Heart and Neck Vessels

PROCEDURE
1. Gathers equipment
• Stethoscope with bell and diaphragm
• Small pillow
• Penlight or movable exam light
• Watch with second hand
• 2 centimeter rulers
2. Explains procedure to the client
3. Assists client to put on gown
NECK VESSELS

1. Inspects jugular venous pulse.

• stand on the right side of the client.
• The client should be in supine position with the
torso elevated 30-45 degrees. Make sure the
head and torso are on the same plane.
• Ask the client to turn the head slightly to the
left.
• Shine a tangential light source onto the neck to
increase visualization of pulsations.
2. Measures jugular venous pressure.
. by watching for distention of the jugular
vein.
• It is normal for the jugular veins to be
visible when the client is supine to
evaluate jugular vein distention
• position the client in a supine position with
the head of the 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 a tangential lighting, observe
for distention, protrusion or bulging.
3. Auscultates carotid arteries for bruits.
• Auscultate the carotid arteries if you
suspect cardiovascular disease or if the
client is middle aged or older
• Place the bell of the stethoscope over
the carotid artery and ask the client to
hold his/ her breath for a moment so
breath sounds do not conceal any
vascular sounds.
• Always auscultate the carotid arteries
before palpating.
 NORMAL
• No blowing or swishing or other
sounds are heard
 ABNORMAL
• A bruit, a blowing or swishing sound.
4. Palpates each carotid artery for
amplitude and contour of the pulse,
elasticity of the vessel and thrills
 NORMAL
• Pulses are equally strong; 2+ or
normal, no variation in strength from
beat to beat
• Contour are normally smooth
• Arteries are elastic and no thrills are
noted.
 Abnormal
• Pulse inequality
• Weak pulses
• Bounding pulses
• Variations in strength
• The strength of the pulse is evaluated on
a scale from 0-4 as follows
• Pulse Amplitude Scale
0 Absent
1+ Weak
2+ Normal
3+ Increased
4+ Bounding
 HEART /PRECORDIUM
1. Inspects for visible pulsations with the
client in supine position with head of the
bed elevated 30 and 45 degree angle.
 HOW?
• Assist the client with the head of
the bed elevated between 30 and 45
degrees.
• Stand on the client’s right side and
look for the apical pulse and any
abnormal pulsations.
 NORMAL
• The apical pulse may or may not be
visible.
• The apical pulse is a result of the
left ventricle moving outward during
systole.
 ABNORMAL
• Present of pulsation (heaves or lifts)
may occur as a result of an enlarged
ventricle from an overload of work.
2. Palpates apical pulse for location, size,
strength and duration of pulsation.
 HOW?
• Remain on the client’s right side and
ask the client to remain supine.
• Use the palmar surfaces of your hand
to palpate the apical pulse in the
mitral area (fourth or fifth
intercostal space at midclavicular
line.) After locating the pulse use one
finger for more accurate palpation
• If this pulsation cannot be palpated,
have the client assume a left lateral
position. This displaces the heart
toward the left chest wall and
relocates the apical pulse further to
the left.
 NORMAL
• Apical pulse is palpated in the mitral area.
• in obese clients or clients with large
breasts, the apical pulse may not be
palpable.
• In older clients the apical pulse may be
difficult to palpate because of increased
anteroposterior chest diameter.
 ABNORMAL
• Apical pulse may be impossible to
palpate especially to client with
emphysema.
• The apical pulse was originally called
the point of maximal impulse (PMI).
However the term is not used
anymore because a maximal impulse
may occur in other areas of the
precordium as a result of abnormal
conditions.
3. Palpates for abnormal pulsation or
vibrations at apex, left sternal border and
base.
 HOW?
• Use your palmar surfaces to palpate
the apex, left sternal border and
base
 NORMAL
• No pulsations or vibrations are
palpated in the area of the apex, left
sternal border or base
 ABNORMAL
• A thrill, which feels similar to purring
cat, or a pulsation is usually
associated with higher murmur.
4. Auscultates heart sounds for rate and
rhythm (apical and radial pulses, pulse rate
deficit, S1 and S2) if irregular rhythm is
detected
 How?
• for the rate- Place the diaphragm of
the stethoscope at the apex and
listen
 NORMAL
• Rate should be 60-100 beats per
minute with regular rhythm
• Pulse rate in females is 5 to 10 beats
per minute faster than in males.
 ABNORMAL
• Bradycardia
• Tachycardia
• Irregular rhythms should be referred
for further evaluation. These types of
irregular patterns may predispose the
client to decreased cardiac output,
heart failure or emboli
For the Rhythm of the apical pulse.
• If you detect an irregular rhythm,
auscultate for a pulse rate deficit.
This is done by palpating the radial
pulse while you auscultate the apical
pulse. Count for a full minute.
 NORMAL
• The radial and apical pulse rates
should be identical.
 ABNORMAL
• Pulse deficit is noted.
(difference between the apical and
radial pulses) may indicate atrial
fibrillation, atrial flutter, premature
ventricular contractions.
5. Auscultate to identify s1 and s2 for
sound location and strength pattern
(louder/softer at locations and with
respirations, splitting of S2)
 HOW?
• Auscultate the first heart sound (s1
or “lub”) and the second heart sound
(s2 or “dubb”)

