assessments heart & neck vessel

Assessment of the Heart and

Peripheral vessels

Maria Carmela L. Domocmat, MSN, RN

Associate Professor, College of Nursing

Manila Adventist College

Anatomy

Heart

8/14/2017 2 Maria Carmela L. Domocmat, RN, MSN

Heart

extends vertically

L, 2nd to 5th

horizontally

R edge sternum to L MCL

inverted cone

o base – upper portion – near L 2nd ICS

o apex – lower portion – near L 5th ICs and L MCL


precordium

anterior chest that overlies the heart and great

vessels

great vessels

large veins and arteries leading directly to and away

from heart


great vessels includes:

o sup and inf vena cava

o pulmo artery, pulmo veins (2 from each lung)

o Aorta

septum – separates the R and L sides of heart


Valves

o AV

o at entrance into ventricles

tricuspid – R; bet R atrium and R ventricle

bicuspid (mitral) – L ; bet L atrium and ventricle

chordae tendinae- anchor AV valve flaps to papillary

muscles within ventricles; prevent reverse open of

AV valves


Valves

o semilunar valves – at exit of each

ventricle at beginning of great vessels

has 3 cusps or flaps that looks like half-

moons

open - during ventricular contraction

close – from pressure of ventricle when

ventricles relax

prevent blood from flowing

backward into relaxed ventricles


Valves

o semilunar valves – at exit of each ventricle at

beginning of great vessels

pulmonic valve – at entrance of pulmo artery as it

exits the R ventricle

aortic valve - at beginning of ascending aorta as it

exists L ventricle


Covering and Walls

pericardium – tough, inextensible, loose-fitting,

fibroserous sac that attaches to great vessels and

surrounds heart

parietal pericardium – serous membrane lining

o secretes small amount of pericardial fluid that allows

for smooth, friction-free movement of heart


Covering and Walls

epicardium – covers outer surface; also has

serous membrane lining

myocardium – thickest layer; made up of

contractile cardiac muscle cells

endocardium – thin layer of endothelial tissue;

forms innermost layer; continuous with

endothelial lining of blood vessels


Electrical Conduction


The Cardiac Cycle

refers to filling and emptying of heart’s

chambers

two phases: diastole & systole

o diastole – filling; relaxation of ventricles

2/3 of cardiac cycle

o systole – emptying; contraction of ventricles

1/3 of cardiac cycle


The Cardiac Cycle

Diastole

Systole


Diastole

early or protodiastolic filling

presystole or atrial systole


Diastole

o early or protodiastolic filling – early, rapid.

passive filling

AV valves open

ventricles relaxed

this causes higher pressure in atria than in ventricles

therefore – blood rushes thru atria into ventricles


Diastole

o followed by period of slow passive filling

o presystole or atrial systole – ―atrial kick‖ – final

active filing phase

atria contract— near the end of ventricular diastole

this complete emptying of blood out of upper

chambers by propelling into ventricles

this raises L ventricular pressure


Systole

o filling phases during diastole –result in large amt

of blood in ventricles

this causes the pressure in ventricles to be higher

than in atria

this causes the valves (mitral & tricuspid) to shut


Systole

o closure of AV valves

produces 1st heart sound (S1); beginning of systole

prevents blood from flowing backward

(regurgitation) into atria during ventricular

contraction


o isometric contraction

at this point – all 4 valves are closed and ventricles

contract

there is now high pressure inside ventricles

causing (1) aortic valve to open on L side of heart;

(2) pulmonic valve to open on R side

blood is ejected rapidly thru these valves


o with ventricular emptying – the ventricular

pressure falls and semilunar valves close

this closure produces the 2nd heart sound (S2); end of systole

o after closure semilunar valves – ventricles relax

o atrial pressure is now higher than ventricular

pressure

causing AV valves to open and diastolic filing to

being again


HEART SOUNDS

8/14/2017 Maria Carmela L. Domocmat, RN, MSN 21

Heart Sounds

produced by valve closure

opening of valve is silent

normal heart sounds

o ―lub dubb‖

o occasionally – extra heart sounds and murmurs are

auscultated


Heart Sounds

Heart Valves

Act as one-way doors, making sure that blood flows

in the correct direction through the heart.

Tricuspid valve

Mitral valve

Pulmonary valve

Aortic valve


atrio-ventricular valves (A-V valves)

openings leading to the right and left ventricles

first heart sound that we hear on the chest wall

occurs when these A-V valves close;

this heart sound is called S1.


