HEART SOUNDS

The sound that the nurse hears is the first heart sound, S1. The first heart sound
(S1) is created by the closure of the mitral and triscupid valves (atrioventricular [AV]
valves). It marks the onset of systole (ventricular contraction). When auscultated,
the first heart sound (S1) is softer and longer than the second heart sound (S2). S1
is low in pitch and is best heard at the left lower sternal border or the apex of the
heart. Disease and stiffened AV valves (as in rheumatic heart disease) may
augment S1; rhythms of asynchrony between the atria and ventricles (as in atrial
fibrillation and with AV block) cause variable intensity of S1. Phonetically, if a typical
heartbeat, composed of the heart sounds S1 and S2, is auscultated as “lub-dup,” S1
is the “lub.” To assess S1, the nurse should assist the client to a supine position (the
head of the bed may be elevated slightly if necessary). The second heart sound (S2)
is related to closure of the pulmonic and aortic (semilunar) valves and is heard best
with the diaphragm at the aortic area. Phonetically, it is the “dup” of the “lub-dup”
of a typical heartbeat (the first heart sound, S1, is the “lub”). It signifies the end of
systole and the onset of diastole (ventricular filling). S2 is characteristically shorter
and higher pitched than the first heart sound (S1). Diastolic filling sounds or gallops
(S3, the third heart sound, and S4, the fourth heart sound) are produced when
compliance of either or both ventricles is decreased. S3 is termed ventricular gallop
and S4 is referred to as atrial gallop. The S3 heart sound (a gallop sound) occurs in
early diastole, during passive, rapid filling of the ventricles. The S4 sound occurs in
the later stage of diastole, during atrial contraction and active filling of the
ventricles. It is a soft, low-pitched sound and is heard immediately before S1.

DVT

The client with deep vein thrombosis requires bedrest to prevent embolization of
the thrombus due to skeletal muscle action, anticoagulation to prevent thrombus
extension and allow for thrombus autodigestion, fluids for hemodilution and to
decrease blood viscosity, and compression stockings to reduce peripheral edema
and promote venous return. While the client is on bedrest, the nurse prevents
complications of immobility by encouraging coughing and deep breathing. Venous
return is important to maintain because it is a contributing factor in DVT, so the
nurse maintains venous return from the lower extremities by avoiding hip flexion,
which occurs with Fowler’s position. The nurse avoids providing foods rich in vitamin
K such as dark green leafy vegetables because this vitamin can interfere with
anticoagulation, thereby increasing the risk of additional thrombi and emboli. The
nurse also would not include use of sequential compression boots for an existing
thrombus. They are used to prevent DVT only, because they mimic skeletal muscle
action and can disrupt an existing thrombus, leading to pulmonary embolism.

AICD
Postdischarge instructions typically include avoiding tight clothing or belts over
AICD insertion sites, rough contact with the AICD insertion site, electromagnetic
fields such as with electrical transformers, radio/TV/radar transmitters, metal
detectors, and running motors of cars or boats. Clients also must alert physicians or
dentists to the presence of the device, because certain procedures such as
diathermy, electrocautery, and magnetic resonance imaging may need to be
avoided to prevent device malfunction. Clients should follow the specific advice of a
physician regarding activities that are potentially hazardous to self or others, such
as swimming, driving, or operating heavy equipment.

COUNTERSHOCK

For cardioversion procedures, the defibrillator is charged to the energy level

ordered by the physician. Countershock usually is started at 50 to 100 joules.

CARDIOVERSION- NOT READY

Digoxin may be withheld for up to 48 hours before cardioversion because it

increases ventricular irritability and may cause ventricular arrhythmias after the
countershock. The client typically receives a dose of an intravenous sedative or
antianxiety agent. The defibrillator is switched to synchronizer mode to time the
delivery of the electrical impulse to coincide with the QRS and avoid the T wave,
which could cause ventricular fibrillation. Energy level typically is set at 50 to 100 J.
During the procedure, any oxygen is removed temporarily, because oxygen
supports combustion, and a fire could result from electrical arcing.

EDEMA

Edema is accumulation of fluid in the intercellular spaces and is not normally

present. To check for edema, the nurse would imprint his or her thumbs firmly
against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If
the pressure leaves a dent in the skin, “pitting” edema is present. Its presence is
graded on the following 4-point scale: 1+, mild pitting, slight indentation, no
perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly;
3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very
deep pitting, indentation lasts a long time, leg is very swollen.

S1 heart sound

The first heart sound (S1) is heard loudest at the lower left sternal border or the
apex of the heart. The apex is located at the fifth intercostal space at the left
midclavicular line.

Exercise, heart

The client’s symptoms are the direct result of the body’s attempt to meet the
metabolic demands of the body during exercise. An adequate cardiac output is
needed to maintain perfusion to the vital organs of the body. With exercise, these
demands increase, and the heart must beat faster (increased heart rate) and harder
(increased stroke volume) to achieve this. Cardiac index is an artificial number used
to determine the adequacy of the cardiac output for a given individual. It is
calculated by adjusting the cardiac output by body surface area.

Cardiac output

The normal cardiac output for the adult can range from 4 to 8 L/min and varies
greatly with body size. The heart normally pumps 5 L of blood every minute.