Heart Murmurs | Aortic/Mitral Stenosis, Regurgitation | How to identify

Heart Murmurs | Aortic/Mitral Stenosis, Regurgitation | How to identify


Hey everybody, this is Jon with NRSNG.com.
Today, I m really excited about our podcast, our video, because we re going to be talking
about murmurs. Now, murmur is going to be somewhat complicating to understand, complicated
to understand in the beginning, but I m gonna provide you with really simple method for
how you can remember murmurs and get them all straight. Before we get started, I wanna
let you know that we ll be giving away a free little chart, we ll be drawing a lot of charts
in this podcast, in this video, but I wanna show you, give you ways on some of these charts
for free. Okay, so if you go to NRSNG.com/Murmurs, there will be some charts there of how you
can remember murmurs and everything. Okay, so that s pretty you, you can do whatever
you want with that chart. So, also, I wanna let you know about a new software product
that we re creating. This software product is called SIMCLEX – Simulation NCLEX. Pretty
creative, right? And if you go to SIMCLEX.com, it isn t out just yet but we are looking for
people to help us in creation of it, as far as giving us feedback and everything with
that. So, if you go to SIMCLEX.com, you can sign up to be part of the beta testing, you
ll be able to get the product before everybody else for free and you re gonna be part of
helping us create that. So, head over to SIMCLEX.com and you can help us create this great product.
So, it will be the first of its kind, computer-adaptive NCLEX testing. Pretty cool, huh? Alright. So, like I said, today, we re gonna be talking
about murmurs. So, to understand murmurs, it s first important that we understand what
normal blood flow through the heart actually looks like. Okay, so, normal blood flow through
the heart, we understand, okay, let s draw a heart. So, we understand normal blood flow
to the heart, so it starts in the right atria, it pumps down into the right ventricle, it
goes out to the lungs, comes back to the left atria, down to the left ventricle and then
out through the aorta, alright? So, that s normal blood flow in the heart. Okay, and
so that s what we re gonna be concerned about with our normal blood flows, is where the
blood should be and what should be happening. So, what s happening during diastole, is these
ventricles fill up, okay. So, during diastole, the ventricles fill. During systole, the ventricles
empty. So, really, that s simple. Diastole, ventricles fill. Systole, ventricles empty.
And they don t completely empty, there s residual volume left within the ventricles but essentially
that s what s going to be happening in these times. Okay? So, let s talk about the valves. Okay, so
the valves within the heart, so we have 4 valves in the heart. Alright, so let s draw
our little heart again. We have 4 valves in the heart, between the atria and the ventricle,
we have valves, and then going out of the heart, here in the pulmonic valve, in the
pulmonary artery going in to the pulmonary artery, we also have a valve, and then coming
to go out of the heart to the body, the aorta also have a valve. Okay, so, going from the
right atria to the right ventricle, we have what s called the tricuspid valve. Okay, so,
tricuspid valve allows blood, permits blood to pass from the right atria to the right
ventricle. And then, going out of the right ventricle, into the lungs, we have the pulmonic
valve. Okay. And then, coming back in to the left ventricle from the left ventricle, or
the left atria (I m sorry). From the left atria in to the left ventricle, we have the
bicuspid valve or also termed mitral valve. Okay. And then going out of the heart into
the aorta, we have the aortic valve. Okay, now to understand murmurs, we re gonna
just talk about murmurs. And so what a murmur is, what is a murmur? Okay, so a heart murmur
is an inappropriately functioning valve. Okay, so, what happens when we have a murmur, so
we get these extra heart sounds and those heart sounds have to be associated with something,
right? Well, a heart sound is associated with these valves not working appropriately. And
we re gonna really focus on mitral valve murmurs and aortic valve murmurs. Okay, so, we have two different kinds of murmurs.
Okay, or two different kinds or ways basically that these valves can be incompetent, okay.
