ASSESSMENT OF THE HEART AND NECK VESSEL .pptx

HEART AND NECK
VESSEL ASSESSMENT
BY: ROMMEL LUIS C. ISRAEL III
1

THE HEALTH HISTORY
5
Common or Concerning Symptoms
• Chest pain
• Palpitations
• Shortness of breath: dyspnea,
orthopnea, or paroxysmal nocturnal
dyspnea
• Swelling or edema

6
Chest Pain.
• Chest pain is one of the most serious and important
symptoms you will assess as a clinician and is the second
leading cause of emergency room visits, after abdominal pain.

EXAMPLES OF ABNORMALITIES
7
• Classic exertional pain, pressure, or
discomfort in the chest, shoulder, back,
neck, or arm in angina pectoris, seen in
50% of patients with acute myocardial
infarction;
• atypical descriptors also are common, such
as cramping, grinding, pricking; rarely,
tooth or jaw pain.

Palpitations.
• Palpitations involve an unpleasant awareness of the
heartbeat.
• When describing palpitations, patients use terms such as
skipping, racing, fluttering, pounding, or stopping of the
heart.
• Palpitations may result from an irregular heartbeat, from
rapid acceleration or slowing of the heart, or from increased
forcefulness of cardiac contraction.
• Such perceptions also depend on how patients respond to
their own body sensations.
• Palpitations do not necessarily mean heart disease. In
contrast, the most serious dysrhythmias, such as ventricular
tachycardia, often do not produce palpitations
8

9
Shortness of
Breath.
• Shortness of breath is a
common patient concern
and may represent
dyspnea, orthopnea, or
paroxysmal nocturnal
dyspnea. Dyspnea is an
uncomfortable awareness
of breathing that is
inappropriate

10
Edema.
• refers to the accumulation of
excessive fluid in the extravascular
interstitial space. Interstitial tissue can
absorb several liters of fluid,
accommodating up to a 10% weight
gain before pitting edema appears.
Causes vary from local to systemic.
• Focus your questions on the location,
timing, and setting of the swelling, and
on associated symptoms. “Have you
had any swelling anywhere? Where?
… Anywhere else? When does it
occur? Is it worse in the morning or
at night? Do your shoes get tight?”

EXAMPLES OF ABNORMALITIES
11
Dependent edema appears in the lowest body parts: the feet and
lower legs when sitting, or the sacrum when bedridden.
Causes may be cardiac (congestive heart failure), nutritional
(hypoalbuminemia), or positional
Edema occurs in renal and liver disease: periorbital puffiness, tight
rings in nephrotic syndrome; enlarged waistline from ascites and
liver failure.

1. OBSERVE FOR JUGULAR
VENOUS PRESSURE
• Stand straight on the Right
side of the patient.
• Patient should be in supine
position w/ torso elevated
30-45degrees.
• Ask pt. to turn head to the
Left.
• Shine light on the neck.
• Inspect suprasternal
notch/area around clavicles
for pulsations.
• JVP is not normally visible
w/ sitting upright.
• This position distends the
vein, & pulsations may or
may not be discernible.
12

ABNORMALITIES:
13
• Fully distended JV in 45
degrees indicate
increased central
pressure
( Right ventricular
pressure, pulmonary
hypertension,
pulmonary emboli)

2. EVALUATE JUGULAR
VENOUS PRESSURE.
14
• Position pt. with head of bed elevated
30, 45, 60, 90 degrees.
• At each increase of the elevation, have
pt’s head turned away from the side
being evaluated.
• Using tangential light, observe for
distention.
• The JV should not be distended,
bulging or protruding @ 45 degrees
or greater.

15
ABNORMALITIES:
Ride-sided HF=
distention, bulging
protrusion at 45,
90 degrees.
COPD= elevated
venous pressure only
during expiration.
Severe constrictive
pericarditis=
inspiratory venous
pressure.

16
3.
AUSCULTATE
CAROTID
ARTERIES
Place bell of steth over the carotid artery
ask the client to hold his or her breath for
moment so breath sounds do not conceal
any vascular sounds.
No blowing or swishing or other sounds
heard.
Pulses are equally strong.
Contour is normally smooth & rapid on
upstroke & slower & less abrupt on the
downstroke.
Arteries are elastic & no thrills are noted.

