HA LEC (NCM 101)
HEART AND NECK VESSEL, PERIPHERAL VASCULAR SYSTEMS AND
ASSESSING THE ABDOMEN
THE HEART
The heart is a fist-sized organ that pumps blood
throughout your body.
It's the primary organ of your circulatory system.
Cardiac cycle
 The hearts serves as a pump that
generates varying pressures as its
chambers contract and relax.
 Systole – period of ventricular contraction
 Diastole – period of ventricular relaxation.
BLOOD FLOW
Blood comes into the right atrium from the body,
moves into the right ventricle and is pushed into
the pulmonary arteries in the lungs. After picking
up oxygen, the blood travels back to the heart
through the pulmonary veins into the left atrium, to
the left ventricle and out to the body's tissues
through the aorta.
Preparing the Client
 Explain that they will need to expose the
anterior chest
 Explain also that the client need to assume
different position for examination.
 Make sure that you explain to the client that
you will be listening to the heart in a number
of places and that this does not necessarily
mean that anything is wrong.
 Provide the client with as much modesty as
possible, and answer any question the client
may have to ease any client anxiety.
Health History
 History of chest pain, palpitations, or dizziness
 Swelling in the ankles and feet
 Number of pillows used to sleep
 Type and amount of medications taken daily
 History of heart defect, rheumatic fever, or
chest or heart surgery
 Personal and family history of hypertension,
myocardial infarction (heart attack), coronary
artery disease, high blood cholesterol levels,
or diabetes mellitus
 History of smoking (how long, how many
packs/day)
 History of alcohol use
 Type and amount of exercise
 Usual foods eaten each day
 Changes in color or temperature of the
extremities
 History of pain in the legs when sleeping or
pain that is worsened by walking
 History of blood clots or sores on the legs that
do not heal
Physical Assessment:
Remember these key points during examination:
 Understand the anatomy and function of the
heart and major coronary vessels to identify
and interpret heart sounds and
electrocardiograms accurately.
 Know normal variations of the
cardiovascular system in the elderly client.
The techniques used for cardiovascular assessment
are
 Inspection
 Palpation
 Auscultation.
 The patient may be in a sitting position or in
a supine position with the head raised about
30 degrees.
Physical Assessment heart
1. Observe the neck and precordium (the
portion of the body over the heart and lower
thorax, encompassing the aortic, pulmonic,
tricuspid, and apical areas, and Erb’s point)
for visible pulsations
2. Inspect the epigastric area at the tip of the
sternum for pulsation of the abdominal
aorta.
NORMAL FINDING:
 Pulsations usually are absent except for
the apical impulse, located at about the
fourth or fifth intercostal space at the left
midclavicular line
ABNORMAL FINDING:
AUSCULTATING HEART SOUNDS
 Findings of neck vein distention or visible
pulsations in precordial areas other than
the apical impulse are considered
abnormal.
PALPATING THE PRECORDIUM
Abnormal Findings
 precordial thrills, which are fine, palpable,
rushing vibrations over the right or left
second intercostal space
 lifts or heaves, which involve a rise along
the border of the sternum with each
heartbeat.
4. Ask the patient to breathe normally. Use
systematic auscultation, beginning at the
aortic area, moving to the pulmonic area,
then to Erb’s point, then to the tricuspid
area, and finally to the mitral area.

3. Using the palmar surface of the hand with Focus on the overall rate and rhythm of the heart
the four fingers held together, palpate the and the normal heart sounds.
precordium gently for pulsations.

Palpate in a systematic manner, assessing

specific cardiac landmarks - the aortic,
pulmonic, tricuspid and mitral areas, and Erb’s
point.

Aortic Area

Heart and Cardiovascular Sounds

During auscultation, the

first heart sound, called
S1, is heard as the
Pulmonic
“lub” of “lub-dub.” This
Area
sound occurs when the
mitral and tricuspid
valves close and
corresponds to the
onset of ventricular
contraction. The sound,
low-pitched and dull, is
heard best at the apical
Apical (Mitral) area.
and Tricuspid
Area
The second heart
sound, S2, occurs at
the termination of
systole and
corresponds to the
4. Palpate the apical impulse in the mitral
onset of ventricular
area. Note size, duration, force, and
diastole. The “dub”
location in relationship to the
of
midclavicular line.
“lub-dub” represents
the closure of the
Normal Findings
aortic and pulmonic
No pulsation palpable over the aortic and
valves. The sound of
pulmonic areas, with a palpable apical
S2 is higher pitched
impulse.
and shorter than S1.
Normal Findings Conditions that contribute to turbulent blood
 S1 is louder at the tricuspid and apical flow
areas. include:
 S2 is louder at the aortic and pulmonic (Causes of murmurs)
areas.
1. increased blood velocity,
Abnormal Findings 2. structural valve defects,
 extra heart sounds at any of the cardiac 3. valve malfunction, and
landmarks 4. abnormal chamber openings
 abnormal rate or rhythm

