PHYSICAL ASSESSMENT:

Assessing the Heart and Neck

Vessels

Week 10
RHODA GRACE ESTIOCO RUELOS, MAN, RN

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Structure and Function
➢Heart:
➢Hollow, muscular
organ located in the
middle of thoracic
cavity between the
lungs in the space
called mediastinum,
about the size of a
clenched fist.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Structure and Function

➢Heart:
➢Four chambers: left
atrium and ventricle,
right atrium and
ventricle
➢Two atrioventricular
valves, two semilunar
valves

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Structure and Function
➢ Heart: Has 3 layers
❑Epicardium-outermost
protective layer of the heart
❑Myocardium-middle and thickest
layer. Muscular layer of the heart
which contracts and responsible
for keeping the heart pumping
blood around the body.
❑Endocardium- innermost layer of
the heart

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Structure and Function
➢Heart:
❑The pericardium acts
as mechanical protection
for the heart and big
vessels, and a
lubrication to reduce
friction between the
heart and the
surrounding structures.
https://pubmed.ncbi.nlm.nih.gov/27654013/

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Heart
Chambers,
Valves, and
Direction of
Circulatory Flow

RHODA GRACE ESTIOCO RUELOS, MAN, RN

❑ VEINS- carry
deoxygenated blood
toward the heart
ARTERIES- carry
oxygenated blood away
from the heart
PULMONARY ARTERY-
carries deoxygenated
blood
PULMONARY VEIN-
carries oxygenated blood

RHODA GRACE ESTIOCO RUELOS, MAN, RN

❑ Blood passes through a valve
before leaving each chamber of
the heart. The valves prevent
the backward flow of blood.
Valves are actually flaps
(leaflets) that act as one-way
inlets for blood coming into a
ventricle and one-way outlets
for blood leaving a ventricle.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

❑ ORDER OF VALVES
T-TOLET- Tricuspid valve
P-PAPER- Pulmonic valve
M-MY- Mitral valve
A- ASSET- Aortic valve

RHODA GRACE ESTIOCO RUELOS, MAN, RN

RHODA GRACE ESTIOCO RUELOS, MAN, RN
RHODA GRACE ESTIOCO RUELOS, MAN, RN
❑ LEFT VENTRICLE- The left
ventricle connects nearly
all organ systems through
its function to pump
oxygenated blood to the
body. Left ventricular
failure would likely result
in impairment to all other
organ systems.
ps://www.ncbi.nlm.nih.gov/books/NBK541098/

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 ENUMERATE

The four chambers

of the heart.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 IDENTIFY
Left Ventricle contracts
and eject blood through
the ________ valve.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 TRUE OR FALSE

The pulmonary
artery carries blood
to the lungs.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 TRUE OR FALSE
Muscular layer of
the heart which
contracts and
responsible for
keeping the heart
pumping blood
around the body.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 ENUMERATE
Order of valves

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 IDENTIFY

All VEINS carry

deoxygenated blood
except____?

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 IDENTIFY

All ARTERIES carry

oxygenated blood
except____?

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrical Conduction of the Heart
➢ Sinoatrial node-
located on
posterior wall of
the Right Atrium
near junction of
superior and
inferior vena cava
➢ Pacemaker of the
heart

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrical Conduction of the Heart
➢ AV node- located in the
lower interatrial septum
➢ Slightly delays incoming
electrical impulses from
the atria and then relays
the impulse to the av
bundle(bundle of His)

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrical Conduction of the Heart
➢ AV bundle (bundle of His)- The
atrioventricular bundle is a
continuation of the specialized
tissue of the AV node and serves to
transmit the electrical impulse from
the AV node to the Purkinje fibers of
the ventricles.
https://teachmeanatomy.info/thorax/organs/heart/conducting-system/

➢ Purkinje fibers- network of

specialized muscle cells that
carry cardiac impulses to the
ventricles of the heart and cause
them to contract.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation
•

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrocardiogram
• Electrical activity of
heart measured by
electrocardiography
(ECG)
• Phases of ECG: P, Q,
R, S, T
• Records
depolarization and
repolarization

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrocardiogram
❑ P wave- ATRIAL CONTRACTION
OR DEPOLARIZATION- this is
when atrium are contracting
❑ QRS complex- VENTRICLE
CONTRACTION OR
DEPOLARIZATION- this is
where ventricles are
contracting
❑ T wave- Ventricle
Repolarization- ventricles are
resting

