HEALTH ASSESSMENT (RLE)

ASSESSMENT OF THE THORAX AND LUNGS ●​ The thorax also provides protection for B.​ Position of the sternum
the heart, lungs, and viscera.
THE RESPIRATORY SYSTEM: Normal Findings: The sternum is midline and
HEART AND LUNGS straight.
●​ reside in the thoracic cavity, as well as
many blood vessels Abnormal Findings:
●​ Pectus excavatum (funnel chest): A sunken
What organs are are located in the thorax… sternum and adjacent cartilages; often
●​ The organs of the thorax include the congenital and rarely symptomatic.
thymus gland, the breasts, the heart, the
ANATOMY OF THE LUNGS lungs, the tracheobronchial tree and the ●​ Pectus carinatum (pigeon chest): A
pleurae. forward-protruding sternum with adjacent
ribs sloping backward. Both conditions
POSTERIOR THORAX can restrict lung expansion and decrease
●​ Inspect the shape and symmetry lung capacity.
●​ Inspect spinal alignment for deformities

📌 A comprehensive assessment of the thorax and

●​ Sternal retractions: Noted with severely
labored breathing, indicating respiratory
lungs involves inspection, palpation, percussion, distress.
and auscultation to evaluate the respiratory
system's structure and function. Each step is crucial C.​ Slope of the ribs
in identifying normal versus abnormal findings that Normal Findings:
may indicate underlying conditions such as chronic ●​ Ribs slope downward with symmetric
obstructive pulmonary disease (COPD), pneumonia, intercostal spaces. The costal angle is
or pleural effusion. within 90 degrees.

📌 EQUIPMENT Abnormal Findings:

-​ Examination gown ●​ A barrel-chest configuration results in
THORAX AND LUNGS -​ Gloves horizontal ribs and a costal angle greater
-​ Stethoscope than 90 degrees, often associated with
THORAX -​ Light source long-standing emphysema.
●​ is the region of the body formed by the -​ Mask
sternum, the thoracic vertebrae, and the -​ Skin marker D.​ Quality and pattern of respiration
ribs. -​ Metric ruler Normal Findings:
●​ It extends from the neck to the diaphragm, ●​ Breathing is relaxed, effortless, quiet, and
and does not include the upper limbs. INSPECTION of regular rhythm (10-20 breaths per
minute in adults).
location: A.​ Shape and configuration
●​ region between the abdomen inferiorly Abnormal Findings:
and the root of the neck superiorly. It Normal findings: ●​ Labored and noisy breathing-commonly
forms from the thoracic wall, its superficial ●​ The anteroposterior (AP) diameter is less seen in severe asthma or chronic
structures (breast, muscles, and skin) and than the transverse diameter, maintaining bronchitis.
the thoracic cavity a ratio of 1:2. ●​ Abnormal patterns include tachypnea,
bradypnea, hyperventilation,
Purpose: Abnormal Findings: hypoventilation, Cheyne-Stokes
●​ provides a base for the muscle ●​ An equal AP and transverse diameter respiration, and Biot respiration
attachment of the upper extremities, the results in a barrel chest, often observed in
head and neck, the vertebral column, and emphysema due to hyperinflation of the E.​ Intercostal spaces
the pelvis. lungs. Normal Findings:
●​ No retractions or bulging.

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HEALTH ASSESSMENT (RLE)

Abnormal Findings:
●​ Retractions suggest increased inspiratory
effort, possibly due to airway obstruction PECTUS EXCAVATUM
or [Link] indicates trapped (funnel chest)
air, seen in emphysema or asthma. -thorax has depression in
lower sternum and is seen
F.​ Use of accessory muscle with COPD, congenital
Normal Findings: conditions that can cause
●​ No use of sternomastoid, scalene, murmurs or compress the
trapezius, rectus abdominis, or intercostal heart and vessels
muscles during normal breathing.
PECTUS CARINATUM
Abnormal Findings: (Pigeon chest)
●​ Use of neck muscles (sternomastoid, -sternum protrudes forward
scalene, trapezius) to facilitate inspiration congenital.
suggests acute or chronic airway -increased AP diameter
obstruction or atelectasis.
●​ Use of abdominal and internal intercostal
muscles for expiration is seen in COPD.
SCOLIOSIS
-lateral S-shaped curve of the
OBSERVING THE POSTERIOR spine
THORAX