So, what we have, is we have regurgitation and stenosis, okay. So what we have, regurgitation
is our valve is not closing when it should be closed. What we have with stenosis is our
valve is not opening when it should be opened. Okay, so, really, that s it. That s all we
really have to understand. During regurgitation, the valve does not close appropriately. During
stenosis, the valve does not open appropriately. So, for example, let s draw again our heart,
we have our mitral valve, now, our mitral valve should be closed during systole, right,
we said systole is when blood pumps out of the heart, okay. So, in order for that blood
to pump out of the heart through our aortic valve, the mitral valve here needs to be closed.
If that doesn t close right, we re dealing with a regurgitation. Okay, now, stenosis,
let s talk about the same valve. So, with stenosis, our mitral valve should be, so during
diastole our mitral valve should be opened, okay. So, what s happening here is, during
stenosis, is the mitral valve does not open enough. So, blood needs to get from the atria
down to the ventricle during diastole and this valve does not open enough for it to
get in here. So, that s gonna be stenotic valve. So, stenotic valve does not open enough,
not enough blood can get through. Okay, so, blood is not able to pass into the area that
needs to be. With regurgitation, the valve does not close enough and blood continues
to pass when it shouldn t be passing. Okay, let s see here. Okay, so, let s go over this one more time,
okay, here. So what we have here, let s draw this little chart here. So, we ll do Aortic
and here, we ll do Mitral, those are the two valves we re talking about. And over here,
we ll do systole and down here, we ll do diastole. Okay, so our aortic valve. Where is our aortic
valve? Okay, our aortic valve sits here in the left ventricle and it is the valve that
opens into the aorta and allows blood to pass from the ventricle throughout the rest of
the body. Okay, so, during systole, okay, when the ventricles are contracting, should
the aortic valve be open or closed? Okay, the aortic valve should be open during systole.
Okay, during diastole, now during diastole when the ventricles are trying to fill, okay,
we re trying to get blood into the ventricles, should the aortic valve be open or closed?
Okay, it should be closed, right? Okay, now how about the mitral valve? Where is our mitral
valve? Okay, the mitral valve is the valve that sits between the left atria and the left
ventricle. Okay, now, during systole, when blood is trying to squeeze out of the heart
to the rest of the body, should our mitral valve be open or closed? It should be closed,
right? Okay, to allow blood to move forward to the body. Now, during diastole, when the
ventricles are filling, should the mitral valve be open or closed? Well, obviously,
it should be open so the ventricles can fill. Okay, so, now that we have this chart, this
is gonna be the most helpful chart for you to be able to help you understand murmurs.
Alright, so, let s draw this up here again. Not opening, that equals what kind of murmur,
okay, that s stenosis or what kind of problem. Not closing, that s regurgitation. Okay. So,
not opening, we re gonna have a stenosis problem. Not closing, we re gonna have a regurgitation
problem. Alright, so, with our aorta during systole should be open. Okay. If our aortic
valve is not opening, what do we have? We re dealing with stenosis. Okay, so aortic
stenosis is a systolic murmur. Okay. The aorta should be open during systole. If it does
not open, it is a aortic stenosis and that s gonna be a systolic murmur, it occurs during
systole, you re gonna hear this during systole. Okay. During diastole, our aorta should be
closed. Now, if it does not close appropriately, we re dealing with regurgitation. Okay, so,
aortic regurgitation is a diastolic murmur. You re gonna hear, if you hear a diastolic
murmur in a specific location, we re go over that later, then you re dealing with aortic
regurgitation. The aorta needs to close during diastole in order for the ventricles to fill
appropriately. If it does not close, that s gonna be regurgitation. Okay, so this side
will be easy. Okay, right? The mitral valve during systole needs to be closed. If it does
not close appropriately, we re dealing again with regurgitation. Okay, so mitral valve
regurgitation is a systolic murmur. Okay, now the mitral valve needs to be opened during
diastole. If your mitral valve does not open during diastole, you re dealing with stenosis,
right? So, mitral valve stenosis is the mitral valve not opening appropriately, is a diastolic
murmur. Okay, now understanding all that, that makes that much easier, right? What you
have to first understand is if the valve doesn t open, it s stenosis, and you need to understand
when these valves should be open. Now, the aortic valve is obviously open during systole,
if it doesn t open right, then you re dealing with systolic murmur or stenosis of the aortic
valve. Alright, so let s go and move on now that we understand that. Okay, let s actually look at this specific
murmurs and specific valves, what they should be doing. Okay, so we kinda talk already about
aortic stenosis and what it is. But let s go ahead and just look at this nice drawing
of it. So, aortic stenosis, right? So, the aortic valve is not opening appropriately.
