Health Assessment (Lecture)

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

Session # 13

LESSON TITLE: The Cardiovascular System (Part 2) reduce coronary heart disease.
LEARNING OUTCOMES: Materials:

Upon completion of this lesson, the nursing student can: Book, pen and notebook, index card/class list

1. Obtain an accurate history of the cardiovascular system;

2. Appropriately prepare and position the patient for
References: Bates’ Nursing Guide to Physical
cardiovascular examination;
Examination and History Taking (Second Edition)
3. Inspect, palpate, and auscultate the jugular veins, carotid
by Beth Hogan-Quigley, Mary Louise Palm, and
arteries, and the precordium to evaluate cardiovascular
Lynn Bickley.
status;
4. Discuss risk factors for coronary heart disease;
5. Discuss risk reduction and health promotion strategies to

MAIN LESSON (60 minutes)

The students will study and read Chapter 14 of their book about this lesson:

Preparation of the Patient:

• The patient should be comfortable and calm as anxiety may elevate the blood pressure or change the heart
rate or rhythm.
• Review the examination procedure with the patient before putting on the examination gown. Explain why
visualization of the anterior chest is important for data gathering.
• The examination gown has the opening in the front, which enables the nurse to open the gown only as
necessary during the examination.
• Assist the patient onto the examination table, if necessary, and immediately drape with a sheet. Perform the
examination from the patient’s right side.

Equipment Needed for Examination

• Stethoscope with a bell and diaphragm
• Sphygmomanometer
• Two 15-cm rulers
• Watch with second hand
• Examination light for tangential lighting

The components of the cardiovascular examination include:

Face  As you are taking the patient’s history inspect the face, noting its color and the presence of any orbital
edema. Look for signs of anxiety. Pallor or cyanosis may indicate poor perfusion of oxygen and orbital
edema may indicate heart failure. Anxiety occurs during heart attacks.
• Infants may exhibit circumoral cyanosis with feeding.

Great Vessels of the Neck

• The Carotid Artery Pulse. The carotid pulse provides valuable information about cardiac function and is
especially useful for detecting stenosis or insufficiency of the aortic valve.

The Amplitude and Contour

• To assess amplitude and contour of the carotid pulse, the patient should be lying down with the head
of the bed elevated to about 30°.
• First inspect the neck for carotid pulsations. These may be visible just medial to the sternocleidomastoid
muscles.

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 • Then place your index and middle fingers on the right carotid artery in the lower third of the neck, press
posteriorly, and feel for pulsations.
• A tortuous and kinked carotid artery may produce a unilateral pulsatile bulge.
• Causes of decreased pulsations include decreased stroke volume and local factors in the artery such as
atherosclerotic narrowing or occlusion.
• Press just inside the medial border of a well-relaxed sternocleidomastoid muscle, roughly at the level of
the cricoid cartilage.
• Avoid pressing on the carotid sinus, which lies at the level of the top of the thyroid cartilage.
• For the left carotid artery, use your right fingers. Never press both carotids at the same time.
• This may decrease blood flow to the brain and induce syncope.
• Slowly increase pressure until the maximal pulsation is felt, and then slowly decrease pressure until you
best sense the arterial pressure and contour.

The Amplitude of the Pulse

• The amplitude of the pulse. This correlates reasonably well with the pulse pressure.
• Small, thready, or weak pulse in cardiogenic shock; bounding pulse in aortic insufficiency

Contour of the Pulse Wave

• The contour of the pulse wave, namely, the speed of the upstroke, the duration of its summit, and the
speed of the downstroke.
• The normal upstroke is brisk. It is smooth and rapid and follows S1 almost immediately.
• The summit is smooth, rounded, and roughly midsystolic.
• The downstroke is less abrupt than the upstroke.

Variations in Amplitude

• Any variations in amplitude, either from beat to beat or with respiration.

• The timing of the carotid upstroke in relation to S1 and S2.
• Note that the normal carotid upstroke follows S1 and precedes S2.
• This relationship is very helpful in correctly identifying S1 and S2, especially when the heart rate is
increased and the duration of diastole, normally shorter than systole, is shortened and approaches the
duration of systole.

Thrills and Bruits

• During palpation of the carotid artery, humming vibrations, or thrills, that feel like the throat of a purring
cat may be detected.
• Routinely, but especially in the presence of a thrill, listen over both carotid arteries with the bell of the
stethoscope for a bruit, a murmur-like sound of vascular rather than cardiac origin.

The Brachial Artery

• Use the index and middle fingers to feel for the pulse just medial to the biceps tendon. The patient’s arm
should rest with the elbow extended, palm up. With your free hand, you may need to flex the elbow to a
varying degree to get optimal muscular relaxation.