●​ Palpating the anterior thorax

●​ Palpating anterior chest expansion

A.​ Tenderness, sensation, and surface

KYPHOSIS masses
-exaggerated increased Normal Findings:
rounding of the thoracic ●​ No tenderness, pain, or abnormal masses
spine, often seen with over the thorax.
NORMAL CHEST osteoporosis in older
CONFIGURATION: women. Abnormal Findings:
-elliptical in shape with ●​ Tenderness over thoracic muscles may
diameter smaller than lateral result from excessive exercise. Pain at the
diameter (1:2) costochondral junction can indicate
fractures, especially in older adults with
osteoporosis.
Athletes who use their arms in an overhead position:
BARREL CHEST -​ Such athletes (including swimmers) often B.​ Crepitus
-thorax is round shaped. have a forward-translated head, Normal Findings:
-an AP AP diameter to the pronounced thoracic kyphosis, lumbar ●​ No palpable
diameter ratio is 1:1, is seen in lordosis, and internally rotated shoulders.
aging adults and chronic Abnormal Findings:
asthma PALPATION ●​ Crepitus (a cracking sensation) may be felt
in extreme congestion or consolidation,
commonly in patients with LUNG DISEASE

C.​ Fremitus (vibrations of the chest wall)

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HEALTH ASSESSMENT (RLE)

Normal Findings: Percussion of the posterior thorax. With the client A.​ Percussion tone
sitting, percuss symmetrical areas of the lungs at 5 Normal Findings:
●​ Fremitus is symmetric and strongest at the cm intervals, starting at the apex of each lung
upper lung regions, diminishing toward Normal percussion tones heard from the posterior ●​ Resonance is heard over normal lung
the bases. thorax tissue.
●​ Dullness over breast tissue, heart, and
Abnormal Findings: liver.
●​ Decreased fremitus suggests air trapping ●​ Tympany over the stomach.
(e.g., emphysema) or airway obstruction. ●​ Flatness over bones and muscles.
●​ Increased fremitus occurs in consolidation
(e.g., pneumonia). Abnormal Findings:
●​ Hyperresonance suggests trapped air
D.​ Anterior chest expansion (e.g., emphysema, pneumothorax).
Normal Findings: ●​ Dullness suggests increased lung density
●​ Symmetric expansion with the thumbs (e.g., consolidation, pleural effusion, or
moving outward equally when the client tumor).
inhales deeply.
AUSCULTATION
Abnormal Findings:
●​ Unequal expansion may result from Sequence for percussing the anterior thorax:
Sequence for auscultating the posterior thorax
atelectasis, pneumonia, chest trauma,
pleural effusion, or pneumothorax.
Decreased excursion at lung bases is
common in COPD.

PERCUSSION

Measuring diaphragmatic excursion:

Normal percussion tones heard from the anterior

thorax:
Location of breath sounds for the posterior thorax
V, vesicular sounds BV, bronchovesicular sounds

NORMAL LUNG SOUNDS

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HEALTH ASSESSMENT (RLE)

