1 | HEALTH ASSESSMENT

ASSESSMENT OF THE THORAX AND LUNGS

● The term thorax identifies the portion of Location of the anterior ribs, angle of Louis, &
the body extending from the base of the the sternum
neck superiorly to the level of the
diaphragm inferiorly.
● Thoracic Cavity: consists of
mediastinum & lungs.

LUNGS

● Apex - extends slightly above the clavicle

● Base - level of the diaphragm.

⚫ Suprasternal notch – hollow U-shaped

depression just above the sternum

⚫ Sternum – breast bone, 3 parts

(manubrium, the body and the xiphoid
process

⚫ Manubriosternal angle – sternal angle,

nd
STRUCTURE OF THE THORAX angle of Louis (continuous with the 2 rib)

⚫ Costal angle – form an angle where they

meet the xiphoid process

Chest Landmarks and Underlying Lungs

Anterior:

Position and Surface Landmarks

⚫ Thoracic cage – bony structure, cone

shaped (narrower at the top)

⚫ Sternum – 12 pairs of ribs, 12 thoracic Posterior:

vertebrae

⚫ Diaphragm – floor of the thoracic cavity

⚫ Costocondral junctions – points at which
ribs joins their cartilages
 2 | HEALTH ASSESSMENT

⚫ Percussion – tones, diaphragmatic

excursion

⚫ Auscultation – quality of breath sounds,

voice transmission
Lateral Chest Landmarks and Underlying
Lungs

Health History:
A. Present health status

1. Allergies
2. Tobacco use
3. Medications
4. Use of aerosols or inhalants
5. Recent Screening test
6. Nutritional data
Chest Wall Landmarks B. Present Illness

1. Cough – type, onset, duration,

pattern, severity
2. Sputum production – amount,
color, odor, consistency, pattern of
production
3. Shortness of breath
4. Chest pain

C. Past health history

D. Family history – TB, cardiac problem,

allergies etc.
GENERAL PRINCIPLES OF PHYSICAL
EXAMINATION OF THE LUNGS & THORAX E. Other considerations – occupation

✔ Undress the pt to the waist, good lighting ✔ Nature of work

✔ Orderly fashion: ✔ Place of work
o Physical exam techniques ✔ Exposure to:
o Comparison of one side to another ✔ Current and past residence
o Work from above down ✔ Travel to places
✔ PE technique ✔ Hobbies
✔ Equipment
✔ Environment Inspection
✔ Positioning
✔ Explain procedure and privacy ● Count the respiratory rate and its pattern
✔ Clothing ● Assess skin for color changes, texture,
lesions
Focus of Assessment & Documentation of
Measure and assess the pattern of
Lungs and thorax

⚫ Inspection
respirations.
– position of the trachea,
✔ Rate and rhythm
thoracic configuration and symmetry,
o Normal rate: 16 – 20
ventilatory pattern, muscle movements,
breath/minute
masses or lesions

⚫ Palpation
o Increased: fever, pain and
– symmetry of ventilatory anxiety
movements, tactile fremitus, tenderness ✔ Skin color
and masses, crepitus
RESPIRATORY PATTERNS

