Heart sounds with large breasts

Double-Helix, BSN, RN · May 21, 2012

Actually, the belief that the heart is best heard above the breast is a misconception for a lot of students. The heart sounds are best heard at the Apex- which is around the 5th intercostal space. This is actually underneath the breast, not over it. So in order to listen to the heart, you need to place your stethoscope underneath the breast tissue- pretty much right where the underwire of the bra would be. You really shouldn't be listening through the breast tissue at all.

Your other landmarks will require you to listen around the left sternal boarder. Locate the sternum and move slightly to the left. You should find it very easy to move the breast tissue slightly and find the intercostal spaces and listen.

Since you're practicing on students, who are typically... "perkier" than older patients, it should be fairly simple to hear heart sounds if you're listening in the right places. If the person has really large breasts or you're listening to a patient, you'll need to lift (or ask the patient to lift) the breast slightly in order to put your stethoscope underneath.

allnurses Guide · May 21, 2012

It's my thought that labs are meant to simulate practice, and in practice you need to hear her heart: communicate to your "patient" that you need to adjust your stethoscope placement and move clothes around so you have access to the landmarks. Respecting modesty is very important and your assessment is as well. You should feel confident and comfortable exposing areas you need to in order to assess because you know that you are as respectful as possible to modesty.

Also make sure that your ear buds are angled forward and if you are listening with diaphragm make sure you have the diaphragm selected on your scope and not the bell.

Close your eyes and concentrate if need be!

Jack245 · May 21, 2012

Being a male, when I have to assess that heart sound I will either ask the patient to move it if need be, or use the back of my hand with the stethoscope in it. It can be tricky at times, but if you don't act nervous they tend to be less nervous about it.

Sparrowhawk · May 21, 2012

Go right under the middle of the bra...should be able to hit the apex just fine :)

anonymousstudent · May 21, 2012

I'm HUGE and I can easily access my apex above my bra line. It's OK to shove some of that tissue out of the way to get to where you need.

Is the problem your stethoscope?

tsm007 · May 22, 2012

Actually, the belief that the heart is best heard above the breast is a misconception for a lot of students. The heart sounds are best heard at the Apex- which is around the 5th intercostal space. This is actually underneath the breast, not over it. So in order to listen to the heart, you need to place your stethoscope underneath the breast tissue- pretty much right where the underwire of the bra would be. You really shouldn't be listening through the breast tissue at all.

I was listening below where the underwire bra was which is what was making it difficult. Honestly I needed her bra to be unhooked so I could move breast tissue up I think. I just couldn't seem to get things lifted out of the way probably because she had a good bra that was doing its job. I'm for now going to assume that if I was in a hospital setting this would be easier to do because a real patient it would be a little less awkward. I don't know.

tsm007 · May 22, 2012

I'm HUGE and I can easily access my apex above my bra line. It's OK to shove some of that tissue out of the way to get to where you need.
Is the problem your stethoscope?

I am going to look into getting a higher quality stethoscope.

loriangel14, RN · May 22, 2012

I am really having a hard time with this. We had to practice on other students and I had a heck of a time finding landmarks first off and hearing sounds second. It was worse because they were in nursing uniforms with underwire bras to complicate things, but I am trying to get the hang of this. Is there any tips for getting the placements right and hearing through breast tissue?

You can't hear "through" the breast tissue. You can lift the breast to listen to the apical.

allnurses Guide · May 22, 2012

Treat lab like its practice. In practice you need to lift pendulous breasts out of the want to palpate the PMI and hear the apex (not to mention inspect for heaves and fungal infections). In lab find a way to modestly do this.

Like a previous poster, I am a male and quickly had to find a way to make awkward exposure less awkward. Now, in the NP role I have a real leg up because I have the ability to be comfortable and confident with patients in exposing circumstances.

melizerd, ASN, RN · May 22, 2012

As a busty girl myself I allowed the 4 male students to really practice on me, since no one else really wanted them too.

I agree that you're going to listen under the breast at the 5th intercostal. Use the BACK of your hand to lift up the patient (or student's) breast. It's really not groping, and explain what you're doing and why. And ditch the underwire for class, use a sports bra, or be willing to un-hook it for fellow classmates. I tend to wear a tank top under my scrub top (and in class we wear street clothes not our uniforms most days), and take off whatever outer top I'm wearing so I'm in the tank in the lab with students and instructors. Being dressed for better physical assessment in the lab makes it easier to learn so you can do it in clinicals.

Tess Deco RN · May 22, 2012

I am going to look into getting a higher quality stethoscope.

Yes! That would be my recommendation. I'm assuming the nursing student whose heart you listened to, was not elderly so you should be able to hear the heart sounds ..even if they are heavy. Ask another student, if you can try their stethoscope and see if it makes a difference.