thus the older client's heart reacts less efficiently to stress. A thorough cardiac assessment can help determine if changes in activity tolerance or other signs and symptoms are an expected part of aging or if they indicate serious heart disease or conditions that would respond to treatment.
Preparing for the Examination
Have the proper equipment available. This includes a stethoscope with a double chest-piece; a quiet, well-lit environment; and a marking pencil for indicating auscultation sites.
It is important to follow the usual sequence of physical examination: history, inspection, palpation, percussion, and auscultation. A common error is to listen to the heart first, because you may miss important clues that will help interpret heart sounds. Explain that a thorough cardiac assessment might take as long as 10 minutes and that the amount of time spent does not necessarily indicate a serious problem. Because a thorough cardiac exam requires the client to assume a number of different positions, you may need to slow the pace of the exam or alter the sequence. As you proceed, monitor the elderly client's level of comfort and breathing pattern.
Certain landmarks on the chest wall determine where cardiac function can be assessed most accurately. Heart sounds result from the closing of the four valves in the heart. They can be auscultated over the entire precordial area, but the sound produced by each of the valves can be heard best at specific locations on the chest. That location is not directly over the valve, but away from it in the direction of blood flow.
Overview of the Examination of the Heart
In the second intercostal space at the right sternal border, you will hear the aortic (A) valve best. Right across from it at the left sternal border, you will hear the pulmonic (P) valve best. The best place to hear the tricuspid valve (T) is in the fifth intercostal space at the left sternal border. The mitral valve (M) can be heard best at the fifth intercostal space at the midclavicular line. The mitral area is also the site used to assess the apical pulse because it lies over the apex of the heart. It may be helpful in the beginning to mark the chest wall with an X at each site or a small A, P, T, or M over the appropriate area.
Just as various locations enhance certain sounds, varying the client's position may elicit certain signs, such as pulsations on the chest wall, or allow you to hear other sounds, such as murmurs. Examine each of the four sites with the client supine; then go through the entire sequence again with the client sitting erect, leaning forward, and finally in a left side-lying position (Table 1).
The first step is to elicit a relevant health history (Table 2). Episodes of fatigue, restlessness, syncope, or confusion may be due to oxygen deprivation and, especially in the elderly, can be early clues of congestive heart failure or myocardial infarction. It is always a good idea to have clients show you any medications that they are taking or "sometimes" take, and to check that the medications are taken as prescribed. If the client does not have the medications on hand, have the client bring them to you.
The next component of the cardiac examination is inspection, which provides clues to the size of the heart and the effect of ventricular contraction on the precordium. Look at the anterior chest with the patient supine for visible pulsations, lifts, or heaves. Visualization is best if the light source is from the side.
The apical impulse, or point of maximal impulse (PMI), is a visible pulsation caused by left ventricular contraction that is synchronous with S1 (the first heart sound) and the carotid impulse. Its location provides a clue to cardiac size because it is near the apex of the heart. Nearly half of all normal adults will not have a visible apical impulse. It may become visible when the client sits up and the heart is closer to the chest wall. The presence or absence of a visible apical impulse can be affected by the shape of the chest wall, obesity, or the amount of air or fluid through which the impulses must pass.
When the apical impulse is present, it should be located near the mitral site, which is also the site for taking an apical pulse. It should be present in only one intercostal space. Describe the location according to both the intercostal space and the midclavicular line. In a client with an enlarged heart, the apical impulse may be displaced distally or laterally. In elderly patients, however, the PMI can be displaced due to kyphosis or scoliosis and not necessarily be indicative of cardiac enlargement.
When cardiac function is abnormally forceful, the pulsation is readily visible even when the client is supine. The ribs may appear to lift as the heart beats, suggesting the presence of a cardiac problem. Document this as a lift or heave and note the location.
Remember to make note of cyanosis, venous or abdominal distention, capillary refill, skin temperature, shortness of breath, or coughing. Each of these can assist in determining the adequacy of cardiac function.
Palpate the precordium systematically, making sure your hands are warm. Use the proximal half of the four fingers or your palm. Apply gentle pressure so that you can detect movements rising up against your hand. An impulse that is more forceful than anticipated can be characterized as a lift or a heave. A heave will be noted near the sternum if the client has increased pressure or enlargement of the right ventricle. Problems in the left ventricle will be detected near or lateral to the apex of the heart. If you note either, check to see if the client has signs of congestive heart failure. Right-sided failure will result in venous and abdominal distention; leftsided failure will result in congestion in the lungs.
