CARDIAC ASSESSMENT

SL.NO CONTENT YES NO

1 Articles Required
1. Vital signs tray
2. Bp apparatus with stethoscope
3. Measuring tape/measuring scale
4. Wrist watch and pen
2 Preparation of the unit
 The room must be quiet, warm, and have good lighting.
 Explain what you’re doing (& why) before doing it
 Expose minimum amount of skin necessary, use gown & drapes (males & females)
 The patient should be supine with upper body elevated at a 15-30E angle.
 You should stand to the right of the patient being examined
 The finger pads are more sensitive in detecting pulsations.
History Of The Client
Health History:
1. Current Health Status
-chest pain ,- shortness of breath ,- swelling of ankles or feet, - heart palpitations ,- fatigue
2. Past Health History
-Congenital heart disease,- Rheumatic fever,- Heart murmur,- High blood pressure, high
cholesterol, diabetes mellitus,- Confusion,- Fatigue
3. Family History
4. Personal Habits
5.Current Lifestyle and Psychosocial Status
• Nutrition • Smoking • Alcohol • Exercise • Drugs
3 Techniques
Inspection , Palpation, Percussion (omitted in cardiac exam) & Auscultation
INSPECTION:
 Shortness of breath (rest or walking)
 Sitting upright? Able to speak?
 Pulsations- these are more visible when patients are thin. A thick chest wall or
increased AP diameter can obscure them. Pulsations may indicate increased blood
volume or pressure.
 Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous
movement of sternum and ribs.
Eyes
• The presence of yellowish plaques on the eyelids (xanthelasma) could indicate
hyperlipoproteinemia, a risk factor for hypertension as well as arteriolosclerosis
Chest
• Observe the chest for overall torso contour.
• Do you see pectus excavatum (caved-in chest)?
• Do you see pectus carinatum (pigeon chest)?
Skin
• Clubbing The presence of clubbing (broadening of the extremities of the digits,
accompanied by nails which are abnormally curved and shiny) indicates chronic poor oxygen
perfusion to the distal tissues of the hand and feet.
Cyanosis
• The presence of cyanosis (bluish colour) also denotes chronic poor oxygen delivery to the
peripheral tissues of the hands and feet.
 Janeway lesions - macules on the back of the hands (infective endocarditis).
  Osler's nodes - tender nodules in the fingertips (infective endocarditis).
 Corneal arcus - a ring around the cornea (normal ageing or hyperlipidaemia).
Xanthomas
• The presence of yellowish plaques under the skin (noneruptive) excoriated through the
skin (eruptive) could indicate hyperlipoproteinemia, a risk factor for hypertension as well as
arteriolosclerosis.
Edema
• The presence of edema (tissue swelling) can be caused by several factors, although most
commonly is associated with decreased cardiac function leading to decreased capillary flow
Palpation
 Use the palm of your hand to feel the chest wall for the "Point of Maximal Impulse"
(PMI), which is usually found at the apex of the heart.
 Thrills- these are the vibrations of loud cardiac murmurs.
 Palpate the peripheral arteries. These include the brachial, radial, femoral, popliteal,
dorsalis pedis, and posterior tibial. Note the contour and amplitude of each
pulsation. These should feel similar bilaterally.
Chest percussion:
• Normally only the left border of heart can be detected by percussion. It extends from the
sternum to mid clavicular line in the third to fifth inter costal space. The right border lies
under the right margin of the sternum and is not detectable. Enlargement of the heart too
either the left or right usually can be noted.

Auscultation of the Heart (All People Enjoy Time Magazine)