Remember these two sounds make up

the cardiac cycle.
• If you have difficulty differentiating
s1 from s2, palpate the carotid pulse:
the harsh sound that occurs with the
carotid pulse is s1.
• S1 starts systole and s2 starts
diastole. The space or systolic pause
between s1 and s2 is of short duration
thus s1 and s2 occur very close
together. Whereas, the space or
diastolic pause, between s2 and the
start of another s1 is of longer
duration.
 NORMAL
• S1 corresponds with each carotid pulsation
and is loudest at the apex the heart.
• S2 immediately follows after s1 and is
loudest at the base of the heart.
• Use the diaphragm of the
stethoscope to best hear S1
• Use the diaphragm of the
stethoscope to best hear S2. Ask the
client to breath normally. Do not ask
the client to hold his or her breath.
Breath holding will cause any normal
or abnormal split to subside.
• If you are experiencing difficulty
differentiating s1 from s2 palpate
the carotid pulse; the harsh sound
that occurs with the carotid pulse is
S1.
6. Auscultates 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).
• Use the diaphragm first then the bell
to auscultate the entire area. Note
the characteristics like location,
timing of any extra sound heard.
• Auscultate during the diastolic pause
( space heard between end of S2 and
the next S1
• While auscultating keep in mind that
development of a pathologic S3 may
be the earliest sign of heart failure
 NORMAL
• No sounds are heard
 ABNORMAL
• Ejection sounds or clicks associated
with mitral valve prolapse
• A friction rub may also be heard
during systolic pause.
• video
Auscultate for murmurs
 murmur
- Is a swishing sound caused by turbulent
blood flow through the heart valves or
great vessels.
 HOW?
• Auscultate for murmurs across the
entire heart.
• Use the diaphragm and the bell of
the stethoscope in all areas of
auscultation because murmurs have a
variety of pitches
 NORMAL
• no murmurs are heard.
 ABNORMAL
• With murmurs
7.Auscultates with the client in the left
lateral position and with the client sitting
up, leaning forward and exhaling.
 HOW?
• Ask the client to assume a left
lateral position.
• Use the bell of the stethoscope and
listen at the apex of the heart
 NORMAL
• S1 and S2 heart sounds are normally
present.
 ABNORMAL
• An S3 or S4 heart sound or a murmur
of mitral stenosis that was not
detected with the client in the supine
position may be revealed when the
client assumes the left lateral
position.
• Ask the client to sit up , lean forward
and exhale. Use the diaphragm of the
stethoscope and listen over the apex
and along the sternal border.
 NORMAL
• S1 and s2 heart sounds are normally
present
 ABNORMAL
• Murmur of aortic regurgitation may
be detected when the client assumes
this position.