17
ABNORMALITIES:
BRUIT- blowing or
sound caused by turbulent
blood flow through a
narrowed vessel indicative
occlusive arterial disease.
Pulse inequality may
arterial constriction or
occlusion in one carotid.

4. PALPATE CAROTID ARTERIES
• Palpate by placing pads of index & middle fingers medial to
the sternocleidomastoid muscle of the neck.
• Note for amplitude & contour of pulse, elasticity of artery and
any thrills.
• The strength of the pulse is evaluated on the scale from 0-4:
• Pulse amplitude scale:
0 =absent 2+ = normal 4+= bounding
1+ = weak 3+ = increased
18

ABNORMALITIES:
19
• Weak pulses may indicate hypovolemia,
shock, or decreased CO.
• Bounding pulse, firm pulse may indicate
hypervolemia or increased CO.
• Variations in strength from beat to beat or with
respirations are abnormal & may indicate
variety of problems.
• Loss of elasticity may indicate arteriosclerosis.
• Thrills may indicate narrowing of artery.

20
5. INSPECT
PULSATIONS.
Place pt. in supine w/ HOB elevated
bet.30 & 45 degrees.
Stand on the R side & look for the
impulse & any abdominal pulsations.
The apical pulse may or may not be
visible.
If apparent, it would be in the MITRAL
AREA( L midclavicular line, 4th 0r 5th
Apical pulse is the result of L ventricle
moving outward during systole.

21
7.
PALPATE
APICAL
PULSE.
Remain pt. on R side
ask to remain in
supine.
Use finger pads to
palpate apical pulse
the mitral are( 4th or
5th ICS)
After locating, use
finger pad for more
accurate palpations.

Apical pulse is palpated in the mitral area ( 4th or
5th ICS) & the size of a nickel ( 1-2cm).
Amplitude is small-like a gentle tap & duration is
brief, lasting through the 1st 2/3 of systole &
often less.
In obese pts. Or with large breasts, the apical
impulse may not b palpable.
22

23

24

ABNORMALITIES:
Apical impulse may be impossible to palpate in
w/ pulmonary emphysema.
Cardiac enlargement- if apical impulse is larger
than 1-2cm, displaced, more forceful or of
duration.
25

26
8. PALPATE
FOR
ABNORMAL
PULSATIONS.
Use palmar surfaces to
palpate apex. Left
border & base.
NO pulsations/
are palpated in the
of the apex, Left sternal
border, or base.

ABNORMALITIES:
27
• A thrill ( similar to
a purring ca) or
pulsation is usually
associated w/
grade IV or higher
murmur.

28
9.
AUSCULTATE
HEART RATE
& RHYTHM.
Place diaphragm of
steth at the apex &
listen closely to the
& rhythm of apical
impulse.
Rate=60-100per
w/ regular rhythm.
Pulse rate in females is
5-10 bpm faster than
males.

29
ABNORMALITIES:
Bradycardia( less
than 60 beats per
minute)
Tachycardia ( more
than 100 beats per
minute) may result
decreased CO.

10. IF YOU
DETECT
IRREGULAR
RHYTHM,
AUSCULTATE
FOR PULSE
RATE DEFICIT.
30
Palpate radial pulse
while you
auscultate the
apical pulse
Count for full
minute.
The radial &
rates should be
identical.

31
ABNORMALITIES:
Pulse deficit ( difference between
radial pulse)
Atrial fibrillation ( an abnormal heart
rhythm characterized by rapid &
beating of the atria)
Atrial flutter ( a common abnormal
rhythm that starts in the atrial
of the heart associated with a fast HR)
PVCs ( premature heartbeats
from the venticles of the heart)

NORMAL ECG TRACING
32

ATRIAL FIBRILLATION AND ATRIAL
FLUTTER WITH VARYING AV
BLOCK
33

PREMATURE VENTRICULAR
CONTRACTIONS
34

35
11.
AUSCULTATE
TO IDENTIFY
S1 & S2.
Auscultate S1( the first heart
“lub”) &
S2 ( 2nd heart sound “ dub”).
S1 corresponds with each carotid
pulsation & is the loudest at the
apex of the heart.
S2 immediately follows after S1
is the loudest at the base of the
heart.