1. Aortic Area-2nd right interspace close to the sternum.
2. Pulmonic Area- 2nd left interspace.
3. ERB's -Point 3rd left interspace.
4. Tricuspid Area-5th left interspace close to the sternum.
5. Mitral Area (Apical)-5th left interspace medial to the MCL
With your stethoscope, identify the first and second heart sounds (S1 and S2) at the aortic
and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of 'lub-
DUB.' S2 is caused by the closure of the aortic and pulmonic valves.
LISTEN FOR MURMUR
 S1 is accentuated in exercise, anemia, hyperthyroidis m and mitral stenosis
 S2-Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on
inspiration.
 S3-A physiologic S3 is frequently heard in children and in pregnant women.
 S4 -It occurs before S1
 Murmur -It is low pitched and best heard with the bell
Heart murmur are heart sound produced when blood flows across one of the heart valves
that is loud enough to be heard with a stethoscope.
 Pericardial Friction Rub
• A pericardial friction rub is usually heard best and is sometimes palpable over the tricuspid
and xyphoid areas. It occurs when inflamed pericardial surfaces rub together
4 Vascular assessment
Carotid Arteries
• Anatomy
• Palpation (ea side separately!)
– Rhythm & Fullness
• Auscultation – Radiation of murmurs – ? Intrinsic atherosclerosis – may produce “shshing”
noise known as bruit
JVP Technique
Find correct area – helps to first identify SCM & triangle it forms w/clavicle
• Look for multi-phasic pulsations (‘a’, ‘c’ & ‘v’ waves)
• Isolate from carotid pulsations, respirations
• Tangential lighting
• Hepatojugular reflux (gentle pressure over liver pushes blood back into IJ & makes
pulsations more apparent)
JVP =s 5cm (height sternal-manubrial angle is above RA) + vertical distance from
sternalmanubrial angle to top of pulse wave
• Normal -cm
Lower Extremity Vascular Exam – General Observation, Including Femoral Region
Expose both legs, noting: asymmetry, muscle atrophy, joint (knee, ankle) abnormalities
• Focus on Femoral Area: – Inspect - ? Obvious swelling
 femoral hernia v large lymph nodes (rare) – Palpate lymph nodes
 Identify femoral pulse • Listen over femoral artery with diaphragm stethescope for
bruits (if suggestion vascular disease by hx, exam)
Popliteal Pulse (behind the Knee)
• W/knee slightly bent, push fingers into popliteal fossa
Vascular Disease of The Lower Leg Components:
– outflow (arterial)
– return (venous, lymphatic)
Clinical Presentations: Arterial: pain (supply-demand) wound healing RFs for
atherosclerosis
Venous: Edema Local v systemic etiology
Lymph (uncommon): Edema (uncommon) obstruction, disruption
Feet and Ankles • Lower leg & feet @ greatest risk atherosclerosis and neuropathy–
particularly if Diabetes
• Observe – ? swelling (edema), discoloration, ulcers, nail deformities
– Look @ bottom of feet, between toes (problem areas) – Symmetry?

• Palpation – Temperature: Use back of examining hand – warm,inflammation;

cool,atherosclerosis &/or hypo-perfusion
– Capillary refill: push on end of toe or nail bed & release. color returns in < 2-3 seconds;
longer, atheroscloerosis &/or hypo-perfusion

Quantifying Edema • One marker of volume status • trace (minimal), can be subtle loss of
tendons on top of foot, contours malleolous
• 4+ =s “a lot” - pitting (divot left in skin after pressure applied)
• Or assess depth of pit in mm.
• Determine how extensive (e.g. limited to feet v up to knee)