Rate and Rhythm of breathing:
● Eupnea - Normal breathing pattern
● Dyspnea - difficulty of breathing (DOB)
● Tachypnea - fast respiration
● Bradypnea - slow respiration
● Orthopnea - inability to breathe easily
unless one is sitting up straight or standing
erect.
● Paroxysmal Nocturnal Dyspnea - is a
sensation of shortness of breath that
awakens the patient, often after 1 or 2
hours of sleep.
● Hyperventilation - Increased rate and
depth. Occur extreme exercise, fear and
anxiety
● Hypoventilation - Decreased rate and
depth; irregular pattern. Associated with
overdose of narcotics or anesthetics.
● Cheyne-Stokes - Regular pattern by
alternating preiods of deep, rapid breathing
followed by periods of apnea. Result from
severe CHF, drug overdose, renal failure
● Biot’s respirations - Irregular pattern
varying depth and rate of respirations
followed by periods of apnea.
INSPECTION OF ANTERIOR, POSTERIOR, &
LATERAL THORAX
Posterior thorax:
1. Inspect for the skin coloration.
● Normal Findings: Pink
● Deviations from Normal: Pallor,
Cyanosis
2. Inspect intercostal spaces
● Normal Findings: Even and
Relaxed
● Deviations from Normal: Bulging,
Retracting
3 | HEALTH ASSESSMENT
3. Inspect for symmetry and configuration
of the thorax
● Normal Findings: Equal
● Deviations from Normal: Unequal
4. Inspect Shape and position of sternum
● Normal Findings: Level with ribs
● Deviations from Normal:
Depressed or projecting
5. Inspect Position of Trachea
● Normal Findings: Midline
● Deviations from Normal: Deviated
to one side
6. Inspect the rib slope
● Normal Findings: <90 degrees
downward
● Deviations from Normal: horizontal
or >90 degrees
7. Inspect for chest expansion
● Normal findings: 3 in deep
inspiration
● Deviations from Normal: <3 inches
o Decreased chest excursion is
commonly found in patients with
COPD.
8. Inspect Anterior-Posterior to Lateral
Diameter
● Normal Findings: 1:2 ratio (AP) 5:7
(Lateral)
● Deviations from Normal: >1:2 ratio
or <1:2 ratio
9. Inspect Use of accessory muscles -
abdominal retraction of the interspaces
during inspiration and expiration
● Localized bulge: mass, tension
pneumothorax
● Localized retraction: collapse or
fibrosis
10. Inspect client’s positioning
● If in tripod position, may suggest
DOB
11. Inspect for thoracic deformities

Abnormal Findings:
● Barrel-shaped thorax – usually found in
patients with emphysema
● Funnel Chest (Pectus Excavatum)
● Pigeon chest (Pectus carinatum)
12. Inspect the spinal alignment for
deformities
Have the client stand from a lateral position,
observe the three normal curvatures: cervical,
thoracic, and lumbar.
Normal Findings:
● Spine vertically aligned.
● Spinal column is straight, right and left
shoulders and hips are at the same height.
Deviation from Normal:
● Exaggerated spinal curvatures (kyphosis,
lordosis, scoliosis)
Spinal column deviates to one side, often
accentuated when bending over, shoulders or hips
not even.
Palpation of the Posterior Thorax
1. Palpate:
● Temperature
● Skin integrity & surface characteristics
(lesions)
● Tenderness
● Normal Findings: 
o Skin is intact; uniform temperature,
free of lesions.
● Deviation from Normal: 
o Skin lesions; areas of hyperthermia
2. Palpate for tenderness and sensation:
4 | HEALTH ASSESSMENT
● Pain over the intercostal space may be due
to inflamed pleura
● Muscle soreness
● Increased warmth
Palpate all chest areas for bulges, tenderness, or
abnormal movements. Avoid deep palpation for
painful areas, especially if a fractured rib is
suspected.
● Normal Findings: 
o Chest wall intact; no tenderness; no
masses
● Deviation from Normal: 
o Lumps, bulges, depressions; areas of
tenderness; movable structures.
3. Palpate crepitus and Fremitus
● Crepitus – air escapes from the lung into
the subcutaneous tissue.
● Tactile fremitus – most sensitive to
vibration is the ball of the hand
o Vibration perceptible on palpation
and produced phonation.
o Decreased vibration as it moves
along to the periphery of the airways.
o Increased vibration on the major
airways.
4. Assess chest expansion:
● Observe thumb movement for lag.
● Separate 3 to 5 cm
^summary lang tong apat pero mas detailed yung
mga susunod, natanga na ako kaya auq na tanggalin
Sequence in palpation of anterior thorax:
Sequence in palpation of posterior thorax:
PROCEDURE OF PALPATION OF THORAX
WITH ABNORMAL AND NORMAL FINDINGS:

1. Palpate thorax at three levels for Sensation
● Normal Findings: No pain or tenderness
● Deviation from Normal: Pain, tenderness
– pain over thorax; inflamed fibrous
connective tissue
o Pain over intercostal area seen with
inflamed pleura.
2. Vocal fremitus
Crepitus – air escapes from the lung into the
subcutaneous tissue.
Tactile fremitus – most sensitive to vibration is the
ball of the hand
✔ Vibration perceptible on palpation and
produced phonation.
✔ Decreased vibration as it moves along to the
periphery of the airways.
✔ Increased vibration on the major airways.
✔ Heard mostly at the apex of the lungs
(auscultation)
Place the ball or the ulnar aspect of your hand,
starting near the apex of the lungs.
● Ask the client to repeat such words as
“blue moon” or “one, two, three”.
● Compares the fremitus: either
1) using one hand and moving it from one
side to the corresponding area on the
other side
2) using two hands that are place
simultaneously on the corresponding
areas of each side of the chest.
● Normal Findings: Vibration decreased
over periphery of lungs and increased over
major airways.
o Bilateral symmetry of vocal fremitus.
o Fremitus is head most clearly at the
apex of the lungs
o Low-pitched voices of males are
readily palpated than higher pitched
voices of females.
● Deviation from Normal: 
o Vibration increased – lung
consolidation  (pneumonia, tumor)
o Vibration decreased over airway –
obstruction, pleural effusion, or
pneumothorax (obese,
pneumothorax, emphysema)
3. Palpate thorax for thoracic expansion by the
following methods:
Place hands on posterior thorax at level of 10
vertebra. Gently press skin between thumbs and
have client take deep breath.
● Normal Findings:  ●
o 2 to 3 inches symmetrical thoracic
expansion
5 | HEALTH ASSESSMENT
o Full symmetrical expansion (thumbs
move apart equal distance in both
directions)
● Deviation from Normal:
o Less than 2 to 3 inches thoracic
expansion asymmetrical expansion
seen with atelectasis or pneumonia.
o Asymmetrical anterior expansion
(thumb movement apart is unequal)
4. Anteriorly, press skin together at lower
sternum and have patient take deep breath.
Observe thumb movement.
● Normal Findings: Symmetrical expansion
(thumbs move apart equal distance in both
directions)
● Deviation from Normal: Asymmetrical
expansion (thumb movement apart is
unequal)
Percussion
Purposes of percussion:
1. Determine the amount of air, fluid or solid
material in the underlying lung
2. Determine the position and boundaries of
an organs
Characteristic in Percussion:
✔ Amplitude – loud or soft
✔ Pitch – frequency
✔ Duration – amount of time
✔ Quality – characteristic of the object being
percussed
⚫
1. Percuss for tone –
⚫
resonance sound elicited
hyperresonance for emphysema,
⚫
pneumothorax
dullness for presence of fluid and solid
tissue (lobar pneumonia, tumor) –
th
Percussion Sounds: Resonant
● Low-pitched, hollow sound
Condition: Normal lung tissue
 6 | HEALTH ASSESSMENT

Percussion Sounds: Hyper-resonant

● Louder and lower pitched than resonant

● Condition: Increased amount of air in the
lungs and pleural space. (emphysema)

Percussion Sounds: Dull sound

● Thud-like, medium-pitched
● Condition: Normally heard over the liver
and heart, if heard over the chest, it may
indicate tumor or consolidation of lung
tissue.
● Lobar pneumonia, pleural effusion or
tumor.
Descent from thoracic 10:
● 3 to 5 cm bilaterally in women and
● 5 to 6 cm in men.
Diaphragm is usually higher on the right side.
2. Percuss for diaphragmatic excursion
Purpose of Auscultation:
● Airflow through the tracheobronchial tree
● Depth of ventilation and presence of
ventilations in all lobes.
● Presence of fluid, mucus, or other
obstruction
● Condition of the surrounding lung tissue
and pleural space.
Auscultate the chest using the flat-disc
diaphragm of the stethoscope.
1. Use the systematic zigzag procedure used in
percussion
● Normal Findings: Vesicular = I>E

