Heart and lung sounds in obese patients

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I am close to graduation and this is one area that I am still frustrated with. I have a couple patients (not many, but one recently in the ICU) that I could not hear her heart beat through all her body fat. It took me a good long time. I did eventually faintly hear a heart beat, but not well enough to determine much of anything. I'm also not sure with patients like this if they are truly having diminished lung sounds or they are just so hard to hear through the extra body fat. It's usually women with large breasts and obese that I have the most issues with. I have gotten comfortable with moving their breast tissue or attempting to. Is there any other tips you have for heart and lung sounds with obese patients? I have a decent stethoscope so I don't think that's the problem and I can hear things fine with most patients. It's just those one or two that I can't find the heart or lung sounds that I am not sure what to do. I'm looking for tips to hear better and also what to do if you really can't hear anything. At the moment I've been getting a second opinion from a second nurse.

nurseprnRN, BSN, RN

1 Article; 5,115 Posts

Sometimes rolling the pt to her left will bring the heart a little closer to the ribcage, maybe enough to make a difference for you. You'll have to reach underneath her to hear under the breast area. You can compress fat somewhat, but recognize that doing that will tighten the skin and thus turn your bell (if you use one to pick up low tones like S3 and S4) into another diaphragm head, so the S1 and S2 might be clearer but you'll lose S3 and S4.. You can also remember that sound carries downstream, and perhaps you'll be able to hear over her aortic arch or even carotids (don't lean on carotids unless you like bradycardia a LOT ;)).

Otherwise, I think it's practice, practice, practice until you have heard so many hearts that you can pick up even smaller more distant tones.

tsm007

675 Posts

Sometimes rolling the pt to her left will bring the heart a little closer to the ribcage, maybe enough to make a difference for you. You'll have to reach underneath her to hear under the breast area. You can compress fat somewhat, but recognize that doing that will tighten the skin and thus turn your bell (if you use one to pick up low tones like S3 and S4) into another diaphragm head, so the S1 and S2 might be clearer but you'll lose S3 and S4.. You can also remember that sound carries downstream, and perhaps you'll be able to hear over her aortic arch or even carotids (don't lean on carotids unless you like bradycardia a LOT ;)).

Otherwise, I think it's practice, practice, practice until you have heard so many hearts that you can pick up even smaller more distant tones.

Thank you. Going to try those tricks and see what happens.

Lev, MSN, RN, NP

4 Articles; 2,805 Posts

Specializes in Family Nurse Practitioner.

Sometimes you can hear better if you listen to their back. Just try not to get your anatomical points confused.

Specializes in ICU.
Sometimes you can hear better if you listen to their back. Just try not to get your anatomical points confused.

This. On an obese patient I can hear the lung sounds much better on the back. For heart sounds, I have them lay on their back so I can move the breast tissue easier. We had a lady at my facility last semester for rehab and she had MS. She was also obese. I know sometimes it is difficult to manipulate, I am a large breasted person myself but not obese, and it was difficult for my partner to especially get my apical heart rate because my breast was in the way. And I think she was uncomfortable touching me there. I just ended up moving it myself and holding it so she could listen. So I would even try having the patient hold it out of the way for you if you are having difficulties.

tsm007

675 Posts

I found a great

showing all the little tricks you shared! You have to forward through it to the female demo, but it really helped me see what you were describing. I think I got it now. I am sure I read all this before, but seeing a visual demo really helped me get the idea. I know someone that I have difficult hearing on so I'm going to ask her if I can try this out and see how much a difference it makes.

vanilla bean

861 Posts

I had a nursing instructor tell us to try Erb's Point if having trouble hearing an apical heartbeat. I've had luck using that tip when auscultating obese women with large breasts. Of course, that won't help you to hear heart tones that you need the apex for, but it's helpful to get a rate. I also agree about listening to breath sounds from the back - if the pt can't sit up for you, then have them roll or turn to the side. Try to minimize ambient room noise (turn off TV volume, etc) and have them take several deep breaths through an open mouth at each site if you can. Apply a little light pressure to the 'arms' (binaurals) of your stethoscope to make sure the ear tips are snugly in your ears and try to focus your attention on what you're hearing. Happy listening :-)

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