This document provides information about assessing the heart and neck vessels as part of a nursing course. It outlines the objectives of the unit, which include describing heart and vessel structures and functions, performing a physical assessment using various techniques, and differentiating normal from abnormal findings. The document then details the anatomy and physiology of the cardiovascular system and steps for performing an assessment, including inspection, palpation, percussion, and auscultation of the neck, precordium, and heart sounds in various positions. It describes normal findings and potential abnormalities.

1. BACHELOR OF SCIENCE IN NURSING:
HEALTH ASSESSMENT
COURSE MODULE COURSE UNIT WEEK
3 12 13
Adult Physical Assessment: Heart & Neck Vessels
✓ Read course and unit objectives
✓ Read and comprehend study guide prior to class
attendance
✓ Read and comprehend required learning
resources
✓ Engage in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks
At the end of this unit, the students are expected to:
Cognitive:
1. Describe the structure and function of the heart and neck vessels
2. Perform a physical assessment of the heart and neck vessels using the correct techniques
of inspection, auscultation, palpation, and percussion.
3. Differentiate between normal and abnormal findings of the heart and neck vessels.
4. Analyze all data from the interview and physical assessment formulate valid nursing
diagnosis, collaborative problems, and/or referrals.

2. Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.
Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class
Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia:
Wolters Kluwer
ASSESSMENT OF THE HEART AND NECK VESSELS
Salient Points Of The Cardiovascular System
• The cardiovascular system plays an important role in the body
o It delivers oxygenated blood
o Removes waste products
• The autonomic nervous system controls how the heart pumps
• The vascular network the arteries, veins, capillaries carries blood throughout the body,
keeps the heart filled with blood and maintains blood pressure
The Heart
• The heart and major blood vessels lie centrally in the chest behind the protective sternum
• A cone-shaped muscle with four chambers

3. • A double pump about the size of a clenched fist (12 cm long and 9 cm wide) 250–390 g
(8.8 13.8 oz) in adult males 200–275 g (7.0–9.7 oz) in adult females
• Pumps blood throughout circulatory system
Heart Chambers, Valves and Circulatory Flow
The Chambers of the HEART
1. RIGHT ATRIUM receives DEOXYGENATED blood from the body via the superior and
inferior vena cavae
2. RIGHT VENTRICLE receives blood from the right atrium and pumps it to the lungs via the
pulmonary artery
3. LEFT ATRIUM receives OXYGENATED blood from the lungs via four pulmonary veins
4. LEFT VENTRICLE receives OXYGENATED blood from the lungs via the left atrium pumps
blood into the systemic circulation via the aorta - the largest and most muscular chamber
The Valves of the HEART
Atrioventricular Valves
1. TRICUSPID VALVE located on the right side of the heart, has three leaflets and prevents
backflow of blood from the right ventricle to the right atrium
2. BICUSPID (MITRAL) VALVE located on the left side of the heart, has two leaflets and
prevents backflow of blood from left ventricle to the left atrium
Semilunar Valves
1. PULMONIC SEMILUNAR VALVE lies between the right ventricle and the pulmonary artery
and prevents backflow of blood from pulmonary trunk to the right ventricle
2. AORTIC SEMILUNAR VALVE lies between the left ventricle and the Aorta prevents
backflow of blood from the aorta into the left ventricle
Heart Sounds
• produced by valve closure, therefore, opening of valve is silent

4. o S1 – “lub”
o S2 – “dubb”
• Extra heart sounds
o S3 and S4
o Murmurs
• Normal Heart Sounds
o S1
▪ the first heart sound
▪ “lub”
▪ the result of closure of the atrioventricular (AV) valves
• the TRICUSPID VALVE
• the MITRAL VALVE
▪ correlates with the beginning of systole
▪ heard at the base and apex of the heart
• softer at the base
• louder at the apex (best heard)
o left MCL, 5th ICS
o S2
▪ the second heart sound
▪ “dubb”
▪ results from closure of the semilunar valves
• the AORTIC VALVE
• the PULMONIC VALVE
▪ correlates with the beginning of DIASTOLE
▪ best heard at the base of the heart
• Extra Heart Sounds
o S3 & S4
▪ diastolic filling sounds
▪ result from ventricular vibration secondary to rapid ventricular filling
▪ S3
• ventricular gallop
• can be heard early in diastole, after S2
• when the mitral valve opens
▪ S4
• atrial gallop
• results from ventricular vibrations secondary to ventricular resistance
during atrial contraction
• can be heard late in diastole, just before S1
o Murmurs
▪ Blood NORMALLY flows silently through the heart

