Ascultati ng for Heart Sound

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Begin auscultation over the aortic area,
placing the stethoscope over the second
intercostal space, along the right sternal border
Then move to the pulmonic area, located at
the left n over the sternal border.
Next assess the triscupid area, which lies
over the fourt and fifth intercostal space, along
the left sternal border
Finally, listen mitral area, located at the fifth
intercostal space, near the midclavicular line.
Heart Sounds
Systole – the period of ventricular
contraction
S1 - first heart sound
S2 - second heart sound

Always identify S11 and S2, then listen for

adventitious sounds, such as third and
fourth heart sounds. Also listen for
murmurs, which sound like vibrating,
blowing, or rumbling sounds.
Hearing Pericardial Friction Rubs
Have the patient lean forward . If the patient
can’t tolerate leaning forward, position him
sitting upright.
Ask the patient to exhale, hen listen with
the diaphragm stethoscope over the third
intercostal space on the left side of the chest.
If you suspect a rub but have trouble
hearing one, ask the patient to hold his
breath.
A friction rub may be heard during atrial
To differentiate a pericardial friction rub form
a pleural friction rub, ask the patient to hold
his breath.
Assessing the vascular system
Inspection
Start by making general observations. Are
arms equal in size? Are legs symmetrical?
Then note skin color, body hair
distribution, and lesions, scars, clubbing,
and edema of the extremities. If the patient
is confined to bed, check the sacrum for
swelling. Examine the finger nails and
toenails for abnormalities.
Palpation
First, asses skin temperature, texture, and
turgor. Then assess capillary refill in the
nail beds on the finger and toes. Refill
time should be no more than 3 seconds, or
long enough to say “capillary refill”.
Palpate the patient’s arms and legs for
temperature and edema. Then palpate the
arterial pulses.
Palpating Arterial Pulses
Carotid pulse
Lightly place your fingers just lateral to the trachea and
below the jaw angle. Never palpate both carotid at the
same time
Brachial pulse
Position your fingers medial to the biceps and tendons
Radial pulse
Apply gentle pressure to medial and ventral side of the wrist,
just below the base of the thumb
Femoral pulse
Press relatively hard at the point inferior to the inguinal
ligament. For an obese patient, palpate in the crease of the
groin, halfway between the pubic bone and the tip bone.
Popliteal pulse
Press firmly in the popliteal fossa at the back of the knee.
Posterior tibial pulse
apply pressure behind and slightly below the malleous of the
ankle.
Dorsalis pedis pulse
Place your fingers on the medial dorsum of the foot while
the patient points his toes down. The pulse is difficult to
palpate here and may seem to be absent in healthy patients.