Cardiac Assessment Notes

Neck Vessels

  • Palpate Carotid Artery:

    • Located on both sides of the neck, but palpate only one at a time. Palpating both simultaneously can reduce blood flow to the brain.
    • Avoid applying hard pressure, especially in older adults, to prevent a vagal response.

  • Vagal Response (Vasovagal):

    • Stimulation of the vagus nerve leads to:
      • Drop in heart rate (bradycardia).
      • Drop in blood pressure.
      • Dizziness and fainting.

  • Approach:

    • Use two fingers gently.
    • Inform the patient before palpating.

Auscultating Carotid Artery

  • Purpose: To assess for a bruit, which indicates turbulent blood flow.
  • When to Auscultate:
    • Older patients due to higher risk of cardiovascular disease.
    • Patients with risk factors for cardiovascular disease, regardless of age.
  • Technique:
    • Apply the stethoscope gently to avoid creating a false bruit by compressing the vessel.

Jugular Venous Pulse and Distension (JVD)

  • Jugular Venous Distension (JVD) Indicates:

    • Increased pressure, often due to:
      • Right-sided heart failure:
      • Fluid overload

  • Heart Failure and Fluid Backup:

    • Left-sided heart failure: Blood backs up into the lungs, causing breathing difficulties and crackles.
    • Right-sided heart failure: Fluid backs up into the venous system, leading to JVD.

  • Patient Positioning:

    • Angle: 30 to 45 degrees. Veins flatten beyond 45 degrees.
    • Remove pillows to maintain the correct angle.
    • Have the patient look to the left and right to visualize the neck veins.
    • Use a strong light source to better visualize pulsations and distension.

Precordium: Inspection and Palpation

  • Precordium: The anterior chest wall over the heart.
  • Inspection: Observe the apical impulse.
    • Location: Fourth or fifth intercostal space, midclavicular line on the left side.
    • Represents the ventricle pushing against the chest wall.
    • May not be visible in patients with significant adipose tissue.
  • Heave or Lift: A forceful thrusting of the heart against the chest wall.
  • Palpation of Apical Impulse:
    • Use one finger pad.
    • Ask the patient to exhale and hold their breath.
    • If not palpable, have the patient turn to their left side to bring the heart closer to the chest wall.
  • Palpation Across the Precordium:
    • Palpate the apex, left sternal border, and base of the heart.
    • Note: Do not palpate the heart itself.
    • Palpate to feel for pulsations.
    • Base of the heart: at the top;
    • Apex of the heart: Bottom
  • Thrills:
    • A palpable vibration indicative of turbulent blood flow; feels like a cat's purr.
    • Use the palmar surface of the hand to detect vibrations.
    • A thrill is the palpable equivalent of a bruit.
    • If you feel a thrill, you will likely hear a murmur.

Auscultation of the Precordium

  • Auscultation Landmarks:
    • Aortic: Second intercostal space, right sternal border.
    • Pulmonic: Second intercostal space, left sternal border.
    • Erb's Point: Third intercostal space, left sternal border.
    • Tricuspid: Fourth intercostal space, left sternal border.
    • Mitral (Apical): Fifth intercostal space, midclavicular line.
  • Note: These are the areas where valve sounds are best heard, not necessarily the exact location of the valves.
  • Technique:
    • Use the diaphragm of the stethoscope first to identify the rate and rhythm.
      • Rate: Typically 60-100 bpm.
      • Rhythm: Regular or irregular.
    • Listen for S1 and S2 sounds in each location.
  • Heart Sounds:
    • S1 (lub): Closure of the AV valves (mitral and tricuspid).
      • Louder at the apex.
    • S2 (dub): Closure of the semilunar valves (aortic and pulmonic).
      • Louder at the base.
  • Murmurs:
    • Use the bell of the stethoscope to listen for murmurs in all valve areas.
    • Murmur sounds like blowing or swooshing.
    • Patient position: Roll to the left side to accentuate S3 and S4 sounds.
  • Grading Murmurs:
    • Murmurs are graded on a scale of 1 to 6.
  • S2 Split:
    • Occurs during inspiration when the aortic and pulmonic valves close at slightly different times.
    • Normal finding.
    • Differentiate from extra heart sounds by observing the patient's breathing.
  • S3:
    • Expected in an elderly patient.
    • Unexpected in a younger patient.
  • S4:
    • Never normal.
  • Summation Sound:
    • When there's no distinguishable s1 or s2 happening all at the same time.

Irregular Heart Rate and Pulse Deficit

  • Technique:
    • Listen to the apical pulse with a stethoscope while simultaneously palpating the radial pulse for a full minute.
  • Pulse Deficit:
    • The apical pulse rate is higher than the radial pulse rate.
    • Indicates that not every heartbeat is generating enough force to be felt at the periphery, suggesting reduced peripheral blood flow.