Okay, it s stenotic, so it s not gonna open. Stenotic means it doesn t open right. Now,
when should the aortic valve be open? Well, the aortic valve needs to be opened during
systole, right? So, our ventricle, as you can see here, is filled with blood, okay,
and it s all ready to pump that blood forward, and as it tried to squeeze, this aortic valve
doesn t open. Okay, so, blood isn t able to go up in here to the aorta in order to profuse
the body. Okay, so our aortic valve doesn t open and that needs to be opened during
systole. So, aortic stenosis is a systolic murmur as the heart is trying to squeeze blood
out of the heart, it s not able to, because this aortic valve does not open appropriately. Now, let s talk aortic regurgitation, right.
So, aortic regurgitation, we re dealing, obviously, again with the aortic valve. Okay, now, the
aortic valve is regurgitation, so what that means is, it s not closing when it needs to
be closed, right? So, all blood pumped up in here to the aorta and then systole ends
and diastole starts. So, diastole starts with this mitral valve opening and trying to fill
the ventricles. So, as this mitral valve opens, it begins to fill the ventricles, your aortic
valve does not close appropriately, you have this blood in your aorta that begins to back
up, it begins to regurgitate into the ventricle. Alright, so, regurgitation means doesn t close.
Now, when does our aortic valve need to be closed? It needs to be closed during diastole.
So, our aortic regurgitation is a diastolic murmur. Okay, very good. Let s move on to our mitral valve issues.
So, with our mitral valve, we re gonna have a couple of different issues here, right?
So, same as the other. So, we have on one side, mitral regurgitation and on the other
side, mitral stenosis. So, mitral valve stenosis, or, sorry, let s do mitral valve regurgitation.
So, mitral valve regurgitation means this valve is not closing like it should, alright?
So, the
mitral valve when it should be closed. Well, the mitral valve should be closed during systole.
So, mitral valve regurg is a systolic murmur, right? So, mitral valve regurgitation, what
s happened here, is our ventricle is filled with blood and okay, boom, the ventricle is
ready to squeeze all that blood out, our aortic valve opens, it starts to squeeze that blood
forward but this valve does not close all the way and some of this blood starts to back
up into our atria. Okay, so that s an issue. Obviously, we re not gonna get the cardiac
output that we need. So, that is what mitral valve regurgitation is. Mitral valve stenosis,
on the other hand, means that our mitral valve isn t opening the way that it needs to. So,
not opening, stenosis, so our mitral valve doesn t open, we re dealing with stenosis
here. So, what s happening here is, during diastole, so during diastole this mitral valve
doesn t open right. We have all this blood sitting up here in the atria, that isn t able
to get down to our ventricle. So, that s gonna be a diastolic murmur, it s happening while
the ventricle is trying to fill. And so, our mitral stenosis is gonna be our diastolic
murmur, okay? So, let s talk about heart sounds. This chart
here looks pretty confusing. But now, understanding everything that we need to understand, this
will be pretty easy to do. So, this first line here, this A line here is our heart sounds.
Lub dub, right? Lub Dub. So, during systole, we re gonna get our lub sound, during diastole,
we re gonna get our dub sound. Okay, lub dub. Now, these other lines talk about the different
murmurs. Okay, so, aortic stenosis, right? Okay, so, what s happening with aortic stenosis,
okay, so, it s stenosis, so it means it s not opening. And we re talking specifically
about our aorta, okay. So, the aorta should be opening during systole, okay? So, we re
dealing with aortic stenosis , so, we re gonna hear that sound during our systole. Okay?
