chapter 22 (health assessment)

Describe your daily activities. How are they different from your routine 5 or 10 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?

Heart disease may impede the ability to perform daily activities. Exertional dyspnea or fatigue may indicate heart failure. An inability to complete ADLs may necessitate a referral for home care.

Heart Sounds

Heart sounds are produced by valve closure, as just described. The opening of valves is silent. Normal heart sounds, characterized as "lubdubb" (S1 and S2), and occasionally extra heart sounds and murmurs can be auscultated with a stethoscope over the precordium, the area of the anterior chest overlying the heart and great vessels.

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?

If heart function is compromised, CO to the kidneys is reduced during episodes of activity. At rest, CO increases, as does glomerular filtration and urinary output. Orthopnea (the inability to breathe while supine) and nocturia may indicate heart failure. In addition, these two conditions may also impede the ability to get adequate rest.

Do you have frequent heartburn? When does it occur? What relieves it? How often do you experience it?

Cardiac pain may be overlooked or misinterpreted as gastrointestinal problems. Gastrointestinal pain may occur after meals and is relieved with antacids. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity.

Electrical Conduction of the Heart

Cardiac muscle cells have a unique inherent ability. They can spontaneously generate an electrical impulse and conduct it through the heart. The generation and conduction of electrical impulses by specialized sections of the myocardium regulate the events associated with the filling and emptying of the cardiac chambers. The process is called the cardiac cycle (see description in next section).

Is there a history of hypertension, MI, coronary heart disease (CHD), elevated cholesterol levels, or diabetes mellitus (DM) in your family?

A genetic predisposition to these risk factors increases a client's chance for developing heart disease.

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?

A person's feeling of self-worth may depend on the ability to perform usual daily activities and fulfill the usual roles. Of more than 1,000 adult US women surveyed, 9.7% identified heart disease as the disease they fear most (National Heart Lung and Blood Institute [NHLBI], 2012).

Have you ever had an electrocardiogram (ECG)? When was the last one performed? Do you know the results?

A prior ECG allows the health care team to evaluate for any changes in cardiac conduction or previous MI.

Do you exercise? What type of exercise and how often?

A sedentary lifestyle is a known modifiable risk factor contributing to heart disease. Aerobic exercise three times per week for 30 minutes is more beneficial than anaerobic exercise or sporadic exercise in preventing heart disease.

Have you ever had rheumatic fever?

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is a significant public health concern around the world (Seckeler & Hoke, 2011). Rheumatic carditis develops after exposure to group A beta-hemolytic streptococci and results in inflammation of all layers of the heart, impairing contraction and valvular function.

Describe what you usually eat in a 24-hour period.

An elevated cholesterol level increases the chance of fatty plaque formation in the coronary vessels.

Neck Vessels

Assessment of the cardiovascular system includes evaluation of the vessels of the neck: the carotid artery and the jugular veins (Fig. 21-5). Assessment of the pulses of these vessels reflects the integrity of the heart muscle.

Systole

At this point in systole, all four valves are closed and the ventricles contract (isometric contraction). There is now high pressure inside the ventricles, causing the aortic valve to open on the left side of the heart and the pulmonic valve to open on the right side of the heart. Blood is ejected rapidly through these valves. With ventricular emptying, the ventricular pressure falls and the semilunar valves close. This closure produces the second heart sound (S2), which signals the end of systole. After closure of the semilunar valves, the ventricles relax. Atrial pressure is now higher than the ventricular pressure, causing the AV valves to open and diastolic filling to begin again.

Murmurs

Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the precordium. Conditions that contribute to turbulent blood flow include (1) increased blood velocity, (2) structural valve defects, (3) valve malfunction, and (4) abnormal chamber openings (e.g., septal defect).

Do you experience chest pain? If the client answers yes, use COLDSPA to explore the symptom. Character: Describe your chest pain (stabbing, burning, crushing, squeezing, or tightness). Onset: When did it start?

Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain worsened by activity are usually related to cardiac chest pain.

Do you smoke? How many packs of cigarettes per day and for how many years? Are you trying to or interested in trying to quit smoking?

Cigarette smoking greatly increases the risk of heart disease (Evidence-Based Practice 21-1). If the client is trying to quit, then the 5 As of smoking cessation (Box 21-4) can be initiated, as even a brief intervention can significantly increase the rates at which patients stop smoking (ACOG, 2016).

Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?

