HEART (Precordium)

● First thing I will do is collect my Subjective Data

Questions to Ask:
a. Family History: Do you have history of Hypertension/ Coronary Heart Disease?
b. Lifestyle and Health Practices: Do you Drink alcohol/ Sleep Routine?

● Gather all the equipments:

1. Steth with bell diaphragm
2. small pillow
3. penlight/movable exam light
4. watch with second hand
5. 2cm ruler
Wash my hands and wear a gloves
● Explain procedure to patient: Ma’am I will be doing the assessment of Heart & Neck
Vessels

● Ask them to put on their gown ( *Put gown )

● Lay down in supine position at 45 deg angle
● turn head a little to the left

NECK VESSELS
( If you see any vein bulging, indication of increase pressure which is abnormal )

1. Auscultate carotid arteries for bruits. ( Use steth bell part *take big breath in sir and out
and hold • I should only hear pulse and no swishing
deviations: Bruits suggest carotid stenosis
2. Palpate each carotid artery for amplitude and contour of the pulse, elasticity of the
vessel, and thrills. ( Feel for strength of pulse/ Nice and smooth )
3. Inspect for jugular venous pulse. * below jaw line
Internal jugular vein is reliable for assessment but harder to see.
4. Measure jugular venous pressure. Put on sternal angle and adjust height to level of
pulsation. Read the level where they intersect (Normal: less 2cm or less )
deviations: JVP greater than 3cm from sternal angle

Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.

hypovolemia (i.e., mean venous pressure less than 5 cm H2O)

HEART
Questions to Ask:
Current Symptoms
a. Chest pain (type, location, radiation, duration, frequency, intensity)?
b. Palpitations?
c. Dizziness?
d. Swollen ankles?
Past History
a. Previous heart problems: heart defect, murmur, heart attack (MI)7
b. Previous diagnosis of rheumatic fever, hypertension, elevated cholesterol, diabetes
mellitus?
c. Heart surgery or cardiac balloon intervention?

HEART
1. Inspect for visible pulsations (note if apical or other).
● Check if there are any pulsations/ movement there ( I only see normal respiratory
movement)

2. Palpate apical pulse for location, size, strength, and

duration of pulsation. ( Ilalim ng chest feel the pulse )
● Loc: 4th/5th interspace midclavicular line
● size: 1cm x 2cm
● duration: short
3. Palpate for abnormal pulsations or vibrations at apex, go
left sternal border, and base.
deviations: note any abnormal pulsations such as thrills
4. Auscultate heart sounds for rate and rhythm
(apical and radial pulses, pulse rate deficit, S1 and S2)
S1- 1st Heart Sound (“lub”)
S2- 2nd Heart Sound (“dub”)
deviations: Bradycardia 60 BPM / Tachycardia 100 BPM
5. Auscultate S1 and S2 heart sounds for sound location
and strength pattern (louder/softer at locations and
with respiration, Splitting of S2

6. Auscultate for extra heart sounds (clicks, rubs) and

murmurs (systolic or diastolic, intensity grade, pitch,
quality, shape or pattern, location, transmission, effect
of ventilation and position).
deviations: may be an early indicator of a serious heart condition.

7. Auscultate with the client in the left lateral position

and with the client sitting up, leaning forward, and
exhaling.
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.

Angina Pectoris- Chest pain resulting from myocardial ischemia

Congestive Heart Failure- Failure of the heart to pump sufficiently to meet the
demands of the body
Atherosclerosis- major cause of congestive heart failure
Pericarditis- inflammation of bisceral/parietal pericatdium