Cardiovascular System

Scenario: ER nurse receiving a patient

Before enetering pt rm:
- Check Doctor’s order on chart/patient’s medical record
- Do Handwashing
- Prepare Equipment
During:
- Introduce Yourself
- Verify pt, Name identifiers
- Explain the procedure
- tilt pt head to left

XIII. Cardiovascular System.

1. Inspect the carotid artery and jugular venous system.
- 4 carotid artery(internal and external),2 jugular vein
- carotid artery located between sternocleidomastoid muscle and trachea
- N- carotid artery and jugular vein are parallel to sternocleidomastoid muscle
- AN- Bounding visible pulsation
- AN- visible venous waveforms

2. Measure jugular venous pressure. Position patient with the head of bed at 30 to 45 degree angle. Place a
ruler vertically, perpendicular to the chest at the angle of Louis (sternal angle). Identify the highest level
of the jugular vein pulsation; if unable to see pulsations, use the highest level of jugular vein
distension. Place another ruler horizontally at the point of the highest level of the venous pulsation.
Measure the distance up from the chest wall.
- angle of Louis (sternal angle)- between sa nipple
- N- JVP 2-3 cm/ 6-8cmwater(machine)
- AN- if unable to see pulsations, use the highest level of jugular vein distension(usually seen in pt
with problems)
- JVP- right-side CHF
- JVP- hypovolemia
- but according kay maam ang abnormal lang daw na findings if above 3cm
3. Inspect the precordium. Look for pulsations on the precordium, paying particular attention to the apex
area.
- N- normally there is pulsation in apex(mitral) in thin adult/child
4. Palpate the neck.
A. Carotid. Lightly palpate each carotid separately. Note rate, rhythm, amplitude, contour, symmetry,
elasticity and thrills.
- N- palpable
- NOTE: rate, rhythm, amplitude contour, symmetry, elasticity, and thrills(bruits upon auscultation)
B. Jugulars. Palpate jugular veins and check direction of fill.
 - easily obliterated, affected by respiration, position and can only be seen if in supine or semi fowlers
position
- pababa ang flow
5. Palpate the precordium. Identify and palpate each cardiac site for pulsations, thrusts, heaves and thrills.
- Sites:
- Aortic(2nd ICS,right), Pulmonic(2nd ICS,left),, Erb’s Point(3rd ICS,left),, tricuspid(4th ICS,left),,,
Mitral(apex) (5th ICS,leftmiddle)
6. Percuss the precordium. Use direct or mediate percussion to determine cardiac borders.
- Sites:
- Aortic(2nd ICS,right), Pulmonic(2nd ICS,left),, Erb’s Point(3rd ICS,left),, tricuspid(4th ICS,left),,,
Mitral(apex) (5th ICS,leftmiddle)
- resonance-intercostal space
- NOTE: difference between direct and mediate percussion
7. Auscultate the vascular structures of the neck. Have client hold breath. Auscultate the carotid with the
bell portion of the stethoscope for bruits. Auscultate the jugulars with the bell portion of the stethoscope
for venous hums.
- Hold breath so no breath sounds
- use bell in carotid and jugular
- AN- carotid- bruits, jugular-venous hums
8. Auscultate the precordium. Note rate, rhythm, extra sounds or murmurs. Auscultate at each site (apex,
LLSB, Erb’s point base left and base right). Note s1, s2, extra sounds or murmurs. Listen at each site
with both the bell and the diaphragm.
- Note rate, rhythm, extra sounds or murmurs. S1,S2,S3,S4
- use both bell and diaphragm