ASSESSMENT PROCEDURE: ASSESSING THE HEART AND NECK VESSELS

Purpose:
1. To identify any sign of heart disease and initiate early referral and treatment
2. To gather data and information that will aid the healthcare team in diagnosing and treatment
Equipment needed:
1. Stetoscope
2. Small pillow
3. Penlight
4. Watch with second hand
5. Tape measure

ASSESSMENT NORMAL FINDINGS

PROCEDURE
Neck Vessels
INSPECTION
1. Observe the jugular Not normally visible with client sitting upright
venous pulse by standing on
the right side of the client
Inspect the suprasternal
notch
2. Evaluate jugular venous The jugular vein should not be distended bulging or protruding at
pressure by watching for 45 degrees or greater
distention of the jugular vein

AUSCULTATION AND
PALPATION
3. Auscultate Carotid Arteries No blowing or swishing or other sounds are heard
if the client is middle-aged or
older or if suspected
cardiovascular disease
4. Palpate the carotid Pulses are strong equally; Contour is normally smooth and rapid on
arteries. Palpate each carotid the upstroke and slower and less abrupt on the down st roke
alternately Arteries are elsatic and no thrills are noted.
HEART (PRECORDIUM),
ANTERIOR CHEST
INSPECTION
5. Inspect any pulsation It may or may not be visible. If apparent, it would be in mitral area
PALPATION
6. Palpate the apical pulse Apical pulse is palpated in the mitral area and may be the size of
nickel
7. Palpate for abnormal No pulsation are palpated in the areas of the apex, left sternal
 pulsations
AUSCULTATION
8. Auscultate Heart rate and
Rhythm
9. Auscultate the pulse rate
deficit
10. Auscultate to identify S1
and S2
11. Auscultate for extra heart
sounds
12. Auscultate for murmurs
13. Auscultate with the
patient assuming other
position
border or base
Rate should be 60-100 bpm with regular rhythm (no skip beats)
Radial and apical pulse should be identical
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 heart
Normally no sounds are heard
Normally no murmurs are heard
S1 and S2 heart sounds are normally presents.

ASSESSMENT OF PERIPHERAL VASCULAR SYSTEM

Purpose:
1. To identify early signs of peripheral vascular abnormalities
2. To aide healthcare team in diagnosing treatment
Equipments:
1. Tape measure
2. Stethoscope
3. Examination gown and drape
Possible Questions:
1. If magkuha og temp sa arms, aha mag sugod?
- Palpate the client’s fingers, hands and arms, capillary refill time, radial pulse, ulnar pulse and
brachial pulses.
2. Location of epitrochlear lymph nodes (I locate nimo)
3. Locate all types of Pulse sites
ASSESSMENT PROCEDURE NORMAL FINDING
ARMS
INSPECTION
1. Observe arm size and venous pattern; also look for Arms are bilaterally symmetric with
edema variation in size and shape
No edema or prominent venous
patterning.
2. Observe coloration of the hands and arms Color varies depending on the client skin
tone
PALPATION
3. Palpate the client’s fingers, hands and arms, note the Skin is warm to touch from fingertips to
temp. upper arms
4. Palpate to assess capillary refill time Cardiac resynchronisation therapy
5. Palpate the radial pulse Radial pulse is bilaterally strong
6. Palpate the ulnar pulses May not detectable
7. Palpate the brachial pulses if you suspect arterial Have equal strength bilateral
insufficiency
8. Palpate the epitrochlear lymph nodes The epitrochlear lymph nodes are not
palpable
9. Perform the Allen Test Pink coloration returns to the palms in 3-5
secs
LEGS
INSPECTION, PALPATION AND AUSCULTATION
10. Observe skin color while inspecting both legs from the Pink color for lighter-skinned clients.
toes to the groin Pink or red tones visible for darker
pigmented skin. There should be no
changed in pigmentation
11. inspect distribution of hair on legs Hair covers the skin on the legs
12. Inspect for lesions or ulcers Legs are free of lesions / ulcerations
13. inspect and palpate for edema Identical size and shape bilaterally.

14. palpate bilaterally for temp. of the feet and legs
15. Palpate the superficial inguinal lymph nodes
16. palpate and auscultate the femoral pulses
17. palpate the other leg pulses, popliteal pulses, Dorsalis
pedis pulse and posterior tibal pulses
18. Inspect for varicosities and thrombophlebitis
No edema
Toes and legs are equally warm bilaterally
Nontender, movable lymph nodes up to 1
or even 2 cm are commonly palpated
Femoral pulses are strong and equal
bilaterally. No sounds auscultated over the
femoral arteries
Not usual for the popliteal pulse to be
impossible to detect. And yet for
circulation to be normal
Dorsalis Pedis pulses are bilaterally strong
The posterior tibial pulses should be
strong bilaterally
Veins are flat and barely seen under the
sruface
Varicosities are common in older clients.