Instruct to take a deep breath and hold it. 2. Ask the client to take slow, deep breaths
● Starts percuss at the apex of the scapula through the mouth.
downward till tone changes and mark the ● Normal Findings:
skin with marking pencil. o Bronchovesicular: I = E
● Then instruct to breathe several times, o Between scapula
exhale completely and hold it. o Below clavicle
● Repeat the percussion from scapulae apex o Main bronchi
and mark the point where tone changes.
3. Compare findings
● Normal Findings: Tracheal or Bronchial =
a. Percuss over shoulder apices and at
posterior, anterior, and lateral intercostal expiration > inspiration
spaces. Deviation from Normal: 
● Normal Findings: 
o Resonance ● Adventitious breath sounds (e.g.,
crackles, rhonchi, wheeze, friction rub)
● Deviation from Normal:
● Absence of breath sounds (associated
o Hyperresonance is heard over
with collapsed and surgically removed lung
emphysematous lungs.
lobes)
b. Percuss for posterior, diaphragmatic
excursions bilaterally.
● Normal Findings: 
o Diaphragm descends 3 – 6 cm from
T10 (w/full expiration held) to T12
(w/full inspiration held)
● Deviation from Normal: 
o Diaphragm descends <3 cm owing to
atelectasis of lower lobes,
emphysema, ascites, or tumors. NORMAL BREATH SOUNDS

Breath Dura Pitch Intensi Location

Auscultation Sounds tion of ty of
of Expira Expira
I&E tion tion
 7 | HEALTH ASSESSMENT

Vesicular I>E Low Soft Peripheral (low-pitc

lung fields hed)
Broncho I=E Mediu Moder Posterior:
vesicular m ate between Auscultate voice sounds:
the
scapulae a. Bronchophony – ask the client to repeat
the phrase “99” while auscultating the
Anterior: chest wall
around the o Normal Findings: Soft, muffled and
upper
distinct
sternum
o Deviation from Normal: Distinct
Bronchia E>I High Loud Trachea
l or and (consolidation from pneumonia,
Tubular Thorax atelectasis or tumor)
(anterior) b. Egophony – repeat the letter “E” while
you listen over the chest wall.
o Normal Findings: Soft, muffled but
distinguishable.
o Deviation from Normal: Sounds is
louder and like “A”
c. Whispered Pectoriloquy – ask the client
to whisper the phrase “1, 2, 3” while you
auscultate the chest wall.
o Normal Findings: Transmission of
sound is very faint and muffled. It
may be inaudible.
o Deviation from normal: Transmit
clearly and distinctly.

Anterior Thorax:

● Muscle used for ventilation – does not

use the accessory muscles to assist
ADVENTITIOUS BREATH SOUNDS breathing
Type Charact Source Associated ● Deviation: when trapezius muscles are
er Conditions used (Chronic airway obstruction or
Crackle Cracklin Originates Pneumonia, atelectasis)
s or g in the Bronchitis, ● The client’s positioning – tripod position
Rales (high-pit alveoli Asthma,
ched Emphysema,
sound) Pulmonary
Trachea or Edema, Long
Bubblin Bronchi term COPD
g
(low-pitc
hed Pleuritis
sound) Pleural
Pleural Spaces
Friction Grating,
dry Acute asthma or
(low-pitc Bronchioles chronic Tripod Position:
Wheeze hed) and small emphysema,
s bronchi Bronchitis, before ● Inability to lie flat.
Musical an episode of ● Leaning forward with arms and elbows
(high-pit sleep apnea supported on over bed table.
Rhonch ched) Large ● Possible etiology: COPD, Asthma in
i bronchi or Stridor: a harsh
exacerbation, Pulmonary edema, Indicated
(Sonoro Snoring trachea honking wheeze
us) or with severe moderate to severe respiratory distress.
moanin broncho-laryngos
g pasms Pedia Variations
 8 | HEALTH ASSESSMENT

Respiratory Rates in Children Diaphragmatic reading - due to anatomic

changes.
Age Respiratory Rate
(breaths/min) ● Hyper-resonance of thorax due to
Newborn  30-60
age-related emphysemic changes.
Early childhood 20-40
● Decreased breath sounds and increased
Late childhood 15-25
Age 15 y/o and 14-20 retention of mucus due to decreased
older pulmonary function.
● Increased in AP diameter (up to 5:7 AP to
Pediatric Variations transverse diameter ratio) due to loss of
resiliency and loss of skeletal muscle
Infant  Anteroposterior (AP) diameter is equal
to transverse diameter (1:1) shape strength.
nearly circular ● Resonance of percussive may increase.
5 to 6 ● AP diameter is equal to
years transverse diameter (1:1) – Same lang naman ng procedure ang adult to geria,
old shape nearly circular. nagkakaron lang ng difference sa expected
● Respirations should be results/what is considered normal.
unlabored and quiet.

