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02.06 Heart (Cardiac) and Great Vessels Assessment

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Overview

  1. Major heart assessments:
    1. Sounds
    2. Murmurs
    3. Apical pulse
  2. The great vessels to be assessed  are:
    1. Carotid arteries
    2. Jugular veins
    3. Aorta

Nursing Points

General

  1. Supplies needed
    1. Pen light
    2. Stethoscope

Assessment

  1. Inspect
    1. Anterior chest for visible apical pulse
      1. 5th ICS, Left MCL
    2. Abdomen for pulsation
      1. May indicate an abdominal aortic aneurysm
    3. Jugular venous pulse
      1. Lay patient at 30-45 degrees, turn head away
      2. Shine penlight on neck
      3. May see slight pulsation
      4. Jugular vein should flatten at 45 degrees or higher
      5. Jugular venous distention (engorged at 30 degrees or higher) may indicate heart failure and/or volume overload
  2. Palpate
    1. Carotid pulses – locate by sliding two fingers laterally from thyroid
      1. ONE AT A TIME
      2. Compare bilaterally
    2. Apical pulsation to locate point of maximum impulse (PMI)
      1. Should be 5th ICS, Left MCL
  3. Auscultate
    1. Heart Sounds
      1. APE To Man
        1. Aortic
          1. 2nd ICS, RSB
        2. Pulmonic
          1. 2nd ICS, LSB
        3. Erb’s Point
          1. 3rd ICS, LSB
        4. Tricuspid
          1. 4th ICS, LSB
        5. Mitral
          1. 5th ICS, Left MCL
      2. Listen with Diaphragm, then Bell (for murmurs)
      3. Make note of quality and timing, presence of extra sounds
    2. Carotid bruit – listen over carotid with bell
    3. Auscultate to count Apical pulse (5th ICS, Left MCL) for a full minute.

Nursing Concepts

  1. Any NEW murmurs should be reported to the provider right away
  2. Refer to the Heart Sounds lesson in the Cardiac course for details on findings

Reference Links

Study Tools

Video Transcript

In this lesson we’re going to look at assessment of the heart and great vessels. When I say “great vessels” I’m talking about the carotid arteries, the jugular veins, and the aorta. So, as always, our assessment starts with inspection.
Before you do a physical assessment, make sure you ask your patient if they are experiencing any chest pain, tightness, or palpitations – and get detailed information about their symptoms, if they have any.

Then, start by facing your patient. We’ll start with the great vessels in the neck and work our way down.
First, make sure your patient is laying at about 30-45 degrees and look at both sides of their neck with a pen light for any jugular venous distention. If you see any pulsation, it should decrease and the vein should flatten as the patient sits up. If you see distention, even after they sit up, it could be a sign of heart failure.
Next, palpate your patient’s carotid arteries. You’ll find it by sliding two fingers laterally from the thyroid gland. It should be strong and regular. Make sure you only palpate one side at a time or you could cause too much vagal nerve stimulation and your patient will pass out on you!
Now we’ll move down to the anterior chest. You want to be able to see their chest, so you will need to remove their gown. For a woman, if they don’t have a bra or tank top on, you can expose one side at a time, or simply lift and adjust their gown to maintain their privacy and dignity.
Inspect the anterior chest for any signs of pulsation. It’s possible you could see the apical pulse, which would be at the 5th intercostal space, left midclavicular line. Then palpate this same spot for the point of maximum impulse, or PMI – this is the point at which the pulse is the strongest.
You’ll also want to inspect and palpate for any pulsations in the abdomen that could indicate an abdominal aortic aneurysm.
Now that you’ve inspected and palpated, we move to auscultation. Using the diaphragm of your stethoscope, you’re going to listen using the APE To Man mnemonic. You should hear an S1 and an S2 sound at each location. A-Aortic, 2nd intercostal space, right sternal border. P-Pulmonic, 2nd intercostal space, left sternal border. E-Erb’s point, 3rd intercostal space, left sternal border. T-Tricuspid, 4th intercostal space, left sternal border. And then M-Mitral, 5th intercostal space, left mid-clavicular line.
While you are in the mitral location, go ahead and listen for a full minute to count the patient’s Apical pulse.
Then you’re going to go back and listen to those same locations with the bell of your stethoscope. As you do this, you’re listening for murmurs and extra heart sounds like an S3 or S4. If you hear something abnormal, make note of what location you heard it at, the timing of it, and the quality of the sound.
While you have the bell of your stethoscope on, you can cover up your patient and return to their neck to listen over their carotid arteries for a bruit, which is like a whooshing sound that may indicate narrowing of the carotid arteries – which is never a good side. Again, one side at a time.

That’s it for the assessment of the heart and great vessels. Any abnormalities should be reported to the provider right away, especially new developments. Make sure you also check out the peripheral vascular assessment to learn how to assess the rest of the circulatory system.

Now, go out and be your best self today. And, as always, happy nursing!

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