Evolve.

Adapt.
Overcome.
CEFI is now ready.

ASSESSMENT OF THE HEART AND NECK

VESSELS, PERIPHERAL VASCULAR SYSTEM:
PULSE

HA SKL: Health Assessment Skills Laboratory

MS. AILEEN M. MERCADO RN, MSN, LPT

College of Nursing
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OBJECTIVES:
At the end of the session, students will be able to:

Review knowledge of anatomy and physiology of the heart

Describe the importance of performing assessment of the heart

Demonstrate assessment of the heart

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GENERAL CONSIDERATIONS
1. The patient must be properly undressed and in gown for
this examinations

2. The examination room must be quiet to perform adequate

auscultation.

3. Observe the patient for general signs of cardiovascular

disease.
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PULSE – the rhythmic dilation of an artery

that results from beating of the heart.
CONSIDERATIONS:
1. Check the radial pulses on both sides.
2. If the radial pulse is absent or weak, check the brachial
pulses.
3. Check the posterior tibia and dorsalis pedis pulses on
both sides.
4. If these pulses are absent or weak, check the popliteal
and femoral pulses.
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PULSE
LOCATION OF PULSES:
a. Carotid – neck
b. Brachial – upper arm
c. Radial – wrist
d. Femoral – groin
e. Popliteal – behind knee
f. Posterior Tibial – back of leg near Achilles tendon
g. Dorsalis pedis (pedal) – top of foot
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PULSE
GRADING FORCE OF PULSE
SCORE DESCRIPTION

0 Absent
1+ Weak,thread
2+ Normal
3+ Increased, full, bounding
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PULSE
Note whether pulse is
a. REGULAR – evenly spaced beats, may vary slightly with
respiration
b. REGULARLY IRREGULAR – regular pattern overall with
“skipped beats”
c. IRREGULARLY IRREGULAR – chaotic, no real pattern,
very difficult to measure rate accurately
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PULSE
INTERPRETATION
NORMAL HEART RATE
AGE BEATS PER MINUTE
Normal Adult Between 60 and 100
10 years old 95
8 years old 100
6 years old 103
2 years old 110
1 year old 115
6 months old 130
Birth 140
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INTERPRETATION

A pulse greater than 100 bpm is called tachycardia while a

pulse less than 60 bpm is called bradycardia.

Tachycardia and bradycardia are not necessarily abnormal.

Athletes tend to be bradycardic at rest (superior conditioning).
Tachycardia is a normal response to stress or exercise.
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BLOOD PRESSURE – the pressure by circulating blood on the walls of blood vessels. The blood pressure in
the circulation is principally due to the pumping action of the heart. Differences in mean blood pressure are responsible for
blood flow from one location to another during circulation. The rate of mean blood flow depends on the resistance to flow
presented by the blood vessels. Gravity affects blood pressure via hydrostatic forces (during standing) and valves in veins,
breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.
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BLOOD PRESSURE
CONSIDERATIONS:
1. The patient should not have eaten, smoked, taken caffeine, or
engaged in vigorous exercise within the last 30 minutes.
2.The room should be quiet and the patient should be comfortable.
3. Position the patient's arm so the antecubital fold is level with the
heart.
4. Center the bladder of the cuff over the brachial artery
approximately 2 cm above the antecubital fold. Proper cuff size is
essential to obtain an accurate reading. Be sure the index line falls
between the size marks when you apply the cuff. Position the patient's
arm so it is slightly flexed at the elbow.
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INTERPRETATION

1. Higher blood pressures are normal during exertion or other stress.

Systolic blood pressures below 80 may be a sign of serious illness or
shock.
2. Blood pressure should be taken in both arms on the first encounter.
If there is more than 10 mmHg difference between the two arms, use
the arm with the higher reading for subsequent measurements.
3. Always recheck "unexpected" blood pressures yourself.
4. It is frequently helpful to retake the blood pressure near the end of
the visit. Earlier pressures may be higher due to the "white coat" effect.
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BLOOD PRESSURE
INTERPRETATION
BLOOD PRESSURE CLASSIFICATION IN ADULTS
CATEGORY SYSTOLIC DIASTOLIC
NORMAL LESS THAN 130 LESS THAN 85
HIGH NORMAL 130 -139 85 - 89
MID HYPERTENSION 140 - 159 90 - 99
MODERATE HYPERTENSION 160 - 179 100 - 109
SEVERE HYPERTENSION 180 - 209 110 -119
CRISIS HYPERTENSION GREATER THAN 210 GREATER THAN 120
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Amplitude and Contour (Carotid)

1. Observe for carotid pulsations.
2. Place your fingers behind the patient's neck and compress the carotid
artery on one side with your thumb at or below the level of the cricoid
cartilage. Press firmly but not to the point of discomfort.
3. Assess the following:
a. The amplitude of the pulse.
b. The contour of the pulse wave.
c. Variations in amplitude from beat to beat or with respiration.
4. Repeat on the opposite side.
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Auscultation for Bruits (Carotids)

