SLIDE 1

Abdominojugular test (AJT)

SLIDE 2

The hepatojugular reflux test involves the application of pressure to the liver whilst observing for a sustained rise in JVP.

JVP briefly rises when pressure is applied to upper abdomen for 10 seconds

JVP normalizes after 2 - 3 seconds of sustained compression.

SLIDE 3

Place your right hand with fingers pointing toward the patient's head over the right upper quadrant of the patient's
abdomen just below the costal margin as seen on the next page Press deeply in and upward and hold the pressure for 30
seconds. This maneuver forces the hepatic venous blood into the vena cavae, elevating the venous blood volume and
pressure.

While you are applying pressure, watch the patient's jugular vein level. The healthy person is able to pump the extra
blood through the heart within a few seconds. The jugular vein pressure will rise for a few seconds and then rapidly
diminish to previous levels.

SLIDE 4

The Heart

For much of the cardiac examination, the patient should be supine, with the upper body raised by elevating the head of
the bed or table to about 30°.

Two other positions are also needed: (1) turning to the left side and (2) sitting and leaning forward. These positions bring
the ventricular apex and left ventricular outflow tract closer to the chest wall, enhancing detection of the PMI and aortic
insufficiency. The examiner should stand at the patient's right side.

SLIDE 5

Even experienced nurses are sometimes uncertain about the timing of heart sounds, especially extra sounds and
murmurs. "Inching" can then be helpful. Return to a place on the chest-most often the base-where it is easy to identify S₁
and S₂. Get their rhythm clearly in mind. Then inch your stethoscope down the chest in steps until you hear the new
sound.
Auscultation alone, however, can be misleading. The intensities of S₁ and S₂, for example, may be abnormal. At rapid
heart rates, diastole shortens, and at about a rate of 120, the durations of systole and diastole become indistinguishable.
Use palpation of the carotid pulse or of the apical impulse to help determine whether the sound or murmur is systolic or
diastolic. Because both the carotid upstroke and the apical impulse occur in systole, right after S₁, sounds or murmurs
coinciding with them are systolic; sounds or murmurs occurring after the carotid upstroke or apical impulse are diastolic.

SLIDE 6

Inspection

Carefully inspect the anterior chest for the location of the apical impulse or PMI and heaves over the precordium, which
indicate increased ventricular movement. Tangential light is useful for making this observation. Use palpation to confirm
the characteristics of the apical impulse.

SLIDE 7

Palpation
Begin with general palpation of the chest wall. First palpate for heaves (lifts) using your finger pads. Hold them
flat or obliquely on the body surface. Ventricular impulses may heave or lift your fingers.

Check for thrills formed by the turbulence of underlying murmurs by pressing the ball of your hand firmly on the chest.

If subsequent auscultation reveals a loud murmur, go back to that area and check for thrills again.

SLIDE 8

Sites for cardiac palpation