Dorsalis Pedis Pulse

• Palpate Dorsalis Pedis pulse – Just lateral to extensor tendon great toe – Use pads of 2-3
fingers of examining hand – Push gently – If unsure whether feeing your pulse v patient’s,
measure your carotid or their radial w/other hand – Graded 0 (not detectable) to 2+
(normal)
Posterior Tibial Pulse
• Palpate Posterior Tibial Pulse – Located posterior to medial malleolous
– Start on top of mallelous & work towards achilles
– Use pads of 2-3 fingers, pushing gently – Same rating scale as for dorsalis pedis
SL.NO CONTENT YES NO
1 Articles Required
 Vital signs tray
 Bp apparatus with stethoscope
 Measuring tape/measuring scale
 Wrist watch and pen
2 Preparation of the unit
 The room must be quiet, warm, and have good lighting.
 Explain what you’re doing (& why) before doing it
 Expose minimum amount of skin necessary, use gown & drapes (males & females)
 The patient should be supine with upper body elevated at a 15-30E angle.
 You should stand to the right of the patient being examined
 The finger pads are more sensitive in detecting pulsations.
3 History Of The Client
Health History:
1. Current Health Status
-chest pain ,- shortness of breath ,- swelling of ankles or feet, - heart palpitations ,- fatigue
2. Past Health History
-Congenital heart disease,- Rheumatic fever,- Heart murmur,- High blood pressure, high
cholesterol, diabetes mellitus,- Confusion,- Fatigue
3. Family History
4. Personal Habits
5.Current Lifestyle and Psychosocial Status
• Nutrition • Smoking • Alcohol • Exercise • Drugs
4 Techniques
Inspection , Palpation, Percussion (omitted in cardiac exam) & Auscultation
INSPECTION:
 Shortness of breath (rest or walking)
 Pulsations- visible when patients are thin. A thick chest wall or increased AP
 Lift or heaves- slight to vigorous movement of sternum and ribs.
Eyes
• xanthelasma The presence of yellowish plaques on the eyelids
Chest
• Observe the chest for overall torso contour. pectus excavatum (caved-in chest)/
• pectus carinatum (pigeon chest)?
Skin
Clubbing -broadening of the extremities of the digits, accompanied by nails which are
abnormally curved and shinyCyanosis cyanosis -bluish colour of the hands and feet.
Janeway lesions - macules on the back of the hands (infective endocarditis).
Osler's nodes - tender nodules in the fingertips (infective endocarditis).
Corneal arcus - a ring around the cornea (normal ageing or hyperlipidaemia).
Xanthomas - The presence of yellowish plaques under the skin Edema
• edema -tissue swelling with decreased cardiac function leading to decreased capillary
flow
Palpation
 Use the palm of your hand to feel the chest wall for the "Point of Maximal
Impulse" (PMI), which is usually found at the apex of the heart.
 Thrills- these are the vibrations of loud cardiac murmurs.
 Palpate the peripheral arteries. These include the brachial, radial, femoral,
popliteal, dorsalis pedis, and posterior tibial. Note the contour and amplitude of
each pulsation. These should feel similar bilaterally.
 Chest percussion:
• Normally only the left border of heart can be detected by percussion. It extends from
the sternum to mid clavicular line in the third to fifth inter costal space. The right border
lies under the right margin of the sternum and is not detectable. Enlargement of the heart
too either the left or right usually can be noted.

Auscultation of the Heart (All People Enjoy Time Magazine)

1. Aortic Area-2nd right interspace close to the sternum.
2. Pulmonic Area- 2nd left interspace.
3. ERB's -Point 3rd left interspace.
4. Tricuspid Area-5th left interspace close to the sternum.
5. Mitral Area (Apical)-5th left interspace medial to the MCL
**With your stethoscope, identify the first and second heart sounds (S1 and S2) at the
aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub
of 'lub-DUB.' S2 is caused by the closure of the aortic and pulmonic valves.
LISTEN FOR MURMUR
 S1 is accentuated in exercise, anemia, hyperthyroidis m and mitral stenosis
 S2-Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on
inspiration.
 S3-A physiologic S3 follows S2 is frequently heard in children and in pregnant
women.
 S4 -It occurs before S1
 Murmur -It is low pitched and soft best heard with the bell
Heart murmur are heart sound produced when blood flows across one of the heart valves
that is loud enough to be heard with a stethoscope.
 Pericardial Friction Rub
• A pericardial friction rub is usually heard best and is sometimes palpable over the
tricuspid and xyphoid areas. It occurs when inflamed pericardial surfaces rub together
5 Vascular assessment
Carotid Arteries
• Anatomy
• Palpation (ea side separately!)
– Rhythm & Fullness
• Auscultation – Radiation of murmurs – ? Intrinsic atherosclerosis – may produce
“shshing” noise known as bruit
JVP Technique
Find correct area – helps to first identify SCM & triangle it forms w/clavicle
• Look for multi-phasic pulsations (‘a’, ‘c’ & ‘v’ waves)
• Isolate from carotid pulsations, respirations
• Tangential lighting
• Hepatojugular reflux (gentle pressure over liver pushes blood back into IJ & makes
pulsations more apparent)
JVP =s 5cm (height sternal-manubrial angle is above RA) + vertical distance from
sternalmanubrial angle to top of pulse wave
• Normal < 8 cm
Lower Extremity Vascular Exam – General Observation, Including Femoral Region
Expose both legs, noting: asymmetry, muscle atrophy, joint (knee, ankle) abnormalities
• Focus on Femoral Area: – Inspect - ? Obvious swelling
 femoral hernia v large lymph nodes (rare) – Palpate lymph nodes
 Identify femoral pulse • Listen over femoral artery with diaphragm stethescope for
bruits (if suggestion vascular disease by hx, exam)
Popliteal Pulse (behind the Knee)
• W/knee slightly bent, push fingers into popliteal fossa