Clients may have medications prescribed for heart disease but may not take them regularly. Clients may skip taking their diuretics because of having to urinate frequently. Beta-blockers may be omitted because of the adverse effects on sexual energy. Education about medications may be needed.

Have you been diagnosed with a heart defect or a murmur?

Congenital or acquired defects affect the heart's ability to pump, decreasing the oxygen supply to the tissues.

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 day?

Fatigue may result from compromised CO. Fatigue related to decreased CO is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day.

Do you cough up mucous? When does it occur? Describe the appearance.

Fluid accumulation in the lungs from heart failure can cause one to cough up white- or pink-tinged sputum.

Do you experience dizziness?

Dizziness may indicate decreased blood flow to the brain due to myocardial damage. However, there are several other causes for dizziness such as inner ear syndromes, decreased cerebral circulation, and hypotension.

Diastole

During ventricular diastole, the AV valves are open and the ventricles are relaxed. This causes higher pressure in the atria than in the ventricles. Therefore, blood rushes through the atria into the ventricles. This early, rapid, passive filling is called early or protodiastolic filling. This is followed by a period of slow passive filling. Finally, near the end of ventricular diastole, the atria contract and complete the emptying of blood out of the upper chambers by propelling it into the ventricles. This final active filling phase is called presystole, atrial systole, or sometimes the "atrial kick." This action raises left ventricular pressure.

Have you ever had a blood test called a lipid profile? Based on your last test, do you know what your cholesterol levels were?

Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis (American Heart Association [AHA], 2014a).

Do you have difficulty breathing (dyspnea) or shortness of breath? When does this occur? What activities cause you to be short of breath? Do you have difficulty breathing when you are lying down? How many pillows do you use to sleep? Does the difficulty in breathing wake you up at night?

Dyspnea may result from congestive heart failure, pulmonary disorders, coronary artery disease, myocardial ischemia, and myocardial infarction (MI). Dyspnea may occur at rest; during sleep; or with mild, moderate, or extreme exertion. Orthopnea is the need to sit more upright to breathe easily due to fluid accumulation in the lungs. Waking up from dyspnea during the night (paroxysmal nocturnal dyspnea) is seen with heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night.

Electrical Activity

Electrical impulses, which are generated by the SA node and travel throughout the cardiac conduction circuit, can be detected on the surface of the skin. This electrical activity can be measured and recorded by electrocardiography (ECG, also abbreviated as EKG), which records the depolarization and repolarization of the cardiac muscle. The phases of the ECG are known as P, Q, R, S, and T. Box 21-1 describes the phases of the ECG.

How much alcohol do you consume each day/week?

Excessive intake of alcohol has been linked to hypertension. More than two drinks per day for men, or one drink per day for women, is associated with high blood pressure and other diseases (AHA, 2015a).

Do you wake up at night with an urgent need to urinate (nocturia)? If so, how many times each night?

Increased renal perfusion during periods of rest or recumbent positions may cause nocturia, which occurs with heart failure.

Has your heart disease had any effect on your sexual activity?

Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart.

Location: Where is the pain? Does it radiate to any other area? Where? Duration: How long does the pain last? How often do you experience the pain? Severity: Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain. Patterns: What brings on the pain (activity, stress, eating, sexual activity, weather change, extreme cold or heat, lying flat, resting)? What relieves the pain (nitroglycerin, rest)? Associated Factors: Do you have any other symptoms with this pain (shortness of breath [dyspnea], perspiration [diaphoresis], pale clammy skin, nausea, vomiting, heart beat skips or speeds up)?

Other symptoms that may occur include dyspnea, diaphoresis, pallor, nausea, palpitations, or tachycardia. Pain is usually seen in clients with angina. However, some clients may experience these other symptoms without the pain.

Preparing the Client

Prepare clients for the examination by explaining that they will need to expose the anterior chest. Explain to the client that it is necessary to assume several different positions for this examination. Explain that you will need to place the client in the supine position with the head elevated to about 30 degrees during auscultation and palpation of the neck vessels and inspection, palpation, and auscultation of the precordium. Tell the client that it will be necessary to assume a left lateral position for palpation of the apical impulse if you are having trouble locating the pulse with the client in the supine position. In addition, explain to the client the necessity to assume a left lateral and sitting-up and leaning-forward position so that you can auscultate for the presence of any abnormal heart sounds. These positions may bring out an abnormal sound not detected with the client in the supine position. Make sure you explain to the client that you will be listening to the heart in a number of places and that this does not necessarily mean that anything is wrong.

Have you ever had heart surgery or cardiac balloon interventions?