1.​ BRONCHIAL ​ Sonorous wheeze: refer as "rhonchi" ASSESSMENT OF THE BREAST AND LYMPHATIC
-​ Auscultated over anterior chest SYSTEM
-refers to a deep, low-pitched rumbling or
coarse sound as air moves through
●​ Heard over the tracheal area INTRODUCTION:
tracheal/bronchial passages in the
●​ Sound will have a high pitch and be loud ●​ Breast assessment is an essential
presence of mucus or respiratory
●​ Inspiration will be slightly shorter than component of a comprehensive health
secretions.
expiration examination for women.
CRACKLES
BREAST
-​ also known as alveolar rales.
2.​ BRONCHOVESICULAR -​ are subject to hormonal influences,
-​ The sound crackles create are fine, short,
-​ Auscultated anteriorly & posteriorly structural changes, and potential disease
high-pitched, intermittent crackling
processes.
sounds.
●​ Heard over the bronchi
-​ The cause of crackles can be from air
●​ Anteriorly: 1st & 2nd intercostal space near COLLECTING SUBJECTIVE DATA: THE NURSING
passing through fluid, pus or mucus.
the sternum HEALTH HISTORY
-​ It is commonly heard in the bases of the
●​ Posteriorly: between the scapulae ●​ When conducting an interview about
lung lobes during inspiration.
(shoulder blades) -​ can be further categorised as coarse or breast health, it is important to be aware
●​ Sound will have a medium pitch fine. of cultural, emotional, and psychological
●​ Inspiration and expiration will be equal factors that may influence the client's
​ Coarse crackles sound quality is willingness to discuss their concerns. Fear
3.​ VESICULAR low-pitched and moist, it may be heard in of breast cancer, body image concerns,
-​ Auscultated anteriorly & posteriorly pulmonary oedema and bronchitis. and embarrassment can impact
communication.
​ Fine crackles sound quality is like hair
●​ Heard throughout peripheral lung fields
rubbing near the ear and may be heard in A. HISTORY OF PRESENT HEALTH CONCERN
●​ Sound will be soft with a low pitch
congestive heart failure and pulmonary Key Questions and Rationale
●​ Inspiration will be slightly greater than
fibrosis.
expiration
1.​ Have you noticed any lumps or swelling in
PLEURAL RUB your breasts?
Other lung sounds:
-​ The pleural rub sound results from the
movement of inflamed pleural surfaces ●​ Possible causes:
STRIDOR
against one another during chest wall
-​ Stridor is a continuous high-pitched, ​ Benign conditions: Fibrocystic breast
movement.
crowing sound heard predominantly on
-​ The sound quality is considered a harsh changes, fibroadenomas
inspiration
grating or creaking. ​ Malignant tumors: Breast cancer
-​ may be heard in conditions such as croup
-​ Potential causes include tuberculosis and
and foreign body obstruction. ●​ Lumps should always be further assessed.
pneumonia.
-​ It's typically loudest over the anterior neck,
as air moves turbulently over a 2.​ Do you have any lumps or swelling in the
VOICE SOUNDS:
partially-obstructed upper airway. underarm area?
Normal Findings:
●​ Voice sounds are muffled and indistinct
WHEEZE ●​ May indicate enlarged lymph nodes, which
when auscultating over the lung fields.
-​ a high-pitched continuous musical sound. can be due to
-​ This is caused by air passing through an
Abnormal Findings:
obstructed, narrow airway.
●​ Bronchophony: Increased clarity of spoken ​ Infection
-​ The classic wheeze may be referred to as
words, suggesting lung consolidation.
sibilant wheeze. ​ Inflammation
●​ Egophony: "E" sounds like "A," indicating
-​ commonly heard in the lungs during
fluid-filled lung tissue. ​ Breast cancer spread
expiration.
●​ Whispered pectoriloquy: Whispered words
-​ It may be heard in asthma, emphysema
sound clear, suggesting pneumonia or
and chronic bronchitis.
tumor.

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HEALTH ASSESSMENT (RLE)