NOTE: Extra heart sounds may be S3, S4,

murmurs, or bruits.

S3, known as the third heart sound, is often

represented by a “lub- dub-dee” pattern
(“dee” being S3); this sound is best heard with
the stethoscope bell at the mitral area, with the
patient lying on the left side.

S3 is considered normal in children and young

adults and abnormal in middle aged and older
adults.

S4 is the fourth heart sound, represented by “dee-lub-

dub.” S4 is considered normal in older adults but
abnormal in children and adults.

EXTRA HEART SOUNDS

Murmurs
 Heart murmurs are extra heart sounds
caused by some disruption of blood flow
through the heart.
 The characteristics of a murmur depend on
the adequacy of valve function, rate of blood
flow, and size of the valve opening
 PERIPHERAL VASCULAR SYSTEMS

PERIPHERAL VASCULAR SYSTEMS  Palpate, carefully and one at a time, the

carotid, brachial, radial, femoral, popliteal,
 It is part of the circulatory dorsalis pedis, and posterior tibial pulses.
system that consists of
veins and arteries not in PULSE SITES
the chest and abdomen
but in arms, hands, legs
and feet.

Normal Findings
Health History  The pulses should be strong and equal
bilaterally.
 Changes in color or temperature of the
extremities Abnormal Findings
 History of pain in the legs when sleeping or  absent, weak, thready pulse
pain that is worsened by walking  a forceful or bounding pulse
 History of blood clots or sores on the legs  an asymmetric pulse
that do not heal
 Allen’s test,
NURSING ASSESSMENT
 Buerger’s test
 capillary refill.
Inspecting the Extremities
 Inspect the skin of the extremities for color, Other specific assessments to determine arterial
temperature, continuity, lesions, venous blood flow include
patterns, and edema.
 Allen’s
Normal Findings test,
Normally, venous patterns, varicosities,  Buerger’s
rashes, ulcers, or edema are absent on the test
lower extremities.  capillary
refill
Abnormal Findings

 If the patient has peripheral vascular

disease, the skin of the lower extremities is
typically pale and cool, shiny with brown
discolorations, and hairless.
 The toenails are thickened.
 Phlebitis of the lower extremity is indicated
by pain, redness, and swelling of the affected
calf or thigh.

Palpating Peripheral Pulses

 Use the pads of the index and middle

fingers to palpate peripheral pulses for
amplitude and symmetry.
NORMAL AGE-RELATED VARIATIONS
OLDER ADULTS
 Difficult-to-palpate apical pulse
 Difficult-to-palpate distal arteries
 Dilated proximal arteries
 More prominent and tortuous blood vessels;
varicosities common
 Increased systolic and diastolic blood
pressure
 Widening pulse pressure
ASSESSING THE ABDOMEN
HEALTH HISTORY
PHYSICAL ASSESSMENT
Preparing the Client:
 Ask the client to empty the bladder before
beginning the examination.
 Instruct the client to remove clothes and put
on gown.
 Help the client to lie supine with the arms
folded across the chest or resting by the
sides.
 A flat pillow maybe placed under the client’s
head to comfort.
 Instruct the client to breathe through the
mouth and to take slow, deep breaths, this
will promote relaxation.
 Before touching the abdomen, ask the client
about tender or painful areas.
 History of abdominal pain
 History of indigestion, nausea or vomiting,
constipation or diarrhea
 History of food allergies or lactose
intolerance
 Appetite and usual food and fluid intake
 Usual bowel and bladder elimination
patterns
 History of gastrointestinal disorders, such as
peptic ulcer disease, bowel disease,
gallbladder disease, liver disease, or
appendicitis History of urinary tract disorders
such as infections, kidney stones, or kidney
disease
 History of abdominal surgery or trauma
 Type and amount of prescribed and over-
the counter medications used
 Amount and type of alcohol ingestion
 For women, menstrual history
 Position the patient in the supine position
with the head slightly elevated and arms at
the sides.
 Make sure that the patient is warm and
comfortable to help prevent contraction of
the abdominal muscles, which makes
palpation difficult.
 To locate organs more easily and to make
documentation more specific, the abdomen
can be divided into four quadrants: right
upper, right lower, left upper, and left
lower.
 PHYSICAL ASSESSMENT
Abdominal Quadrants
The sequence of techniques used to
assess the abdomen
 inspection
 auscultation
 percussion
 palpation