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Electrocardiogram
❑ PR Interval- the time from the
beginning of the P wave (atrial
depolarization) to the beginning of
the QRS complex (ventricular
depolarization). The normal PR
interval measures 0.12-0.20 seconds
(120-200 milliseconds).
❑ A long PR interval (of over 200 ms)
indicates a slowing of conduction
between the atria and ventricles,
usually due to slow conduction
through the atrioventricular node (AV
node). This is known as first degree
heart block.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

RHODA GRACE ESTIOCO RUELOS, MAN, RN
 Cardiac Cycle
➢Filling and emptying of the heart’s chamber
➢Two phases: diastole and systole
➢Diastole: relaxation of the ventricles known
as filling
➢Systole: contraction of the ventricles known
as emptying

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Normal Heart Sounds
❑ S1- First heart sound
(“lub”) result of closure of
AV valves (mitral and
tricuspid valves)
❑ S2- second heart sound
(“dubb”) results from
closure of the semilunar
valves (aortic and
pulmonic)

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Extra Heart Sounds
❑ Murmurs- Turbulent blood
flow with a swooshing or
blowing sound when doing
auscultation
❑ Conditions that contribute
are structural heart valve
defects, valve malfunction,
and septal defect

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Collecting Subjective Data
• History of present health concern: chest pain,
palpitations
• Past health history
• Family history
• Lifestyle and health practices

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 History of present concern: CHEST
PAIN
➢ Do you experience chest
pain? (COLDSPA)
➢ RATIONALE:
➢ Angina is chest pain or
discomfort caused when your
heart muscle doesn't get
enough oxygen-rich blood. It
may feel like pressure or
squeezing in your chest.
➢ https://www.heart.org/en/health-topics/heart-attack/angina-
chest-pain

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 History of present concern: Tachycardia
and Palpitations
➢ Do you experience faster heartbeat,
skip beats or extra heartbeat?
➢ Do you experience easy fatigability,
dyspnea or SOB?
➢ RATIONALE: Tachycardia may be
seen with weak heart muscles.
Palpitations may occur with an
abnormality of the heart’s conduction
system. Fatigue may result from
compromised cardiac output and
Dyspnea may result from CHF.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Personal History
➢ Have you been diagnosed with a heart defect or
murmur, had rheumatic heart fever and heart
surgery?
➢ Have you ever had ECG, blood test(lipid profile)?
➢ Do you take medications for heart disease?
➢ RATIONALE: Heart defects and diseases affects
heart’s ability to pump. Previous heart surgery may
change the heart sounds hearing during
auscultation.
➢ A prior ECG allows health care team to evaluate
any changes in cardiac conduction. Elevated
cholesterol levels have been linked to CAD.
➢ Client may have medications prescribed for heart
disease but may not be taking them regularly.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Family History
➢ Is there hypertension, MI,
coronary heart disease(CHD),
elevated cholesterol levels,
or diabetes mellitus(DM) in
your family?
➢ RATIONALE: A genetic
predisposition to these risk
factors increases a client’s
chance for developing heart
disease.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Lifestyle and Health Practices
➢ Do you smoke? How many packs
of cigarettes per day? For how
many years now?
➢ What type of stress do you have
in your life?
➢ RATIONALE: Cigarette smoking
greatly increases the risk of heart
disease.
➢ Stress has been identified as a
possible risk factor for heart
disease.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Lifestyle and Health Practices
➢ Describe what you usually eat in a
day? Do you exercise?
➢ RATIONALE: An elevated cholesterol
level increases the chance of fatty
plaque formation in the coronary
vessels.

➢ Sedentary lifestyle is a risk factor for

development of heart disease

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Physical Examination
Collecting Objective Data
➢ Preparing the client
➢Explain the procedures and describe the steps
➢Client must assume different position
➢REMEMBER: Key points during examination
➢Understand anatomy and function of the heart to
identify and interpret findings between normal and
abnormal.
➢Know normal variations of the cardiovascular system in
older adult clients.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Equipment/Materials
➢ Stethoscope with a bell and
diaphragm
➢ Small pillow
➢ Penlight or movable
examination light
➢ Watch with second hand
➢ Centimeter rulers

