Heart Assessment: Physical Examination

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HEART ASSESSMENT

Physical Examination

Subjective data collected about the heart and neck vessels help the nurse identify abnormal
conditions that may affect the client’s ability to perform activities of daily living and to fulfill his role and
responsibilities.

A major purpose of this examination is to identify any sign of heart disease and thereby initiate early
referral and treatment. Data collection also provides information on the client’s risk for cardiovascular
disease and helps to identify areas where health education is needed.

Preparing the Client

1. Explain to the client that they will need to expose the anterior chest. Female clients may keep their
breasts covered and may simply hold the left reast out of the way when necessary.

2. Explain to the client that she /he will need to assume several different positions for this
examination.

3. Explain to the client that that you will be listening to the heart in a number of places and that this
does not necessarily mean that anything is wrong.

4. Provide the client with as much modesty as possible during the examination.

5. Describe the steps of the examination, and answer any questions the client may have. These
actions will help to ease any client anxiety.

Equipments:

1. Stethoscope with a bell and diaphragm


2. Small pillow
3. Penlight or movable examination light
4. Watch with second hand
5. Centimeter rulers (two)

A. N ECK VESSELS

Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of
the client. The client should be in a supine position with the torso elevated 30to 45 degrees. Make
sure the head and torso are on the same plane. Ask the client to turn the head slightly to the left.
Shine a tangential light source onto the neck to increase visualizations of pulsations as well as
shadows. Next inspect the suprasternal notch or the area around the clavicles for pulsations of the
internal jugular veins.

 Normal Findings:
o The jugular venous pulse is not normally visible with the client sitting upright. This
position fully distends the vein, and pulsations may or may not be discernible.
Evaluate jugular venous pressure by watching for distention of the jugular vein. It is normal for the
jugular veins to be visible when the client is supine; to evaluate the distention, place the client in
supine position with the head of th bed elevated 30, 45, 60, and 90 degrees. At each increase of the
elevation, have the client’s head turned slightly away from the side being evaluated. Using tangential
lighting, observe for distention, protrusion, or bulging.

 Normal Findings:
o The jugular vein should not be distended, bulging, or protruding at 45 degrees or
greater.

Auscultate the carotid arteries if the client is middle-aged or older or if you suspect cardiovascular
disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her
breath for a moment so breath sounds do not conceal any vascular sounds.

J Always auscultate the carotid arteries before palpating because palpation may increase
or slow the HR, therefore, changing the strength of the carotid impulse heard.

 Normal Findings:
o No blowing or swishing or other sounds are heard.
o Pulses are equally strong; a 2+ or normal with no variation in strength from beat to beat.
Contour is normally smooth and rapid on the upstroke and slower and less abrupt on
the downstroke. Arteries are elastic and no thrills are noted.

Palpate the carotid arteries alternately by placing the pads of the index and middle fingers medial to
the sternocleidomastoid muscle on the neck. Note amplitude an contour of the pulse, elasticity of the
artery, and any thrills. Palpate the arteries individually because bilateral palpation could result in
reduced cerebral blood flow.

 Normal Findings:
o The strength of the pulse is evaluated on a scale from 0 to 4 as follows:
 Pulse Amplitude Scale
0 = absent
1+ = weak
2+ = normal
3+ = increased
4+ = bounding

B. HEART (PRECORDIUM)

Inspect pulsations with the client in supine position with the head of bed elevated between 30 and
45 degrees, stand on the right side and look for the apical pulse and any abnormal pulsations.

 Normal Findings:
o The apical impulse may or may not be visible. If apparent, it would be in the mitral area
(5th ICS Left Midclavicular line). The apical pulse is a result of the left ventricle moving
outward during systole.

Palpate the apical pulse. Remain on the right side of the client and ask the client to remain supine.
Use the palmar surfaces of your hand to palpate the apical pulse in the mitral area (4th or 5th ICS at
the midclavicular line). After locating the pulse, use one finger pad for more accurate palpation.
J If this pulsation cannot be palpated, have the client assume a left lateral position. This
displaces the heart toward the left chest wall and relocates the apical impulse farther to
the left.

 Normal Findings:
o The apical pulse is palpated in the mitral area and may be the size of a nickel (1 to
2cm).
o Amplitude is usually small—like a gentle tap.
o The duration is brief, lasting through the first two-thirds of systole and often leess. In
obese clients or clients with large breasts, the apical pulse may not be palpable.

Palpate for abnormal pulsations. Use your palmar surfaces to palpated the apex, left sterna borer,
and base.

 Normal Findings:
o No pulsations or vibrations are palpated in the areas of the apex, left sterna border, or
base.

Auscultating Heart Sounds

Traditional areas of auscultation:


 Aortic area: 2nd ICS at the right sterna border—the base of the heart
 Pulmonic area: 2nd or 3rd ICS at the left border—the base of the heart
 Erb’s point: 3rd to 5th ICS at the left sterna border
 Mitral (apical): 5th ICS near the left midclavicular line—apex of the heart
 Tricuspid area: 4th or 5th ICS at the left lower sternal border

Auscultate HR and rhythm.


Position yourself on the client’s right side. The client should be supine withe upper trunk
elevated 30 degrees. Use the diaphragm of the stethoscope to auscultate all areas of the precordium
for high pitched sounds. Use the bell of the stethoscope to detect or differentiate low pitch sounds or
gallops. The diaphragm should be applied firmly to the chest, whereas the bell should be applied
lightly. Closing your eyes reduces visual stimulation and distractions and may enhance your ability to
concentrate on auditory stimuli.