Heart Valves

Tricuspid Valve

• right A-V valve

• between right atrium

& right ventricle

Bicuspid Valve

• left A-V valve

• between left atrium &

left ventricle

Pulmonary Valve

• semilunar valve

• between right

ventricle & pulmonary

trunk

Aortic Valve

• semilunar valve

• between left

ventricle & aorta

15-7

Skeleton of Heart

• fibrous rings to which the heart valves are attached

15-10

Heart Valves

Pulmonary and Aortic Valve

semilunar valves

openings leading to the pulmonary trunk and aorta

pulmonic valve and the aortic valve

second heart sound occurs when these semilunar

valves close:

these heart sounds is called S2.


S1 – ―lub‖

o result of closure of AV valves (mitral and tricuspid)

o correlates with beginning of systole

o heard over entire precordium – heard best at apex (L

MCL, 5th ICS)


S2 – ―dub‖

o result from closure of semilunar valves (aortic and

pulmonic)

o correlates with beginning of diastole

o heard over base

o splitting of S2 – may be exaggerated during

inspiration and disappear during expiration


Extra heart sounds

o S3 and S4 - referred as diastolic filing sounds or extra

heart sounds


Extra heart sounds

o S3

can be heard early in diastole, after S2

often termed ventricular gallop

results from ventricular vibration secondary to rapid

ventricular filling


Extra heart sounds

o S4 -

heard late in diastole, just before S1

often termed atrial gallop

results from ventricular vibration secondary to rapid

ventricular resistance (noncompliance) during atrial

contraction


Murmurs


Murmurs

o blood normally flows silently through heart

o there are conditions that can create turbulent

blood flow in which swooshing or blowing

sound may be auscultated over precordium


Murmurs

o conditions that contribute to turbulent blood

flow include

increased blood velocity

structural valve defects

valve malfunction

abnormal chamber openings (e.g., septal defect)


Cardiac Output (CO)


Cardiac Output (CO)

the amount of blood pumped by ventricles

during a given period of time (usually 1 min)

determined by stroke volume (SV) multiplied by

heart rate (HR): SV x HR = CO

normal adult CO is 5 to 6 L/min


SV

o amount of blood pumped from heart with each

contraction

o SV from L ventricle is usually 70 ml


Factors that influence SV

degree of stretch of the heart muscle up to a

critical length before contraction (preload)

the greater the preload – the greater the SV

unless heart muscle is stretched so much that is

cannot contract effectively



pressure against which heart muscle has to eject

blood during contraction (afterload)

increased afterload results in decreased SV

synergy of contraction

i.e, uniform, synchronized contraction of

myocardium

conditions that cause an asynchronous contraction

decrease SV



compliance or distensibility of ventricles

decreased compliance decreased SV

contractility or force of contraction of

myocardium under loading conditions


HEALTH HISTORY


Present Health History

Q: Do you experience chest pain?

When did it start?

Describe the type of pain, location,

radiation, duration, and how

often you experience the pain.

Rate the pain on a scale 0 to 10,

with being the worst possible

pain.

Does activity make the pain worse?

Did you have perspiration

(diaphoresis) with the chest

pain?


Present Health History

R: Chest pain can be cardiac, pulmonary,

muscular, or GIT in origin. Angina (cardiac

chest pain) is usually described as a sensation of

squeezing around the heart; a steady, severe

pain; and a sense of pressure. It may radiate to

the left shoulder and down the left arm or to the

jaw. Diaphoresis and pain worsened by activity

are usually related to cardiac chest pain.


Q: Do you experience

palpitations?

R: Palpitations may occur

with an abnormality of

the heart’s conduction

system or during the

heart’s attempt to

increase cardiac output

by increasing the heart

rate. Palpitations may

cause the client to feel

anxious.


Q: DO you tire easily? Do you

experience fatigue? Describe

when the fatigue started. Was

it sudden or gradual? Do you

notice it at any particular

time day?

R: Fatigue may result from

compromised cardiac

output. Fatigue related to

decrease cardiac output

is worse than the evening

or as the day progresses.


Q: Do you have difficulty

breathing or shortness of

breath (dyspnea)?