A thrill has been described as a palpable heart murmur and will be felt as a vibration. If you detect a thrill, be alert for a murmur when you auscultate. Note the location of any lifts or thrills, using the intercostal spaces and midsternal or midclavicular lines as landmarks.
Percussion to estimate the size of the heart or to define the cardiac borders by identifying areas of dullness is less reliable than chest x-ray or other diagnostic studies. Sufficient preliminary information can be obtained by inspection and palpation.
Becoming skillful at auscultating heart sounds takes concentration and practice. If you are a beginner, practice on family members, friends, and colleagues. The more familiar you become with normal heart sounds, the more adept you will become at hearing variations. Listen to as many elderly people as possible to differentiate normal changes associated with the aging heart, eg, occasional extra beats, from pathologic ones. It is beyond the scope of this article to fully detail and explain all possible normal and abnormal heart sounds, rhythms, and murmurs. However, information will be provided to help you identify and describe the characteristics of normal heart sounds and the occurrence of split sounds, extra heart sounds, and murmurs.
Normal Heart Sounds
Remember that normal heart sounds are produced by the closing of the valves of the heart. The first sound, S1, results from the closure of the atrioventricular (AV) valves, the mitral and tricuspid. The closure of the AV valves and S1 mark the beginning of systole, the period of maximal contraction and pressure. The second heart sound, S2, results from the closure of the semilunar valves, the aortic and pulmonic. S2 marks the end of systole and the beginning of diastole, the period during which the heart muscle is relaxed. Diastole is normally of longer duration than systole. Normal heart sounds are produced when the valves and the heart muscle are working efficiently.
Begin auscultation with the client lying on his back, or with the head elevated 30° to 45° if the client is short of breath. Auscultate from the right side if you are right-handed; left side if left-handed. Begin at the mitral or aortic area, but use the same sequence with each client. Listening systematically will improve your skill in interpreting the sounds. Use both the diaphragm and the bell to listen in each area. The diaphragm is best for picking up the higher pitched sounds of S1 and S2 and split sounds, and it should be applied firmly to the chest. The bell is best for picking up the lower pitched sounds of S3 and S4 and should be applied lightly to the chest.
Focus on one sound at a time, blocking out other heart sounds, breath sounds, and room noises. This is important because even at a heart rate of 60 beats per minute, all of the events in the cardiac cycle occur within a second. Elderly clients frequently have more rapid, less distinct heartbeats. Listen for the normal heart sounds (S1 and S2, "lubdub") first. Tune in to S1 first ("lub"). Because this results from the closure of the mitral and tricuspid valves, the intensity will be greatest in those areas and loudest at the mitral valve (the apex). To ensure you are listening to S1, check if the carotid pulse is in synchrony with the sound. Inch the stethoscope from site to site, listening at each place to the characteristics of S1.
Make another round of the auscultation sites, listening this time for S2 ("dub"). It will be heard best at the pulmonic and aortic areas, but loudest at the aortic. After identifying normal heart sounds, note the location of greatest intensity. Greater intensity may be heard in other than the usual site if the heart is enlarged or if normal blood flow is altered. Also listen to whether the intensity seems diminished or muffled or if it varies from beat to beat, which may suggest heart block. Note the rate (usually between 60 and 90 beats per minute) and the rhythm. Atrial fibrillation and infrequent ectopic (extra) beats are fairly common in the elderly, but any irregularity should be documented and reported. Always refer clients with irregular rhythms that occur without a pattern.
After listening to the first and second heart sounds, listen for split sounds. They are usually heard best on the right side (the pulmonic and tricuspid sites). The left valves usually close before the right, but the timing is so close that no split is detected. When the timing widens, each sound is heard. A split S1 sounds like t-lub-dub. It is generally considered abnormal in middle-aged and older adults. A split S2 sounds like lub-t-dub. If the split S2 is heard only during inspiration or disappears when the client sits up, it may be normal or physiologic. If it is unaltered by breathing or position, it is not normal and could indicate right ventricular failure or other cardiac disease.
Extra Heart Sounds
Although many practitioners consider the presence of extra heart sounds to be abnormal in adults, the presence of S3 or S4 does not necessarily indicate cardiac pathology but must be evaluated in light of other heart sounds and diagnostic clues. It is important, however, for the nurse to be aware that S3 or S4 may be the earliest signs of heart failure and may need to be brought to the attention of a nurse practitioner or a physician.