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Hepatojugular Reflux

• If heart failure is suspected from the patient history or physical examination or if the jugular venous pressure
is elevated, perform the hepatojugular reflux maneuver.
• Position the patient supine with the head of the bed at the same angle used for the jugular venous pressure
examination.
• Place your right hand with fingers pointing toward the patient’s head over the right upper quadrant of the
patient’s abdomen just below the costal margin as seen on the next page.
• Press deeply in and upward and hold the pressure for 30 seconds. This maneuver forces the hepatic venous
blood into the vena cavae, elevating the venous blood volume and pressure.
• While you are applying pressure, watch the patient’s jugular vein level. The healthy person is able to pump
the extra blood through the heart within a few seconds. The jugular vein pressure will rise for a few seconds
and then rapidly diminish to previous levels.

The Heart
• For much of the cardiac examination, the patient should be supine, with the upper body raised by elevating
the head of the bed or table to about 30°.
• Two other positions are also needed: (1) turning to the left side and (2) sitting and leaning forward. These
positions bring the ventricular apex and left ventricular outflow tract closer to the chest wall, enhancing
detection of the PMI and aortic insufficiency. The examiner should stand at the patient’s right side.
• Note the anatomic location of sounds in terms of intercostal spaces and their distance from the midsternal or
midclavicular lines.
• The midsternal line offers the most reliable zero point for measurement, but some feel that the midclavicular
line accommodates the different sizes and shapes of patients.
• Identify the timing of impulses or sounds in relation to the cardiac cycle.
• Timing of sounds is often possible through auscultation alone. In most people with normal or slow heart
rates, it is easy to identify the paired heart sounds by listening through a stethoscope.
• S1 is the first of these sounds, S2 is the second, and the relatively long diastolic interval separates one pair
from the next.

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 • S1 is sometimes called ―lub‖ and S2 ―dub.‖ Listen for the lub-dub sequence to distinguish the two sounds.
• The relative intensity of these sounds is also helpful. S1 is usually louder than S2 at the apex; S2 is usually
louder than S1 at the base.

Inspection
• Carefully inspect the anterior chest for the location of the apical impulse or point of maximal impulse or
heaves over the precordium, which indicate increased ventricular movement. Tangential light is useful for
making this observation. Use palpation to confirm the characteristics of the apical impulse.

Palpation
• Begin with general palpation of the chest wall. First palpate for heaves, (lifts), using your fingerpads. Hold
them flat or obliquely on the body surface. Ventricular impulses may heave or lift your finger.
• Check for thrills, formed by the turbulence of underlying murmurs, by pressing the ball of your hand firmly on
the chest. If subsequent auscultation reveals a loud murmur, go back to that area and check for thrills again.
• Thrills may accompany loud, harsh, or rumbling murmurs as in aortic stenosis, patent ductus arteriosus,
ventricular septal defect, and, less commonly, mitral stenosis. They are palpated more easily in patient
positions that accentuate the murmur.

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 • On rare occasions, a patient has dextrocardia—a heart situated on the right side. The apical impulse will then
be found on the right. If you cannot find an apical impulse, percuss for the dullness of theheart and liver and
for the tympany of the stomach. In situs inversus, all three of these structures are on opposite sides from
normal. A rightsided heart with a normally placed liver and stomach is usually associated with congenital
heart disease.
• Be sure to assess the right ventricle by palpating the right ventricular area at the lower left sternal border and
in the subxiphoid area, the pulmonary artery in the left 2nd intercostal space, and the aortic area in the right
2nd intercostal space (see the diagram with palpation areas indicated.
• Palpable pulsations of the right ventricle may indicate an enlarged right ventricle.

The Apical Impulse or Point of Maximal Impulse

• The apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during
contraction and touches the chest wall.
• Note that in most examinations the apical impulse is the point of maximal impulse, or PMI; however, some
pathologic conditions may produce a pulsation that is more prominent than the apex beat, such as an
enlarged right ventricle, a dilated pulmonary artery, or an aneurysm of the aorta.
• If you cannot identify the apical impulse with the patient supine, ask the patient to roll partly onto the left side
—this is the left lateral decubitus position.
• Palpate again, using the palmar surfaces of several fingers. If you cannot find the apical impulse, ask the
patient to exhale fully and stop breathing for a few seconds.
• When examining a woman, it may be helpful to displace the left breast upward or laterally as necessary;
alternatively, ask her to do this for you.
• The apex beat is palpable in only 25% to 40% of healthy adults in the supine position and in 50% of healthy
adults in the left lateral decubitus position, especially those who are thin

Pulmonic Area – The Left 2nd Intercostal Space

• This intercostal space overlies the pulmonary artery. As the patient holds expiration, look and feel for an
impulse and feel for possible heart sounds. In thin or shallow-chested patients, the pulsation of a pulmonary
artery may sometimes be felt here, especially after exercise or with excitement.