ASSESSING THE BREASTS

Percussion:
AND AXILLAE
● Infant and young children – normally
hyper-resonant throughout because of BREAST
thinness of chest wall. Any decrease in
resonance is equal to dullness in the adult.
⚫ Vertically extend from 2nd – 6th rib;
horizontally from sternum to the midaxillary

⚫
line
Auscultation:
Breast divided into four quadrants; the
● Bell or small diaphragm should be used to upper outer quadrant extends into the

⚫
localize findings, especially in infants and axillary area referred as tail of Spence
young children. Breast tissue response to the hormone

⚫
● Breath sounds will be louder and harsher estrogen and progesterone
Lymph nodes drain lymph from the breasts
owing to close proximity to origin of
to filter out microorganisms and return
sounds from thin chest wall.
⚫
water and protein to the blood.
● Wheezes and rhonchi occur more
Smooth skin, nipple located at the center of
frequently in infants and young children. the breast, contains tiny openings of the
lactiferous ducts through which milk

⚫
passes.
Geriatric Variations The areola surrounds the nipple (1 – 2 cm
radius) and contains elevated sebaceous
● Increase in normal respiratory rate (16-25)  glands (Montgomery glands).
● Loss of elasticity, fewer functional
Risk Factors:
capillaries, and loss of lung resiliency 
● Decreased to cough effectively  ● Increasing Age
● Accentuated dorsal curve (kyphosis) ● Personal history
● Sternum and ribs maybe more prominent ● Family history
● Decreased thoracic excursion ● Early Menarche and late menopause
● Increased diaphragmatic breathing ● No natural children
● First child after age 30
Cough – weaker muscles and rigid thoracic wall
● Higher education and socioeconomic
Kyphosis – thoracic spine status
● Regular alcohol intake
Prominent – loss of subcutaneous fat
●  Previous breast irradiation
Thoracic excursion – due to calcification of costal ● Hormone replacement with progesterone
cartilages and loss of the accessory musculature. ● No or poor breast self-examination
 9 | HEALTH ASSESSMENT

● Poor screening

Lateral view of the female breast:

Location of the cervical, axillary, and mammary

lymph nodes

Subjective Data:
Four breast quadrants and the axillary tail of ✔ History of Present Health Concern –
spence: COLDSPA
✔ Past History – previous surgery or biopsy,
trauma, implants; menstrual cycle; OB
history
✔ Family history
✔ Lifestyle and health practices
✔ Cultural beliefs

Objective Data: Physical Exam

✔ Inspect color and texture

✔ Inspect superficial venous pattern
✔ Inspect for the areolae, nipples for color,
size, shape, texture, lesion or discharge
Types of Breast Tissue ✔ Inspect for retraction and dimpling
1. Glandular – contain 15 – 20 lobes that
radiate in a circular fashion from the nipple.
2. Fibrous – provide support for glandular
tissue by way of bands called Cooper’s
ligaments
3. Fatty – provides most of the substance to
the breast (size and shape)

LYMPH NODES

Major Axillary Lymph Nodes

✔ Anterior (pectoral)
✔ Posterior (subscapular)
✔ Lateral (brachial) Note: the client will be asked to perform this
✔ Central (midaxillary) position in order to assess the appearance of the
breast.

Inspection

Inspect the Breasts

1. Size and Symmetry 

● Normal Findings: Relatively equal with
slight variations
● Deviation from Normal: 
● Recent change to unequal size
● Recent increase in size of one
breast may indicate inflammation or
abnormal growth.
 10 | HEALTH ASSESSMENT

2. Procedure: Shape 
● Normal Findings: Round and Pendulous 
● Deviation from Normal: Retraction or
dimpling may be due to fibrosis or
malignant tumor.

c. Other abnormal breast findings:

Retracted signs, skin dimpling, nipple retraction &

deviation, edema of skin (Peau d’orange sign),
Abnormal contours

A. B.

Note: picture A shows that the breast is

asymmetric comparing on the other breast while
picture B shows the normal appearance (slightly
deviated)

Inspect the Areola and Nipples

1. Size
● Normal Findings: Relatively the same,
slight variations 
● Deviation from Normal: Large variations Palpation
2. Color Palpate the breast for the following:
● Normal Findings: Pink to dark brown ● Erythema - indicates inflammation if
(varies with skin and hair color)  client is not lactating or has not just
● Deviation from Normal: Inflamed given birth
● Nontender - slightly tender
3. Shape  (tenderness and fullness may occur
● Normal Findings: Round, oval, everted  before menses)
● Deviation from Normal:  ● Masses - note size, shape, mobility,
o Inversion, if it occurs after maturation consistency, and location according
or changes with movement. to quadrant
o Recent retraction or previously 1. Temperature
everted, suggests malignancy
● Normal Findings: Warm  
ABNORMAL BREAST FINDINGS ● Deviation from Normal: Erythema
a. Dimpling Nipple:
2. Elasticity
● Normal Findings: Elastic 
● Deviation from Normal: Lumpy

3. Tenderness
● Normal Findings: Non-tender, slightly
tender 
● Deviation from Normal: Painful

b. Discoloration of nipple: Take note:

● Use flat pads of three fingers to compress
tissue against breast wall gently
● Palpate with patient sitting
 11 | HEALTH ASSESSMENT

● Have patient lie down and place arm of ● Redness and inflammation may indicate
side being examined over head with pillow infection of sweat gland; dark, velvety
under upper back pigmentation (acanthosis nigricans);
● Palpate in circular motion at the 12 O’clock malignancy
position moving in concentric rings inward
to areola
● Bimanual palpation = large breasted clients

4. Masses
NURSING DIAGNOSIS: Ineffective therapeutic
Location, size, shape, consistency, mobility,
tenderness, erythema, dimpling, depth of mass regimen management related to knowledge deficit
of breast self-examination.
Normal Findings: Bilateral firm inframammary
transverse ridge at base of breast. American Society (2005):

Deviation from Normal: ● Monthly BSE for women age 20 y/o or

● Masses or nodules
● Malignant tumors are most often found in
upper outer quadrant, usually unilateral
with irregular, poorly delineated borders.
● Hard, Non-tender, Fixed to underlying
tissues, fibroadenomas.
● Benign: 1-5 cm, round or oval, mobile,
firm, solid, elastic, nontender, single or
multiple in one or both breasts.
● Fibrocystic Disease (benign) consists of
bilateral, multiple, firm, regular firm,
rubbery, mobile nodules with wee
demarcated borders.
5. Nipple Discharge
older.
● Breast clinical examination for women age
20 to 39 y/o every 3 years and every year
for women ages 40 and older.
● Annual mammography for women ages 40
years and older.
Reinforce the following recommendations:
● Annual mammography for women age 40
years and older as long as a woman is in
good health.
● Women at risk should talk to their physician
about more frequent exams.
● Advise that cancer of the breast can be
treated and often cured if detected early.
● Encourage breast-feeding, exercise, and
maintaining a healthy body weight.

● Normal Findings: None, Clear yellow (2

days after childbirth) CARDIOVASCULAR
● Deviation from Normal: Unilateral serous,
ASSESSMENT
serosanguineous, clear, yellow, dark red.
Note: 
● Discharge may be seen in endocrine
disorders and with some medications, such
as antihypertensives, antidepressants,
and estrogen.
● Discharge from one breast may indicate
benign intraductal papilloma, fibrocystic
disease, or breast cancer.
6. Lymph nodes
In the ff areas: supraclavicular, subclavian,
intermediate, brachial, scapular, mammary, internal
mammary

● Normal Findings: Non-palpable

● Deviation from Normal: Palpable Lymph
Nodes (>1cm)
7. Inspect and palpate Axilla