R: Dyspnea may result

from congestive heart

failure pulmonary

disorders, coronary

artery disease, myocardial

ischemia, and myocardial

infarction. Dyspnea may

occur at rest, during

sleep, or with mild,

moderate or extreme

exertion. 8/14/2017 Maria Carmela L. Domocmat, RN, MSN 52

Q: Do you wake up at night

with an urgent need to

urinate (nocturia)? How

many times a night?

R: Increase renal perfusion

during periods at rest or

recumbency may cause

nocturia. Decreased

frequency may be related

to decrease cardiac

output.


Q: Do you experience

dizziness? R: Dizziness may indicate

decreased blood flow to

the brain due to

myocardial damage;

however, there are

several other causes for

dizziness such as inner

ear syndromes, decreased

cerebral circulation and

hypotension. Dizziness

may put the client at risk

for falls.


Q: Do you experience swelling

(edema) in your feet, ankles

or legs?

R: Edema of the lower

extremities may occur as

a result of heart failure.


Q: Do you have frequent heart

burn? When does it occur?

What relieves it? How often

do you experience it?

R: Cardiac pain may be

overlooked or

misinterpreted as GIT

problems. GIT pain may

occur after meals, and is

relieved with antacids,

whereas cardiac pain may

occur anytime, is not

relieved with antacids

and worsens with activity


Family health History

Q: Is there a history of

hypertension, myocardial

infarction, coronary heart

disease, elevated cholesterol

levels, or diabetes mellitus in

your family?

R: A genetic

predispositions to these

risk factors increases a

client’s chance for

development of heart

disease.


Lifestyle and Health Practices

Q: Do you smoke? How many

packs of cigarettes per day

and how many years?

R: Cigarette smoking

greatly increases the risk

of heart disease.


Q: What type of stress do you

have in your life? How do

you cope with it?

R: Stress has been

identified as a possible

risk factor for heart

disease.


Q: Describe what you usually

eat in a 24-hour period.

R: An elevated cholesterol

level increases the chance

of fatty plaque formation

in the coronary vessels.


Q: How much alcohol do you

consume each day/week?

R: Excessive intake of

alcohol has been linked

to hypertension.


Q: Do you exercise? What type

of exercise and how often?

R: A sedentary lifestyle is

known modifiable risk

factor contributing to

heart disease. Aerobic

exercise three times per

week for 30 minutes is

more beneficial than

anaerobic exercise or

sporadic exercise in

preventing heart disease.


Q: Describe your daily

activities. How are they

different from your routine

5 or 10 years ago? Does

fatigue, chest pain, or

shortness of breath limit

your ability to perform daily

activities? Describe. Are you

able to care for yourself?

R: Heart disease may

impede the ability to

perform daily activities.

Exertional dyspnea or

fatigue may indicate

heart failure. An

inability to complete

activities of daily living

may necessitate a

referral for home care.


Q: Has your heart disease had

any effect on your sexual

activity?

R: Many clients with heart disease are

afraid that sexual activity will

precipitate chest pain. If the client

can walk one block or climb two

flights of stairs without

experiencing symptoms, it is

generally acceptable client to

engage in sexual intercourse.

Nitroglycerin can be taken before

intercourse as prophylactic for

chest pain. In addition, the side-

lying position for sexual

intercourse may reduce the

workload on the heart.


Q: How many pillows do you

use to sleep at night? Do

you get up to urinate during

the night? Do you feel

rested in the morning?

R: If heart function is

compromised, cardiac output

to the kidneys is reduced

during episodes of activity. At

rest, cardiac output increases,

as does glomerular filtration

and urinary output. Orthopnea

(the inability to breathe while

supine) and nocturia may

indicate heart failure. In

addition, these two conditions

may also impede the ability to

get adequate rest. 8/14/2017 65

Q: How important is having a

healthy heart to your ability

to feel good about yourself

and your appearance? What

fears about heart disease do

you have?

R: A person’s feeling of

self-worth may depend

on his or her ability to

perform usual daily

activities and fulfill his or

her usual roles.


PREPARING THE CLIENT


• explain - need to expose the

anterior chest

• Female clients may keep their

breast covered and may

simply hold the left breast

out of the way when

necessary

Explain need to assume

several different

positions for the

examination.


• supine position with the head

elevated to about 30 degrees..

• Auscultation and palpation of

the neck vessels and

• inspection, palpation and

auscultation of the pericordium

• left lateral position

• palpation of the apical

impulse

• if the examiner is having

trouble locating the pulse

with the client in the

supine position.


