Assessment of the Heart and Neck Vessels
Assessment of the Heart and Neck Vessels
Subjective data collected about the heart and neck vessels helps the nurse to identify abnormal conditions that may affect the client’s ability to perform activities of daily living and to fulfill his role and responsibilities.History of present health concern
Chest pain and Palpitations
- Do you experience chest pain? When did it start? Describe the type of pain, location, radiation, duration, and how often you experience the pain. Rate the pain on a scale of 0 to 10, with 10 being the worst possible. Does the activity make the pain worse? Did you have perspiration with the chest pain?
- Do you experience palpitations?
- Do you tire easily? Do you experience fatigue? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time of the day?
- Do you have difficulty breathing or shortness of breath?
- Do you wake up at night with an urgent need to urinate? How many times at night?
- Do you experience dizziness?
- Do you experience swelling (edema) in your feet, ankles, or legs?
- Do you have frequent heartburn? When does it occur? What relieves it? How often do you experience it?
Past health history
- Have you been diagnosed with a heart defect or a murmur?
- Have you ever had rheumatic fever?
- Have you ever had heart surgery or cardiac balloon interventions?
- Have you ever had an electrocardiogram? When was the last one performed? Do you know the results?
- Have you ever had a blood test called a lipid profile? Based on your last test, do you know what your cholesterol levels were?
- Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?
- Do you monitor your own heart rate or blood pressure?
Family history
- The family history should include as many generic relatives as the client can recall; in addition to genetic predisposition, it is also helpful to see other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems.
- Is there a history of hypertension, myocardial infarction, coronary heart disease, elevated cholesterol levels, or diabetes mellitus in your family?
Lifestyle and health practices
- Do you smoke? How many packs of cigarettes per day and for how many years?
- What type of stress do you have in your life? How do you cope with it?
- Describe what you usually eat in a 24-hour period.
- How much alcohol do you consume each day/week?
- Do you exercise? What type of exercise and how often?
- Describe your daily activities. How are they different from your routine 5 or 20 years ago? Does fatigue, chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself?
- Has your heart disease had any effect on your sexual activity?
- How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning?
- How important is having a healthy heart to your ability to feel good about yourself and your appearance? What fears about heart disease do you have?
Neck Vessels
Inspection- Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of the client. The client should be in a supine position with the torso elevated 30 to 45 degrees. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualizations of pulsations as well as shadows.
- Evaluate jugular venous pressure. Evaluate jugular venous pressure by watching for the distention of the jugular vein.
- Auscultate the carotid arteries. Auscultate the carotid arteries if the client is middle-aged or older or if you suspect cardiovascular disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so breath sounds do not conceal any vascular sounds.
- Palpate the carotid arteries. Palpate each carotid artery alternately by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck.
Heart
Inspection- Inspect pulsations. with the client in a supine position with the head of the bed elevated between 30 and 45 degrees, stand on the client’s right side and look for the apical impulse and abnormal pulsations.
- Palpate the apical pulse. Remain on the client’s right side and ask the client to remain supine. Use the palmar surfaces of your hand to palpate the apical impulse in the mitral area.
- Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.
- Auscultate heart rate and rhythm. Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse.
- If you detect an irregular rhythm, auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute.
- Auscultate to identify S1 and S2. Auscultate the first heart sound (S1 or “lub”) and the second heart sound (S2 or “dub”). Use the diaphragm of the stethoscope to best hear S1. Use the diaphragm of the stethoscope to hear S2 and ask the client to breathe regularly.
- Auscultate for extra heart sounds. Use the diaphragm first, then the bell, to auscultate over the entire heart area. Note the characteristics of any extra sound heard. auscultate during the systolic pause.
- Auscultate for murmurs. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also, auscultate with the client in different positions because some murmurs occur or subside according to the client’s position.
- Auscultate with the client assuming other positions. Ask the client to assume a left lateral position. Use the bell of the stethoscope and listen at the apex of the heart. Ask the client to sit up, lean forward, and exhale. Use the diaphragm of the stethoscope and listen over the apex and along the left sternal border.
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