Bruits
Bruits: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Commonly an indicator of life- or limb-threatening vascular disease, bruits are swishing sounds caused by turbulent blood flow. They’re characterized by location, duration, intensity, pitch, and time of onset in the cardiac cycle. Loud bruits produce intense vibration and a palpable thrill. A thrill, however, doesn’t provide any further clue to the causative disorder or to its severity.
Bruits are most significant when heard over the abdominal aorta; the renal, carotid, femoral, popliteal, or subclavian artery; or the thyroid gland. (See Preventing false bruits, page 120.) They’re also significant when heard consistently despite changes in patient position and when heard during diastole.
History
Obtain a medical history including past injuries, illnesses, surgeries, and family medical history. Ask about diet and alcohol intake. Take a drug history, including past and present prescriptions, over-the-counter drugs, and herbal remedies. Also obtain a social history.
Physical assessment
If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen’s sign). Either of these signs — or severe, tearing pain in the abdomen, flank, or lower back — may signal life-threatening dissection of an aortic aneurysm. Also, check peripheral pulses, comparing intensity in the upper versus lower extremities.
If you suspect dissection, monitor the patient’s vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; weak, thready pulse; tachypnea; altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.
If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.
If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.
If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation — edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Also, watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.
If you detect a bruit, be sure to check for further vascular damage and perform a thorough cardiac assessment.
Medical causes
Abdominal aortic aneurysm
A pulsating periumbilical mass accompanied by a systolic bruit over the aorta characterizes an abdominal aortic aneurysm. Associated signs and symptoms include a rigid, tender abdomen; mottled skin; diminished peripheral pulses; and claudication. Sharp, tearing pain in the abdomen, flank, or lower back signals imminent dissection.
Abdominal aortic atherosclerosis
Loud systolic bruits in the epigastric and midabdominal areas are common in abdominal aortic atherosclerosis. They may be accompanied by leg weakness, numbness, paresthesia, or paralysis; leg pain; or decreased or absent femoral, popliteal, or pedal pulses. Abdominal pain is rarely present.
Carotid artery stenosis
Systolic bruits can be heard over one or both carotid arteries in a patient with carotid artery stenosis. Other signs and symptoms may be absent. However, dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals TIA and may herald a stroke.
Peripheral arteriovenous fistula
With a peripheral arteriovenous fistula, a rough, continuous bruit with systolic accentuation may be heard over the fistula; a palpable thrill is also common. Other signs and symptoms depend on the location of the fistula. For example, there may be claudication or absent pulses distal to the fistula. Skin distal to the fistula may be cool.
Peripheral vascular disease
Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower extremity ulcers that heal with difficulty.
Renal artery stenosis
With renal artery stenosis, systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear.
Subclavian steal syndrome
With subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of narrowing of the arterial lumen. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.
Thyrotoxicosis
A systolic bruit heard over the thyroid gland commonly occurs with thyrotoxicosis. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.
Special considerations
Because bruits can signal a life-threatening vascular disorder, frequently check the patient’s vital signs and auscultate over the affected arteries. Be especially alert for bruits that become louder or develop a diastolic component.
As needed, administer prescribed drugs, such as a vasodilator, an anticoagulant, an antiplatelet drug, or an antihypertensive. Prepare the patient for diagnostic tests, such as blood studies, radiographs, an electrocardiogram, cardiac catheterization, and ultrasonography.
Pediatric pointers
Bruits are common in young children but are usually of little significance — for example, cranial bruits are normal until age 4. However, certain bruits may be significant. Because birthmarks commonly accompany congenital arteriovenous fistulas, carefully auscultate for bruits in a child with port-wine spots or cavernous or diffuse hemangiomas.
Geriatric pointers
Elderly patients with atherosclerosis may experience bruits over several arteries. Those related to carotid artery stenosis are particularly important because of the high incidence of associated stroke. Close follow-up is mandatory as well as prompt surgical referral when indicated.
Patient counseling
Instruct the patient to inform the physician if he develops dizziness, pain, or any symptom that suggests a stroke because this may indicate a worsening of his condition. For the patient with atherosclerosis or peripheral vascular disease, discuss lifestyle modifications, such as stopping smoking, exercising regularly (after consulting with the physician), and eating a healthy diet.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Medical Books Excerpts
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Abdominal Masses (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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