Cardiac, Thorax, Peripheral

Vascular System Assessment

DEBBIE KING MSN, FNP-C, PNP-C

FALL 2009
 Chest Exam

Visual Inspection/Palpation
 Skin for cyanosis, venous distention, nail beds for
capillary refill
 Asymmetry of the chest cage (A/P & lateral)
 PMI (point of maximal impulse) at the left 5th ICS at the
midclavicular line usually (may be slightly displaced in
the muscular, pregnant, obese and elderly)
 Place patient in the supine position to palpate the heart
 Palpate for thrills at the apex, left sternal border, and the
base (prominent impulses may suggest heart
enlargement)
 Land Marks
 Count interspaces
 Identify your ...
o Midsternal line
o Midclavicular line
o Anterior axillary line
o Midaxillary line
 Auscultation

Five ausculatory areas

 Aortic valve area- second right intercostal space at the
right sternal boarder
 Pulmonic valve-2nd left ICS at LSB

 Second pulmonic area-3rd LICS at LSB

 Tricuspid area- 4th LICS Lower LSB

 Mitral or apical area- apex:5th LICS at the midclavicular

line
 Auscultation

 Systole: the ventricles contract

 The right ventricle pumps blood into the pulmonary arteries
(pulmonic valve is open)
 The left ventricle pumps blood into the aorta
(aortic valve is open)
 Diastole: the ventricles relax
 Blood flows from the right atrium → right ventricle (tricuspid valve
is open)
 Blood flows from the left atrium → left ventricle (mitral valve is
open)
 Auscultation

Use the diaphragm, then the bell to assess the 5

cardiac areas
 Patient sitting, leaning slightly forward
 Best to focus on heart sounds during expiration-best for
high pitch murmurs
 Patient supine

 Patient left lateral recumbent, best to hear low pitched

sounds in diastole with bell
 Other positions-PRN

 Inch don’t jump

 Heart Sounds

S1 Mitral/Tricuspid close (atrioventricular valves)

S2 Aortic/Pulmonic close (semilunar valves close)
 S2 splitting inspiration (physiologic) expiration
(pathologic)
 S2 splitting common and normal in children and young adults
S3 Atrial ejection “Ken-tuc-ky”
S4 Ventricle filling “Tenn-es-see”
 S3 & 4 should be quiet and may be difficult to hear.
 Heart Murmurs

Disruption of blood flow through the heart

due to
 Stenosis - narrowed or thicken, stiff valve
 Regurg - slack valve leaflets causing retrograde
flow
 Other causes – pregnancy, anemia,
thyrotoxicosis, CAD, Arteritis
 Evaluate using the bell and the diaphragm
 Murmur Grading

Grade I –barely audible in quiet room

Grade II – quiet but clearly audible
Grade III – moderately loud
Grade IV – loud, associated with thrill
Grade V – very loud, thrill easily palpable
Grade VI – very loud audible w/stethoscope not
contacting chest wall, thrill palpable & visible
 Characteristics of murmurs

Timing & duration (early, mid, or late systolic)

 Refer all diastolic murmurs!
Pitch (high, medium, or low)
Intensity (grades)
Pattern (crescendo, decrescendo)
Quality (harsh, raspy, vibratory, blowing, musical)
Location (anatomic landmarks)
Radiation (anatomic landmarks )
Variation w/respiratory phase (intensity, quality,
timing)
 Murmurs

Most are innocent, esp. in children and

young athletes
 Result of vigorous myocardial contraction
Some are benign- result of a mild anomaly
 Comparison of systolic Murmurs

 Right sided chamber

 with inspiration gets louder
 With expiration gets softer
 Hypertrophic cardiomyopathy
 With Valsalva gets louder
 With rapid squat to stand for 30 sec gets louder
 With standing to squatting rapidly gets softer
 Passive leg elevation to 45 degree gets softer
 Mitral regurg
 With handgrip gets louder
 Aortic stenosis
 Diagnosis made by exclusion
 Chest Pain
(Rarely originates in the heart)

