VISUAL ACUITY

• Check distance vision

- Check distance vision with Snellen chart 20 feet from client (Cover Left then to Right)
- Instruct the patient to read as many lines as possible on the chart
- After the assessment you have to:
Note: number at the end of the last line the patient was able to read

• Check near vision

- Ask the patient to stand or sit holding the Rosenbaum chart at a 14 inches distance form the
face
- Ask the patient to read the smallest line possible

PHERIPHERAL VISION

- Face the patient at a distance of 2 to 3 feet

- Patient and examiner should look directly ahead and cover eye directly opposite each other
Note: patient and examiner should see the object at the same time as it approaches from
the periphery.

EOM

- Ask the patient to sit or stand 2 feet away facing the nurse on eye level with patient
- Ask the client to hold this head still and follow the movement of your finger with her eyes as
it is moved in 6 cardinal fields
- Keep finger about 1 foot from the client’s face and move it through the 6 fields of gaze:
UP&DOWN; LEFT&RIGHT; DIAGONALLY UP&DOWN TO THE RIGHT

PERRLA

- Stand in front of the patient in a darkened room

- Ask the patient to look straight ahead
- Move the penlight from right side of the client’s face and focuses the light on the right pupil
- Observe the pupillary reaction
Note: size of the pupil (2-4 mm); Constrict with light; Dilate in darkness

VOICE WHISPER

- Have the client place a finger on the tragus of one ear

- Whisper a 2-syllable word 1 to 2 feet behind the client

WEBER TEST

- Lateralization of sound
- Stand in front of the patient and give instruction to the patient that you will place a tuning
fork on top of his head and ask if he hears the sound equally on both ears.
- Strike the tuning fork on the base of the palm
- Place the tuning fork on top of the patient’s head
- Ask the patient if the sound is heard equally
Note: perceived sound by the patient should be equal in both ears

ROMBERG TEST

- Ask the patient to stand erect with arms at side and feet together
- Stand near the client to prevent a fall should the patient lose balance
Note: any unsteadiness or swaying
- Ask the patient to stay in her body position and then, close her eyes for 20 seconds
Note: any unsteadiness or swaying
: REPEAT IN SEMI-TANDEM AND TANDEM POSITION)
INSPECTION OF HEART – inspect chest to identify landmarks that aid in assessment of the heart

• Locate the ICS (Intercostal space)

- Locate by finding the sternal angle, which is felt at a ridge in the sternum approximately 2
inches below the sternal notch
- The adjacent rib is the 2nd rib with the 2nd ICS directly below it
- Other ICSs can be identified by counting from the 2nd ICS
- 5th ICS is at the junction of the sternum and xiphoid process
• Midsternal Line (MSL)
- Imaginary line extending down the chest through the middle of the sternum
- It divides the anterior chest in half
• Midclavicular Line (MCL)
- Imaginary line extending from the middle of the clavicle down the chest dividing right and
left anterior chest into 2 parts
• Anterior Axillary Line (AAL)
- Imaginary line extending along the lateral wall of the anterior chest and even with the
anterior axillary fold

PALPATION- patient lying down. Palpate with fingertips and palmar surfaces in an organized fashion,
beginning at the aortic area and moving down the chest toward the tricuspid area.

• Aortic area- palpate 2nd ICS at right sternal border

• Pulmonic area- palpate 2nd ICS at left sternal border
• Erbs point- palpate 3rd ICS at left sternal border
• Tricuspid area- palpate 5th ICS at lower left sternal border
• Mitral area- palpate 5th ICS at the left MCL, called as Point of Maximum Impulse (PMI)
• If this pulsation cannot be palpated, have the client assume a left lateral position. This displaces
the heart toward the left chest wall and relocates the apical impulse farther to the left

AUSCULTATE

- Auscultate in an orderly, symmetric manner beginning with the aortic area

- Move across and then down the chest
- Focus on one sound at a time
- Auscultate each area with the stethoscope diaphragm applied firmly to the chest
- Repeat the sequence using the stethoscope bell applied lightly to the chest
- Auscultate the client in the supine position
- Then listen the apex with the bell while the client is in the left lateral position
- Assist the client to a sitting position and auscultate the pericardium with the diaphragm
- Have the client lean forward and exhale while you listen over the aortic area with the
diaphragm
• Auscultate to identify the 1st heart sound (S1) LUBB; 2nd sound (S2) DUB
• Auscultate for rate and rhythm
• If irregular rhythm is detected auscultate for pulse rate deficit by comparing the radial pulse
with the apical pulse for a full minute
• Auscultate and focus on each sound and pause individually
-Auscultate S1&S2: heard best with diaphragm
-Auscultate systolic pause space: heard between S1 and S2
• Auscultate diastolic pause space: heard between S2 and the next S1
• Auscultate S3 with bell of stethoscope: low, faint sound occurring at the beginning of the
diastolic pause
• Auscultate S4: soft, low-pitched sound heard best with client in supine or left lateral position
with stethoscope bell ATRIAL GALLOP
Jugular veins- passageway of blood from skull, superficial parts of face then majority parts of the neck to
the superior vena cava, largest vein in upper body; svc transports blood to heart and lungs

Level of jugular venous pressure reflects right atrial (central nervous) pressure

Murmurs- consequence of turbulent blood flow through the heart and large vessels

- Blowing or swooshing
- Vibrations in heart and great vessels
- Abnormal heart sound
- Incompetent glauvalves

Gallops- extra heart sounds that create triple rhythm

- Mimicking horse’s gallop

Pericardial friction rub- produced by inflammation of pericardial sac

- Sound described as “to and fro”, scratchy, sound when rubbing hair between thumb and
forefinger

Heart sounds- produced by valve closure, bc. Opening of valve is silent

- S2 has higher pitch and heard at the beginning of ventricular diastole

- ^ due to closure of semilunar valves (aortic and pulmonic valves)
- Diastole (ventricular filling)

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.
- Pulse; Vessel elasticity; thrills

• Auscultate carotid arteries with stethoscope bell while patient holds breath
a. Gently locate the artery on the side of the neck
b. Palpate the artery
c. Place the stethoscope over the carotid artery beginning at the jaw line
d. Ask the patient to hold his/her breath
e. Lightly press the diaphragm
f. Repeat on the other side
Note: no sounds should be heard
• Palpate each carotid artery alternately for rate, rhythm, symmetry, strength, and elasticity
Note: 60-90 beats per minute regular, equal, strong, and elastic
Caution: use light palpation over carotids (one at a time) because increased pressure may
stimulate carotid sinus reflex and lower heart rate, and blood pressure

Air conduction > bone conduction

Dilate large