S3 and S4 occur during diastole and are best heard with the bell of the stethoscope with the patient in the left sidelying position. S3 occurs early in diastole and sounds like lub-dub-dee. In the elderly, it is generally considered pathologic and is usually due to left ventricular failure. If S3 is heard, auscultate the lungs for crackles, which indicate that fluid is collecting in the respiratory system, perhaps due to left ventricular failure. S4 occurs late in diastole and sounds like dee-lub-dub. When either sound becomes intense, the heart rhythm sounds like a gallop. This occurs frequently in geriatric clients because the heart muscle has become less compliant. Gallops should always be reported.
Describe the location, timing, and characteristics of the client's heart sounds. You may be uncertain as to what is causing the extra or different sounds, but you can learn to hear them and to document your findings. Report what you hear even if you are unable to distinguish, for example, between a split S2 or an S3.
Six-Point Grading Seuroale of Heart Murmurs
A murmur is heard as a relatively prolonged swishing sound between normal heart sounds and is the result of turbulent or backward flow of blood through the heart. After S1 and S2 (systole) there should be a silent interval (diastole) until the next cardiac cycle. As a person ages, the heart valves become thicker, more rigid, and do not shut as effectively. The turbulence of the blood flow around these valves produces a heart murmur, which sounds like a hum. Not all murmurs are the result of valvular defects. Other causes could include diminished strength of myocardial contraction or a condition in the major vessels near the heart. Remember that the presence of a murmur does not necessarily indicate cardiac disease and, conversely, cardiac disease can be present without evidence of a murmur. Murmurs are usually heard best with the client in the left lateral position.
A murmur should be documented by location (where on the chest wall it is loudest), quality, (harsh, blowing, musical), loudness or intensity (using a grading system such as in Table 3), radiation, and timing.
Murmurs are described by the location on the chest where they sound loudest. The point on the chest wall where a murmur is best heard may not correspond to the valve site because of transmission of sound. Murmurs of the aortic valve frequently radiate to the third intercostal space at the left midsternal line. This site is known as Erb's point and is frequently recommended as an additional inspection/ auscultation site. In addition to documenting the location at which the murmur sounds loudest, describe the radiation of the sound. Specific information can be helpful in diagnosis: murmurs of mitral origin frequently radiate to the axilla, whereas aortic murmurs radiate to the carotid arteries.
It is important to note the timing of the murmur. Does it occur during systole (systolic murmur) or diastole (diastolic murmur)? Early, soft systolic murmurs are fairly common in the elderly. If a murmur is heard best in midsystole, it is termed an ejection murmur. If loudness is equal throughout systole, it is called a pansystolic murmur. Diastolic murmurs are usually associated with valvular abnormalities. Early diastolic murmurs that fade out in late diastole are described as decrescendo; late diastolic murmurs that become louder toward S1 are termed crescendo.
Although some murmurs may be benign, or functional, the discovery of a heart murmur requires careful assessment. It is important that you describe and document what you hear. Physical examination alone cannot always identify the cause of the murmur, but it can narrow the possibilities so that the client can be referred for appropriate diagnostic follow-up.
Individual differences in the client's age, build, and state of health will affect the visibility, palpable force, and sounds of the heart's action. In general, heart sounds are not as loud in the elderly as they are in younger clients. Findings in clients with thin, nonmuscular chests may be clearer or louder than in muscular or obese clients. In these clients, visible or palpable pulsations and heart sounds may be more difficult to elicit. Changes in the anteroposterior diameter of the chest related to aging or emphysema can alter the location of the pulsations and make heart sounds more difficult to hear; eg, kyphosis can alter the location of heart sounds and of the apical impulse.
- Bowers, A., Thompson, J. Clinical manual of health assessment, 3rd ed. St. Louis: CV Mosby, 1988.
- Gawlinski, A., Jensen, G. The complications of cardiovascular aging. Am J Nurs 1991; Nov:26-30.
- Seidel, B., Ball, J., Dains, J., Benedict, G. Mosby's guide to physical examination, 2nd ed. St. Louis: CV Mosby, 1991.
- Sherman, J., Fields, S. Guide to patient examination. New York: Medical Examination Publishing, 1988.
- Visich, M.A. Knowing what you hear: A guide to assessing breath and heart sounds. Nursing81 1981; Nov:65-76.
Overview of the Examination of the Heart
Six-Point Grading Seuroale of Heart Murmurs