Describing Heart Tones
• The strength of heart sounds can be weak (muffled), strong, or bounding.
• Strong heart sounds are expected, and all sounds will be distinguishable.
• Bounding heart sounds are heard in hyperdynamic states such as anemia or sepsis. As the condition resolves, the heart sounds should become strong (and not bounding).
• Weak heart sounds are also described as being “muffled”. On presentation, the heart sounds may be muffled by several conditions, such as obesity, and in COPD patients with a barrel chest.
• On initial assessment, if the heart sounds are strong, and then become weak, a deterioration in clinical condition has occurred.
• Weak (muffled) heart sounds are present in late shock, pericardial effusion, and cardiac tamponade.

Valve Replacement
• Loud “clicking” sounds with be heard with a mechanical valve replacement. At times, it may be heard audibly and without a stethoscope.
• No abnormal sounds will be heard with a tissue replacement valve.

Summary

Heart tones are an important part of assessment and changes often signify deterioration. Developing a systematic approach and consistently describing heart tones on presentation and with subsequent assessments provides an elevated level of assessment and clinical expertise.

Examples of descriptions can include:
• Heart sounds strong and clear.
• Heart sounds strong with a systolic murmur heard in the 5th intercostal space, midclavicular line. (Signifies mitral regurgitation).
• Heart sounds muffled.
• Heart sounds muffled with possible S3 gallop present. (Would be seen in an obese patient with left ventricular failure).
• Heart sounds strong with valvular click heard on auscultation. (Seen with valve replacement).

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