So, it s aortic stenosis, the aorta is not opening appropriately, we re gonna hear that
sound during systole, okay? Now, let s talk about this one here. Mitral regurgitation.
Okay, so, regurgitation. The mitral valve, so we re dealing with regurgitation, it means
it s not closing. Okay, so when should the mitral valve be closed? Well, the mitral valve
should be closed during systole. So, with regurgitation, it s not closing, so, we are
going to have this heart sound, this murmur is going to be heard during systole. Okay,
now, aortic regurgitation, means it s not closing, it means the aorta is not closing
at it should, okay? Now, when should the aorta be closed? Well, the aorta needs to be closed
during diastole. Okay, so, an aortic regurgitation is gonna be a diastolic murmur, that s where
the heart sound is gonna be heard. Now, with mitral stenosis, okay, stenosis, not opening
appropriately. When should the mitral valve be open? Well the mitral valve needs to be
open during diastole, okay. So, mitral valve stenosis is gonna be a diastolic murmur. Alright,
does that makes sense? Hopefully that is a little bit more clear. Okay. So, now we re gonna talk about the different
heart sounds. Okay, so when, one thing that you ll probably have learned in nursing school
is this APE To Man mnemonic. Aortic, Pulmonic, Erb s Point, Tricuspid, Mitral Valve. Okay,
now we re talking about our aortic and our mitral valves here. Okay, so, what this mnemonic
is basically telling us where are you gonna hear heart sounds. Okay, so let s say, this
is a person, this is their heart and this is their rib cage here. So, what the APE means,
is you re gonna hear your aortic sound over your right 2nd intercostal space. That s where
you re gonna hear all your aortic sounds. Now, your mitral sounds, you re gonna hear
down here in your apex, 5th intercostal space, mid clavicular line, okay? Okay, so, that
s gonna be termed as the APEX. So, your mitral sounds, you re gonna hear it at your apex.
Your aortic sounds, you re gonna hear it at your 2nd right intercostal space. Okay, so,
those are the two murmurs we re talking about, the two locations where you re gonna hear
these valves, you re gonna hear these murmurs over these valves, correct? Okay. So, mitral
murmurs are gonna be heard at the APEX, aortic murmurs are gonna be heard in the 2nd right
intercostal space. Okay, so, let s just really quickly draw the
chart that we have drawn earlier. Okay, so, okay, the chart that we had here, right, so,
we have our aortic, mitral, systole, diastole. Okay, so during systole, aorta should be open
and the mitral valve should be closed. During diastole, the aorta should be closed, and
the mitral valve should be open, right? So, if the aorta is not opening appropriately,
we re gonna be dealing with stenosis. If the mitral valve is not closing appropriately,
we re gonna be dealing with regurgitation. The aorta, during diastole should be closed.
If it doesn t close appropriately, we re dealing with regurg. During diastole, the mitral valve
should be open, if it does not open, we re dealing with stenosis. Okay, so, now, where
are we going to hear these murmurs? Okay, we know, right? Our aorta we re gonna be hearing
at the 2nd right intercostal space. Okay. Mitral valve murmurs are gonna be heard at
the APEX. Okay, so this is gonna be really easy now, right? So, let s say, we hear
a systolic murmur at the APEX, what are we
dealing with? Okay, we re dealing with mitral regurgitation. Okay, let s say, we hear a
diastolic murmur at the APEX, that s gonna be mitral stenosis. Okay, let s say, we hear,
let s say, where are you gonna hear aortic stenosis? We re gonna hear that at our 2nd
right intercostal space. Okay, what type of murmur are you going to have with an aortic
diastolic murmur? Okay, aortic diastolic murmur is gonna be aortic regurgitation heard at
the 2nd right intercostal space. Okay, so, I suggest you draw this chart out or we ll
have this chart out available at NRSNG.com/Murmurs and
you ll be able to find this chart there. Okay,
so, mitral valve murmurs are gonna be heard at the APEX always, aortic valves are heard
at the 2nd right intercostal space. Okay, so, let s do one more example here.