5. ▪ In conditions of an audible and prolonged sounds, murmurs are auscultated
over the precordium, a swooshing or blowing sound resulting from turbulence
created within the vascular system
▪ Conditions that contributes to turbulent blood flow includes
• increased blood velocity;
• structural valve defects;
• valve malfunction; and
• abnormal chamber opening (septal defect)
▪ increased flow through normal blood vessels, creating frictional, audible
sounds flow through constricted blood vessels (e.g., aortic stenosis).
▪ flow of blood into a dilated blood vessel from one of normal size
Cycles of Heart Sounds
Auscultating Heart Sounds
• The Traditional 5 Areas
o Aortic Area

6. ▪ 2nd ICS at the right sternal border
▪ base of the heart
o Pulmonic Area
▪ 2nd or 3rd ICS at the left sternal border
▪ base of the heart
o Erb’s point
▪ 3rd to 5th ICS at the left sternal border
o Mitral (Apical)
▪ 5th ICS near the left MCL
▪ apex of the heart
o Tricuspid Area
▪ 4th or 5th ICS at the left lower sternal border
• Take Note!
o the 4 valve areas do not reflect the anatomical position of the valves
o sounds always travel in the direction of the blood flow
o the areas described in the traditional auscultation overlaps extensively and sounds
produced by the valves can be heard all over the precordium
• The Alternative Areas
o AORTIC AREA
▪ right 2nd ICS to apex of heart
o PULMONIC AREA
▪ 2nd and 3rd left ICS close to sternum but may be higher or lower
o LEFT ATRIAL AREA
▪ 2nd to 4th ICS at the left sternal border
o RIGHT ATRIAL AREA
▪ 3rd to 5th ICS at the right sternal border
o LEFT VENTRICULAR AREA
▪ 2nd to 5th ICS, extending from the left sternal border to the left MCL
o RIGHT VENTRICULAR AREA
▪ 2nd to 5th ICS, centered over the sternum

7. • Korotkoff’s Sounds
o Phase I:
▪ A faint, clear, rhythmic tapping noise that gradually increases in intensity
o Phase II:
▪ A swishing sound that is heard as the vessel distends with blood
o Phase III:
▪ Sounds become more intense
▪ Vessel is open in systole but not in diastole
o Phase IV:
▪ Sounds begin to muffle, and pressure is closest to diastolic arterial pressure
o Phase V:
▪ Sounds disappear because vessel remains open
ASSESSMENT PROPER
• You will use all four techniques of physical assessment to assess the cardiovascular
system
o I
o P
o P
o A
• Perform the assessment in 3 positions
o sitting, supine, and left lateral
• Inspection
o Neck
▪ Differentiate carotid arteries and jugular veins
▪ Normal
• Carotids have visible pulsation
• Jugulars have undulated wave
• Carotids have palpable pulsations
• Jugulars are obliterated
• Carotids not affected by respirations, jugulars are
• Carotids not affected by position

8. • Jugulars normally only visible when client is supine
▪ Deviations from normal
• Large, bounding visible pulsation in neck of suprasternal notch:
o HTN, aortic stenosis, or aneurysm
• Abnormal venous waveforms
• Giant A waves
• Tricuspid stenosis, right ventricular hypertrophy
o cor pulmonale
• Absent A wave
o atrial fibrillation
o Precordium
▪ Look for pulsations on the precordium, paying particular attention to the apex
area.
▪ Normal
• Positive pulsation at apex
• May note slight pulsations over base in thin adults and children
▪ Deviations from normal
• Pulsations may occur
o to right of sternum
o epigastric area
o sternoclavicular areas
▪ AORTIC ANEURYSM
• Apical pulsation displaced toward axillary line
o left ventricular hypertrophy
• Palpation
o Carotid Artery
▪ Lightly palpate each carotid separately
▪ Note
• rate
• rhythm
• amplitude
• contour
• symmetry
• elasticity