Aortic Area – The Right 2nd Intercostal Space

• This intercostal space overlies the aortic outflow tract. Search for pulsations and palpable heart sounds.
• A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary artery. A
palpable S2 suggests increased pressure in the pulmonary artery (pulmonary hypertension).

Percussion
• Percussion is rarely used today to estimate cardiac size. X-rays, ECG, and echocardiography provide
accurate measurement. Palpation of the apical impulse can provide a rough size estimate.

Auscultation

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 • The diaphragm. The diaphragm is better for picking up the relatively high-pitched sounds 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 and the 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 apex, and then move medially along the lower sternal border. Resting the heel of your hand on the
chest like a fulcrum may help you to maintain light pressure.

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not
allowed. You are given 20 minutes for this activity:

Multiple Choice

1. When assessing the amplitude and contour of the patient’s carotid pulse, Nurse Sakura must place the
patient in a
a. High Fowler’s position
b. Supine position
c. Head of the bed elevated to 30 degrees
d. Left Sim’s Position

ANSWER: C
RATIONALE: To assess amplitude and contour of the carotid pulse, the patient should be lying down with
the head of the bed elevated to about 30°.

2. What will happen if the nurse has accidentally pressed both carotid arteries at the same time while assessing
the
patient’s neck?
a. Syncope
b. Hypertension
c. Stroke
d. Myocardial infarction

ANSWER: A
RATIONALE: If both arteries are pressed at the same time, this may decrease blood flow to the brain and
induce syncope.

3. What would be the characteristic of the pulse of a patient who is suffering from aortic insufficiency?
a. Slow, weak, and thready
b. Bounding pulse
c. Fast and bounding
d. Weak and almost unpalpable

ANSWER: B
RATIONALE: The bounding pulse is the characteristic of a patient who is suffering from aortic insufficiency.

4. The hepatojugular reflux is elicited by applying pressure on the patient’s abdomen. Which quadrant will the
nurse apply pressure on?

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 a. Right upper quadrant
b. Left upper quadrant
c. Right lower quadrant
d. Left lower quadrant

ANSWER: A
RATIONALE: The nurse will apply pressure on the right upper quadrant of the patient’s abdomen just below
the costal margin as seen on the next page. As this maneuver forces the hepatic venous blood into the vena
cavae, elevating the venous blood volume and pressure.

5. When detecting the point of maximal impulse on the patient, the nurse must stand at the
a. Left side of the patient
b. Right side of the patient
c. Head of the patient
d. None of the above

ANSWER: B
RATIONALE: When detecting the point of maximal impulse on the patient, the nurse must stand at the right
side of the patient. Gently place palmar surface of fingers at the apex of the heart. Have patient turn slightly
to left side if unable to locate pulsation with patient in supine position.

6. When assessing for any palpable thrills over the heart of the patient, Nurse Ikumi must use her
a. Finger pads
b. Index and the middle finger
c. Thumb
d. Ball of her hand

ANSWER: D
RATIONALE: When checking for thrills, formed by the turbulence of underlying murmurs, by pressing the
ball of your hand firmly on the chest. If subsequent auscultation reveals a loud murmur, go back to that area
and check for thrills again.

7. Which of the following conditions can exhibit thrills in a patient?

a. Aortic stenosis
b. Patent ductus arteriosus
c. Ventricular septal defect
d. All of the above

ANSWER: D
RATIONALE: In aortic stenosis, patent ductus arteriosus, ventricular septal defect, and, less typically, mitral
stenosis, thrills may accompany loud, harsh, or rumbling murmurs. They are easier to detect when the
patient is in a position that accentuates the murmur.

8. This is a condition where the internal organs from the thoracic and abdominal cavity are found on the
opposite sides from what is normal
a. Dextrocardia
b. Situs inversus
c. Congenital heart disease
d. Cardiomegaly

ANSWER: B

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RATIONALE: Situs inversus is a hereditary disease in which the organs of the chest and abdomen are
mirrored in their normal positions. The left atrium of the heart and the left lung, for example, are located on
the right side of the body.

9. The right ventricle of the heart can be palpated at the

a. Left 2nd intercostal space
b. Right 2nd intercostal space
c. Left 5th intercostal space
d. Lower left sternal border in the subxiphoid area

ANSWER: D
RATIONALE: Assess the right ventricle by palpating the right ventricular area at the lower left sternal border
and in the subxiphoid area.

10. When assessing the point of maximal impulse in a female patient, we tell the patient to do which of the
following?
a. Let the patient displace her left breast upward and laterally
b. Let the patient displace her left breast downward and medially
c. Let the patient displace her left breast upward
d. Let the patient displace her left breast laterally

ANSWER: D
RATIONALE: In assessing the point of maximal impulse in a female patient, we tell the patient to displace her
left breast to the side (laterally).

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help
you track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Turn and talk

(Students turn to talk partner/s to – find out, summarize, clarify, share ideas, point of view or opinions)

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