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Neck Vessels: Inspection
➢ Observe jugular venous pulse by
standing on the right side of the client
with torso elevated 30-45 degrees. Ask
client to turn head slightly to left. Shine
a tangential light source onto the neck
to better visualize pulsations and
shadows. Next inspect suprasternal
notch.
➢ FINDINGS: Jugular venous pulse is not
normally visible with the client sitting
upright. This position fully distends the
vein and pulsations may or may not be
visible.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Neck Vessels: Inspection
➢ Evaluate jugular venous pressure by
watching for distention of the jugular
vein. It is normal to the jugular veins
to be visible when the client is
supine. To evaluate JVD, position
client in a supine position with the
head of bed elevated 30, 45, 60, and
90 degrees. At each increase of the
elevation, have the client’s head
turned slightly away from the side
being evaluated. Using tangential
lighting, observe for distention,
protrusion, or bulging.
➢ FINDINGS: The jugular vein should
not be distended, bulging, at 45
degrees or greater.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Neck Vessels: Inspection
➢ Evaluate jugular venous pressure.
➢ Measure the vertical distance (in cm)
between the horizontal lines drawn from
the upper level of venous pulsation and the
sternal angle. This can be done by using
2 rulers – one placed horizontal to the
upper level of pulsation and another
taking the vertical distance of that
ruler from the sternal angle
➢ FINDINGS: The jugular vein should
not be distended, bulging, at 45
degrees or greater.
➢ In healthy individuals this should be
no greater than 3cm.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation and Palpation
➢ Auscultate carotid arteries.
Place bell of the stethoscope
over carotid artery and ask
client to hold his/her breath for
few seconds so that breath
sounds do not conceal vascular
sounds.
➢ FINDINGS: . No blowing or swishing
or other sounds are heard. A bruit
or swooshing sound is indicative of
occlusive arterial disease.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation and Palpation
➢ Palpate carotid arteries by placing
the pads of your index and middle
fingers.
➢ FINDINGS: Pulses are equally strong,
a 2+ or normal with no variation in
strength from beat to beat.
➢ PULSE AMPLITUDE SCALE
❑0= absent
❑1+= weak, diminished
❑2+= normal
❑3+= bounding

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Inspection: Anterior Chest
➢ Inspect and palpate apical
impulse. Palpate for
abnormal pulsations
➢ FINDINGS: Apical impulse may or
may not be visible.
➢ Apical impulse is palpated in the
mitral area (point of maximal
impulse-PMI). Amplitude is
usually small(like a gentle tap),
duration is brief.
➢ No pulsations or vibrations are
palpated in the areas of the
apex, left sternal border or base.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation: Anterior Chest
➢ Auscultate heart rate(HR)
and rhythm.
➢ FINDINGS: Heart rate should
be 60-100 beats/minute, with
regular rhythm.
➢BRADYCARDIA
➢TACHYCARDIA

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation: Anterior Chest
➢ PULSE RATE DEFICIT is done
by palpating the radial pulse
while you auscultate the
apical pulse. This is done by 2
person. Count for 1 full
minute.
➢ FINDINGS: The radial pulse
and apical pulse should be
identical.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation: Anterior Chest
➢ Auscultate 5 areas of the
heart.
➢ Auscultate heart sounds.
➢ “lub”- S1
➢ “dubb”- S2
➢ FINDINGS:
➢ S1 and S2 sounds make up
the cardiac cycle of systole
and diastole.
➢ S1 is loudest at the apex of
the heart and S2 is loudest
at the base of the heart.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Auscultation: Anterior Chest
➢ Auscultate for extra
heart sounds and
murmurs.
➢FINDINGS:
➢Normally no sounds
are heard, no
murmurs.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

***Physiologic murmur is caused by a
temporary increase in blood flow; it can occur
with anemia, pregnancy, fever, and
hyperthyroidism.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Older Client
• Be cautious with older
clients because
atherosclerosis may have
caused obstruction, and
compression may easily
block circulation.
• In older clients, the
apical impulse may be
difficult to palpate
because of increased
anteroposterior chest
diameter.

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Analysis of Data
• Validating and documenting findings
• Diagnostic reasoning
• Collaborative problems

RHODA GRACE ESTIOCO RUELOS, MAN, RN

• RESOURCE/S:

➢HEALTH ASSESSMENT IN NURSING, Janet

Weber & Jane Kelley, 6th Edition

RHODA GRACE ESTIOCO RUELOS, MAN, RN

 Thank you! =)

RHODA GRACE ESTIOCO RUELOS, MAN, RN