3.​ Have you noticed any redness, warmth, ●​ Mother, sister, or maternal grandmother -​ Slide for specimen
dimpling, or rashes on your breasts or with breast cancer increases a woman's
nipples? likelihood of developing it. Physical Assessment
●​ Redness and warmth→ Possible infection Key points for physical assessment include the
or inflammation D. LIFESTYLE AND HEALTH PRACTICES following:
●​ Dimpling or nipple retraction→ Possible 1.​ Medication use
breast cancer ●​ Explain to the client what the steps of the
●​ Hormones, contraceptives, and examination are and the rationale for
4.​ Do you experience breast pain? antipsychotics can cause breast them.
enlargement or tenderness. ●​ Warm your hands.
●​ Cyclic pain (related to menstrual cycle) → ●​ Observe and inspect breast skin, areolas,
Often benign 2.​ Environmental exposure and nipples for size, shape, rashes,
●​ Persistent pain→ May indicate infection, dimpling, swelling, discoloration,
trauma, or a late sign of cancer ●​ Radiation, benzene, and asbestos retraction, asymmetry, and other unusual
exposure increase cancer risk. findings.
5.​ Do you have any nipple discharge? ●​ Palpate breasts and axillary lymph nodes
3.​ Diet and lifestyle for swelling, lumps, masses, warmth or
1.​ Bloody or blood-tinged Requires further inflammation, tenderness, and other
evaluation ●​ High-fat diet → May contribute to breast abnormalities.
2.​ Clear or milky → May be cancer risk. ●​ Remember it is important to carefully
medication-induced (e.g., oral ●​ Excessive alcohol intake and smoking → perform the breast examination on male
contraceptives, antipsychotic drugs) Associated with increased breast cancer as well as female clients.
risk.
B. PERSONAL HEALTH HISTORY ●​ Caffeine intake → May aggravate B.​ INSPECTION OF THE BREAST
1.​ Have you had any previous breast fibrocystic breast conditions. (Perform in different positions to assess symmetry,
diseases, surgeries, biopsies, implants, or ●​ Regular exercise and proper bra support skin texture, and nipple characteristics.)
trauma? → Help maintain breast health.
1.​ Observe Breast Size, Symmetry, and
●​ Previous breast conditions or procedures 4.​ Breast self-awareness and Contour
may affect current breast structure and self-examination
function. ●​ Note any asymmetry (some difference may
●​ Trauma can cause bruising and tissue ●​ Becoming familiar with breast be normal).
changes. appearance, shape, and feel can help ●​ Look for dimpling, bulging, or skin
detect changes early. retraction.
2.​ Menstrual and reproductive history
COLLECTING OBJECTIVE DATA: PHYSICAL 2.​ Inspect Skin Characteristics
●​ Early menarche (before 12 years old) and ASSESSMENT
late menopause (after 52 years old) → ●​ Check for redness, rashes, thickening, or
Increased breast cancer risk A.​ PREPARING THE CLIENT FOR peau d'orange (orange peel texture).
●​ Nulliparity (never having given birth) or EXAMINATION ●​ Observe for prominent venous patterns
first pregnancy after 30 years old Higher ●​ Explain the procedure and ensure privacy (may indicate increased circulation,
breast cancer risk and comfort. pregnancy, or malignancy).
●​ Have the client sit upright for inspection
C. FAMILY HISTORY and lie down for palpation. 3.​ Assess the Areola and Nipples
1.​ Is there a history of breast cancer in your
family? Equipment ●​ Examine color, shape, and position.
-​ Centimeter ruler ●​ Look for discharge, retraction, cracks, or
●​ Genetic factors (BRCAI and BRCA2 -​ Small pillow lesions.
mutations) increase risk. -​ Gloves
-​ Client handout for BSE

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HEALTH ASSESSMENT (RLE)

●​ Note the presence of Montgomery ASSESSMENT FOR RETRACTION AND DIMPLING ​ Wedge (Radial Spokes) Pattern: Move
tubercles (small, raised bumps on the
Figure A: the client first raise her arms over her head fingers outward from the nipple like spokes
areola).
on a wheel.
4.​ Observe for Retraction and Skin Changes Figure B: then lowers them and presses them
●​ Ask the client to: against the hips, finally..

Figure C: presses the hands together with the FIGURE: Palpation of the breast with three fingers.
a. Raise arms overhead.
b. Press hands on hips. fingers of one hand pointing opposite the fingers of
c. Press hands together with fingers pointing the other hand.
opposite each other.
d. Lean forward.

●​ Assess for dimpling, nipple retraction, or

restricted breast movement

FIGURE: Anatomy of the female breast

FIGURE 20-7 Supernumerary nipple (Used with

permission from Logan-Young, W., & Hoffman. NY
[1994] Breast cancer A practical guide to diagnosis.
-​ Client should sit with arms hanging at Mt. Hope Publishing
sides during assessment of breast size
and symmetry
C. PALPATION OF THE BREAST

1.​ Position the Client Supine

●​ Place a pillow or folded towel under the
shoulder of the breast being examined.
●​ Have the client place one hand behind the
head to spread out the breast tissue.

