Patient Sitting in Bed

Inspects the Neck (2 Steps)

1.  Uses tangential lighting. Side lighting, casting shadow.

2.  Observes the neck right side, then left.  Looking for pulsation. 

Inspect the Jugular Veins (2 Steps)

3.  Inspects the jugular venous pulse with the patient's torso at a 30-45 degree angle.  Remove pillow and turn patient's head away from examined side.

4.  Uses tangential lighting and inspect both sides of the neck.

** Should not see jugular veins in an upright position - CHF abnormality **

5.  Presses gently on carotid artery in lower 2/3 of the neck with finger pads.

6.  Do not palpate simultaneously.

7.  Uses bell of stethoscope.  Auscultates right side, then left.

8.  Asks the patient to take a deep breath, exhale, and hold his/her breath briefly during auscultation.

9.  Inspects arms and havds (skin, hair, & nails).  Uses dorsal surface of hands to assess.  Assesses temperature of hands and arms.

10.  Observes both arms and hands for size, presence of edema and venous patterning.

11.  Presses on at least one fingernail of each hand to check for capillary refill.

12-13.  Palpates right brachial artery, and left, either singly or simultaneously.

14-15.  Palpates right radial artery, and left, either singly or simultaneously.  Take radial pulse.

16.  Flexes patient's elbow to 90-degree angle supports the forearm.

17.  Palpates the node on the medial surface of the arm above the elbow.  Palpates the right node, then left.

**Auscultates Blood Pressure (if needs to be repeated only) **

Patient in Supine Position

Inspection (the Anterior Chest) (2 Steps)

18.  Uses adequate lighting - tangential

19.  Observes anterior chest for at least two respiratory cycles.  **masses, nodules, or lesions**

20.  Uses palmar aspect of base of fingers (ball of hand).

21.  Palpates the five areas:  aortic, pulmonic, 3rd left intercostal space (Erb's space), tricuspid, and mitral (any vibrations or murmurs).

22.  Notes timing of any palpable pulsations.

23.  Uses finger pads to further analyze any pulsations (thrill-palpation of chest; "purring of a cat").

24-25.  Palpates the Apical Impulse (PMI) for 60 seconds (mitral area). 

26.  Uses the diaphragm of the stethoscope.

"LUB" / "DUB"

27.  Presses the diaphragm firmly on the chest.

28.  Starts at the base of the heart and moves gradually to each auscultatory area (aortic, pulmonic, Erb's space, tricuspid, and mitral) or in reverse order, starting at mitral area (under nipple).

29.  Allows time for several cardiac cycles before moving to next area.

30.  Counts heart rate at mitral valve (apex).  Note rate and rhythm.  

31.  Turns stethoscope to use bell.

32.  Applies bell lightly, but with enough pressure to produce air seal.

33.  Auscultates in five auscultatory areas, in same or reverse order as with the diaphragm.

34.  Assists patient to turn halfway to left side.

35.  Listens in mitral area with bell of stethoscope.

**Ventrical lies against ribs.  Sounds louder**

Peripheral Vascular

Inspects and Palpates Legs and Feet (skin, hair, nails) (3 Steps)

84.  Assesses temperature, using the dorsal surface of the fingers.

85.  Palpates over dorsum of foot, behind medial malleolus and anterior tibia. **Muscle tone, edema, discoloration**

86.  Presses firmly, 5-6 seconds over each site.

87.  Squeezes calf muscles, right then left. 

88.  Observes patient's face, while palpating, and asks patient if there is any tenderness present.  **Notice if verbal and non-verbal communication are the same**

89.  Dorsiflexes patient's foot and asks if there is any tenderness present, right then left. **Point feet to chin; pain indicates possible DVT**

90-91.  Palpates the posterior tibial pulse located in the groove between the malleolus and the Achilles tendon, righ then left.

92.  Locates the dorsalis pedis pulse on the superior aspect to the foot, proximal to the first toe space, palpates the right then left. 

93.  Assess capillary refill of toenails.

**Same bilaterally?**

94-95.  Palpates the popliteal pulse located in the popliteal fossa, right then left.

96-97.  Palpates the femoral pulse below the inguinal ligament, right then left. 

98.  Auscultates for bruit (brewy) if pulse is weak or diminished.

99-100.  Palpates nodes, using finger pads in a circular motion, right then left.

Patient Sitting

Inspects the Anterior Chest (4 Steps)

101.  Uses adequate lighting.

102.  Observes anterior chest for 2 respiratory cycles.

103.  Has patient lean forward slightly.

104.  Listens with diaphragm of stethoscope in aortic and pulmonic areas.

**Congenital CHF. Physiological S3/S4 changes positions**

Accentuation of Heart Sounds (2 Steps)

105.  Asks patient to take a deep breath, blow all the air out, and hold his/her breath, then listens to heart sounds with diaphragm.

106.  Holds breath at the same time as patient (in order not to allow patient to hold breath too long).

109.  Uses dorsal surface of hand to inspect calf, right then left.

110.  Observes and palpates saphenous veins.  Asks patient if there is any tenderness while palpating saphenous system.

• Precordium without abnormal pulsations, heaves, or lifts.
• Apical impulse at 5th intercostal space within left mid-clavicular line.
• S1-S2 audible, without murmur or rub.
• Apical rate 76 and regular.
• No carotid bruits/thrills.
• No jugular venous distention at 45 degrees.
• Peripheral pulse76 and regular.
• Carotid, radial, brachial, dorsalis pedis, posterior tibial, popliteal, and femoral pulses present and equal bilaterally.
• No edema, varicosities, or ulcerations of the lower extremities.
• Negative Homans sign.
• No lymphadenopathy.