ASSESSING THE HEART AND CENTRAL VESSELS Simultaneously inspect and palpate the precordium for the presence of abnormal pulsations, lifts, or heaves. Locate the valve areas of the heart:
- Locate the angle of Louis. It is felt as prominence on the sternum.
- Move your fingertips down each side of the angle until you can feel the second intercostal space. The client’s right second intercostal space is the aortic area, and the left second intercostal space is the pulmonic area. From the pulmonic area, move your fingertips down three left intercostal spaces along the side of the sternum. The left fifth intercostal space close to the sternum is the tricuspid or right ventricular area.
- From the tricuspid area, move your fingertips laterally 5 to 7 cm (2 to 3 in.) to the left midclavicular line. This is the apical or mitral area or point of maximal impulse (PMI). If you have difficulty locating the PMI, have the client roll onto the left side to move the apex closer to the chest wall.
- Inspect and palpate the aortic and pulmonic areas, observing them at an angle and to the side, to note the presence or absence of pulsations. Observing these areas at an angle increases the likelihood of seeing pulsations.
- Inspect and palpate the tricuspid area for pulsations and heaves or lifts.
- Inspect and palpate the apical area for pulsation, noting its specific location(it may be displaced laterally or lower) and diameter. If displaced laterally, record the distance between the apex and the MCL in centimeters.
- Inspect and palpate the epigastric area at the base of the sternum for abdominal aortic pulsations.
2. Auscultate the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical (mitral). Auscultation need not be limited to these areas; however, the nurse may need to move the stethoscope to find the most audible sounds for each client.
- Eliminate all sources of room noise.
- Keep the client in a supine position with head elevated 15° to 45°.
- Use both the diaphragm and the bell to listen to all areas.
- In every area of auscultation, distinguish both S1 and S2 sounds.
- When auscultating, concentrate on one particular sound at a time in each area: the first heart sound, followed by systole, then the second heart sound, then diastole. Systole and diastole are normally silent intervals.
- Later, reexamine the heart while the client is in the upright sitting position.
3. Palpate the carotid artery ,using extreme caution.
– Palpate only one carotid artery at a time.
– Avoid exerting too much pressure or massaging the area
– Ask the client to turn the head slightly toward the side being examined. This makes the carotid artery more accessible.
4. Auscultate the carotid artery. • Turn the client’s head slightly away from the side being examined.
- Auscultate the carotid artery on one side and then the other.
- Listen for the presence of a bruit. If you hear a bruit, gently palpate the artery to determine the presence of a thrill.
5. Inspect the jugular veins for distention while the client is placed in the semi Fowler’s position (15° to 45° angle), with the head supported on a small pillow.
6. If jugular distention is present, assess the jugular venous pressure (JVP).
- Locate the highest visible point of distention of the internal jugular vein. Although either the internal or the external jugular vein can be used, the internal jugular vein is more reliable.
- Measure the vertical height of this point in centimeters from the sternal angle, the point at which the clavicles meet. Repeat the preceding steps on the other side.
7. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate.