 Normal Findings:
o Rate should be 60-100 beats/minute with regular rhythm. A regular irregular rhythm,
such as sinus arrhytmia when heart rate increases with inspiration and decreases with
expiration, may be normal in young adults.
o Normally the pulse rate in females is 5 to 10 beats per minute faster than in males.
Pulse rates do not differ by race or age in adults.

 If you detect an irregular rhythm, auscultate for a pulse rate deficit.


o This is done by palpating the radial pulse while you ausculate the apical pulse. Count
for a full minute.
Normal Findings:
 The radial and apical pulse rate should be identical.
Auscultate to identify S1 and S2.
Ausculatate the 1st heart sound (S1 or “lub”) and the 2nd heart sound (S2 or “dub”). Remember
these two sound make up the cardiac cycle of systole and diastole.

 Normal Findings:
o S1 correspond with each carotid pulsation and is loudest at the apex of the heart. S2
immediately follows after S1 and is loudest at the base of the heart.

Listen to S1 by using the diaphragm of the stethoscope.


 Normal Findings:
o A distinct sound is heard in each area but loudest at the apex. May become softer with
inspiration. A split S1may be heard normally in young adults at the left lateral sterna
border

Listen to S2 by using the diaphragm of the stethoscope. Ask the client to breath regularly.
 Normal Findings:
o Distinct sound is heard in each area but is loudest at the base. A split S2 (into two
distinct sounds of its components—A2 and P2) is normal and termed Physiologic
Splitting. It is usually heard late in inspiration at the second or third left interspaces.

Auscultate for extra heart sounds by using the diaphragm first then the bell to auscultate over the
entire heart area. Note the characteristics of an extra sound heard. Auscultate during the systolic
pause (space heard between S1 and S2).

 Normal Findings:
o Normally no sounds are heard.

Auscultate during the diastolic pause (space heard between end of S2 and next S1).

 Normal Findings:
o Normally no sounds are heard. A physiologic S3 heart sound is a benign finding
commonly heard at the beginning of the diastolic pause. In children, adolescents, and
young adults. It is rare after age 40. The physiologic S3 usually subsides upon standing
or sitting up. A physiologic S4 heart sound may e heard near the end of diastole in well-
conditioned athletes and in adults older than age 40 or 50 with no evidence of heart
disease, especially after exercise.

Auscultate for murmurs across the entire heart area. Use the diaphragm and the bell of the
stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also auscultate
with the cient in different positions because some murmurs occur or subside according to the client’s
position.

 Normal Findings:
o Normally no murmurs are heard. However, innocent and physiologic mid systolic
murmurs may be present in a healthy heart.

Auscultate in with the client assuming other positions. Ask the client to assume a left lateral
position. Use the bell of the stethoscope and listen at the apex of the heart. Ask the client to sit up,
lean forward, and exhale. Use the diaphragm of the stethoscope and listen over the apex and along
the left sterna border.
 Normal Findings:
o S1 and S2 heart sound are normally present.

Extra Heart Sounds

 S3 (Ventricular Gallop)

Has a low frequency and is heard best in using the bell of the stethoscope at the apical area or lower
right ventricular area of the chest with the patient in the left lateral position. The sound is often
accentuated during inspiration and has the rhythm of the word “Ken-tuc-ky”. S3 is the result of
vibrations caused by blood hitting the ventricular wall during rapid ventricular filling.

 S4 (Atrial Gallop)

A low-frequency sound occurring at he end of diastole when the atria contract. It is caused by
vibrations from blood flowing rapidly into the ventricles after atrial contraction. S4 has the rhythm of
the word “Ten-nes-see” and may increase inspiration. It is best heard with the bell of the stethoscope
over the apical area with the patient in supine or left lateral position and is never heard in the absence
of atrial contraction.

 Patent Ductus Arteriosus (PDA)

A congenital anomaly that leaves an open channel between the aorta and pulmonary artery. Found
over the 2nd left ICS, the murmur of PDA may radiate to the left clavicle. It is classified as a
continuous murmur because it extends through systole and into part of diastole. It has a medium pitch
and a harsh, machinery-like sound. The murmur is loudest in late systole, obscures S2, fades in
diastole, and often has a silent interval in late diastole.

 Aortic regurgitation

Occurring when the leaflets of the aortic valve fail to close completely, the murmur of aortic
regurgitation is the result of blood flowing from the aorta back into the left ventricle. This results n left
ventricular volume overload. An ejection sound also may be present.

Location: 2nd to 4th left ICS


Radiation: may radiate to the apex or left sterna border
Intensity: grade 1 to 3
Pitch: high
Quality: blowing, sometime mistaken for breath sounds
Position: heard best with the patient sitting, leaning forward. Have the patient exhale and then hold
his or her breath.

 Ventricular Septal Defect (VSD)

A congenital abnormality in which blood flows from the left ventricle into the right ventricle through a
hole in the septum, a VSD causes a loud murmur that obscures the A2 sound. Other findings vary
depending on the severity of the defect and any associated lesions.

Location: 3rd, 4th, and 5th left ICS


Radiation: often wide
Intensity: very loud, with a thrill
Pitch: high
Quality: harsh
Position: increase with exercise

DOCUMENTATION

Sample of Objective Data


 Carotid pulse equal bilarerally, 2+, elastic
 No bruit auscultated over carotids
 Jugular venous pulsation disappears when upright
 Jugular pressure x 2cm
 No visible pulsations, heaves, or lift on precordium
 Apical impulse palpated in the 5th ICS LMCL, approximately the size of a nickel, with no thrill.
 Apical heart rate auscultated, 70 beats/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

Nursing Diagnoses

Wellness Diagnoses
 Readiness for enhance cardiac output
 Health-seaking behaviour: 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 inequality between oxygen supply and demand
 Anxiety
 Ineffective tissue perfusion: cardiac related to impaired circulation.

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