INSPECTING THE ABDOMEN

 Inspect skin color and surface

characteristics, including the
umbilicus, contour, symmetry,
peristalsis, pulsations, and visible
masses.
 The skin color may be slightly lighter
than exposed areas

NORMAL FINDINGS
Abdominal Regions  The skin color may be slightly lighter
than exposed areas.
 Fine white or silver lines (striae) may
be visible, often the result of skin
stretching from weight gain or
pregnancy

 The umbilicus should be centrally

located and may be flat, rounded, or
concave.
 The abdomen should be evenly
rounded or symmetric, without visible
peristalsis.
 In thin people, an upper midline
pulsation may normally be visible.

ABNORMAL FINDINGS

 swelling of the abdomen

 abdominal masses
 unusual pulsations
AUSCULTATING BOWEL SOUNDS
 Auscultation is used to assess bowel
sounds and vascular sounds.
 Warm the stethoscope and using light
pressure, place the flat diaphragm on the
right lower quadrant of the abdomen.
 Using the bell of the stethoscope,
auscultate over the abdominal aorta,
femoral arteries, and iliac arteries for bruits
 Listen carefully for bowel sounds.
 Before documenting bowel sounds as
absent, the nurse must listen for 2 minutes
or longer in each abdominal quadrant.
NORMAL FINDINGS
 A series of intermittent, soft clicks and
gurgles are heard at a rate of 5–30 per
minute. Interval of 5-15 seconds.
 Bowel sounds in all four quadrants.
 Bowel sounds audible at ileocecal valve
area
ABNORMAL FINDINGS
 Increased bowel sounds
 Decreased bowel sounds
 Absent bowel sounds
 Bowel sounds of high-pitched tinkling or
rushes of high-pitched sounds indicate a
bowel obstruction.
PERCUSSING THE ABDOMEN
 If the patient complains of abdominal pain,
palpate the area of pain last.
PALPATING THE ABDOMEN
 The pads of the fingers are used to palpate
with a light, gentle, dipping motion and do
deep palpation.
 Watch the patient’s face for nonverbal signs
of pain during palpation.
 Palpate each quadrant in a systematic
manner, noting muscular resistance,
tenderness, enlargement of the organs, or
masses.
 If the patient complains of abdominal pain,
palpate the area of pain last.
Light palpation
is used to identify
areas of
tenderness and
muscular
resistance.

 Percussion is useful in assessing a full

bladder or changes in abdominal contents.
 Percuss the abdomen in all four quadrants
in a systematic, clockwise manner to
identify fluid, masses, or air.
 Note the distribution of sounds

NORMAL FINDINGS
 Normally, tympany, the dominant NORMAL FINDINGS
percussion tone, is heard over the abdomen  The abdomen should normally be soft,
while dullness is heard over the liver and a relaxed, and free of tenderness.
full bladder.
ABNORMAL FINDINGS
ABNORMAL FINDINGS  involuntary rigidity
 decreased tympany  spasm
 Increased dullness, possibly caused by fluid  pain
or a mass.
PALPATING THE ABDOMEN

 The pads of the fingers are used to palpate

with a light, gentle, dipping motion and
do deep palpation.
 Watch the patient’s face for nonverbal signs
of pain during palpation.
 Palpate each quadrant in a systematic
manner, noting muscular resistance,
tenderness enlargement of the organs, or
masses.

NORMAL AGE-RELATED VARIATIONS

INFANT/CHILD
 Umbilical cord in newborns; dries and falls
off within the first few weeks of life
 A “pot-belly” (under 5 years of age)
 Visible peristaltic waves
 Easily palpated liver and spleen

OLDER ADULT
 Decreased bowel sounds
 Decreased abdominal tone
 Liver border palpated more easily