HEART ASSESSMENT

• There are landmarks on the chest wall that will yield important information about the function of the heart and its valves. 
• ANGLE OF LOUIS: Located 1 inch below the sternal notch, where the manubrium and the body of the sternum are joined.
• ANGLE OF LOUIS: The 2nd ribs extend to the right and left of this angle.
• Once the 2nd rib is located, palpate downward and obliquely away from the sternum to identify the remaining ribs and intercostal spaces.
• Look for the point of maximum impulse (PMI) or apical pulse at the left midclavicular, 5th intercostal space.
• Normally, there are no bulges on the chest.
• An apical impulse may or may not be observable.
• There should be no other pulsations over the chest, aside from the apical impulse.
• Use the ball of the hand to detect vibrations, or “thrills,” which may be caused by murmurs.
• Use the fingertips or palmar surface to detect pulsations.
• Palpate for thrills and pulsations in each area: Aortic, Pulmonic, Tricuspid, and Mitral.
• AORTIC AREA

  Palpate on the 2nd right intercostal space, close to the sternum.
• PULMONIC AREA

  Palpate on the 2nd left intercostal space close to the sternum.
• TRICUSPID AREA

  Use the palm of the hand to detect any heaving or thrusting of the precordium.
• MITRAL AREA

  This is the apex of the heart (PMI).
• MITRAL AREA

  Palpate in the 5th ICS, left, midclavicular area.
• Thrills are vibrations caused by turbulence of blood moving through valves that are transmitted through the skin – feels similar to a purring cat.
• The apical pulse should be felt in the left 5th ICS, midclavicular area. It is a sharp, quick impulse
• Percuss outward from the sternum with the stationary finger parallel to the intercostal space until dullness is no longer heard.
• Begin by identifying the first (S1) and 2nd (S2) heart sounds. v Si (“lub”) is caused by the closing of the tricuspid and mitral valves. v s2 (“dub”) results from the closing of the aortic and pulmonic valves.
• Listen to the four areas – Aortic, Pulmonic, Tricuspid, Mitral, and at the Erb’s point (3rd left ICS close to the sternum). Use the diaphragm of the stethoscope first (detects higher pitched sounds) and then use the bell detects lower pitched sounds).
• Normally, two sounds are heard – “lub” and “dub”
• The heart sounds are regular with a rate of 60 to 100 beats/min (in adult). In the athlete or jogger, the resting pulse may be between 40 and 60 beats/minute.
• Chest pain – This indicates inadequate myocardial tissue oxygenation.
• Orthopnea – Need to assume a more upright position to breath. Needs several pillows to sleep.
• Cough – Sputum production, hemoptysis.
• Fatigue – Which is worse at night. This is due to decreased cardiac output.
• Cyanosis or pallor – Occurs with low cardiac output that results to decreased tissue perfusion.
• Edema – (dependent feet and legs) – Worse at evening and better in the morning after elevating legs at night. It is caused by heart failure.
• Nocturia – Recumbency at night promotes fluid reabsorption and excretion. This occurs with heart failure in the person who is ambulatory during the day.
• Murmurs – Blowing swooshing sounds that occur with turbulent blood flow in the heart or great vessels. This may due to valvular defects.
• Bruit – Over carotid artery. Blowing, swishing sound due to blood flow turbulence.
• Jugular vein distention (JVD) – indicates heart failure.
• Heave or lift – Sustained forceful thrusting of the ventricles during systole. It occurs with ventricular hypertrophy as a result of increased workload.
• S3 (ventricular gallop/ third heart sound) – Abnormal for person above 35 years of age. This is indicates congestive heart failure.
• S4 (atrial gallop/ fourth heart sound) – This indicates congestive heart failure.
• Diminished pulse – Feels small and weak “thready”. This is due to decreased cardiac output.
• Full, bounding pulse. Easily palpable, pounds melter the fingertips. May indicate hypervolemia (increased blood)
• Weak, Thready Pulse: 1+ Hard to palpate, need to search for it, may fade in and out easily obliterated by pressure
• Weak, Thready Pulse