9. • thrills
o Jugular Veins
▪ Palpate jugular veins and check direction of fill.
▪ 3 ways
1. Occluding under the jaw, the jugular should flatten, but the wave form
will become more prominent.
o Assessing Jugular Flow
▪ Compress jugular below jaw.
▪ Jugular vein collapses and jugular wave is more
prominent at supraclavicular area
2. Occluding above the clavicle, the jugular normally distends while the
jugular wave diminishes.
o Checking Jugular Fill
▪ Compress jugular above clavicle.
▪ Jugular distends and jugular wave disappears.
3. Testing Abdominojugular (Hepatojugular) Reflux
o Position patient at 45-degree angle, place hands over the
midabdominal area and apply 20 to 30 mm Hg of pressure for
about 15 to 30 sec.
o Estimate the pressure by placing a partially inflated BP cuff on
the abdomen under your hand.
o Look at the jugular veins while applying pressure
▪ note increase vein distension
▪ return to normal upon release of pressure

10. ▪ Deviations from normal
• Cardiac Rate >100 bpm
o Sinus tachycardia
o Supraventricular tachycardia (SVT)
o Paroxsymal tachycardia (PAT)
o Uncontrolled atrial fibrillation
o Ventricular tachycardia
▪ causes include CHF drugs, such as:
▪ atropine
▪ nitrates
▪ epinephrine
▪ isoproterenol
▪ nicotine and caffeine
▪ HYPERCALCEMIA
• Cardiac Rate <60 bpm
o Sinus bradycardia heart block
o causes include MI drugs, such as:
▪ digoxin
▪ quinidine
▪ procainamide, and
▪ beta-adrenergic inhibitors;
▪ HYPERKALEMIA
• Irregular rhythm
o arrhythmia
▪ abnormal pulses
▪ unequal pulses
o obstruction or occlusion
▪ stiff, cordlike arteries
o Right – sided CHF
o tricuspid regurgitation
o tricuspid stenosis
o constrictive pericarditis
o cardiac tamponade
o inferior vena cava obstruction
o HYPERVOLEMIA
o Precordium

11. ▪ Apex (left ventricular area) or mitral area
▪ 5th ICS, MCL
▪ Normal
• Apex (left ventricular area):
o PMI is 1–2 cm
o Negative thrills
o Amplitude may normally be increased in high-output states
SUCH AS EXERCISE
o Apical pulsation may not always be palpable
o Left lateral displacement of PMI may occur during the last
trimester of pregnancy
• LLSB (tricuspid area) 4th to 5th ICS at left sternal border
• LLSB
o May not be palpable, although small, nonsustained, systolic
impulse may be palpated, especially in thin patients
o Negative thrills
• Base left (pulmonic area)
o 2nd ICS, left sternal border
• Base right (aortic area)
o 2nd ICS, right sternal border
• Epigastric area

12. o Below the xyphoid process
o Normal
▪ Positive slight pulsation may be normal, no diffusion
▪ Palpations not palpable
• at base left, the pulmonic area
• base right, the aortic area
o except in thin patients
• Abnormal
o Enlargement and displacement of PMI to left midaxillary line
o Cause:
▪ Ventricular hypertrophy with dilation
o Apical impulse located on right side of precordium:
▪ DEXTROCARDIA
▪ Cause:
• a heart located on the right side, often associated
with congenital heart disease
o Enlarged apical pulsation without displacement >2–2.5 cm with
patient supine or >3 cm with patient in left lateral recumbent
position
▪ Cause:
• Ventricular enlargement, HTN, aortic stenosis
o Sustained pulsation
▪ Cause:
• Hypertrophy
• HTN
• Overload
• CMP
DEVIATIONS FROM NORMAL
THRILLS
o cause: murmur
PALPABLE LIFTS OR HEAVES
o cause: right ventricular hypertrophy
PULSATIONS FELT ON THE FINGERTIPS
o cause: may come from the right ventricle, indicating right ventricular hypertrophy
LARGE DIFFUSE EPIGASTRIC PULSATION
o cause: abdominal aortic aneurysm
ACCENTUATED PULSATION IN PULMONIC AREA
o cause: pulmonary HTN
ACCENTUATED PULSATION IN AORTIC AREA
o cause: HTN or aneurysm

13. • Percussion
o Dullness at 3rd, 4th, and 5th ICS to left of sternum at MCL
o Left sternal border extends to midaxillary lines in an enlarged, dilated heart
• Auscultation
o Neck
▪ Have client hold breath.
▪ Auscultate the carotid with the bell portion of the stethoscope for bruits.
▪ Auscultate the jugulars with the bell portion of the stethoscope for venous
hums.
▪ Normal
• Positive carotid bruit may be normal in children and is associated with
high-output states
• Negative venous hum
• Positive venous hum may be normal in children
▪ Deviations from normal
• Bruit suggests carotid stenosis
• Murmurs can also radiate up to the neck from the heart, as in aortic
stenosis
o Precordium
▪ Auscultate at apex

14. ▪ Note rate, rhythm, extra sounds, or murmurs.
▪ Auscultate at each site (apex, LLSB, Erb’s point, base left and base right).
▪ Note S1, S2, extra sounds, or murmurs.
▪ Listen at each site with both the bell and the diaphragm.
▪ The diaphragm of the stethoscope is best for detecting high-pitched sounds.
▪ The bell is best for detecting low-pitched sounds.
▪ Use firm pressure with the diaphragm and light pressure with the bell.
▪ Apex (Mitral)
• Rate:
o depends on age
• Rhythm:
o regular
o S1 S2;
o high-pitched systolic
o short duration
o No extra sounds
• Physiological S3 and S4 may be heard in children and young adults
without heart disease
▪ Deviations from normal
• Bradycardia rates 60 BPM or tachycardia rates 100 BPM
• Irregular rhythm: Arrhythmia
• Quadruple rhythm, S3 S4 with fast rate is called a summation gallop
COMMON ABNORMALITIES
Angina Pectoris
• Chest pain resulting from myocardial ischemia
o Anxiety, chest pain
o Skin pale, diaphoretic, cool, clammy
o Dyspnea, tachycardia, pulsus alternans,
o arrhythmias, S4, S3
o Nausea, belching
o Weakness, paresthesias
Congestive Heart Failure
• Failure of the heart to pump sufficiently to meet the
• demands of the body
• CHF can be right, left, or both.
• Right-Sided Failure
• Fatigue, weight gain, confusion
• Skin pale, cool
• Neck vein distension
• Tachycardia, right ventricular heaves, murmurs, S3, right-sided pleural effusion
• Anorexia, bloating, RUQ tenderness, hepatomegaly, ascites

15. • Edema, diminished hair growth
Left - Sided Failure
• Fatigue, confusion
• Skin pale, dusky, cyanotic, cool
• Left ventricular heaves, pulsus alternans, increased heart rate, displaced PMI, S3, S4,
dyspnea, crackles, orthopnea, dry, hacking cough, PND
• Nocturia
Coronary Artery Disease
• A progressive narrowing of the coronary arteries
• Atherosclerosis is the major cause of CAD
• CAD can present as angina pectoris, acute MI, or sudden cardiac death
• MI is necrosis of myocardial tissue from ischemia
• Anxiety, dizziness, chest pain, fatigue
• Skin pale to ashen, cool, diaphoretic, feverish
• Neck vein distension
• Dyspnea, tachypnea, crackles, tachycardia or bradycardia, arrhythmias, elevated BP
initially, S3, S4, murmur, rubs, and diminished heart sounds
• Nausea, vomiting, low urinary output
• Cool, pale, decreased pulses
• Chest pain aggravated by inspiration, coughing, or movement
• Fever
• Friction rub at LLSB
Pericarditis
• An inflammation of the visceral or parietal pericardium, resulting in cardiac compression,
decreased ventricular filling and emptying, and cardiac failure
• Often occurs 2 to 3 days after MI
https://www.nurseslearning.com/courses/nrp/NRP-1616/Section2/index.htm
http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-
content/9780781762403_Weber/ch18.pdf
Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing
6th Edition, Philadelphia: Wolters Kluwer