• left lateral and sitting-up and

leaning-forward position

• auscultate for the presence of

any abnormal heart sounds.

• These positions may bring

out an abnormal sound not

detected with the client in the

supine position.

• Make sure you explain to

the client that you will be

listening to a heart in a

number of places and that

this does not necessarily

mean that any thing is

wrong.


• Help ease any anxiety

• Provide with such modesty as

possible during the

examination

• describe the steps of the

examination

• and answer any questions the

client may have.


EQUIPMENTS


Steth with bell and diaphragm

Sml pillow

Penlight or movable exam light

Watch with second hand

Cm rulers (2)


PHYSICAL ASSESSMENT


ASSESSMENT OF THE HEART


Overview


Assessment of the Heart

Inspect pulsations

Palpate apical impulse

Palpate abnormal pulsations

Auscultate heart rate and rhythm

Auscultate heart sounds

Auscultate : pulse rate deficit


Assessment of the Heart



If detect an irregular rhythm, auscultate for pulse

rate deficit

Auscultate to identify S1 and S2

Auscultate for extra heart sounds

Auscultate for murmurs

Auscultate in with the client assuming other

position


Inspect pulsations

Client supine position with the head of the bed

elevated between 30 and 45 degrees

stand on client’s right side and look for the

apical impulse and any abnormal pulsation


Inspect pulsations

o Note: apical pulse – originally called PMI (point

of maximal impulse)

not used anymore – bcoz maximal impulse may

occur in other areas of precordium as result of

abnormalities


Inspect pulsations

o normal findings:

apical impulse – may or may not be visible

if visible – in mitral area (Left MCL, 4th or 5th ICS)

result of left ventricle moving outward during systole


Inspect pulsations

o abnormal findings:

pulsations – or heaves or lifts –other than the apical

pulsation

may occur as result of enlarged ventricle from an

overload of work.


Abnormal ventricular impulses

Lift

Thrill

Accentuated Apical Impulse

Laterally displaced apical impulse


PALPATION


Palpate the apical impulse

Remain on the client’s right side

Client remain supine

Use palmar surfaces of hand

palpate the apical impulse in the mitral area

(fourth or fifth intercostals space at the

midclavicular line).

After locating the pulse, use one finger pad for

more accurate palpation.


Palpate the apical impulse

If cannot be palpated

Have client assume left

lateral position

This displaces heart toward left

chest wall and relocates apical

impulse farther to left

Elderly

May be difficult to palpate

Bcoz of increased AP chest

diameter


Normal findings:

Palpation apical impulse

apical impulse – palpated in mitral area; size –

nickel (1-2 cm)

amplitude – small – like gentle tap

duration – brief; lasting thru first 2/3 of systole

and often less

obese or large breasts – may not be palpable


Normal findings:

Palpation apical impulse


not palpable – pulmonary emphysema

suspect cardiac enlargement

If larger than 1 to 2cm,

displaced more forceful, or

of longer duration


Palpate: abnormal pulsations

Use palmar surfaces to palpate the

apex,

left sternal border, and

base


Palpate abnormal pulsations

o normal findings:

oNo pulsations or vibrations in the areas of the apex,

left sternal border, or base


thrill – feels similar to purring cat

is usually associated with Grave IV or higher

murmur


AUSCULTATION



Place the diaphragm of the stethoscope at the

apex and listen closely to the rate and rhythm of

the apical impulse.

Concentrate on systematically moving the steth

from left to right across entire heart area from

base to apex (top to bottom) or from apex to

base (bottom to top)



o Traditional 5 areas

aortic area : 2nd ICS, R sternal border (base of heart)

pulmonic area : 2nd or 3rd ICS, L sternal border

(base of heart)

Erb’s point : 3rd to 5th ICS, L sternal border

tricuspid area : 4th or 5th ICS, L lower sternal border

mitral or apical area : 5th ICS, L lower sternal border


Heart Sounds


1. 2.

3.

4.

