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.