Heart and Neck Vessels

Neck Vessels
. Ins. jugular venous pulse (Normal: Not visible)
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. Measure jugular venous pulse (Normal: not be distended, bulging, or protruding at 45
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degrees)
. Aus. carotid arteries for bruits (Normal: No blowing or swishing or other sounds heard)
. Palpate each carotid artery for amplitude and contour of the pulse, elasticity of the
vessels and thrills. (Normal: Pulses equally strong, and 2+)

Heart (Precordium)

. Ins. for visible pulsations with the client in supine position. (Normal: The apical pulse may
or may not be visible.)
. Palpate apical pulse for location, size, strength, and duration of pulsation. (Normal: The
apical pulse is palpated in the mitral area // may be the size of a nickel. 1-2 cm // Amplitude is
usually small-like a gentle tap // The duration is brief // lasting through the first two thirds of
systole and often less)
. Palpate for abnormal pulsation or vibrations at apex, left sternal border, and base.
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(Normal: No pulsations/ vibrations palpated in the areas of apex, left sternal border or base)

. Auscultate heart sounds for rate and rhythm (apical and radial pulse, pulse rate deficit ,
S1 and S2) if irregular rhythm is detected. (Normal: Rate 60-100 bpm with regular rhythm.)
. Auscultate S1 and S2 heart sounds for location and strength pattern // (louder/ softer at
locations and with respiration, splitting of S2). (Normal: S1 corresponds with each carotid
pulsation and loudest at the apex of the heart. S2 immediately follows after s1 and is the
loudest at the base of the heart)
. Auscultate for extra heart sounds (clicks, rubs), murmurs (systolic or diastolic, intensity
grade, pitch, quality, shape or pattern, location, transmission, effect of ventilation and
position). (Normal: Normally no sound are heard)
. Auscultate with the client in the left lateral position and with the client sitting up, leaning
forwards, and exhaling. (Normal: S1 and S2 heart sounds are normally present)