2.​ Use Systematic Palpation Techniques

FIGURE : 3 Systematic Palpation Techniques

​ Vertical Strip Pattern (Preferred): Move

fingertips in an up-and-down pattern
across the breast.
​ Circular (Concentric) Pattern: Start at the
nipple and move outward in circular
motions.

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HEALTH ASSESSMENT (RLE)

●​ Resulting from edema, an orange peel

3.​ Palpate the Axillary Lymph Nodes appearance of the breast is associated
●​ Use firm, circular motions to examine: with cancer
​ Central Axillary Nodes (deep in the axilla)
PAGET DISEASE WITH INVASIVE INTRADUCTAL
​ Pectoral Nodes (anterior axilla) CARCINOMA

​ Subscapular Nodes (posterior axilla)

​ Lateral Nodes (along the inner upper arm)

●​ Note any enlarged, firm, or tender lymph
nodes.

3.​ Palpate for the Following:

●​ Redness and flaking of the nipple may be
●​ Breast Tissue Consistency - Normal breast
seen early in Paget disease and then
tissue may feel firm, soft, or nodular.
disappear.
●​ Presence of Lumps or Masses
●​ However, further assessment is needed
​ Note size, shape, consistency, mobility, because this does not mean the disease is
and tenderness. gone. Tingling, itching, increased
●​ Tenderness or Thickening - Mild sensitivity, burning, discharge, and pain in
tenderness is common before the nipple are late signs of Paget disease.
menstruation. It may occur in both breasts, but is rare.
●​ Temperature Differences - Compare breast
temperature to the chest wall NIPPLE INVERSION FROM BREAST CANCER

●​ Nipple inversion may suggest malignancy

4.​ Palpate the Nipples

RETRACTED BREAST TISSUE

●​ Gently compress the nipple to check for

discharge. ●​ Retracted breast tissue suggests
●​ Note any lumps, retraction, or unusual malignancy
findings.
ABNORMALITIES Noted on Inspection of the Breast
MASTITIS
PEAU D'ORANGE.
D. PALPATION OF THE AXILLAE

1.​ Position the Client - Ask the client to relax

the arm at the side while slightly lifting it.

2.​ Assess the Skin - Check for redness,

rashes, or irritation.

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HEALTH ASSESSMENT (RLE)

●​ Reddened, painful area on breasts warm

to palpation otherwise.

MASTECTOMY TACHYCARDIA May indicate

arrhythmias or
●​ A surgery to remove a breast AND compensatory
PALPITATIONS mechanisms due to
A.​ Radical mastectomy ●​ an increase in the amount of breast gland weak heart muscles.
tissue in boys or men. Can cause anxiety.
●​ An imbalance of the hormones estrogen
and testosterone causes it. FATIGUE Fatigue from
decreased cardiac
output (CO) worsens as
ASSESSING HEART AND NECK VESSELS the day progresses,
while fatigue from
●​ removes the entire breast, all underarm CARDIOVASCULAR SYSTEM depression is constant
-​ plays a crucial role in maintaining throughout the day.
lymph nodes, and chest wall muscles
circulation and oxygenation of body
B.​ Modified radical mastectomy tissues. DYSPNEA Can result from heart
-​ assessment helps identify early signs of: failure, coronary artery
(SHORTNESS OF disease, myocardial
●​ heart disease
BREATH) infarction (MI), or
●​ allowing timely intervention. pulmonary disorders.
Dyspnea at rest, while
COLLECTING SUBJECTIVE DATA: THE NURSING sleeping, or during
HEALTH HISTORY exertion should be
SUBJECTIVE DATA assessed.
●​ removes the entire breast and most Orthopnea (difficulty
-​ help nurses identify conditions affecting a
underarm lymph nodes, but spares the breathing when lying
client's ability to perform activities of daily
chest wall muscles flat) suggests heart
living (ADLs) and assess cardiovascular failure. Paroxysmal
disease risk. It also guides health nocturnal dyspnea
CARCINOMA OF THE BREAST
education (sudden nighttime
(note bulging and skin changes) breathlessness) is
common in heart
failure.
QUESTION RATIONALE
COUGH Pink-tinged sputum
may indicate fluid
CHEST PAIN Cardiac chest pain
accumulation in the
(angina) is often
described as lungs from heart
●​ a type of cancer, specifically a malignant failure.
squeezing, crushing, or
tumor, that originates in the breast tissue, tightness around the
most commonly in the milk ducts or heart, possibly DIZZINESS May indicate reduced
lobules. radiating to the left cerebral blood flow due
shoulder, jaw, or arm. to cardiac issues. Can
Pain with exertion, also be caused by
​ Carcinoma: cancer that starts in the cells relieved by rest, hypotension or inner
lining the organs and tissues of the body, suggests angina. Other ear problems.
also known as epithelial cells. causes include
pulmonary,
​ Breast Carcinoma: When a carcinoma gastrointestinal, NOCTURIA Increased renal
(FREQUENT perfusion when lying
develops in the breast, it's called breast musculoskeletal, or
NIGHTTIME down is common in
psychogenic issues.
cancer or breast carcinoma heart failure.
Assume cardiac URINATION
ischemia until proven
GYNECOMASTIA