Okay, so, for example, let s say you hear a 2nd right intercostal space murmur during
diastole, okay, so, 2nd right intercostal space. What is that? So, we know in our 2nd
right intercostal space, that s gonna be aortic, and it is a diastolic murmur. Okay, so, what
should the aorta be doing during diastole? Okay, during diastole, right, this is when
the ventricles are filling. So, the aorta should be closed, okay? Now, if it s not closing,
alright, not closing appropriately, is regurgitation. So, 2nd right intercostal space diastolic
murmur is aortic regurgitation. Okay, so let s do another one. Let s say here at the APEX,
we hear a systolic murmur. Okay, APEX, what valve are we dealing with? We re dealing with
the mitral valve, okay, and what should the mitral valve be doing during systole? Okay,
during systole, right, is where the ventricles squeeze that blood into the aorta and the
blood goes throughout the body. So, the mitral valve should be closed again at this point,
right? So, it s not closing as it should, so, we re dealing with regurgitation again.
Okay, now, that s really all there is to it. We take your location, figure out what valve
that is, and then what should that valve be doing during that time. Okay, if the valve
should be open during that time and it s not opening, then you re dealing with stenosis.
If it s not closing, you re dealing with regurg. Okay, so, that s really all there is to it
and then understanding what valve we re dealing with, what that valve should be doing and
then labeling that murmur appropriately. Okay, so, one more chart really quick. Let
s say, now there s other kinds of murmurs and everything, we re just dealing with these
two types of murmurs cause I think they re the ones that you really mostly need to know
for testing and things. And also, the principle will be exactly the same when you re dealing
with the right side of the heart. Okay and there are different sounds and things. We
re not dealing with the picture of the sounds, we re really just dealing with how you re
gonna find these murmurs. Okay, so, with murmurs, you re either dealing with diastolic or you
re dealing with systolic. Okay, and then once you know that, then you re dealing with your
location, it s either gonna be at the APEX or is it gonna be at the 2nd right intercostal
space? Okay, so this is why you listen to your patient s heart drop all locations, okay,
right? Okay, so, you re listening to your patient, you re listening at the 2nd right
intercostal space and you hear a diastolic murmur. Okay, so, a diastolic murmur in the
right 2nd intercostal space is going to be aortic regurgitation. Okay, 2nd right intercostal
space during diastole, okay, 2nd right intercostal space, aorta, during diastole, aorta should
be closed, it s not, so that s regurgitation. At the APEX, you re dealing with mitral. During
diastole, the mitral valve should be open, it s not, that s mitral valve stenosis, okay?
Let s say, you re listening to the 2nd right intercostal space, you hear a systolic murmur
during systole, 2nd right intercostal space is aorta. Okay, during systole, the aortic
valve should be open, it s not opening, that s stenosis. Okay, systole, you re listening
at the APEX, APEX is mitral valve, during systole, the mitral valve should be closed,
if it s not closed, that s regurgitation. Okay, so a couple of things to remember: locations,
what the valves, regurgitation, what stenosis is, regurgitation, is the valve should be
closed, if not, stenosis should be open, it s not, and then just from systole and diastole,
determining between those two. Alright. So, that s really, basically it,
honestly with these murmurs. For a quick way to remember these murmurs, head on over to
NRSNG.com/murmurs to get some of these free charts. Also, be sure to head on over to SIMCLEX.com,
this is a very first of its kind ever simulation NCLEX that are actually computer adapted to
how you re answering questions. It s gonna be awesome. I m so excited for this. This
is something I really want and school was never able to find. If you have any questions,
contact me directly. This is Jon with NRSNG.com. You can contact me at [email protected] or
you can find me on, you can find us at NRSNG at facebook, podcast, youtube channel, we
re all over the place. Excited to hear from you. Thanks a lot.
����8: