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:
• Stethoscope, Small pillow, Penlight, Watch with second hand, Tape measure
Assessment Procedure Normal Findings Abnormal Findings
NECK VESSELS
INSPECTION The jugular venous pulse is Fully distended jugular veins with
1. Observe the jugular venous not normally visible with the the client torso more than 45 degrees
pulse by standing on the right side of the client sitting upright. This indicate increased central venous
client. The client should be on supine position position fully distends the pressure that may be the result of
with the torso elevated 40-45 degrees. Ask vein, and pulsations may or right ventricular failure, pulmonary
the client to turn the head slightly to the left. may not discernible. hypertension, pulmonary emboli, or
Shine a tangential light source into the neck cardiac tamponade.
to maximize visualization. Next inspect the
suprasternal notch around the clavicles for
pulsations of the internal jugular veins.
2. Evaluate jugular venous pressure by The jugular vein should not Distention, bulging, or protrusion at
watching for distention of the jugular vein. be distended bulging or 45, 60, or 90 degrees may indicate
TECHNIQUE: Position the client in a supine protruding at 45 degrees or rightsided heart failure. Document at
position with head of the bed elevated 30, 45, greater. which positions you observe
60, and 90. At each increase of the elevation, distention. CONSIDERATIONS:
have the client’s head turned slightly away Clients with COPD may have
from the side being evaluated. Using elevated venous pressure only during
tangential lighting, observe for distention, expiration. An inspiratory increase in
protrusion, or bulging. venous pressure, called Kussmaul
sign, may occur in clients with
severe constrictive pericarditis.
Auscultation and Palpation
3. Auscultate the carotid arteries if the client No blowing or swishing or A bruit, a blowing or swishing sound
is middle-aged or older or if you suspect other sounds are heard. created by turbulent blood flow
cardiovascular disease. TECHNIQUE: Place through a narrowed vessel, is
the bell of the stethoscope over the carotid indicative of occlusive arterial
artery and ask the client to hold his or her disease. However, if the artery is
breath for a moment so that breath sounds do more than two-thirds occluded, a
not conceal any vascular sounds. bruit may not be heard.
4. Palpate the carotid arteries. Palpate each Pulses are equally strong; a Pulse inequality may indicate arterial
carotid artery alternately by placing the pads 2+ or normal with no constriction or occlusion in one
of the index and middle fingers medial to variation in strength from beat carotid. Weak pulses may indicate
sternocleidomastoid muscle on the neck. Note to beat. Contour is normally hypovolemia, shock, or decreased
amplitude and contour of the pulse, elasticity smooth and rapid on the cardiac output. A bounding, firm
of the artery, and any thrills. upstroke and slower and less pulse may indicate hypervolemia or
PRECAUTION: Palpate the arteries abrupt on the down stroke. increased CO. Variations in strength
individually because bilateral palpation could PULSE AMPLITUDE from beat to beat or with respiration
result in reduced cerebral blood flow. If you SCALE: 0 = Absent are abnormal and may indicate
detect occlusion during auscultation, palpate 1+ = Weak variety of problems. A delayed
very lightly to avoid blocking the circulation 2+ = Normal upstroke may indicate aortic stenosis.
or triggering vagal stimulation and 3+ = Increased Loss of elasticity may indicate
bradycardia, hypotension, or even cardiac 4+ = Bounding arteriosclerosis. Thrills may indicate
arrest. CONSIDERATION: Be cautious Arteries are elastic and no a narrowing of the artery.
with older clients because atherosclerosis thrills are noted.
may cause obstruction and compression may
easily block circulation.

Heart (Precordium), Anterior Chest

Inspection The apical impulse may or Pulsations, which may also call
5. Inspect for any pulsation on anterior chest may not be visible. If heaves or lifts, other than apical
over heart. Position the client in supine with apparent, it would be in the pulsation are considered abnormal
head of the bed elevated between 30- 45 mitral area (left MCL, fourth and should be evaluated. A heave or
degrees, stand on the client’s right side and of fifth ICS). The apical lift may occur as the result of an
look for the apical impulse (PMI) and any impulse is a result of the left enlarged ventricle from an overload
abnormal pulsation. ventricular movement toward of work.
during systole.
Palpation The apical pulse is palpated in The apical impulse may be
6. Palpate the apical pulse. Remain on the the mitral area and may be the impossible to palpate in clients with
client’s right side and ask the client to remain size of a nickel (1-2 cm). pulmonary emphysema. If the apical
supine. Use one or two finger pads to palpate Amplitude is usually small- pulses larger than 1-2 cm, displaced,
the apical pulse in the mitral area (fourth or like a gentle tap. more forceful, or of longer duration,
fifth ICS). You may ask the client to roll to CONSIDERATIONS: suspect cardiac enlargement.
the left side to better feel the impulse using Clients who are obese, with
your finger pads. OTHER TECHNIQUE: If large breast and older client’s
the apical pulsation cannot be palpated, have apical pulse may be difficult
the client assume a left lateral position. This to palpate.
displaces the heart toward the left chest wall
and relocates the apical impulse farther to the
left.
7. Palpate for abnormal pulsations. No pulsation or vibrations are A thrill or a pulsation is usually
TECNIQUE: Use your palmar surfaces to palpated in the areas of the associated with grade IV or high
palpate the apex, left sternal border, and base. apex, left sternal border, or murmur.
base.
Auscultation Rate should be 60-100 bpm, Bradycardia is less than 60 bpm
8. Auscultate HR and rhythm. How to with regular rhythm no skip Tachycardia is more than 100 bpm
auscultate: beats. may result in decreased carbon
1. Position yourself on the client’s right oxygen. Refer clients with irregular
side. The clients should be supine with the rhythms/skip beats (note the
upper trunk elevated 30 degrees. frequency of skip beats in a full
2. Use the diaphragm of the stethoscope to minute).
auscultate all the areas of the precordium for
high-pitched sounds. Use the bell to detect
(differentiate) low-pitched sounds or gallops.
Apply the diaphragm firmly to the chest, but
apply the bell lightly.
3. Note the rate (full 60 secs), rhythm, skip
beats.
4. Auscultate at least 5 sec each landmark.
Concentrate on systematically moving the
stethoscope from left to right across the entire
heart from the base to apex or vice versa.
Alternative Landmark: Aortic Area: Right
second ICS to apex of the heart Pulmonic
Area : 2nd and 3rd left ICS close to sternum
but may be higher or lower Left Atrial Area :
2nd to 4th ICS at the left sternal boarder.
Right Atrial Area: 3rd to 5th ICS at the right
sternal border. Left ventricular area: 2nd to
fifth ICS extending from the left sternal
boarder to the left MCL. Right ventricular
area : 2nd to 5th ICS centered over the
sternum.
9. If you detect an irregular rhythm, The radial pulse and apical A pulse deficit (difference between
auscultate for pulse rate deficit. Palpate the pulse should be identical. the apical and peripheral/radial
radial pulse while you auscultate the apical pulses) may indicate atrial
pulse. fibrillation, atrial flutter, PVC, and
varying degrees of heart block.
10. Auscultate to identify S1 and S2 S1 correspond with each Murmurs and extra heart sound may
Auscultate the first heart sound (S1 or ‘’lub’’) carotid pulsation and is indicate problem with the heart.
and the second heart sound (s2 ‘’dub’’). loudest at the apex of the
Listen to S1, use the diaphragm of the heart. S2 immediately follows
stethoscope to hear the S1. Listen to S2, use after S1 and is loudest at the
the diaphragm of the stethoscope. Ask the base of the heart
client to breathe regularly.
11. Listen to Extra heart sounds, use the Normally no sounds are heard Ejection sounds or clicks A friction
 diaphragm first then the bell to auscultate the
entire heart area. Note the characteristics
(location, timing) of any extra heart sound
Auscultate during the systolic pause (space
heard between S1 and S2). Auscultate during
the diastole pause (space heard between end
of S2 and the next S1).
12. Auscultate for murmurs. A Murmur is a
swishing sound caused by turbulent blood
flow through the heart valves or great vessels.
Auscultate for murmurs across the entire
heart area. Use the diaphragm and the bell of
stethoscope in all areas of auscultation
because murmurs have a variety of pitches.
13. Auscultate with the client assuming other
positions. a. Ask the client to assume a left
lateral position. Use the bell of the
stethoscope and listen at the apex of the heart.
b. Ask the client to sit up, lean forward, and
exhale. Use the diaphragm of the stethoscope
and listen over the apex and along the left
sternal border.
ASSESSMENT OF PERIPHERAL VASCULAR SYSTEM
Purpose:
1. To identify and refer early signs of peripheral vascular abnormalities.
2. To aide healthcare team in diagnosing and treatment.
Equipment’s:
Tape measure, Stethoscope, Examination gown and drape
Assessment Procedure
ARMS
INSPECTION
1. Observe arm size and venous pattern;
also look for edema. If there is an
observable difference, measure bilaterally
the circumference of the arms at the same
locations with each measurement and
records in centimeters. Mark locations on
arms with permanent marker to ensure the
exact same locations are used with each
assessment.
2. Observe coloration of the hands and
A physiologic S3 heart sound
is a benign finding commonly
heard at the beginning of the
diastolic pause in children,
adolescents and young adults.
It is rare after age 40. The
physiologic S3 usually
subsides upon standing or
sitting up A physiologic S4
heart sound may be heard
near end of diastole in well-
conditioned athletes and in
adults older than age 40 or 50
with no evidence of heart
disease, especially after
exercise.
Normally no murmurs are
heard, however, innocent and
physiologic mid systolic
murmurs may be present in
healthy heart.
S1 and S2 heart sounds are
normally presents.
Normal Findings
Arms are bilaterally symmetric
with minimal variation in size and
shape. No edema or prominent
venous patterning.
Color varies depending on the
rub may also be heard during the
systolic pause. A pathologic S3
(ventricular gallop) may be heard
with ischemic heart disease,
hyperkinetic state, or restrictive
myocardial disease. A pathologic S4
(atrial gallop) toward the left side of
precordium may be heard with CAD,
hypertensive heart disease,
cardiomyopathy, and aortic stenosis.
A pathologic S4 toward the right side
of the precordium may be heard with
pulmonary hypertension and
pulmonic stenosis.
Pathologic midsystolic murmur,
pansystolic murmur and diastolic
murmur should be reported and
documented: Characteristic of
Murmur: Timing, Intensity, Pitch,
Quality, Shape or Pattern.
An S3 or S4 heart sound or a
murmur of mitral stenosis that was
not detected with the client in the
supine position may be revealed
when the client assumes the left
lateral position. Murmur of aortic
regurgitation may be detected when
the client assumes this position.
Abnormal Findings
Lymphedema results from blocked
lymphatic circulation, which may
be caused by breast surgery.
Raynaud disorder a vascular
arms.
Palpation
3. Palpate the client’s fingers, hands and
arms, note the temperature.
4. Palpate to assess capillary refill time.
Compress the nail bed until it blanches.
Release the pressure and calculate the time
it takes for color to return. This test
indicates peripheral perfusion and reflect
cardiac output.
5. Palpate the radial pulse. Gently press the
radial artery against the radius. Note
elasticity and strength.
6. Palpate the ulnar pulses. Apply pressure
with your first three fingertips to the medial
aspects of the inner wrists. The ulnar pulses
are not routinely assessed because they are
located deeper than the radial pulses and
are difficult to detect. Palpate the ulnar
arteries if you suspect arterial insufficiency.
7. Palpate the brachial pulses if your
suspect arterial insufficiency. Place first
three fingertips of each hand at the client’s
brachial area.
8. Palpate the epitrochlear lymph nodes.
Take the client’s left hand in your right
hand as if you were shaking hands. Flex the
client elbow about 90 degrees. Use your left
hand to palpate behind the elbow in the
groove between the biceps and triceps
muscle. If node is detected evaluate for
size, tenderness, and consistency. Repeat
palpation on the opposite arm.
9. Perform the Allen Test The Allen test
evaluates patency of the radial or ulnar
arteries. An Allen test is essential before
arterial sampling (arterial blood gas) or
arterial line insertion/placement. It is
implemented when patency is questionable
or such procedure as a radial artery
puncture. The test begins by assessing ulnar
patency. Have the client rest the hand palm
side up the examination table and make a
fist. The use your thumbs to occlude the
radial and ulnar arteries. Continue the
pressure to keep both arteries occluded and
have the client release the fist. Note that the
palm remains pale. Release the pressure on
the ulnar artery and watch for color to
return to the hand. To assess the radial
patency, repeat the procedure before, but at
client skin tone, although colors
should be same bilaterally.
Skin is warm to touch bilaterally
from fingertips to upper arms.
CRT 2 seconds or less.
Radial pulse are bilaterally strong
(2+) Artery walls have a resilient
quality (bounce).
The ulnar pulses may not
detectable.
Brachial pulses have equal
strength bilateral
Normally, epitrochlear lymph
nodes are not palpable.
Pink coloration returns to the
palms within 3-5 seconds if the
ulnar artery is patent. Pink
coloration returns to the palms
within 3-5 seconds if the radial
artery is patent.
disorder caused by
vasoconstriction or vasospasm of
fingers and toes, characterized by a
rapid change of color (pallor,
cyanosis and redness), swelling
pain, numbness, tingling, burning,
throbbing and coldness.
A cool extremity may be sign of
arterial insufficiency.
CRT exceeding 2 secs may
indicate vasoconstriction,
decreased cardiac output, shock,
arterial occlusion, or hypothermia.
Increased radial pulse volume
indicates a hyperkinetic state (3+
or bounding pulse). Diminished
(1+) or absent (0) pulse suggest
partial or complete arterial
occlusion (which is more common
in the legs than the arms).
Obliteration of the pulse may result
from compression by external
sources, as in compartment
syndrome. Lack of resilience or
inelasticity of the wall may
indicate arteriosclerosis.
Brachial pulses are increased,
diminished or absent.
Enlarged epitrochlear lymph nodes
may indicate an infection in the
hand or forearm, or they may occur
with generalized
lymphadenopathy. Enlarged lymph
nodes may also occur because of a
lesion in the area.
With arterial insufficiency or
occlusion of the ulnar/radial artery
pallor persists.
the last step, release pressure on the radial
artery.
LEGS
INSPECTION, PALPATION, AND
AUSCULTATION
Ask the client to lie supine. Then drape the
groin area and place a pillow under the
clients head for comfort.
10. Observe skin color while inspecting
both legs from the toes to the groin.
11. Inspect distribution of hair on legs.
12. Inspect for lesions or ulcers
13. Inspect and palpate for edema. Inspect
the legs for unilateral or bilateral edema.
Note veins, tendons, and bony
prominences. If legs appear asymmetric,
use centimeter tape to measure in four
different areas:
Circumference at mid-thigh. Largest
circumference at the calf. Smallest
circumference above the ankle. Across the
forefoot. Compare both extremities at the
same locations.
Palpate the area to determine if it’s pitting
or non-pitting. Press the edematous area
with the tips of your fingers hold for few
seconds, then release. If the depression does
not rapidly refill and the skin remains
indented on release, pitting edema is
present.
14. Palpate bilaterally for temperature of
the feet and legs. Use the backs of your
fingers. Compare your findings in the same
areas bilaterally. Note location of any
changes in temperature.
15. Palpate the superficial inguinal lymph
nodes. First expose the client’s inguinal
area, keeping the keeping the genitals
draped. Feel over the upper medial thigh for
the vertical and horizontal groups of
Pink color for lighter-skinned
clients and pink or red tones
visible under darker pigmented
skin. There should be no changed
in pigmentation.
Hair covers the skin on the legs
and appears on the dorsal surface
of the toes.
Legs are free of lesions or
ulcerations.
Identical size and shape
bilaterally; no swelling or
atrophy. No edema
Toes and legs are equally warm
bilaterally.
Nontender, movable lymph nodes
up to 1 or even 2cm are
commonly palpated.
Pallor, especially when elevated,
and rubor, when dependent,
suggest arterial insufficiency. Dark
colored toes and blister are seen
with arterial insufficiency and
gangrene. Cyanosis when
dependent suggest venous
insufficiency. A rusty, ruddy or
brownish pigmentation (rubor)
around the ankles indicates venous
insufficiency.
Loss of hair on the legs suggest
arterial insufficiency. Often thin,
shiny skin is noted as well.
Ulcers with smooth, even margins
that occur at pressure areas, such
as the toes and lateral ankle, result
from arterial insufficiency. Ulcers
with irregular edges, bleeding, and
possible bacterial infection that
occur on the medial ankle result
from venous insufficiency.
Bilateral edema may be detected
by the absence of visible veins,
tendons, or bony prominences.
Bilateral edema/pitting edema
usually indicates a systemic
problem, such as heart failure, or
local problem such as
lymphedema, but lymphedema is
usually unilateral unless
elephantiasis is diagnosed or
prolonged standing or sitting. A
difference in measurement
between legs may also be due to
muscular atrophy.
Pitting edema scaling:
1+ = Slight pitting.
2+ = Deeper pitting than 1+. 3+ =
Noticeable deep pit; extremely
looks larger
4+ = very deep pit; gross edema
extremely.
Generalized coolness in one leg or
change in temperature from warm
to cool as you move down the legs
suggest arterial insufficiency.
Increased warmth in the legs may
be caused by superficial
thrombophlebitis resulting from a
secondary inflammation in the
tissue around.
Lymph nodes larger than 2cm with
or without tenderness may be from
a local infection nor generalized
lymphadenopathy. Fixed nodes
may indicate malignancy.
superficial inguinal lymph nodes. If
detected, determine sizes, mobility, or
tenderness. Repeat palpation on the
opposite thigh.
16. Palpate and auscultate the femoral
pulses. Ask the client to bend the knee and
move it out to the side. Press deeply and
slowly below and medial to the inguinal
ligament. Use two hands if necessary.
Release pressure until you feel the pulse.
Repeat on the opposite side. Compare
amplitude bilaterally. If arterial obstruction
is suspected in the femoral pulse, position
the stethoscope over the femoral artery and
listen for bruits. Repeat for the other artery.
17. Palpate the other Leg pulses Palpate the
popliteal pulses. Ask the client to raise
(flex) the knee partially. Place your thumbs
on the knee while positioning your fingers
deep in the bend of the knee. Apply
pressure to locate the pulse. It is usually
detected lateral to the medial tendon.
Palpate Dorsalis Pedis pulse. Dorsiflex
the clients foot and apply light pressure
lateral to and along the side of the extensor
tendon of the big toe. The pulses of both
feet may be assessed at the same time to aid
in making comparison. Assess amplitude
bilaterally.
Palpate the Posterior Tibial pulses.
Palpate behind and just below the medial
malleolus (in the groove between the ankle
and the Achilles tendon). Palpating both
posterior tibial pulses at the same time aids
in making comparisons. Assess amplitude
bilaterally. CLINICAL TIP: Use Doppler
if pulses are absent. It may difficult or
impossible to palpate a pulse in an
edematous foot.
18. Inspect for varicosities and
thrombophlebitis. Ask the client to stand
because varicose veins may not visible
when the client is supine and not as
pronounced when the client is sitting. As
the client is standing, inspect for superficial
vein thrombophlebitis. To fully assess for
suspected phlebitis, lightly palpate for
tenderness. If superficial vein
thrombophlebitis is present, note redness or
discoloration on the skin surface over the
vein.
Femoral pulses strong and equal
bilaterally. No sounds auscultated
over the femoral arteries.
It is not usual for the popliteal
pulse to be difficult or impossible
to detect, and yet for circulation
to be normal. Dorsalis pedis
pulses are bilaterally strong. This
pulse is congenitally absent in 5-
10% of the population.
The posterior tibial pulses should
be strong bilaterally. However
about, in about 15% of healthy
clients, the posterior tibial pulses
are absent
Veins are flat and barely seen
under the surface.
Geriatric considerations:
Varicosities are common in the
older client.
Weak or absent femoral pulses
indicate partial or complete arterial
occlusion. Bruits over one or both
femoral arteries suggest partial
obstruction of the vessel and
diminished blood flow to the lower
extremities.
Although normal popliteal arteries
may be nonpalpable, an absent
pulse may be the result of an
occluded artery. Further circulatory
assessment is needed. A weak of
absent pulse may indicate impaired
arterial circulation. Further
circulatory assessment is needed.
The posterior tibial pulses should
be strong bilaterally. However
about, in about 15% of healthy
clients, the posterior tibial pulses
are absent
Varicose veins may appear as
distended, nodular, bulging, and
tortuous, depending on severity.
Varicosities are common in the
anterior lateral thigh and lower leg,
the posterior lateral calf, or anus
results from incompetent valve in
the veins, weak vein walls, or an
obstruction above the varicosity.
Swelling and inflammation are
often noted.