 Differential Diagnosis
 Angina Pectoris
 Cardiac risk factors, specific onset, forces pt to stop, relief with nitro, often in
am, more likely if cold
 Musculoskeletal
 Trauma, vague onset, >with effort, continues with rest, heat and Advil helpful,
worse with day of physical effort, worse with cold damp temps
 Gastrointestinal
 Indigestion, vague, related to food, lasts hours, unrelated to effort, may awaken,
relief with antacids, no other triggers, occurs any time
 Pulmonary
 Pneumonia, asthma, pleurisy, cancer, list is endless. Improves with
bronchodilators, antibiotics ECT
 Chest Pain-Specific diagnosis

 Angina
 Coronary insufficiency
 Emphysema
 MI
 Hiatal hernia
 Mitral valve prolapse
 Reflux
 Dissection of the aorta
 Esophageal spasm
 Pericarditis
 Cholecystitis
 Pleurisy
 Ulcer
 Pneumothorax
 Pancreatitis
 Cocaine use
 Pneumonia
 Shoulder disorder
 Embolus
 Cervical
radiculopathy
 Costochondritis
 History for patient with chest pain

History of present illness

 Describe the Pain, onset, frequency, location, severity,
associated symptoms
Past medical history
Family history
Personal and social history
 Peripheral Vascular System
Blood Vessels
Palpate the arterial pulses, the best are close to the
surface and over boney areas
 Carotid-most useful, close to the heart
 Brachial
 Radial
 Femoral
 Popliteal
 Dorsalis pedis
 Posterior tibial
 Peripheral Vascular System
Palpation
 Palpate with the digital pads of the second and third fingers
 You may use the thumb and is sometimes helpful with
moving vessels
 Palpate firmly without occluding the artery
 Lack of symmetry suggests impaired circulation
 Femoral is as strong as radial if its not or its absent suggests
coarctation of the aorta
 May also measure capillary refill time to assess severity of
arterial occlusion
 Techniques of Examination – Palpate Pulses

 Femoral pulse
 Press deeply below inguinal ligament, midway between anterior
superior iliac spine and symphysis pubis
 Popliteal pulse
 Flex knee some, leg relaxed

 Place fingertips of both hands to meet midline behind knee and

press deeply into popliteal fossa
 Dorsalis pedis pulse
 Feel dorsum of foot, lateral to extensor tendon of great toe

 Posterior tibial pulse

 Curve fingers behind and slightly below medial malleolus of ankle
 Evaluation of pulses

Rate – 60-90 bpm

Rhythm – regular
Contour – pulse wave should be smooth, rounded
or domed shape
Amplitude – scale of 0-4
 4 = bounding
 3 = full, increased
 2 = expected
 1 = diminished
 0 = absent or no pulse
 Pulse Abnormalities
bradycardia less than 60,tachycardia over 100

 Alternating pulse  Labile pulse

 Weak/strong  Amplitude increased with
 Left ventricular failure sitting or standing
 Pulsus bisferiens  Not associated with disease
 Two strong separated with dip  Paradoxic pulse
 Aortic regurg with or without stenosis
 Bigeminal pulse
 Decreases on inspiration
 COPD, pericarditis or effusion
 Two pulses rapid followed by longer
interval  Trigeminal pulse
Ventricular premature beats
Three beats then pause


 Bounding pulse  Often benign, or severe disease
 Rapid rise, brief peak, rapid fall  Water-hammer pulse
 Atherosclerosis, PDA,
hyperthyroid, anxiety, fever,
 Jerky pulse with full expansion
anemia then sudden collapse
 Aortic regurgitation, patent ductus arteriosus
History of present illness with abnormal
pulse findings

Leg pain or cramps (claudication)

 Describe- onset, duration, what relieves, character IE
burning or cramping, skin changes or hair loss or sores
ECT
Dizziness
Severe headaches
Swollen ankles
Treatment attempted
 Compartment syndrome

The Ps
 Pallor
 Pain
 Pulselessness
 Paresthesias if major artery occluded
 Paralysis, is rare
 Auscultation for Bruits

Carotid
Thyroid
Temporal
Abdominal aorta
Renal
Iliac
Femoral
 Auscultation for bruits

Should be done after the cardiac assessment

Usually low pitched and hard to hear
Use the bell directly over the artery
 Auscultation of the neck

 Carotid bruits heard best at the anterior margin of the

sternocleidomastoid muscle as the patient holds their breath, may be
one of three types
 A murmur transmitted from aortic stenosis, ruptured chordae tendineae of
the mitral valve or severe aortic regurg
 Vigorous left ventricular ejection-heard more in children
 Obstructive disease in carotid arteries-complete obstruction will eliminate
 May also hear a venous hum
 Heard at medial end of clavicle and anterior border of sternocleidomastoid
muscle
 Usually of no significance, but in adults may mean anemia, thyrotoxicosis or
intracranial arteriovenous malformation
 Confused with bruits
 Inspection of Extremities

Color (pink)
Skin texture (elasticity)
Nail changes (brittle, cracked, dry)
Presence of hair (lack of)
Muscular atrophy (thinning, wasting)
Edema or swelling (fat ankles)
Varicose veins (dilated or swollen)
 Techniques of Examination - Arms

 Inspect both arms from fingertips to shoulders

 Note the following:

o Size, symmetry, and any swelling
o Venous pattern
o Color of skin and nail beds; texture of skin
 Palpate radial pulse

 Use finger pads on flexor surface of wrist

 Partially flex patient’s wrist
 Compare pulse in both arms
 Techniques of Examination-Arms

 Palpate brachial pulse

 Flex elbow slightly

 Palpate artery medial to biceps tendon in antecubital
crease
 Epitrochlear nodes

 Flex elbow 90°

 Support forearm
 Feel in groove between biceps and triceps muscle, 3 cm
above medial epicondyle
 Techniques of Examination-Legs

 Patient should lay down, draped so external genitalia is

covered and legs are fully exposed
 MUST remove patient’s stockings or socks

 Inspect both legs from groin and buttocks to feet

 Note the following:

 Size, symmetry, and any swelling
 Venous pattern/venous enlargement
 Pigmentation, rashes, scars, or ulcers
 Color and texture of skin, color of nail beds, distribution of hair on
lower legs, feet, and toes
 Techniques of Examination-Legs

 Palpate superficial inguinal nodes

 Horizontal/vertical groups

 Note size, consistency, and discreteness and tenderness

 Nontender, discrete nodes up to 1-2 cm are palpable in

normal people
 Palpation of extremities Summary

Warmth
Pulse quality
Tenderness along a superficial vein
Pitting edema
 1+ slight pitting, disappears rapidly
 2+ slightly deeper pit, disappears in 10-15 sec
 3+ noticeable deep, last > 1 min. (extremity looks full &
swollen)
 4+ deep pit lasting 2-5 min., grossly distorted
 (if edema is unilateral suspect occlusion of a major vein & edema
w/o pitting suspect arterial disease or occlusion)
 Evaluation of Edema

 Compare one foot and leg with the other

 Note relative size and prominence of veins, tendons, and
bones
 Check for pitting edema
 Press firmly with thumb for 5 seconds over dorsum of
each foot, behind medial malleolus and shins
 Severity of edema graded on four-point scale (slight to very
marked)
 Evaluation of Edema

If edema is present, look for causes

 Recent deep venous thrombosis
 Chronic venous insufficiency
 Lymphedema
Note color of skin
 Local area of redness
 Brownish areas near ankles
 Ulcers and where
 Thickness of skin
 Blood Pressure

Bilateral measurements, supine & standing

 Better to use a larger cuff than smaller
 Measured by the width of the bladder than the cloth
 Mercury column is most reliable, but no longer permitted
 Aneroid sphygmomanometer lose accuracy with age and
use
 Preferred position is seated and the cuff at heart level

 Advise patients not to have caffeine, rushing, ECT before

the appointment
 How to take a BP

 Both arms with arms flexed and supported, free of clothing

 Use the appropriate size cuff that is snug and secure
 Center the deflated bladder over the brachial artery, just medial to the
biceps tendon, with the lower edge 2-3cm above the antecubital
 Checking the palpable systolic pressure first with avoid being mislead in
auscultatory gap
 Inflate to 20-30 mm HG above the point where you do not feel pulse. Deflate
slowly until you feel pulse.
 Place bell over brachial artery pausing for 30 seconds inflate to 20-30
MM Hg over the palpable systolic pressure
 Deflate slowly
 Review Korotkoff sounds
 JVD measurement

Evaluate jugular vein distention (JVD)

 Use a ruler at least 15 cm long
 Use a light for tangential illumination across the neck
 Patient is initially in supine position which results in engorgement
of veins.
 Raise the head of the bed gradually until pulsations are seen
between the jaw and the clavicle
 Palpating the contralateral carotid pulse helps distinguish them
from the carotid pulsation
 To assess for hepatojugular distention which is seen in right heart failure; apply
firm and sustained pressure to the midepigastric area with patient breathing
normal, if RHF is present the JVD will get measure larger
 CHEST & LUNG EXAM

HPI, PMH, FHX, Social & Personal HX

Have pt sit up w/o support, w/o shirt.
Clothing is a barrier
Warm hands, warm stethoscope, lighting
Look for landmarks: refer to text
 Midsternal line, R&L midclavicular lines, R&L
anterior, midaxillary, and posterior lines, vertebral
line, R&L scapular lines
 Anatomy and Physiology

 Anatomy of the chest wall

 Anatomy and Physiology (cont.)

 To locate findings around the circumference of the chest,

imagine a series of vertical lines
 Anatomy and Physiology (cont.)
 Lungs, fissures, and lobes
 Each lung is divided roughly in half
by an oblique (major) fissure
 The right lung is further divided by
the horizontal (minor) fissure
 These fissures divide the lungs into
lobes
o The right lung is divided into
upper, middle, and lower
lobes
o The left lung is divided into
upper and lower lobes
 Chest -Bone Structures

 Anatomy of the chest to assess

 Larynx
 Trachea
 Manubrium
 Sternum
 Xiphoid
 Clavicle
 Acromion Process
 Scapula
 Ribs
 Anatomy of the back to assess
 Scapular –height and prominence
 Spinal curve and muscle equality
 Scoliosis
 Kyphosis
 Chest –Muscles to assess
Anterior Posterior
 Sternocleidomastoid  Serratus posterior
 Scalenus superior
 Pectoralis minor  Intercostal
 Intercostal muscles  Transverse
 Serratus anterior  Diaphragm
 Rectus abdominus  Serratus
 Posterior inferior
 Anatomic/Topographic
Landmarks of the chest
Suprasternal notch Clavicle
Clavicle Manubrium
Second rib Manubriosternal
Body of sternum junction or angle of Louis
Nipple Costal angle

Xiphoid
 Inspection of Chest

 Size & shape: barrel chest-result of compromised respiration, structural

 Carinatum pectus or pigeon chest
 Pectus excavatum or funnel chest
 Symmetry: (AP < transverse diameter)
 Skin color - inspect nails, lips, & supernumerary nipples (pink, no pallor
or cyanosis)
 Superficial venous patterns (heart disorder, vascular disorder or
disease)
 Prominence of ribs (underlying fat clue to nutritional state)
 Bone and muscle landmarks
 Anatomic/Topographic landmarks
 Respirations and Chest Movement

Rate – normal 12-20 bpm

Rhythm/pattern – note movement of chest,
expansion should be bilaterally symmetric, breathes
easily w/o distress, breathing should be even, non
labored.
Use of accessory muscles
No bulging of the Intercostal muscles.
 Descriptions of abnormal Respirations

Dyspnea- SOB-difficult, labored-lung or cardiac

issues, sedentary life style, obesity.
Orthopnea-SOB when pt lies down, sleeps on
more than 1 pillow.
Paroxysmal nocturnal dyspnea-sudden onset of
SOB after a period of sleep
Platypnea- dyspnea increases in upright
position.
 Irregular patterns of respirations

 Tachypnea- increased RR 20 rpm

 Bradypnea- slower than 12 rpm
 Hyperpnea- faster than 20 breaths, deep breathing.
 Kussmaul- rapid, deep, labored- Metabolic acidosis.
 Hypopnea- abnormally shallow breaths IE: pleurisy.
 Cheyne-Stokes- depth along with apnea, seriously ill
pt’s.
 Air trapping- difficulty in getting breath out d/t
prolonged inefficient expiratory effort.
 Palpation of Thorax