Previous heart surgery may change the heart sounds heard during auscultation. Surgery and cardiac balloon interventions indicate prior cardiac compromise.

Extra Heart Sounds

S3 and S4 are referred to as diastolic filling sounds, or extra heart sounds, which result from ventricular vibration secondary to rapid ventricular filling. If present, S3 can be heard early in diastole, after S2 (Fig. 21-4). S4 also results from ventricular vibration but, contrary to S3, the vibration is secondary to ventricular resistance (noncompliance) during atrial contraction. If present, S4 can be heard late in diastole, just before S1 (Fig. 21-4). S3 is often termed ventricular gallop, and S4 is called atrial gallop. Extra heart sounds are described further in the Physical Assessment section of the text and in Assessment

Do you monitor your own HR or blood pressure?

Self-monitoring of HR or blood pressure is recommended if the client is taking cardiotonic or antihypertensive medications. A demonstration is necessary to ensure appropriate technique

What type of stress do you have in your life? How do you cope with it?

Stress has been identified as a possible risk factor for heart disease.

Stroke Volume

Stroke volume (SV) is the amount of blood pumped from the heart with each contraction (SV from the left ventricle is usually 70 mL). SV is influenced by several factors: The degree of stretch of the heart muscle up to a critical length before contraction (preload); the greater the preload, the greater the SV. This holds true unless the heart muscle is stretched so much that it cannot contract effectively. The pressure against which the heart muscle has to eject blood during contraction (afterload); increased afterload results in decreased SV. Synergy of contraction (i.e., the uniform, synchronized contraction of the myocardium); conditions that cause an asynchronous contraction decrease SV. Compliance, or distensibility, of the ventricles; decreased compliance decreases SV. Contractility, or the force of contractions, of the myocardium under given loading conditions; increased contractility increases SV.

Does your heart ever beat faster? Does your heart ever skip beats, or have extra beats? When does this occur and how long does it last? What makes this better or worse?

Tachycardia may be seen with weak heart muscles, an attempt by the heart to increase CO. Palpitations may occur with an abnormality of the heart's conduction system (arrhythmias) or during the heart's attempt to increase CO by increasing the HR. Palpitations may cause the client to feel anxious.

Systole

The filling phases during diastole result in a large amount of blood in the ventricles, causing the pressure in the ventricles to be higher than in the atria. This causes the AV valves (mitral and tricuspid) to shut. Closure of the AV valves produces the first heart sound (S1), which is the beginning of systole. This valve closure also prevents blood from flowing backward (a process known as regurgitation) into the atria during ventricular contraction.

Heart Covering and Walls

The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The myocardium is the thickest layer of the heart, made up of contractile cardiac muscle cells. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels (Fig. 21-2).

Carotid Artery Pulse

The right and left common carotid arteries extend from the brachiocephalic trunk and the aortic arch, and are located in the groove between the trachea and the right and left sternocleidomastoid muscles. Slightly below the mandible, each bifurcates into an internal and external carotid artery. They supply the neck and head, including the brain, with oxygenated blood. The carotid artery pulse is a centrally located arterial pulse. Because it is close to the heart, the pressure wave pulsation coincides closely with ventricular systole. The carotid arterial pulse is good for assessing amplitude and contour of the pulse wave. The pulse should normally have a smooth, rapid upstroke that occurs in early systole and a more gradual downstroke.

Pathways

The sinoatrial (SA) node (or sinus node) is located on the posterior wall of the right atrium near the junction of the superior and inferior vena cava. The SA node, with inherent rhythmicity, generates impulses (at a rate of 60 to 100 per minute) that are conducted over both atria, causing them to contract simultaneously and send blood into the ventricles. The current, initiated by the SA node, is conducted across the atria to the AV node located in the lower interatrial septum (Fig. 21-3). The AV node slightly delays incoming electrical impulses from the atria and then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum. The electrical impulse then travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles, causing them to contract almost simultaneously. Although the SA node functions as the "pacemaker of the heart," this activity shifts to other areas of the conduction system, such as the Bundle of His (with an inherent discharge of 40 to 60 per minute), if the SA node cannot function.

Jugular Venous Pulse and Pressure

There are two sets of jugular veins: internal and external. The internal jugular veins lie deep and medial to the sternocleidomastoid muscle. The external jugular veins are more superficial; they lie lateral to the sternocleidomastoid muscle and above the clavicle. The jugular veins return blood to the heart from the head and neck by way of the superior vena cava.

Listen to S1. Use the diaphragm of the stethoscope to best hear S1.

normal findings: A distinct sound is heard in each area but loudest at the apex. May become softer with inspiration. A split S1 may be heard normally in young adults at the left lateral sternal border. abnormal findings: Accentuated, diminished, varying, or split S1 are all abnormal findings (Box 21-2).

Listen to S2. Use the diaphragm of the stethoscope. Ask the client to breathe regularly (Fig. 21-13).

normal findings: Distinct sound is heard in each area but is loudest at the base. A split S2 (into two distinct sounds of its components—A2 and P2) is normal and termed physiologic splitting. It is usually heard late in inspiration at the second or third left interspaces (Box 21-3). abnormal findings: Any split S2 heard in expiration is abnormal. The abnormal split can be one of three types: wide, fixed, or reversed.

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 that breath sounds do not conceal any vascular sounds

normal findings: No blowing or swishing or other sounds are heard. abnormal findings: A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is indicative of occlusive arterial disease. However, if the artery is more than two-thirds occluded, a bruit may not be heard.

Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.

normal findings: No pulsations or vibrations are palpated in the areas of the apex, left sternal border, or base. abnormal findings: A thrill or a pulsation is usually associated with a grade IV or higher murmur.

Auscultate for murmurs. A murmur is a swishing sound caused by turbulent blood flow through the heart valves or great vessels. Auscultate for murmurs across the entire heart area. 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 as described in the next section because some murmurs occur or subside according to the client's position.

normal findings: Normally no murmurs are heard. However, innocent and physiologic midsystolic murmurs may be present in a healthy heart. abnormal findings: Pathologic midsystolic, pansystolic, and diastolic murmurs. Abnormal Findings 21-5 describes pathologic murmurs.

Auscultate for extra heart sounds. Use the diaphragm first, then the bell (Fig. 21-14) to auscultate over the entire heart area. Note the characteristics (e.g., location, timing) of any extra sound heard. Auscultate during the systolic pause (space heard between S1 and S2). Auscultate during the diastolic pause (space heard between end of S2 and the next S1). Clinical Tip

normal findings: Normally no sounds are heard. A physiologic S3 heart sound is a benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults. It is rare after age 40. The physiologic S3 usually subsides upon standing or sitting up. A physiologic S4 heart sound may be heard near the end of diastole in well-conditioned athletes and in adults older than age 40 or 50 with no evidence of heart disease, especially after exercise. abnormal findings: Ejection sounds or clicks (e.g., a mid-systolic click associated with mitral valve prolapse). A friction rub may also be heard during the systolic pause. Abnormal Findings 21-4 provides a full description of the extra heart sounds (normal and abnormal) of systole and diastole. A pathologic S3 (ventricular gallop) may be heard with ischemic heart disease, hyperkinetic states (e.g., anemia), or restrictive myocardial disease. A pathologic S4 (atrial gallop) toward the left side of the precordium may be heard with coronary artery disease, hypertensive heart disease, cardiomyopathy, and aortic stenosis. A pathologic S4 toward the right side of the precordium may be heard with pulmonary hypertension and pulmonic stenosis. S3 and S4 pathologic sounds together create a quadruple rhythm, which is called a summation gallop. Opening snaps (OSs) occur early in diastole and indicate mitral valve stenosis. A friction rub may also be heard during the diastolic pause (Abnormal Findings 21-4).

Always auscultate the carotid arteries before palpating because palpation may increase or slow the HR, changing the strength of the carotid impulse heard.

normal findings: Pulses are equally strong; a 2+ or normal with no variation in strength from beat to beat. Contour is normally smooth and rapid on the upstroke and slower and less abrupt on the downstroke. The strength of the pulse is evaluated on a scale from 0 to 3 as follows: Pulse Amplitude Scale 0 = Absent 1+ = Weak, diminished (easy to obliterate) 2+ = Normal (obliterate with moderate pressure) 3+ = Strong (obliterate with firm pressure) 4+ = Bounding (unable to obliterate) Arteries are elastic and no thrills are noted. abnormal findings: Pulse inequality may indicate arterial constriction or occlusion in one carotid. Weak pulses may indicate hypovolemia, shock, or decreased cardiac output. A bounding, firm pulse may indicate hypervolemia or increased CO. Variations in strength from beat to beat or with respiration are abnormal and may indicate a variety of problems (Abnormal Findings 21-1). A delayed upstroke may indicate aortic stenosis. Loss of elasticity may indicate arteriosclerosis. Thrills may indicate a narrowing of the artery.