Thorax
● Located in the neck and drain blood from
the head, brain, face, and neck and convey
it toward the heart.
● Observe jugular venous pressure:
o Observe the person from the right
side
o Positioning: HOB 30-45 degrees
head slightly to the left.
o Provide tangential lighting to neck
area measure the distance (in cm)
from the sternal angle to the top of
distended jugular vein.
o Pulsations visible at >3cm is
abnormal
NECK VESSELS
● Observes the jugular venous pulse.
● Evaluates jugular venous pressure.
THE CARDIAC CYCLE:
Two phases: (“lub-dub” on auscultation: normal
sounds)
✔ Ventricular systole (S1: “lub”) – closing
of mitral valve
✔ Ventricular diastole (S2: “dub”) – closing
of tricuspid valve
Abnormal heart sounds – murmurs
Subjective Data:
Present Health History:
✔ Medication, Family history
12 | HEALTH ASSESSMENT
✔ Nutrition, Lifestyle
✔ Elimination
Present Illness:
✔ Chest pain, Palpitations
✔ Fatigue, Dyspnea
✔ Nocturia
✔ Dizziness
✔ Edema
✔ Heart burn
Past history – history of any cardiac diseases,
ever been treatment for heart problems or had
surgery, last ECG stress test, serum cholesterol,
echo
Personal habits – smoking, alcohol use, exercise,
diet, drugs (rx, otc, herbal, street)
Inspection
1. Inspect the jugular veins for distention;
The client is placed in a semi-fowler’s position, with
head supported on a small pillow.
● Normal Findings: 
o Veins not visible (indicating right
side of heart is functioning
normally)
● Deviation from Normal: 
o Veins visibly distended
2. Inspect the precordium
⚫ Normal findings: location of apical
pulse or PMI (5th ICS, MCL)
⚫ Deviation from normal: displaced PMI
Palpation
1. Palpate major precordial landmarks
Note any pulsations, thrills, or rubs: describe
location, amplitude, duration, and direction of
impulse
● APETM (usually ball of your hand)
● Perform palpation in 3 different positions:
supine forward sitting or left lateral
decubitus
● Normal findings: pulsatile movements
(PMI)
● Deviations from normal: vibrations or
palpable thrills
2. Palpate the carotid artery (use extreme
caution)

● Normal Findings:
o Symmetric pulse volumes
o Full pulsations, thrusting quality
o Elastic arterial wall
● Deviation from Normal:
o Asymmetric volumes
o Decreased pulsations
o Increased pulsations
o Thickening, hard, rigid, beaded,
inelastic walls.
Heart (Precordium): Simultaneously inspect and
palpate the precordium.
3. Inspect and palpate the aortic and pulmonic
areas.
Observing them at an angle and to the side, to
note the presence or absence of pulsations.
● Normal Findings:
o No pulsations
o No pulsations
o No lifts to heaves
● Deviation from Normal:
o Pulsations
o Pulsations diffuse lifts or heaves
Aortic
Pulmonic
4. Palpate 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 the MCL in cm.
● Inspect and palpate the epigastric area at
the base of the sternum for abdominal
pulsations
● Normal Findings:
o Pulsations visible in 50% of adults
and palpable in most PMI in the 5
LICS or to MCL.
o Aortic pulsations
● Deviation from Normal:
o PMI displaced laterally or lower
diameter over 2 cm.
o Bounding abdominal pulsations.
13 | HEALTH ASSESSMENT
5. Inspect and palpate the tricuspid area for
pulsations and heaves or lifts.
● Normal Findings:
o No pulsations
o No pulsations
o No lifts to heaves
● Deviation from Normal:
o Pulsations
o Pulsations
o Diffuse lifts or heaves
Apical and Tricuspid Area:
ABNORMAL FINDINGS: PALPATION
✔ Thrills – vibration felt in the precordium;
feel like the throat of a purring cat.
✔ Heaves or lift – forceful cardiac
contraction causes a vigorous movement
of sternum and ribs
Auscultation
1. Auscultate the heart in all four anatomic
sites; aortic, pulmonic, tricuspid, and apical
(mitral).
2. Identifies S1 & S2
3. Auscultates for extra heart sounds
✔ Heart rate and rhythm – 60 to 100 bpm,
regular
✔ Cardiac cycle
✔ Heart sounds and murmurs
CARDIAC LANDMARKS
✔ Aortic: 2nd ICS right sternal border
✔ Pulmonic: 2nd ICS left sternal border
✔ Erb: 3rd ICS left sternal borer
✔ Tricuspid: 5th ICS left lower sternal border
✔ Mitral: 5th ICS left MCL
th
 14 | HEALTH ASSESSMENT