36
ABNORMALITIES:
LIFT- associated with right ventricular
hypertrophy caused by pulmonic valve
disease, pulmonic HPN & chronic lung
disease.
THRILL-palpated over the 2nd & 3rd ICS;
indicate severe aortic stenosis & systemic
HPN.
ACCENTUATED APICAL IMPULSE- sign of
pressure overload.
LATERALLY DISPLACED APICAL IMPULSE-
of volume overload.

37
12.
AUSCULTATE
FOR EXTRA
HEART
SOUNDS.
Use diaphragm first
the bell to auscultate
the entire heart area.
Note characteristics (
location, timing)
Normally, no sounds are
heard.

38
KNOW YOUR
STETHOSCOPE!
It is important to understand the uses of both the diaphragm and
bell.
The diaphragm.
The diaphragm is better for picking up the relatively high-pitched
of S1 and S2, the murmurs of aortic and mitral regurgitation, and
pericardial friction rubs. Listen throughout the precordium with the
diaphragm, pressing it firmly against the chest.
The bell.
The bell is more sensitive to the low-pitched sounds of S3 and S4
murmur of mitral stenosis. Apply the bell lightly, with just enough
pressure to produce an air seal with its full rim. Use the bell at the
then move medially along the lower sternal border. Resting the heel
your hand on the chest like a fulcrum may help you to maintain
pressure.

39

40

41
ABNORMALITIES:
Ejection sounds/
clicks- associated w/
mitral valve
Heard just after S1
Friction rub- may be
heard during
pause.

42
13.
AUSCULTATE
FOR
MURMURS.
Auscultate murmurs across
the entire heart. Use
diaphragm & bell of the
steth in all areas in
positions.
MURMUR-swishing sound
caused by turbulent blood
flow through the heart
valves or vessels.
No murmurs heard.

43
ABNORMALITIES:
Midsystolic Murmur-
type of murmur; occur
ventricular ejection.
Pansystolic murmur-
when blood flows from a
chamber with high pressure
a chamber of low pressure
an orifice that should be
clossed.

44

45
14.
AUSCULTATE
CLIENT WHILE
ASSUMING
OTHER
POSITIONS.
Ask pt. to assume left
position.
Use bell of the steth &
at the apex of the heart.
Ask patient to sit up, lean
forward & exhale. Use
diaphragm of steth &
over the apex & left
border.
S1 & S2 heart sounds are
normally present.

ABNORMALITIES:
• S3 ( 3rd heart sound)
• Ventricular gallop
• Has low frequency & is heard using the bell of steth at the
apical area.
• Accentuated during inspiration & has rhythm of the word “
KEN-TUC-KY”
• Normal to young children, people with high CO.
• Associated with myocardial failure, CHF.
46

ABNORMALITIES:
• S4 ( 4th heart sound)
• Atrial gallop
• Low-frequency sound occurring at the end of diastole when
atria contract.
• Has rhythm word “ TEN-NES-SEE”
• Normal in trained athletes & some older patients.
• Abnormal to coronary artery dse. , HPN, AMI.
47

48
RECORDING
YOUR
FINDINGS
Recording the Physical
Examination—The
Cardiovascular Examination
“The jugular venous pulse
is 3 cm above the sternal
with the head of bed elevated
30°. Carotid upstrokes are
without bruits.
The point of maximal impulse
(PMI) is tapping, 7 cm lateral
the midsternal line in the 5th
intercostal space. Crisp S1 and

49
RECORDING
YOUR
FINDINGS
The JVP is 5 cm above the sternal
with the head of bed elevated to 50°.
Carotid upstrokes are brisk; a bruit is
heard over the left carotid artery.
The PMI is diffuse, 3 cm in diameter,
palpated at the anterior axillary line
the 5th and 6th intercostal spaces.
S1 and S2 are soft. S3 present at the
apex. High-pitched harsh 2/6
holosystolic murmur best heard at
apex, radiating to the axilla.”

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