Vascular Disease of The Lower Leg Components:

– outflow (arterial)
– return (venous, lymphatic)
Clinical Presentations: Arterial: pain (supply-demand) wound healing RFs for
atherosclerosis
Venous: Edema Local v systemic etiology
Lymph (uncommon): Edema (uncommon) obstruction, disruption
Feet and Ankles • Lower leg & feet @ greatest risk atherosclerosis and neuropathy–
particularly if Diabetes
• Observe – ? swelling (edema), discoloration, ulcers, nail deformities
– Look @ bottom of feet, between toes (problem areas) – Symmetry?

• Palpation – Temperature: Use back of examining hand – warm,inflammation;

cool,atherosclerosis &/or hypo-perfusion
– Capillary refill: push on end of toe or nail bed & release. color returns in < 2-3 seconds;
longer, atheroscloerosis &/or hypo-perfusion

Quantifying Edema • One marker of volume status • trace (minimal), can be subtle loss of
tendons on top of foot, contours malleolous
• 4+ =s “a lot” - pitting (divot left in skin after pressure applied)
• Or assess depth of pit in mm.
• Determine how extensive (e.g. limited to feet v up to knee)

Dorsalis Pedis Pulse

• Palpate Dorsalis Pedis pulse – Just lateral to extensor tendon great toe – Use pads of 2-3
fingers of examining hand – Push gently – If unsure whether feeing your pulse v patient’s,
measure your carotid or their radial w/other hand – Graded 0 (not detectable) to 2+
(normal)
Posterior Tibial Pulse
• Palpate Posterior Tibial Pulse – Located posterior to medial malleolous
– Start on top of mallelous & work towards achilles
– Use pads of 2-3 fingers, pushing gently – Same rating scale as for dorsalis pedis
 RESPIRATORY ASSESSMENT

SL.NO CONTENT YES NO

1 Articles Required
 Vital signs tray
 Bp apparatus with stethoscope
 Measuring tape/measuring scale
 Wrist watch and pen
 Two cardboard
2 Technique for Respiratory Exam
 Quiet environment
 Proper positioning (patient sitting for posterior thorax exam, supine
for anterior thorax exam)
 Expose skin for auscultation
 Patient comfort, warm hands and diaphragm of stethoscope, be
considerate of women (drape sheet to cover chest)
 After that the nurse should apply the four techniques; Inspection,
Palpation, Percussion and Auscultation
Subjective data: the nurse must ask the client about:-
Coughing (productive, non productive)
Sputum (type & amount)
Allergies, dyspnea or SOB (at rest or on exertion).
Chest pain, history of asthma, bronchitis, emphysema, tuberculosis.
Cyanosis, pallor.
Exposure to environmental inhalants (chemicals, fumes).
History of smoking (amount and length of time)
3 Inspection
Inspect for nasal flaring and pursed lip breathing
Observe color of face, lips, and chest
Inspect color and shape of nails
Inspect configuration. While the client sits with arms at the sides, stand
behind the client and observe the position of scapulae and the shape and
configuration of the chest wall. The ratio of anteroposterior to transverse
diameter is 1:2.[ scoliosis, barrel chest, Kyphosis]
Observe use of accessory muscles.- Trapezius, or shoulder, muscles are used
to facilitate inspiration in cases of acute and chronic airway obstruction or
atelectasis
Inspect the client’s positioning-tripod position. This is often seen in COPD
PALPATION
Palpate for tenderness and sensation. Palpation may be performed with one
or both hands, but the sequence of palpation is established
Palpate for crepitus-
Palpate for fremitus
Assess chest expansion. Place your hands on the posterior chest wall with
your thumbs at the level of T9 or T10 and pressing together a small skin fold.
As the client takes a deep breath, observe the movement of your thumbs
Percussion of chest:
Done to determine relative amounts of air, liquid, or solid material in the
underlying lung, and to determine positions and boundaries of organs.
Percussion done for posterior and anterior and lateral aspects of chest with
all directions, and with about “5”cms intervals.
Percuss for tone. Start at the apices of the scapulae and percuss across the
tops of both shoulders. Then percuss the intercostal spaces across and down,
comparing sides. Percuss to the lateral aspects at the bases of the lungs,
comparing sides.
Auscultation:
To obtains information about the function of respiratory system & to detect
any obstruction in the passages.
Instruct the client to breathe through the mouth more deeply and slowly
than in usual respiration and then to hold the breath for a few seconds at the
end of inspiration to increase intrapleural pressure and reopen collapsed
alveoli.
Auscultate all areas of chest for at least one complete respiration: 12
anterior locations and 14 posterior locations
Auscultate symmetrically: Should listen to at least 6 locations anteriorly and