5.


o Alternative areas

o (by chamber)

aortic area

pulmonic area

left atrial area

right atrial area

left ventricular area

right ventricular area


Auscultation of heart sounds


Traditional areas of

auscultation

Aortic area

Pulmonic area

Erb’s point

Mitral (apical) area

Tricuspid area

“Alternative” areas

Aortic area

Pulmonic area

Left atrial area

Right atrial area

Left ventricular area

Right ventricular area


Systematically auscultate in each of the five areas

while the patient is breathing regularly and holding

breath for the following: Rate, rhythm S1 ,S2

Splitting

S3 and S4

Extra heart sound snaps, clicks, friction rubs, or murmurs


Normal findings:

Heart rate and rhythm

60-100 bpm

regular rhythm

regularly irregular rhythm – sinus arrhythmia

when HR increases with inspiration and

decreased with expiration

female – 5 to 10 beats faster than male

do not differ by race or age in adults


Abnormal findings:

Heart rate and rhythm

bradycardia (‹60 bpm)

tachycardia (›100 bpm)

regular irregular rhythms (i.e., premature

atrial contraction or PVC)

irregular rhythms (i.e., atrial fibrillation,

atrial flutter) – may predispose client to

decreased CO, heart failure, emboli


If detect irregular rhythm,

auscultate for a pulse rate deficit.

Palpate radial pulse while auscultate apical pulse

Count for a full minute.


Auscultate : pulse rate deficit

Normal findings

radial and apical pulse rates –

identical

Abnormal findings

pulse deficits

difference between apical

and peripheral/radial

pulse

indicate atrial fibrillation,

atrial flutter, PVC, varying

degrees of heart block


S1 AND S2


Auscultate to define S1 and S2

Auscultate the first heart sound (S1 or ―lub‖)

and the second heart sound (S2 or ―dub‖).

Remember these two sounds make up the

cardiac cycle of systole and diastole.

S1 starts systole

S2 starts diastole.



o S1- first heart sound

―lub‖

the result of closure of AV valves – indicate start of

systole

best heard – apex of heart; where S1 is louder than

S2

lower in pitch and a bit longer than S2

occurs immediately after diastole



o S2 – second heart sound

―dubb‖

result of closure of semilunar valves- indicate end of

systole, starts diastole

higher in pitch, shorter duration than S1


Normal findings:

Auscultation : S1 and S2

o S1 corresponds with each

carotid pulsation and is

loudest at the apex of the

heart

o Note: if have difficulty

differentiating S1 from S2

– palpate carotid pulse

o S1 – harsh sound that

occurs with carotid pulse

.

S2 immediately follows

after S1 and is loudest

at the base of the

heart.



• abnormal findings:

– ventricular impulses

• lift

• thrills

• accentuated apical impulse

• laterally displaced apical impulse

– abnormal heart rhythms

• premature atrial or junctional contractions

• premature ventricular contractions

• sinus arrhythmia

• atrial fibrillation and atrial flutter with varying ventricular response


S1


Listen to S1

Use the diaphragm of the stethoscope to best

hear S1.

Intensity of S1 depends on

position of mitral valve at start of systole

Structure of valve leaflets

How quickly pressure rises in the ventricles

All these factors influence speed and amount of

closure of the valve


S1

o Normal finding

distinct sound heard in each area

loudest – apex

may become softer with inspiration

split S1 – young adults; left lateral sternal

border


S1

Normal variations

Softer at base and louder at apex of heart

May be split along the lower left sternal border,

where tricuspid component of sound, usually too

faint to be heard, can be auscultated

Split S1 heard over apex – may be an S4


S1

o abnormal finding

Accentuated S1

Diminished S1

Varying S1

Split S1


S2


Listen to S2

o use diaphragm of steth

o breathe regularly

o Note: do not ask to hold breath –

breath holding may cause any normal or

abnormal split to subside


Listen to S2

o normal finding

distinct sound heard in each area

loudest – base

physiologic split

split S2 – two distinct sounds of its

components – A2 and P2

heard at in late inspiration at 2nd or 3rd left

ICS


Listen to S2

o abnormal finding

Any split S2 heard in expiration is abnormal.

The abnormal split can be one of these three types:

Wide

Fixed

Reversed


EXTRA HEART SOUNDS

Snaps

Clicks

Friction rubs

Murmurs



o 1st - use diaphragm then bell of steth

o to auscultate over entire heart area

o (1) auscultate during systolic pause

o (2) auscultate during diastolic pause



o systolic pause

space between S1 and S2

short duration

that’s why occur S1 and S2occur very close together

o diastolic pause

space between end of S2 and next S1

longer duration


Auscultate during the systolic

pause

Auscultate during the systolic pause

space between S1 and S2


Normal findings:

Auscultation systolic pause

o systolic pause

o no extra heart sounds


Abnormal findings:

Auscultation systolic pause

extra heart sounds

ejection sounds or clicks

e.g., midsystolic click associated with mitral valve prolapse

friction rub – heard during systolic pause


Auscultate during the diastolic

pause

Auscultate during the diastolic pause

space heard between end of S2 and S1


Normal findings:

Auscultation diastolic pause

Normally no sounds are heard.