✔ Stenosis occurs when valve is

open and blood flow is forced thru
a stiff noncompliant valve causing
murmur sound
✔ Turbulent blood flow-related to
excess blood volume
● Pericardial Friction Rub
o Extra heart sound originating from
pericardial sac. May be sign of
inflammation and infection
o Described as short, high pitched &
scratchy sound
HEART SOUNDS

Normal findings: JUGULAR VEIN

⚫ S – loudest at the apex (mitral area) – left

1
Located in the neck and drain blood from the head,
brain, face and neck and convey it toward the
⚫ S loudest at the base (pulmonic area)
th
5 ICS-MCL
heart.
⚫ Note intensity and splitting (physiologic
2

✔ Observe jugular venous pressure

⚫
split) o observe the person from the right

⚫ S3: in children & young adults

S4: in many older adults
side
o positioning: HOB 30 – 45 degrees
Abnormal findings: head slightly to the left

⚫ o provide tangential lighting to neck

⚫
Splitting (S1 & S2) area measure the distance (in cm)

⚫
3rd heart sound from the sternal angle to the top

⚫
4th heart sound of distended jugular vein
o pulsations visible at >3cm is
⚫
Opening snap
abnormal
⚫
Ejection clicks

⚫
Mid-systolic click Arteries and veins of the right side of the neck

⚫
Pericardial friction rubs

⚫
Bruit – epigastric area
Murmur

ABNORMAL HEART SOUNDS

● S3 “ventricular gallop” - Auscultated in

children, young adults, people w/ high
cardiac output & in women in 3rd trimester
of pregnancy.
● S4 “atrial gallop” - Auscultated in athletes Assessing the Highest Point of Distention of
& some older clients especially after the Jugular Vein
exercise
● Murmur - are extra heart sounds that are
produced as a result of turbulent blood
flow which is sufficient to produce audible
noise; many murmurs are simply normal
extra sounds.
Causes of murmur:
✔ Regurgitation occurs when valve
should be closed but doesn’t,
resulting in backflow of blood
causing murmur sound
 15 | HEALTH ASSESSMENT

✔ Allen Test: To determine the patency of

radial and ulnar arteries

Assess for Presence of Edema

VASCULAR SYSTEM
✔ Inspect carotid artery for bulging or kinking
– HTN
✔ Inspect for symmetry of extremities, any
engorgement (varicose vein); discoloration
✔ Palpate:
o Temperature, tenderness
o Assess for bilateral equity and
symmetry peripheral pulse. Compare
the carotid pulse and heart rate
(synchronous pulse). Abnormal
(pulse deficit)
Note: press firmly for 5 to 10 seconds over bony
surface, such as tibia, fibula, sacrum or sternum.
Grading:
✔ 0 – No edema
✔ +1 – Slight pitting, normal contour
✔ +2 – Deeper, contours still present
✔ +3 – Deep pitting, puffy appearance
✔ +4 – Deep persistent pitting, frankly
swollen

PULSE SITES

Arterial Pulse

✔ Homan’s sign – determine DVT

✔ Ankle-brachial index – to assess valve
competency
✔ Axillary pulse
✔ Brachial pulse
✔ Brachial pulse in the cubital fossa
✔ Ulnar pulse in distal forearm
✔ Radial pulse in distal forearm
✔ Radial pulse in the anatomical snuffbox
✔ Femoral pulse
✔ Posterior tibial pulse
✔ Popliteal pulse
✔ Dorsalis pedis pulse

Palpation of pulse

✔ Marked diminished or absent pulses –

arterial occlusion, e.g., Buerger’s disease
or thromboangitis obliterans
 16 | HEALTH ASSESSMENT

How to calculate the ankle-brachial index

ABI Value Interpretation

Greater than 1.4 Calcification/Vessel
Hardening
1.0 – 1.4 Normal
0.9 – 1.0 Acceptable
0.8 – 0.9 Some arterial disease
0.5 – 0.8 Moderate arterial
disease
<0.5 Severe arterial disease

Manual Compression test:

Trendelenburg test: