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.y Begin auscultation over the aortic area, placing

the stethoscope over the second intercostal space,along the right sternal border

y Then move to the pulmonic area, located at the

left n over the sternal border.y Next assess the triscupid area,which lies over

the fourt and fifth intercostal space, along the left

sternal bordery Finally, listen mitral area, located at the fifth

intercostal space, near the midclavicular line.

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Heart Sounds

y Systole the period of ventricular contraction

yS1 - first heart sound

yS2

- second heart sound

yAlways identify S11

and S2, then listen for

adventitious sounds, such as third and fourth

heart sounds. Also listen for murmurs,whichsound like vibrating, blowing, or rumbling

sounds.

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Hearing Pericardial Friction Rubs

y Have the patient lean forward . If the patient cant

tolerate leaning forward, position him sitting

upright.

y Ask the patient to exhale, hen listen with the

diaphragm stethoscope over the third intercostal

space on the left side of the chest.

y If you suspect a rub but have trouble hearing one,ask the patient to hold his breath.

y A friction rub may be heard during atrial systole,

ventricular systole, or ventricular diastole.

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y To differentiate a pericardial friction rub form a

pleural friction rub, ask the patient to hold his

breath.

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Assessing the vascular system

y Inspection

yStart by making general observations. Are arms

equal in size? Are legs symmetrical?Then note

skin color, body hair distribution, and lesions,

scars, clubbing, and edema of the extremities. If

the patient is confined to bed, check the sacrum

for swelling. Examine the finger nails andtoenails for abnormalities.

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y Palpation

yFirst, asses skin temperature, texture, and

turgor.Then assess capillary refill in the nail

beds on the finger and toes. Refill time should

be no more than 3 seconds, or long enough to

say capillary refill. Palpate the patients arms

and legs for temperature and edema.Thenpalpate the arterial pulses.

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PalpatingArterial Pulses

y Carotid pulse

y Lightly place your fingers just lateral to the trachea and below

the jaw angle. Never palpate both carotid at the same time

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y Brachial pulse

y Position your fingers medial to the biceps and tendons

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y Femoral pulse

y Press relatively hard at the point inferior to the inguinal ligament.

For an obese patient, palpate in the crease of the groin, halfwaybetween the pubic bone and the tip bone.

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y Popliteal pulse

y Press firmly in the popliteal fossa at the back of the knee.

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y Posterior tibial pulse

y apply pressure behind and slightly below the malleous of the ankle.

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y Dorsalis pedis pulse

y Place your fingers on the medial dorsum of the foot while the

patient points his toes dow

n.T

he pulse is difficult to palpate hereand may seem to be absent in healthy patients.