Other normal findings

Physiologic S3 heart sound

Physiologic S4 heart sound


Normal findings:


Physiologic S3 benign finding

quiet sound heard during diastole - as ventricle fill form

atria

resembles rhythm of ―Tenn-es-see‖

heard at beginning of diastolic pause

Normal among: children, adolescence, young adults

rare after age 40

usually subsides upon standing or sitting up


Normal findings:


Physiologic S4 o quiet sound

o sound like ―Ken-tuc-ky‖

o occur in second phase of ventricle filling from atria

o heard near the end of diastole

oNormally heard among:

owell-conditioned athletes

o adults older than 40 or 50 with no evidence of heart dse, esp

after exercise


Abnormal findings:



pathologic S3 – (ventricular gallop)

pathologic S4 – (atrial gallop)

summation gallop

snaps

friction rub

Abnormal findings:



pathologic S3 – (ventricular gallop)

ischemic heart dse, hyperkinetic states (e.g., anemia),

restrictive myocardial dse

Abnormal findings:

Auscultation

pathologic S4 – (atrial gallop)

toward left side of precordium

o coronary artery dse (CAD), hypertensive heart dse,

cardiomyopathy , aortic stenosis

toward right side of precordium

opulmonary HTN, pulmo stenosis


Abnormal findings:

Auscultation

summation gallop

S3 and S4 pathologic sounds together - creates

quadruple rhythm

friction rub Harsh, grating sound that can be heard in both systole and

diastole

caused by abrasion of inflamed pericardial surfaces

(pericarditis)

Heard best with diaphragm of steth, patient sit and

leaning forward


Abnormal findings:

Auscultation

Note: normally no sound produced when valves

open

Opening snaps: abnormal diastolic sounds heard

during opening of AV valve (mitral stenosis)

Systolic click: result of opening of a rigid and

calcified aortic or pulmonic valve during ventricular

contraction


MURMURS


Murmur

o swishing sound caused by turbulent blood flow

thru heart valves or great vessels


Heart Murmurs


o use diaphragm and bell

o bcoz murmurs have diff pitches

o different positions & across entire heart area

o bcoz murmurs occur or subside according to

client’s position



o normal findings:

no murmurs

innocent and physiologic midsystolic murmurs –may

be present




pathologic midsystolic, pansystolic, diastolic

murmurs (p.382)

types of murmur:

systolic: early, mid, late, pansystolic

diastolic: early, mid, late, pandiastolic


AUSCULTATE : DIFFERENT

POSITION


Auscultate in with the client

assuming other position

o (1) client assume left lateral position

use bell – apex of heart

o (2) client sit up, lean forward, and exhale

use diaphragm – apex, along left sternal border


Auscultation: Other position

o Normal findings:

S1 and S2 heart sounds present


Auscultate in with the client assuming

other position

o Abnormal findings:

heard when client assume left lateral position

S3 and S4 or murmur

not detected on supine – indicate mitral stenosis

murmur from aortic regurgitation

May be heard sit up, lean forward, and exhale


CLINICAL PEARLS


Heart sounds

It is a common to try to hear all of the sounds in the cardiac

cycle at one time. Take the time to isolate each sound and each

pause in the cardiac cycle, listening separately and selectively for

as many beats as necessary to evaluate the sounds. It takes time

to tune in, so you must not rush. Avoid jumping the stethoscope

from one site to another; instead, inch the endpiece along the

route. This maneuver prevents missing important sounds,

particularly more widely transmitted abnormal sounds, and it

allows tracking of a sound from its loudest point to its farthest

reach (e.g. into the axilla or the back).


The infant heart and liver

If heart failure is suspected, note that the infants

liver may enlarged before there is any of

moisture in the lungs, and that the left lobe of

the liver may be more distinctly enlarged than

the right.