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HEALTH ASSESSMENT (RLE)

EDEMA Bilateral edema is LIPID PROFILE High cholesterol cardiovascular risk.

often due to heart increases the risk of
(SWELLING IN failure, while unilateral
HISTORY atherosclerosis and
FEET, ANKLES, edema with pain cardiovascular disease. EXERCISE HABITS A sedentary lifestyle is
a modifiable risk factor
LEGS) suggests deep vein for heart disease.
thrombosis (DVT).
CURRENT Clients may skip Regular aerobic
medications due to exercise is beneficial.
MEDICATIONS side effects (e.g.,
HEARTBURN Gastrointestinal pain
diuretics causing
often occurs after
meals and improves frequent urination, DAILY ACTIVITIES Limitations in ADLs
due to fatigue,
with antacids, while beta blockers affecting AND ADLS dyspnea, or chest pain
cardiac pain is sexual function). may indicate heart
unrelated to meals and failure.
worsens with activity.

Impact of HEART Sexual activity is

usually safe if the
FAMILY HISTORY DISEASE on client can walk one
SEXUAL ACTIVITY block or climb two
PERSONAL HEALTH HISTORY QUESTION RATIONALE
flights of stairs without
symptoms.
QUESTION RATIONALE FAMILY HISTORY OF Genetic predisposition Nitroglycerin can be
Hypertension, increases used prophylactically
HISTORY OF HEART Congenital or acquired Myocardial Infarction cardiovascular disease for chest pain.
DEFECTS OR defects can impact (MI), Coronary Heart risk.
heart function and Disease (CHD), or
MURMURS Diabetes Mellitus (DM)
oxygen delivery.
TYPES OF CARDIOVASCULAR PAIN USING COLDSPA
HISTORY OF Can cause rheumatic
heart disease, leading ANGINA (MYOCARDIAL ISCHEMIA)
RHEUMATIC FEVER LIFESTYLE AND HEALTH PRACTICES
to valvular dysfunction. -​ A temporary decrease in blood flow to the
heart muscle, octen triggered by exertion
HISTORY OF HEART May alter heart sounds QUESTION RATIONALE or emotional stress
SURGERY OR CARDIAC and indicate prior
INTERVENTIONS heart conditions.
SMOKING Increases COLDSPA DESCRIPTION
cardiovascular disease
HISTORY COMPONENT
ECG HISTORY Previous risk. Smoking cessation
electrocardiograms is crucial.
(ECGs) provide baseline C- CHARACTER Tight, pressing
data for detecting sensation
changes. STRESS AND Chronic stress is a
COPING possible risk factor for
MECHANISMS heart disease. O- ONSET Discomfort occurring
SELF-MONITORIN Necessary for clients with or without exertion
on cardiotonic or
G OF HEART RATE antihypertensive DIETARY HABITS High-fat,
L- LOCATION Across the chest, may
OR BLOOD medications. The high-cholesterol, and radiate to shoulders,
PRESSURE American Heart low-fiber diets jaws, neck, or upper
Association (AHA) contribute to abdomen
recommends annual atherosclerosis.
BP screening from age
20. D- DURATION Lasts 20 mins
ALCOHOL Excessive alcohol
intake raises blood
CONSUMPTION pressure and increases S- SEVERITY Mild to moderate pain

