Head-To-Toe Assessment P. Thorax (Cardiovascular System)

Posted by: Admin

To receive automatic updates of Nursing News, Nursing Care Plans, Case Studies and the much awaited November 2008 Nursing Board Exam Result: click Subscribe to NursingCrib.com by Email or via RSS. If you have other topics to discuss, make a post on our Nursing Crib Forum. Thanks for visiting and enjoy your stay!

Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts

Normal Findings:

1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size).
2. There should be no lift or heaves.

Palpation of the Heart
The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex, moving to the left sternal border, and then to the base of the heart.

Normal Findings:

1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness.

Auscultation of the Heart

Anatomic areas for auscultation of the heart:

Aortic valve – Right 2^nd ICS sternal border.

Pulmonic Valve – Left 2^nd ICS sternal border.

Tricuspid Valve - – Left 5^th ICS sternal border.

Mitral Valve - Left 5^th ICS midclavicular line

Positioning the client for auscultation:

• If the heart sounds are faint or undetectable, try listening to them with the patient seated and learning forward, or lying on his left side, which brings the heart closer to the surface of the chest.
• Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem.
• The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and extra heart sounds.

Auscultating the heart

1. 1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
   2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve.
   3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
   4. Count heart rate at the apical pulse for one full minute.

Normal Findings:

1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.

_____________________________________________________________________________________________

• Head-To-Toe Assessment (R. Abdomen) In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles. Inspection of the abdomen Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour
• Head-To-Toe Assessment (O. Neck) The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension. Normal Findings: The neck is straight. No visible mass or lumps. Symmetrical No jugular venous distension
• Head-To-Toe Assessment (L. Ears) 1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process. 3. Inspect the auditory meatus or the
• Head-To-Toe Assessment N. Cranial Nerve I (olfactory Nerve) To test the adequacy of function of the olfactory nerve: The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. (e.g. coffee). Ask the client to identify the odor. Each side
• Head-To-Toe Assessment (I. Pupils) Examination of the pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is observed for consensual response of constriction. The test for papillary accommodation is the examination for the change in papillary size as the is switched from a