posteriorly anerior

Breath Sounds
Normal breath sounds are distinguished by their location over a specific area
of the lung and are identified as tracheal, vesicular, bronchovesicular, and
bronchial (tubular) breath sounds as the next:
1. Tracheal
Very loud, high pitched sound
Inspiratory = Expiratory sound duration
Heard over trachea in the neck
2. Bronchial
Loud, high pitched sound
Expiratory sounds > Inspiratory sounds
Heard over manubrium of sternum
If heard in any other location suggestive of consolidation
3. Bronchovesicular
Intermediate intensity, intermediate pitch
Inspiratory = Expiratory sound duration
Heard best 1st and 2nd ICS anteriorly, and between scapula posteriorly
If heard in any other location suggestive of consolidation
4. Vesicular
Soft, low pitched sound
Inspiratory > Expiratory sounds
Major normal breath sound, heard over most of lungs
Adventitious Breath Sounds
An abnormal condition that affects the bronchial tree and alveoli may
produce adventitious (abnormal= additional) sounds. Adventitious sounds
are divided into two categories: discrete, noncontinuous sounds (crackles)
and continuous musical sounds (wheezes) as the next:
1. Crackles (Rales)
Discontinuous, intermittent, nonmusical, brief sounds.
Heard more commonly with inspiration
Classified as fine or coarse
Crackles caused by air moving through secretions and collapsed alveoli and
associated with the following conditions: pulmonary edema, early CHF, and
pneumonia
2. Wheeze
Continuous, high pitched, musical sound, longer than crackles
Whistle quality, heard during expiration, however, can be heard on
inspiration
Produced when air flows through narrowed airways
Associated conditions: asthma, chronic bronchitis, and COPD
3. Rhonchi
Similar to wheezes (subtype of wheeze)
Low pitched, snoring quality, continuous, musical sounds
Implies obstruction of larger airways by secretions
Associated condition: acute bronchitis
4. Stridor
Inspiratory musical wheeze
Loudest over trachea
Suggests obstructed trachea or larynx
Medical emergency requiring immediate attention
Associated condition
inhaled foreign body
5. Pleural Friction Rub
Pleural friction rubs are specific examples of crackles. Discontinuous or
continuous brushing sounds
It is a loud dry, cracking or grating sound indicating of pleural irritation,
heard over lateral and anterior lung in sitting position that heard during both
inspiratory and expiratory phases
Occurs when pleural surfaces are inflamed and rub against each other
Associated conditions as pleural effusion, Pneumonothorax

Auscultate voice sounds.

Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you
auscultate the chest wall.

Egophony: Ask the client to repeat the letter “E” while you listen over the
chest wall.

Whispered pectoriloquy: Ask the client to whisper the phrase “one–two–

three” while you auscultate the chest wall.