Chest wall thickness

The heart of an infant or child, particularly a

preschool child, is very close to the chest wall;

thus it is much easier to hear the innocent

sounds cause by the necessary rush of the

cardiovascular system.


DOCUMENTATION


Sample of subjective data:

No chest pain, dyspnea, dizziness or palpitations. No

previous history of cardiovascular diseases. Denies

rheumatic fever, no current medications or treatment.

Denies family history of hypertension, myocardial

infarction, CAD, high cholesterol levels, or diabetes

mellitus. Has never had an ECG, states he needs to

exercise more and consume less fat. Client does not

monitor own pulse or blood pressure. Denies the use

of tobacco. Sleeps 6-8 hours per night. Feels rested

after sleep. States that job can be somewhat stressful.


Sample of objective data:

Carotid pulse equal bilaterally, 2+, elastic. No bruits

auscultated over carotids. Jugular venous pulsation

disappears when upright. Jugular venous pressure x 2

cm. no visible pulsations, heaves or lifts on

pericardium. Apical impulse palpated in the 5th ICS, at

the left MCL, approximately the size of a nickel, with

no thrill. Apical heart rate auscultated, 70 beats per

min,, regular rhythm, S1 heard best at apex, S2 heard

best at base. No S3 or S4 auscultated. No splitting of

heart sound, snaps, clicks, or murmurs noted


NECK VESSEL ASSESSMENT


Neck vessel

Observe for jugular venous pulse

Evaluate jugular venous pressure

Auscultate carotid arteries

Palpate carotid arteries



o normal findings:

o jugular venous pulse – not visible when sitting

upright; visible on supine




o visible jugular venous pulse – right ventricular

failure, pulmo htn, pulmo emboli, cardiac

tamponade



o normal findings:

jugular vein – not distended, bulging, or protruding

at 45 degrees or greater




distended, bulging, or protruding at 45 degrees or

greater – right sided heart failure

document at which positions you observe distention

elevated venous pressure on expiration – obstructive

pulmonary disease

elevated venous pressure on inspiration –

Kussmaul’s sign – severe constrivtive pericarditis


AUSCULTATE & PALPATE

CAROTID ARTERIES


Observing Jugular Venous Pulse &

Evaluating Jugular venous pressure


Note: always auscultate first before palpating – palpation

may increase or slow the HR, therefore, changing

strength of impulse



o normal findings:

no blowing or swishing sound or other sounds




bruit

blowing or swishing sound; cause- turbulent blood flow

thru narrowed vessel

occlusive arterial disease

no bruit heard – if more than 2/3 artery occluded



o Note: if detect occlusion during auscultation –

palpate very lightly

to avoid blocking circulation or triggering vagal

stimulation and bradycardia, hypotension, or cardiac

arrest



o normal findings:

pulses – equally strong; 2+; no variation in strength

contour

smooth and rapid on upstroke

slower and less abrupt on down stroke

arteries – elastic and no thrills noted


Pulse Amplitude Scale

0 = Absent

1+ = Weak

2+ = Normal

3+ = Increased

4+ = Bounding




unequal pulse – arterial constriction or occlusion in 1

carotid

weak pulse – hypovolemia, shock, decreased CO

bounding, firm pulse – hypervolemia or increased CO

variations in strength from beat to beat

delayed upstroke – aortic stenosis

loss of elasticity – arteriosclerosis

thrills – narrowing of artery

180 8/14/2017 Maria Carmela L. Domocmat, RN, MSN

NURSING DIAGNOSES

Wellness

Readiness for enhanced cardiac output

Health seeking behavior: Desired information

on exercise and low fat diet

Risk Diagnoses

Risk for sexual dysfunction related to

misinformation or lack of knowledge regarding

sexual activity and heart disease

Risk for ineffective denial related to smoking

and obesity

Actual Diagnoses

Fatigue related to decreased cardiac output

Activity intolerance related to compromised

oxygen transport secondary to heart failure

Acute pain: Cardiac related to an inequality

between oxygen supply and demand

Ineffective tissue perfusion related to impaired

circulation.

References

Weber J; Kelly J. (2007). Health assessment in

nursing (3rd ed.) Philadelphia: Lippincott Williams

and Wilkins.

National Institute of Health. (n.d.). Heart

Diseases. Retrieved from

www.nlm.nih.gov/medlineplus/heartdiseases.ht

ml - Health Information-MedlinePlus


assessments heart & neck vessel

Health & Medicine