 Feel for pulsations, areas of tenderness (rib fx), bulges, depressions,

unusual movements, and unusual positions.
 Crepitus-crackly or crinkly sensation
 Pleural friction rub- inflammation of pleural surfaces (leather rubbing
on leather)
 Thoracic expansion
 Assess both anterior and posterior
 Thumbs should move equally
 Tactile fremitus
 Use palmar or ulnar aspects at the same time, or move dominant hand
 Ask patient to say ‘99’
 Should be symmetrical fremitus
 Palpation of Thorax

Position of trachea
 Put index finger in suprasternal notch and move gently
side to side at the upper edges of each clavicle and in the
spaces above to the inner borders of the
sternocleidomastoid muscles
 Spaces should equal on both sides, trachea should be midline
directly over the suprasternal notch
 Simultaneously palpating with both thumbs on either
side of the thyroid, again the thyroid should be midline,
but may deviate slightly to the right
 Percussion

 Compare bilaterally
 Use one side as control for the other
 Patient sitting head bent arms folded in front
 Move systematically side to side at intervals of several
centimeters
Dullness- thud like- atelectasis, asthma, pleural
effusion, pneumothorax
Resonance- hollow-heard all areas of lungs
Hyperresonance- booming-hyperinflation (asthma,
emphysema, pneumothorax).
Tympanic- drum like-usually over abdomen
 Percussion

Diaphragmatic excursion.
 Patient takes a deep breath and holds
 Percuss scapular line until dullness is heard
 Mark this point
 Allow patient to breath normally
 Repeat deep breath then exhale and hold
 Percuss up from the mark until resonance is heard
 Mark the area
 Repeat on other side in real practice, one side for the
video
 SMELL

Smell the breath

 Fruity-ketoacidosis
 Fishy-uremia
 Halitosis-Tonsillitis, gingivitis, GERD
 Feculent-intestinal obstruction
 Putrid- sinusitis, FB, cancer lung abscess
 Cinnamon-pulmonary TB
 Auscultation

 Thoracic Landmarks
 Anterior thorax
 Right lateral thorax
 Posterior thorax
 Procedure- use diaphragm
 Patient upright, same position as percussion
 breathe slow and deep
 Comfortable pace
 Elderly begin low and go up
 All others begin up and go low
 Use side to side as in percussion listening to ins and exp
 Auscultation
Normal breath sounds

Vesicular-most lung fields, soft pitch with low

intensity
Bronchovesicular-main bronchus and upper
right posterior lung-medium pitch E=I
Bronchial/tracheal- heard only over trachea,
high pitch E is louder than I
 Abnormal Breath Sounds

Crackles- heard during middle or end of

inspiration, not cleared by cough.
Rhonchi- loud, low, coarse, coughing may clear.
Wheeze-musical-louder during inspiration
 A more significant finding if heard in expiration
Pleural Friction rub- dry rubbing.
Hamman Sign- crackling, clicking crunching and
gurgling with heart beat, heard better when pt lies
or leans to left and indicates mediastinal
emphysema
 Cough

 Preceded by deep inspiration, followed by closure of the glottis and

contraction of the chest and abdominal muscles the spasmodic
expiration, forcing opening of the glottis.
 May be voluntary, but usually reflexive to irritants
 Differentials of coughs include:
 Infection

 Irritants and allergens

 Compression

 Congenital malformation

 Acquired abnormally- yelling, FB, tumor

 Neurogenic or vocal cord paralysis

 Cough description

Dry or Moist- may have sputum

Onset- acute or slow onset
Frequency –seldom or often
Regularity –irregular is the most common, regular
is seen in pertussis
Pitch/loudness- loud/quiet, high or low pitch
Postural- worse when supine with PND
Quality- brassy with compression, hoarse with
croup, inspiratory whoop with pertussis
 Other Breath Sounds

Bronchophony- increased loudness of spoken words

Whispered pectoriloquy- with consolidation even a
whisper can be heard
Egophony- nasal quality E to A with increased
intensity also seen with consolidation
 All the above will be diminished with blockage such as in
emphysema
Croup- seal like bark