PURPOSE

To identify significant factors that can influence cardiovascular health such as

high blood cholesterol, cigarette use, diabetes, or hypertension.

ASSESSMENT
1 Inquire if the client has any of the following:

2 Family history of incidence and age of heart disease, high cholesterol

levels, high blood pressure, stroke, obesity, congenital heart disease, arterial
disease, hypertension, and rheumatic fever;

3 Client’s past history of rheumatic fever, heart murmur, heart attack,

varicosities, or heart failure;

4 Present symptoms indicative of heart disease (e.g., fatigue, dyspnea,

orthopnea, edema, cough, chest pain, palpitations, syncope, hypertension, wheezing,
hemoptysis);

5 Presence of diseases that affect heart (e.g., obesity, diabetes, lung

disease, endocrine disorders);

6 Lifestyle habits that are risk factors for cardiac disease (e.g., smoking,
alcohol intake, eating and exercise patterns, areas and degree of stress
perceived).

Equipment
• Stethoscope

• Centimeter ruler

1 Prior to performing the procedure, introduce self and verify the client’s
identity using 2 identifiers.

Identification of the patient ensures that the assessment will be performed on the
right patient
2 Explain to the client what you are going to do, why it is necessary, and how
he or she can cooperate.

Explanation helps to alleviate anxiety, promotes cooperation, and facilitates

the examination.

3 Discuss how the results will be used in planning further care or treatments

4 Perform hand hygiene and observe other appropriate infection prevention

procedures

Hand hygiene deters the risk of microorganism transmission.

5 Provide for client privacy
Position the client into semi reclined position or semi fowlers position

Simultaneously inspect and palpate the precordium for the presence of

abnormal pulsations, lifts, or heaves. Locate the valve areas of the heart:
• Locate the angle of Louis. It is felt as a prominence on the sternum.
• Using the palmar surface of your fingers held together, palpate the
precordium gently for pulsations. Remember the hands should be warm. Palpation
proceeds in a systematic manner, with assessment of specific cardiac landmarks —
the aortic right second intercostal space, and the left second intercostal space is
the pulmonic, the left fourth intercostal space close to the sternum tricuspid, and
Erb’s point should be in the 3rd intercostal space and lastly the mitral area
should be in the left midclavicular line 5th intercostal space this is the apical
or mitral area, or point of maximal impulse (PMI).

This helps identify any precordial thrills, which are fine, palpable, rushing
vibrations over the right or left second intercostal space, and any lifts or
heaves, which involve a rise along the border of the sternum with each heartbeat.
Normal findings include no pulsation palpable over the aortic and pulmonic areas,
with a palpable apical impulse.

Use systematic auscultation, beginning at the aortic area, moving to the pulmonic
area, then to Erb’s point, then to the tricuspid area, and finally to the mitral
area. Ask the patient to breathe normally. The stethoscope diaphragm is first used
to listen to high-pitched sounds. Focus on the over-all rate and rhythm of the
heart and the normal heart sounds.
• If you have difficulty locating the PMI, have the client roll onto the left
side to move the apex closer to the chest wall
• Then check for S3 and S4 using the bell of the stethoscope

Auscultation evaluates heart rate and rhythm and assesses for normal sounds. The
normal heart sounds are generated by the closing of the valves (aortic, pulmonic,
tricuspid, mitral).

Replace the patient’s gown and assist the patient to a comfortable position.

This ensures the patient’s comfort

Perform hand hygiene.

This deters the spread of microorganisms.
Document findings and the procedure done.
Documentation prevents clinical errors during the practice.

Assessing the Neck

1 Auscultate the carotid artery
Always auscultate the carotid arteries before palpating because palpation may
increase or slow the heart rate, changing the strength of the carotid impulse
heard.
Turn the client’s head slightly away from the side being examined
This facilitates placement of the stethoscope
Place the bell of the stethoscope and auscultate the carotid artery on one
side and then the other. 3 parts to listen on both sides:
• Angle of the jaw
• Mid cervical
• Base of the neck

Listen for the presence of a bruit. If you hear a bruit, gently palpate the artery
to determine the presence of a thrill.

Palpate the carotid artery, using extreme caution.

Avoid exerting too much pressure or massaging the area.

This ensures adequate blood flow through the other artery to the brain.

Pressure can occlude the artery, and carotid sinus massage can precipitate
bradycardia. The carotid sinus is a small dilation at the beginning of the internal
carotid artery just above the bifurcation of the common carotid artery, in the
upper third of the neck.
 JUGULAR VEINS
1 Inspect the jugular veins for distention while the client is placed in the
semi Fowler’s position (30° to 45° angle), with the head supported on a small
pillow.

2 If jugular distention is present, assess the jugular venous pressure (JVP).

Jugular distension may be caused by heart conditions that affect blood

vessels including congestive heart failure it is the deterioration of the heart's
ability to pump blood and Constrictive pericarditis or infection of the lining that
surrounds the heart that decreases the lining's flexibility
Locate the highest visible point of distention of the internal jugular vein.
Although either the internal or the external jugular vein can be used, the internal
jugular vein is more reliable.

The external jugular vein is more easily affected by obstruction or kinking

at the base of the neck
Measure the vertical height of this point in centimeters from the sternal
angle, the point at which the clavicles meet.
❸ Repeat the preceding steps on the other side
3 Document findings in the client record using printed or electronic forms or
checklists supplemented by narrative notes when appropriate.