Health Assessment

1. HEALTH ASSESSMENT

29. Percussion
Percussion is a
method of tapping body
parts with fingers, hands, or
small instruments as part of
a physical examination. It is
done to determine: The
size, consistency, and
borders of body organs. The
presence or absence of fluid
in body areas

30. There are two types of
percussion: direct, which uses
only one or two fingers, and
indirect, which uses the
middle/flexor finger.
There are four types of
percussion sounds: resonant, hyper-
resonant, stony dull or dull. A dull
sound indicates the presence of a
solid mass under the surface.

43. Sites of peripheral pulses

46. Assessment of the Head:
• Assessment of hair
• Assessment of eyes and vision
• Assessment of nose and sinuses
• Assessment of skull and face
• Assessment of ears and hearing acuity
• Assessment of mouth and oropharynx

47. Assessment of hair:
• Colour –Black, Brown, brunette, blound, grey
• Texture- Coarse and dry; Smooth and oily
• Distribution-equal, dense, sparse, alopecia
• Density-thin, brittle, thick
• Assess the scalp for dandruff
• Any infection or infestation

48. Assessment of skull and face:
• Observe the size of head/skull-Normocephalic,
Hydrocephalous, Microcephalic
• Observe for symmetry
• Palpate for nodules or masses or depressions in
skull
• Observe for dehydration - sunken eyes, cheeks
and
• Observe for round and puffy face-moon face
• Observe for symmetry of facial features
• Observe for symmetric facial movements.

50. Assessment of eyes and vision
• An eye assessment is recommended every 3-5
years for people <40 years old and every 2
years for people >40 years

51. Internal structures:
• Inspect the eyebrows - hair distribution, alignment
and movement.
• Inspect the eyelashes for distribution and
direction of curl.
• Inspect the eyelids:
Entropion-inward turning of the eyelid
Ectropion-outward turning of the eyelid
Inspect the eyelids

53. • Palpate the lacrimal gland, the lacrimal sac and
naso lacrimalduct.
• Perform corneal reflex test.
• Look for any inflammatory conditions or
infections of the eye and surrounding structures

55. • Conjunctivitis - redness, itching, tearing,
mucopurulent discharge.
• Dacryocystitis-inflammation of the lacrimal sac-
tearing, discharge from nasolacrimal duct
• Hordeolum-(sty) redness, swelling and tenderness
of hair follicle and glands of the eyelid
• Iris-inflammation of the iris (Pain, tearing,
photophobia)
• Contusions or hematomas-"black eyes“ resulting
from injury
• Cataract-opacity of lens

56. Assessment of pupils :
Check color
Look for mydriasis (enlarged pupils) Miosis
(constricted pupils) Anisocoria (unequal pupils)
Observe reaction to light

57. Ocular movement : to determine eye
alignment and coordination
• 6 Ocular movements-to give exercise to the 6
muscles that govern the eye (superior and
inferior, medial and lateral rectus, superior
and inferior oblique muscles)

59. Assessment of visual acuity: Finger count,
reading, Snellen's chart (20/20 vision on Snellen
chart-normal color vision
Common problems are:
• Hypermetropia (farsightedness)
• Myopia (nearsightedness)
• Presbyopia (loss of elasticity of lens and thus loss
of ability to focus on closer object)
• Astigmatism-an uneven curvature of cornea.

60. Assessment of visual fields - Confrontation method:
Have the client face you at a distance of 2-3
feet
Move object from periphery into field of vision

61. Assessment of cars and hearing acuity:
Inspect and palpate the external ear:
• Auricle/pinna-lobule, helix, antihelix, tragus,
triangular fossa, external auditory canal
• Inspect for color, size, symmetry and placement.

62. • Observe tympanic membrane- cerumen-pearly
gray, semi-transparent.
• Middle ear: Ear ossicles, Eustachian tube.
• Inner ear: Cochlea, vestibule, semicircular
canals.

64. Assessment of hearing acuity:
Hearing Loss:
• Conduction hearing loss- interruption of transmission
through outer and middle ear structure
• Sensorineural hearing loss-damage to inner ear, auditory
nerve or hearing center in brai
• Mixed hearing loss.
• Normal voice, ticking of a watch, Tuning fork tests
• Tuning fork tests - Weber's test, Rinne test (you hear
better) air conduct and bone conduction is more- -
sensorineural loss. Your impaired ear hears better-
Conduction hearing loss

65. • Weber's test- assesses bone conduction
• Sound heard in both ears (Weber negative)
Sound heard better.
Impaired ear (conductive HL)
Good ear (sensorineural HL)
• Rinne test-assesses air conduction
AC >BC (Positive Rinne)
BC >AC: AC=BC (Negative Rinne-indicates
conductive HL).

67. Assessment of nose and sinuses:
• Look for nasal flaring,, discharge from nose-Check
for patency of nasal cavities (flashlight).
• Palpate for tenderness of nose
• Check olfactory sense (coffee/mint).
• Inspect the nasal septum –push the tip of the nose
upward and use flaslight
• Inspect and palpate the facial sinuses –maxillary
and frontal sinuses for tenderness

68. Assessment of mouth and oropharynx
• Inspect the outer lips for –color,symmetry and
ability to purse lips
• Ask client to open mouth-observe the oral cavity
(buccal mucosa)- color, moistness, odor.
• Inspect the alignment of the teeth.
• Look for dental caries (decayed teeth), stained teeth
and other periodontal diseases
• Use a tongue depressor and inspect the teeth and
gums.
• Ask client to put out tongue and inspect-color,
position and texture.

69. • Periodental disease-Gingivitis, glossitis, parotitis.
• Gingivitis-Inflammation of gums-red, swollen
gingiva, receding gum lines.
• Glossitis-Inflammation of the tongue.
• Stomatitis-Inflammation of the oral mucosa.
• Parotitis-Inflammation of the parotid salivary gland
• Plaque-Invisible, soft film that adheres to the
enamel surface of the teeth
• Tartar-Visible, hard deposit of plaque, dead bacteria
at the gumline.
• Sordes-Accumulation of foul matter (food,
microorganisms, epithelial elements) on teeth and
gums

70. • Abnormalities:Smooth red tongue- Iron, Vit-B, B,
deficiency.
• Dry, furry tongue-fluid deficit.
Inspect tongue movement - ask client to roll tongue
upward, and move it from side to side.
Inspect base of the tongue and floor of the mouth.
Palate for any nodules, lumps or excoriated areas on
the tongue and floor of mouth.
Inspect the hard and soft palates- color and texture
(irregular).
 Inspect the uvula for position and mobility. Ask
client to say 'ah' so the uvula can be better seen.
 Use a flashlight and observe the tonsils.

71. Grading system to describe size of Tonsils:
Grade 1 (Normal): The tonsils are behind the
tonsillar pillars.
Grade 2: The tonsils are between the pillars and
uvula.
Grade 3: The tonsils touch the uvula.
Grade 4: Tonsils extend to the midline of the
oropharynx.
--The tonsils are normally larger in children than in
adults and commonly extend beyond the palatine
arch until the age of 11 or 12 years.
--Use the opportunity of oral assessment to provide
oral and dental care teaching.

72. ASSESSMENT OF THE NECK
Examination of the neck includes the muscles,
lymph nodes, trachea, thyroid gland, carotid and
jugular veins.

73. Assessment of the neck muscles
Inspect the muscles-Symmetry in size, whether
head is centered.
Palpate for any masses are swelling
Sternocleidomastoid muscle - Extends from the upper
sternum and the medial third of the clavical to the
mastoid process of the temporal bone behind the ear.
They turn and laterally flex head
Trapezius muscle- Extends from the occipital bone of
the skull to the lateral third of the clavicle .head to side
and back; elevate the chin, elevate the shoulders to
shrug them.

75. Assess the movement of muscles
Sternocleidomastoid muscle:
Move chin to chest
Move head to that the ear is moved toward the
shoulder on each side
Turn head to right and left.
Trapezius muscle:
Move head back so that the chin points upward.
Shrug shoulders.

76. Assess the strength of muscles:
Sternocleidomastoid muscle.
Ask client to turn the head to one side against
the resistance of your hand. Repeat with the other
side.
Trapezius muscle:
Shrug the shoulders against the resistance of
your hands.

77. Assessment of the lymph nodes:
Palpate for lymph nodes of Neck
 The neck is flexed. Stand behind or to the side of
the patient for all the lymph nodes (Exception
Supraclavicular-stand in front of the patient.)
Lymph nodes can be palpated simultaneously.
Palpate the nodes using the pads of fingers. Move
the fingertips in a gentle rotating motion

79. Occipital-At the posterior base of the skull.
Post auricular-Behind the ear and in front of the
mastoid process.
Pre auricular-In front of the tragus of the car.
Anterior cervical chain -Along the anterior side of
the sternocleidomastoid muscle.
Posterior cervical chain -Along the anterior aspect of
the trapezius muscle.
Deep cervical chain- Under the sternocleidomastoid
muscle.
Supraclavicular nodes-Above the clavicle, in the
angle between the clavicle and the
sternocleidomastoid muscle

80. Assessment of Trachea
Trachea should be centrally placed. Palpate the
trachea for lateral deviation. Place your fingertip
or thumb on the trachea in the suprasternal
notch and then move your finger laterally to the
left and the right.

84. Assessment of thyroid gland:
Inspection:
Stand in front of the client
Have the client swallow, with the neck
hyperextended.
Look for the free mobility of the thyroid gland.
Normal: The gland ascends but is not visible.

85. Palpation:
• Stand behind the client
• Have the neck flexed.
• Note the temperature over the thyroid gland
• Palpate the thyroid for any masses
• If enlarged, auscultate for bruit (a soft rushing
sound created by the turbulent blood flow).

86. Assessment of the carotid arteries
Palpation:
• Palpate one carotid artery at a time - prevents
possible ischemia due to occlusion.
• Ischemia is a deficiency of blood to a body part
due to constriction or obstruction of a blood
vessel.
• Ask client to turn the head slightly toward the side
being examined - makes it easily accessible.
• Massage of the carotid sinus can result in
bradycardia.

87. Auscultation:
• Turn the head slightly away from the side being
examined-to place the stethoscope.
• Auscultate the carotid artery on one side and then
the other.
• Listen for the presence of a bruit turbulent flow
of blood
• If bruit is heard ,gently palpate the artery to
determine the presence of a thrill(Bruit is
abnormal indicates occlusive artery disease)

91. Assessment of jugular vein
pressure(JVP)
Inspection:
Position the client in semi-fowler’s position .Inspect
the Jugular veins for distension –no distension
(Normal) Slight distension (advanced
cardiopulmonary disease)
If jugular vein distension is present then assess the
jugular vein pressure

93. Assessment of Jugular Vein Pressure(JVP)
• Position the client in semi fowler position
• Locate the highest visible point of distension of
internal jugular vein(more reliable than the
external jugular vein)
• Measure the vertical height of this point in cm
from the sternal angle ,the point at which the
clavicles meet
• Bilateral measurements above 3-4cm are
considered elevated (May indicate Rt.sided
heart failure )
• Unilateral distension may be caused by local
obstruction.

94. • Assessment of chest and back
• Assessment of respiratory system
• Assessment of the cardiovascular system
• Assessment of Breasts
`

96. Chest land marks
• Midsternal line
• Anterior axillary lines(right and left)
• Posterior axillary lines (right and left)
• Vertebral line
• Midclavicular lines (right and left)
• Mid axillary lines(right and left)
• Scapular lines(right and left)

97. Diagnostic equipments such as x ray films,
magnetic resonance imagine(MRI), Computered
tomography (CT) scans create little need for the
use of percussion as an assessment measure.

98. Assessment of Chest and Back
Observation:
The nurse usually examines the Posterior
chest first, then the anterior chest. Observe the skin
for any scars or lesions.

99. Back:
The back could be deformed
Kyphosis – Excessive convex curvature of the
thoracic spine
Scoliosis – Lateral deviation of the spine
Kyphoscoliosis- The coexistence of both kyphosis and
scoliosis
Lordosis – The increased curvature of the lumbar
spine
Observe the shape, size of the thorax. The
overall shape of the thorax is elliptical. The
anteroposterior diameter is half its transverse diameter

101. Abnormal Shapes:
• Barrel chest – increased anteroposterior
diameter the ration of AP diameter to transverse
diameter is 1:1
• Pigeon chest (pectus carinatum)- The sternum is
deviated anteriorly (protruding sternum)
• The anteroposterior diameter is large than the
transverse diameter(AP>TD)
• Funnel chest (pectus excavatum)- The sternum
is deviated posteriorly/inward

104. ASSESSMENT OF THE RESPIRATORY
SYSTEM
• Locate the T3 spinous process (posteriorly) and
the 6th rib (anteriorly)
• Observe breathing patterns
• Inspect and palpate for symmetrical lung
expansion 6" rib (anteriorly)
• Palpate for tactile fremitus
• Percuss the lung field for resonance
• Auscultate for breath sounds
• Auscultate for vocal fremitus

105. Locate the T3 Spinous
process(posteriorly) and the 6th rib
(anteriorly):
Location of the T-3 spinous process is a pertinent
landmark for identifying the underlying lung lobes .Ask the
client to flex the neck anteriorly, a prominent process can be
observed and palpated.
This is the process of the 7th cervical vertebra also
referred to as the vertebra prominens. If two spinous es are
observed, the superior one is C 7, and the inferior one is the
spinous process of the first thoracic vertebra (T1). Form this
the T3, spinous process can be palpated and counted. The
oblique fissuredes the lungs into the upper and the lower
lobes runs from the level of the T3, vertebra to the level of
sixth rib at the midclavicular line

108. The starting point for locating the ribs
anteriorly is the angle of Louis, the junction
between the body serum and the manubrium. The
superior border of the second rib attaches to the
sternum at this isternal junction. The other ribs are
now palpated from this landmark. The right lung
is furtherd by a minor fissure into the right upper
lobe and right middle lobe. This fissure runs
anteriorly from midaxillary line at the level of the
5 rib to the level of the 4"

110. Observe for the breathing pattern
Altered Breathing Patterns and Sounds:
Rate:
• Tachypnea - Quick, shallow breaths.
• Bradypnea-Abnormally slow breathing.
• Apnea - Cessation of breathing.

112. Volume:
Hyperventilation - Overexpansion of the lungs
characterized by rapid and deep breaths
Hypoventilation - Under expansion of the
lungs, characterized by shallow respirations

113. Rhythm :
Cheyne-stokes breathing - Rhythmic waxing
and waning of respirations, from very deep to
ventilate shallow breathing and temporary apnea.

114. Ease or Effort:
• Dyspnea - Difficult and labored breathing
during which the individual has a persistent,
unsatisfied need for air and feels distressed.
• Orthopnea - Ability to breath only in upright
sitting or standing positions.

115. Audible breath sounds:
Stridor-A high-pitched, whistling sound most
often heard while taking in a breath
Stertor- one type of noisy breathing is stertor.This
term implies a noise created in the nose or the back
of the throat
Wheeze-Continuous, high-pitched musical squeak
or whistling sound occurring on expiration normal
sometimes on inspiration when air moves through
a narrowed or partially obstructed air or airway
Bubbling - Gurgling sounds heard as air passes
through moist secretions in the respiratory tract

116. Inspect chest movements and palpate for
symmetrical lung expansion:
Observation - Chest movements:
Intercostals retraction: Indrawing between the
ribs(due to reduced air pressure inside your chest)
Substernal retraction: are inward movement of
the abdomen at the end of the breastbone
Suprasternal retraction: when the skin in the
middle of your neck sucks in Indrawing above the
clavicles.

120. • Observe the thorax as a whole. It normally
expands and relaxes regularly with equality of
movement bilaterally. In healthy adults the
normal respiratory rates vary from 12 to 20
respirations per minute.

124. Auscultation -Breath sounds

127. Auscultation
Whispered pectoriloquy- Ask the patient to
whisper a sequence of words such as one-two-three”
and listen with a stethoscope .Normally, only faint
sounds are heard .However over arears of tissue
abnormality the whispered sound will be clear and
distinct
Bronchophony Abnormal:
Ask the patient to say 99 in a normal voice.
Listen to chest with a stethoscope. The expected finding
is that the words will be indistinct. Bronchophony is
present sounds can be heard clearly

128. Egophony –Normal
While listening to the chest with a
stethoscope, ask the patient to say the vowel ‘e’
,Over normal lung tissues, the same ‘e’ (as in
beet) will be heard.
If the lung tissue is consolidated the ‘e’
Sound will change to a nasal ‘a’ (as in ‘say’)

129. HEART
Compare the assessment of heart function with
findings from the vascular assessment
Alteration in either systems sometimes
manifest as changes in the other

131. ASSESSMENT MENT OF THE
CARDIOVASCULAR SYSTEM
During an assessment, the nurse will use the
skills of inspection, auscultation, and palpation.
Learning how to perform a nursing health
assessment takes practice.

133. LANDMARKS
• The landmarks of the chest (thorax) include
the ribs, clavicle, manubrium, Angle of Louis,
the body of the sternum, and xiphoid process.
There are twelve (12) pairs of ribs. There are
seven (7) true ribs and five (5) false ribs.
• The manubrium provides a place for the first rib
and clavicle to attach to the sternum. The Angle of
Louis is the joint between the manubrium and the
body of the sternum.

134. xiphoid process.

135. • The body of the sternum is just below the
manubrium. And the xiphoid process is the
lowest bone of the sternum. The nurse can easily
palpate the manubrium, the body of the sternum,
and xiphoid process in some people.
• There are several terms to become familiar with
related to the landmarks of the chest (thorax).
First, is the term costal which refers to the ribs.
Next, is the intercostal space. This is the area
between the ribs. Some additional terms to know
include the left sternal border (LSB), right
sternal border (RSB), and the midclavicular
line (MCL).

136. • The right and left sternal borders are the right
and left edges of the sternum. The
midclavicular line is an imaginary line drawn
down the middle of the right or left rib cage.
The midclavicular line is sometimes called the
nipple line.

137. Landmarks
Use the technique of palpation to become familiar
with the intercostal space. First, find the clavicle.
The first rib is immediately below the clavicle.
Therefore the first intercostal space is located below
the first rib.
There are five landmarks on the chest (thorax) that
are helpful to know. These landmarks extend from
the second intercostal space to the fifth intercostal
space.
It is helpful to practice palpating the first through the
fifth or sixth ribs and intercostal spaces. Also,
practice palpating the sternum and the sternal
borders. The five landmarks include:

138. The second intercostal space right sternal border
(2nd ICS, RSB)
The second intercostal space left sternal border
(2nd ICS, LSB)
The third intercostal space left sternal border (3rd
ICS, LSB)
The fourth intercostal space left sternal border
(4th ICS, LSB)
The fifth intercostal space midclavicular line (5th
ICS, MCL)

140. Assess Vital Signs
A good set of vital signs are important for any patient but
especially for a patient with cardiovascular symptoms or
complications.
Always take a full set of vital signs including blood
pressure, heart rate (pulse, apical pulse), respiratory
rate and temperature. It is usually a good idea to take a
manual blood pressure when a patient is experiencing
cardiac symptoms. Also, obtain a weight unless a baseline
weight has already been taken.
Also, take an orthostatic blood pressure. An orthostatic
blood pressure should include the heart rate and blood
pressure in the standing, sitting and lying position.
Be sure to be efficient with measuring and the charting of
your findings especially if they are baseline measurements.
If your measurements are not the baseline measurements,
compare them to the baseline measurements.

141. Interview the Patient for Cardiac Symptoms
• Your patient can be your greatest source of
information to assist in the diagnosis of a problem.
In a focused nursing assessment of the
cardiovascular system, it is important to gather
information about symptoms and behaviours that
may affect the cardiovascular system directly or
indirectly.
• The subjective data or the interview of your patient
is just as important as the objective data or the
physical examination.

142. • Some of the more common cardiac symptoms
include chest pain, angina, and palpitations or
irregular heartbeat. However, there are other
symptoms that affect different parts of the body
that may have a cardiovascular origin.
• It is important for the nurse to be aware of all
symptoms related to the cardiovascular system.
Ask the patients questions related to the cardiac
system and any other symptoms that they may
have.

143. Palpitations
• Palpitation is another symptom. A palpitation is an
irregular heartbeat that feels like a sensation in the
throat or chest.
• It may feel as if the heart has skipped a beat or
speeds up for a second. Ask the patient if they have
experienced these symptoms.
• It is ok to assist the patients in describing symptoms
or to give them cues. They did not take a health
assessment class. Ask the usual questions.
• How long have they had this symptom?
• When does it happen?
• Does it happen more when they are active or
inactive, etc?

144. Assess the Vessels of the Neck
• The neck vessels include the jugular veins and the
carotid arteries. The jugular veins drain blood
from the face, head, and neck and empty into
the superior vena cava.
• The jugular veins are an assessment tool to
measure central venous pressure (CVP) or right
atrial pressure. Monitoring right atrial pressure
gives an idea of fluid balance in the body.

145. Inspect the Jugular Veins
• Inspect for the internal jugular veins and the external jugular
veins. The internal and external jugular veins are usually not
visible in most patients.
• Use inspection to look for any distention. The patient should be
elevated to about a 45-degree angle. The jugular veins are
usually flattened and disappear at this angle.
• This is a normal finding. The veins will become distended with
an increased in central venous pressure.
Palpate the Carotid Arteries
• Use palpation to assess the carotid artery. The carotid artery is
located on each side of the neck lateral to the trachea.
• The patient should be at a 45-degree angle. Use the fingertips to
palpate the carotid artery. Remember to apply gentle pressure.
Applying too much pressure may occlude the pulsation.
• You should be able to palpate a pulse on each side. Palpate only
one carotid artery at a time. An absence pulse may indicate an
obstruction.

147. Feel the Thrill – Auscultate the Bruit
• Some students may be familiar with a thrill and a bruit as it relates to
dialysis patients that have a graft or AV shunt. This is a great patient to
practice feeling a thrill and auscultating a bruit.
• When performing a nursing assessment on the cardiovascular system,
you will use palpation and auscultation to assess the carotid arteries for a
thrill and a bruit.
• The thrill is a vibration against your fingers. It can feel like a buzzing or
humming under the skin. Use the same method as palpating the carotid
arteries. If you feel a thrill, listen for a bruit.
• As a result of hearing a thrill, you should listen for a bruit. Use a
stethoscope to auscultate a bruit.
• A bruit sounds like rushing fluid in a rhythm. It can sometimes sound
like a fetal heart tone. Turbulent blood flow causes a bruit. Normally, a
patient should not have a carotid thrill or bruit.
• To auscultate a bruit, have the patient hold their breath and listen with the
bell of the stethoscope midpoint of the carotid artery.

149. Inspect and Palpate the Chest (Thorax)
Inspect the Chest
• Inspect the chest for pulsations. Look for pulsations at the five
landmarks. Inspect the chest with the patient in a high, mid and
low Fowler’s position.
• First, observe the second intercostal space at the right sternal
border.
• Next, move to the second intercostal space at the left sternal
border.
• Then, inspect the third and fourth intercostal space at the left
sternal border.
• Finally, move to the fifth intercostal space at the midclavicular
line where the apex of the heart is located.
• This is the point of maximal impulse. Covered below is the
assessment of the apical pulse and point of maximal impulse.
• Inspect the chest for rises or lifts at those landmarks or anywhere
else. These pulsations are called heave or lifts. You can visualize
or palpate a heave or a lift.

151. Palpate the Chest
• Next, palpate the chest. Feel for pulsations over the five landmarks.
• Place the patient in a high, mid or low Fowlers position to palpate the chest
wall.
• Use the fingerpads or the palm of the hand to palpate the chest wall. You are
feeling for pulsations, lifts or heaves.
• First, feel over the second intercostal space at the right sternal border.
• Next, move to the second intercostal space at the left sternal border.
• Then, palpate the third and fourth intercostal space at the left sternal
border. There should be no pulsations present at these landmarks.
• Finally, move to the fifth intercostal space at the midclavicular line where
the apex of the heart is located.
• When you palpate at this location you should feel a slight tapping sensation.
This tapping sensation coincides with the heartbeat. This is the apical pulse.
• The apical pulse should be the only pulsation felt on the chest wall.

153. Assess the Point of Maximal impulse – Apical Pulse
• Although apex means peak, the apex of the heart is at the
bottom. The base is the top. The apical pulse is located at
the fifth intercostal space midclavicular line.
• This is also called the point of maximal impulse (PMI).
Also, the mitral valve can be auscultated at this location.
• Note the location and characteristics of the apical pulse.
An enlarged heart and pregnancy can displace the apical
pulse.
• During a cardiovascular assessment, it would be a good
idea to count the heart rate by auscultating the apical
pulse with your stethoscope and compare to peripheral
pulse.

154. Auscultate the Chest
• Use the stethoscope to auscultate the chest for the
apical pulse. Note the rate, rhythm, and any extra
heart sounds. The rate will be normal (60-100), fast
(tachycardia >100), or slow (bradycardia <60). The
rhythm will be regular or irregular.
• Next, auscultate over the five landmarks of the
chest.
• First, auscultate the aortic valve. This is located at
the second intercostal space right sternal border.
• Second, auscultate the pulmonary valve. It is
located at the second intercostal space left sternal
border.

155. • Third, auscultate Erb’s point. Erb’s point is located at
the third intercostal space left sternal border.
• Fourth, auscultate the tricuspid valve. This is located
at the fourth intercostal space at the left sternal
border.
• Fifth, auscultation of the mitral valve. The mitral
valve is located at the fifth intercostal space
midclavicular line. This is the same placement as the
apical pulse and the point of maximal impulse.
• Next, auscultate the heart sounds. You are listening
for S1 and S2 heart sounds. The closure of the heart
valves produces the S1 and S2 heart sounds.
• Use the diaphragm of the stethoscope to hear these
sounds the best. If you think your patient may have
an extra heart sound (S3 or S4), use the bell of the
stethoscope. Also, note any abnormal heart sounds.

157. Assess S1 and S2 Heart Sounds
S1 Heart Sound
• The first heart sound is the S1 heart sound. This sound is heard best
over the apex of the heart. The closure of the tricuspid and bicuspid
(mitral) valve produces the S1 sound.
• The fourth intercostal space left sternal border is the location of
the tricuspid valve sound. The fifth intercostal space left sternal
border is the location of the bicuspid (mitral) valve sound.
• Therefore, this heart sound is heard the loudest over the fourth and
fifth intercostal spaces or the apex of the heart.
• The heart sound S1 is composed of the
sounds M1 and T1. Consequently, the M1 sound is the closure of the
bicuspid (mitral) valve. And, the T1 sound is the closure of the
tricuspid valve.
• The mitral valve closes slightly before the tricuspid valve. Although
there is a slight separation, both the M1 and T1 are heard as one
sound (S1).

158. S2 Heart Sound
• The second heart sound is the S2 heart sound. This heart sound is
heard the loudest over the base of the heart. This sound is
the closure of the pulmonary and aortic valve.
• Remember, the second intercostal space right sternal border is
the location of the aortic valve sound. And, the second
intercostal space left sternal border is the location of
the pulmonary valve sound.
• Therefore, the S2 heart sound is the loudest over the second
intercostal space at the left and right sternal borders or the
base of the heart.
• The combined A2 and P2 heart sounds produce the S2 heart
sound The A2 sound is the closure of the aortic valve.
The P2 is the closure of the pulmonary valve.
• The aortic valve closes slightly before the pulmonary valve. Even
with the slight separation, both the A2 and P2 are heard as one
sound (S2).
• Correspondingly, the S1 and S2 heart sounds can be heard with
equal intensity at the third intercostal space left sternal
border. This location is Erb’s Point.

159. • S3 Heart Sound
• Depending on the diagnosis of your patient you may
hear an additional heart sounds. One such heart sound
is S3 heart sound. The placement of the S3 heart
sound is after the S2 heart sound.
• It is sometimes hard to distinguish between
an S3 heart sound and a split S2 heart sound. The split
S2 heart sound is when the A2 and P2 sounds are
separated enough to make a distention between the
two.
• An S3 heart sound can be normal or abnormal. You
may hear an S3 heart sound in patients with heart
failure, volume overload, and other conditions. When
it is abnormal, a ventricular gallop is another name
for the S3 heart sound.

160. • The S3 heart sounds happen during ventricular
filling in early diastole. Blood hitting the ventricle
causes the S3 sound when it is overly
compliant. Compliance refers to distensibility or
expansion.
• However, it is not easy to determine an S3 heart
sound. It is better to assess the patient in a quiet
room.
• The nurse should use the bell of the stethoscope.
The apex of the heart is the best place to hear this
sound. It is helpful to place the patient on their left
side.
• The S3 heart sound is low and deep. Correcting the
underlying condition causes the S3 heart sound to go
away.

161. S4 Heart Sound
• Another additional heart sound is the S4 heart
sound. The placement of the S4 heart sound is
immediately before the S1 heart sound.
• An S4 heart sound is usually abnormal. You may
hear an S4 heart sound in patients with
cardiovascular disease, high blood pressure, and
other conditions. An atrial gallop is another name
for an S4 heart sound.
• The S4 heart sound happens during ventricular
filling in late diastole. A patient with increased
ventricular resistance will usually have an S4
heart sound.

162. • In order to assess a patient with an S4 heart
sound, place the patient in a quiet room. Use the
bell of the stethoscope to auscultate.
• The S4 heart sound is even harder to auscultate
than the S3 heart sound. Placing a patient on the
left side helps auscultate the S4 heart sound
better. The sound of the S4 is soft and low. The
apex of the heart is the best location to hear the
S4 heart sound.
• A way to remember the placement of the normal
and additional hearts sounds is:

163. S4 – S1 – S2 – S3
• There are additional heart sounds besides S3 and
S4. While performing a nursing assessment for
the cardiovascular system you may
hear murmurs, clicks, or a split heart sounds.
• As assessment skills progress and with practice
you will be able to distinguish more heart sounds.
As a nursing student, hearing any other sound
besides S1 and S2 is fabulous.

165. Assessment of the peripheral vessels
• Measurement of blood pressure usually done at the
beginning of physical examination
• Palpation peripheral pulses
• Inspection the skin and tissues to determine
perfusion to the extremities

166. Palpation of peripheral pulses
• Peripheral pulses are checked simultaneously and
systematically to determine the symmetry of
pulse volume
• Assess peripheral leg veins for signs of phlebitis
• Inspect calves for firmness or tension of the
muscles, the presence of edema over the dorsum
of the foot and areas of localized warmth

171. • It is a simple test to measure the time taken
for colour to return to an external capillary
bed after pressure is applied, typically by
pressing the end of a finger with the thumb
and forefinger. Normal capillary refill time is
usually 2 seconds or less.

172. Assessment of The Breast
The Breast of men and women need to be inspected
and palpated
 Glandular breast tissue is a potential site for
malignancy
 Men have some glandular tissue below the nipple
 Women have glandular tissue throughout the breast
the largest portion located in the upper outer
quadrant
 The projection of breast tissue to the axillary tail of
spence
 Women have glandular tissue throughout the breast.
The projection of breast tissue to the axill-Axillary tail
of spence

173. Breast health guidelines
From menarche to 39yrs
-Monthly Breast self examination
-Clinical breast examination by a health
professional every 3 years
From 40 yrs and above
-Monthly breast self examination
-Clinical breast examination by ahealth
professional every year
-Screening Mammogram every year

182. Assessment of the Abdomen
Location and describing the abdominal findings
the abdomen is divided into:
• Four quadrants
• Nine regions
Imaginary lines
Vertical line: From xiphoid process to symphysis
pibis
Horizontal line: Across the umbilicus

183. With abdominal assessment, you inspect first,
then auscultate, percuss, and palpate. This order
is different from the rest of the body systems, for
which you inspect, then percuss, palpate, and
auscultate.