St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING

ASSESSING HEART AND NECK VESSELS

A. LEARNING OBJECTIVES:
The students will be able to:
• Evaluate the client’s current physical condition
• Detect early sign of developing health problem
• Establish a baseline for future comparisons
• Evaluate the client’s responses to medical and nursing interventions

B. EQUIPMENT NEEDED:
• Stethoscope with a bell and diaphragm
• Small pillow
• Penlight or movable examination light
• Watch with second hand
• Centimeter rulers (two)

EVIDENCE TO BE PRODUCED RATIONALE

1. Introduce self to patient Enhances cooperation.
2. Explain what you are going to do, why
it is necessary, and how he/ she can
cooperate.
3. Identify client using 2 patient Recognizes correct patient.
identifiers.
4. Perform hand hygiene or apply alcohol
based handrub.
5. Provide client’s privacy. Provides comfort and safety.
6. Assembles equipment.
7. Inquires if the client has any of the
following:
• Family history of incidence and
age of heart disease, high
cholesterol levels, highblood
pressure, stroke, obesity,
congenital heart disease, arterial
disease hypertension, rheumatic
fever.
• Client’s past history of rheumatic
fever, heart murmur, heart attack,
varicosities, or heart failure.
• Present symptoms indicative of
heart disease (fatigue, dyspnea,
orthopnea, edema, cough, chest
pain, palpitations, syncope, HPN,
wheezing, hemoptysis).
• Presence of diseases that affect
the heart (obesity, DM, lung or
endocrine diseases).
• Lifestyle habits that are risk factors
for cardiac disease (smoking,
alcohol intake, eating and exercise
patterns, areas and degree of stress
perceived)
8. Simultaneously inspects and palpates
the precordium for the presence of
abnormal pulsations, lifts, or heaves.
Locates the valve areas of the heart.
• Locate the angle of Louis. It is felt
as a prominence on the sternum.
• Move your fingertips down each
side of the angle until you can feel
the 2nd ICS. The R 2nd ICS is the
aortic area, and the L 2nd ICS is
the pulmonic area.
• From the pulmonic area, move
your fingertips down 3rd ICS
along the side of the sternum. The
L 5th ICS close to the sternum is
the tricuspid or R ventricular area.
• From the tricuspid, move your
fingertips laterally 5 to 7cm (2 to 3
in.) to the LMCL. This is the apical
or mitral area or PMI.
9. Inspect and palpates the aortic and
pulmonic areas, observing them at an
angle and to the side, to note the presence
or absence of pulsations.
10. Inspect and palpates tricuspid area for
pulsation and heaves or lifts.
11. Inspect and palpates the apical area for
pulsation, noting its specific location (it
may be displaced laterally or lower) and
diameter. If displaced laterally, record the
distance between the apex and MCL in
diameter.
12. Inspects and palpates the epigastric
area at base of the sternum for abdominal
aortic pulsations.
13. Auscultates the heart in all four
anatomic sites: aortic, pulmonic,
tricuspid, apical (mitral).
• Make sure room is quiet.
• Position: Supine with head
elevated 30-45 degrees
• Use diaphragm and bell to listen to
all areas.
• When auscultating, concentrate on
one particular sound at a time in
each area: the 1st heart sound, then
systole, then the 2nd heart sound,
then diastole.
• Later, re-examine the heart while
the client’s is in upright sitting
position.
Carotid Artery
14 Auscultate the carotid artery.
• Turn his head slightly toward the
side being examined.
• Auscultate the carotid artery on
one side and then the other.
Listen for a bruit. If heard, gently palpate
for a thrill.
15. Palpates the carotid artery. Use
extreme cautions.
• Palpate only one carotid artery at
a time.
• Avoid too much pressure and
 massaging the area.
Ask client to turn his head slightly toward
the side being examined.
Jugular Veins
16. Inspect for jugular vein distention.
Position: semi-fowler’s with the head
supported on a small pillow.
17. If jugular vein is present, assess the
jugular vein (JVP).
• Locate the highest visible point of
distention on the internal jugular
vein.
• Measure the vertical height of this
point in centimeters from the
sternal angle, the pint at which the
clavicles meet.
• Repeat the steps above on the
other side.
18. Documents findings in the client.