Auscultate HR and rhythm. Follow the guidelines given in Assessment Guide 21-1. Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse.

normal findings: Rate should be 60-100 beats/min, with regular rhythm. A regularly irregular rhythm, such as sinus arrhythmia when the HR increases with inspiration and decreases with expiration, may be normal in young adults. Resting pulse rate (RPR) varies by age, gender, and ethnic/racial factors (Ostchega et al., 2011). Adult female RPRs are a few beats faster than male RPRs. abnormal findings: Bradycardia (less than 60 beats/min) or tachycardia (more than 100 beats/min) may result in decreased CO. Refer clients with irregular rhythms (i.e., premature atrial contraction or premature ventricular contractions, atrial fibrillation, atrial flutter with varying blocks) for further evaluation. These types of irregular patterns may predispose the client to decreased CO, heart failure, or emboli (Abnormal Findings 21-3).

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 (Fig. 21-15).

normal findings: S1 and S2 heart sounds are normally present. abnormal findings: Murmur of aortic regurgitation may be detected when the client assumes this position.

Auscultate to identify S1 and S2. Auscultate the first heart sound (S1 or "lub") and the second heart sound (S2 or "dubb"). Remember these two sounds make up the cardiac cycle of systole and diastole. S1 starts systole, and S2 starts diastole. The space, or systolic pause, between S1 and S2 is of short duration (thus S1 and S2 occur very close together); the space, or diastolic pause, between S2 and the start of another S1 is of longer duration.

normal findings: S1 corresponds with each carotid pulsation and is loudest at the apex of the heart. S2 immediately follows after S1 and is loudest at the base of the heart.

Palpate the apical impulse. Remain on the client's right side and ask the client to remain supine. Use one or two finger pads to palpate the apical impulse in the mitral area (fourth or fifth ICS at the MCL) (Fig. 21-11A). You may ask the client to roll to the left side to better feel the impulse using your finger pads (Fig. 21-11B).

normal findings: The apical impulse is palpated in the mitral area and may be the size of a nickel (1-2 cm). Amplitude is usually small—like a gentle tap. The duration is brief, lasting through the first two-thirds of systole and often less. In obese clients or clients with large breasts, the apical impulse may not be palpable. abnormal findings: The apical impulse may be impossible to palpate in clients with pulmonary emphysema. If the apical impulse is larger than 1-2 cm, displaced, more forceful, or of longer duration, suspect cardiac enlargement.

Inspect for any pulsations on anterior chest over heart. With the client in 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 any abnormal pulsations.

normal findings: The apical impulse may or may not be visible. If apparent, it would be in the mitral area (left MCL, fourth or fifth ICS). The apical impulse is a result of the left ventricle moving outward during systole. abnormal findings: Pulsations, which may also be called heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated. A heave or lift may occur as the result of an enlarged ventricle from an overload of work. Abnormal Findings 21-2 describes abnormal ventricular impulses.

Evaluate jugular venous pressure (Fig. 21-8). Evaluate jugular venous pressure by watching for distention of the jugular vein. It is normal for the jugular veins to be visible when the client is supine. To evaluate jugular vein distention, position the client in a supine position with the head of the bed elevated 30, 45, 60, and 90 degrees. At each increase of the elevation, have the client's head turned slightly away from the side being evaluated. Using tangential lighting, observe for distention, protrusion, or bulging

normal findings: The jugular vein should not be distended, bulging, or protruding at 45 degrees or greater. abnormal findings: Distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate right-sided heart failure. Document at which positions (45, 60, and/or 90 degrees) you observe distention. Clients with obstructive pulmonary disease may have elevated venous pressure only during expiration. An inspiratory increase in venous pressure, called Kussmaul sign, may occur in clients with severe constrictive pericarditis.

Imspection: 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 30-45 degrees. Make sure the head and torso are on the same plane. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualization of pulsations as well as shadows. Next, inspect the suprasternal notch or the area around the clavicles for pulsations of the internal jugular veins.

normal findings: The jugular venous pulse is not normally visible with the client sitting upright. This position fully distends the vein, and pulsations may or may not be discernible. Abnormal findings: Fully distended jugular veins with the client's torso elevated more than 45 degrees indicate increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade.

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.

normal findings: he radial and apical pulse rates should be identical. abnormal findings: A pulse deficit (difference between the apical and peripheral/radial pulses) may indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block.