If the patient is late middle aged or older, you should auscultate
for bruits. A bruit is often, but not always, a sign of arterial
narrowing and risk of a stroke.
1. Place the bell of the stethoscope over each carotid artery in
turn. You may use the diaphragm if the patient's neck is highly
contoured.
2. Ask the patient to inhale deep breath then exhale and hold
momentarily.
3. Listen for a blowing or rushing sound--a bruit. Do not be
confused by heart sounds or murmurs transmitted from the
chest.
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Jugular Venous Pressure

1. Position the patient supine with the head of the bed elevated 30
degrees.
2. Use tangential, side lighting to observe for venous pulsations in the
neck.
3. Look for a rapid, double (sometimes triple) wave with each heart beat.
Use light pressure just above the sternal end of the clavicle to eliminate
the pulsations and rule out a carotid origin.
4. Adjust the angle of bed elevation to bring out the venous pulsation.
5. Identify the highest point of pulsation. Using a horizontal line from this
point, measure vertically from the sternal angle.
6. This measurement should be less than 4 cm in a normal healthy adult.
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Precordial Movement
1. Position the patient supine with the head of the bed slightly elevated.
2. Always examine from the patient's right side.
3. Inspect for precordial movement. Tangential lighting will make
movements more visible.
4. Palpate for precordial activity in general. You may feel "extras" such as
thrills or exaggerated ventricular impulses.
5. Palpate for the point of maximal impulse (PMI or apical pulse). It is
normally located in the 4th or 5th intercostal space just medial to the
midclavicular line and is less than the size of a quarter.
6. Note the location, size, and quality of the impulse.
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Capillary Refill
1. Press down firmly on the patient's finger or toe nail
so it blanches.
2. Release the pressure and observe how long it takes
the nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds
suggest peripheral vascular disease, arterial blockage,
heart failure, or shock.
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Heart Sounds
1. Position the patient supine with the head of the table slightly
elevated.
2. Always examine from the patient's right side. A quiet room is
essential.
3. Listen with the diaphragm at the right 2nd interspace near the
sternum (aortic area).
4. Listen with the diaphragm at the left 2nd interspace near the sternum
(pulmonic area).
5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces
near the sternum (tricuspid area).
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Heart Sounds
6. Listen with the diaphragm at the apex (PMI) (mitral area).
7. Listen with the bell at the apex.
8. Listen with the bell at the left 4th and 5th interspace near the sternum
9. Have the patient roll on their left side. Listen with the bell at the apex.
This position brings out S3, S4 and mitral murmurs.
10. Have the patient sit up, lean forward, and hold their breath in
exhalation. Listen with the diaphragm at the left 3rd and 4th interspace
near the sternum. This position brings out aortic murmurs.
11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any
murmurs.
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Heart Sounds
S1: normal: closure AV, start systole, heard all over, loudest apex
S2: normal: closure of semilunar valves, end systole, all over but loudest
base, “dub”
S3: extra heart sounds: vibrations that come from filling ventricles, start
diastolic usually; audible in children, young adults, pregnant women –
otherwise may be indicative of disease
S4: extra heart sounds: end of diastolic, vibrations; usually abnormal to
hear – may be indicative of disease
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MURMURS
1. Grade i-ii functional systolic murmurs are common in
young children and resolve with age
2. Auscultate for blowing, swishing sound.
3. Some are ‘innocent” murmurs, but most are indicative
of disease.
4. Murmurs are graded. A grade “2” murmur would be
rated ii/vi.
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MURMURS
Grade Description

i Barely audible. Heard only if room silent and then still hard
to hear
ii Clearly audible, but faint
iii Moderately loud, easy to hear
iv Loud, associated with thrill on chest wall
v Very loud, can hear with edge of stethoscope off chest
vi Loudest, can hear with entire stethoscope off chest wall
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EDEMA, CYANOSIS, AND CLUBBING

1. Check for the presence of edema (swelling) of the
feet and lower legs.
2. Check for the presence of cyanosis (blue color) of the
feet or hands.
3. Check for the presence of clubbing of the fingers.
a) Normal = 160 degrees
b) Curved = 160 degrees or less
c) Early clubbing = 180 degrees
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PITTING EDEMA
Scale Level of pitting Indentation Swelling of leg
1+ Mild Slight Not noticeable
2+ moderate Subsides rapidly
3+ Deep Remains for Leg looks
short time swollen
4+ Very deep Remains for long Grossly swollen
time and misshapen
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LYMPHATICS
1. Check for the presence of epitrochlear lymph nodes.
(antecubital)
2. Check for the presence of axillary lymph nodes.
(breast and arm)
3. Check for the presence of inguinal lymph nodes.
(groin)
4. PEDIATRICS: to assess lymph nodes in younger
children, tilt head slightly to check neck nodes.
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Thank you for your time!