Have patient assume semi-fowler's o

Have patient assume semi-fowler's or supine position.
3.


Explain procedure.
4.


Be sure that room is quiet.
5.


Assess the heart:
6.


Form image of location of the heart in your mind.
a.


Find the angle of Louis, which is felt as a ridge in the sternum approximately 5cm below the suprasternal notch.
b.


Find the following anatomical landmarks.
c.


The aortic area is at the second intercostals space, right of the sternum.
(1)


The pulmonic area is at the second intercostals space, left of the sternum.
(2)


Erb,s point ( second pulmonic area ) is at the third intercostals space.
(3)


The tricuspid area is located at the forth left intercostals space along the sternum.
(4)


The mitral area is located at the fifth intercostals space at the left midclavicular line.
(5)


The epigastric area is at the inferior tip of the sternum.
(6)


Stand to patient's right to inspect and palpate the precorduim with patient supine. Note any visible pulsations or lifts.
d.


Locate point of maximal impulse (PMI) by palpating along the fifth ICS in the midclavicular line.
e.


If palpation of PMI is difficult, turn patient onto left side.
f.


Inspect the epigastric area and palpate the abdominal aorta. Note a localized strong beat.
g.


Auscultate heart sounds with patient sitting, supine, and in left lateral recumbent position. In a female patient lift left breast.
h.


Ask patient not to speak but to breathe comfortably . Begin with the diaphragm of the stethoscope lightly; then with the bell.
(1)


Begin at the apex or PMI; move systematically to the aortic area, pulmonic area, Erb's point, tricuspid area and mitral area, S1 is best heard at the apex.
(2)


Listen to S2 at each site. This sound is best heard at the aortic area.
(3)


After both sounds are heard clearly as " lub-dub", count each combination of S1 and S2 as one heart beat. Count the number for 1 minute.
(4)


Assess heart rhythm by noting the time between S1 and S2 (systole) and the time between S2 and the next S1( diastole). There should be a distinct pause between S1and S2.
(5)


When the heart rate is irregular, compare apical and radial pulses.
(6)


Assess neck vessels:
(7)


Assess carotid arteries with patient in sitting position.
a.


Inspect neck on both sides for obvious arterial pulsation. Ask patient to turn head slightly away from artery being examined.
b.


Palpate each carotid artery separately with index and middle fingers around medial edge of sternocleidomastoid muscle . Ask patient to raise chin slightly, keeping the head straight. Note rate and rhythm, strength and elasticity of artery. Note if the pulse changes with inspiration and expiration.
c.


Place bell of stethoscope over each carotid artery, auscultating for blowing sound orbruit. Ask client to hold breath during auscultation.
d.


Assess peripheral vascular area:
8))


Inspect lower extremities for changes in color and condition of skin. Note skin and nail texture, hair distribution, venous patterns, edema and scars or ulcers. Compare skin color lying and standing.
a.


Palpate edematous areas, note mobility, consistency, and tenderness.
b.


Assess for pitting edema by pressing area firmly for 5 seconds, then releasing. Use tape measure to measure circumference of the extremity.
c.


Check capillary refill by grasping patient's fingernail or toenail. Next apply gentle, firm pressure to the nail bed. Release quickly, watching for color change.
d.


Ask if patient experiences pain or tenderness and palpate for heat, firmness, or localized swelling of the calf muscle.
e.


Start at the most distal part of each extremity, palpate each peripheral artery for quality, comparing side to side; elasticity of vessel wall; and strength of pulse using the rating scale of 0 to 4+.

f.


Palpate radial pulse by lightly placing tips of first and second fingers in groove formed along radial side of forearm.
g.


Palpate ulnar pulse by placing fingertips along ulnar side of forearm.
h.


Palpate brachial pulse by locating groove between biceps and triceps muscles above elbow at antecubital fossa.
i.


Have patient lie supine with feet relaxed and palpate dorsalis pedis pulse. Gently place fingertips between great and first toe, slowly move fingers along groove between extensor tendon of great and first toe until pulse is palpable.
j.


If pulses are difficult to palpate or not palpable , use a Doppler instrument over the pulse site.
k.


Apply conducting gel to the patient's skin over the pulse site or onto transducer tip of probe.
(1)


Turn Doppler on. Gently apply ultrasound probe to the skin, changing Doppler angle until pulsation is audible. Wipe off gel from patient and Doppler.
(2)


Palpate posterior tibial pulse by having patient relaxed and slightly extend feet. Place fingertips behind and below medial malleolus (ankle bone).
(3)


Palpate popliteal pulse by having patient slightly flex knee with foot resting on table or bed, Instruct patient to keep leg muscles relaxed. Palpate deeply into popliteal fossa with fingers of both hands, placed just lateral to midline. Patient may also lie prone.
(4)


With patient supine, palpate femoral pulse by placing first two fingers over inguinal area below inguinal ligament.
(5)