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HEALTH ASSESSMENT (RLE)

P- PATTERN May be relieved with C- CHARACTER Tearing, ripping changes, and

nitroglycerin sensation coughing; may be
relieved by sitting
forward
A- ASSOCIATED May occur with O- ONSET Abrupt and sudden
difficulty breathing,
FACTORS nausea, or sweating A- ASSOCIATED May also present with
L- LOCATION Chest, radiating to the
FACTORS fever, weakness,
neck, back, or tiredness, coughing,
MYOCARDIAL INFARCTION (HEART ATTACK - abdomen trouble breathing,
IRREVERSIBLE HEART DAMAGE DUE TO ISCHEMIA) and/or pain when
-​ A complete blockage of blood flow to the D- DURATION Lasting for hours swallowing
heart muscle, leading to tissue death.
S- SEVERITY Severe PREPARING THE CLIENT FOR CARDIOVASCULAR
COLDSPA DESCRIPTION ASSESSMENT
COMPONENT P- PATTERN Aggravated by
hypertension; relieved Before performing the examination, proper client
only with treatment preparation is essential.
C- CHARACTER Heavy, tight, pressing
pain
A. Explanation and Positioning
A- ASSOCIATED May also cause
difficulty swallowing, -​ Explain the procedure to the client,
O- ONSET Discomfort occurring FACTORS hoarseness, leg pain, ensuring they understand why multiple
with or without exertion
and syncope (fainting) positions are needed.
-​ Inform the client that the assessment
L- LOCATION Across the chest, may
radiate to shoulders, PERICARDITIS (INFLAMMATION OF THE PARIETAL involves listening to different areas of the
jaws, back, or upper PLEURA NEXT TO THE PERICARDIUM) chest, which does not necessarily mean
abdomen anything is wrong.
-​ Inflammation of the sac surrounding the
heart, often due to infection or -​ Provide privacy and ensure client comfort.
D- DURATION Last 20 mins to hrs. autoimmune conditions.
B. REQUIRED EQUIPMENT
●​ Stethoscope (with diaphragm and bell)
S- SEVERITY Often moderate to
COLDSPA DESCRIPTION ●​ Small pillow
severe
COMPONENT ●​ Penlight or movable examination light
●​ Watch with a second hand
P- PATTERN Rest does not relive
pain C- CHARACTER Sharp, stabbing, ●​ Two centimeter rulers
pounding pain with
each heartbeat
A- ASSOCIATED May occur with CLIENT POSITIONS FOR ASSESSMENT
nausea, vomiting, I.​ Supine position
FACTORS weakness, and O- ONSET Ongoing -​ Head elevated at 30 to 45
sweating degrees (for most auscultation
L- LOCATION Pericardial pain and palpation steps).
radiating to shoulders II.​ Left lateral position
AORTIC DISSECTING ANEURYSM (TEAR IN THE
or neck -​ Helps in palpating the apical
WALL LINING THE AORTA)
-​ A life-threatening condition in which a tear impulse if it is not easily felt in
in the aorta causes blood to flow between D- DURATION Ongoing the supine position.
its layers. III.​ Sitting up and leaning forward
-​ Best for auscultating abnormal
S- SEVERITY Severe
heart sounds
COLDSPA DESCRIPTION -​ e.g., murmurs
COMPONENT P- PATTERN Aggravated by
IV.​ Client with large breasts
breathing, position

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HEALTH ASSESSMENT (RLE)

pulmonary embolism, or cardiac

tamponade.
●​ Unilateral jugular vein distention -> May
indicate a kink or aneurysm.

B. EVALUATION OF JUGULAR VENOUS PRESSURE

(JVP)
Procedure:
-​ Ask the client to pull their breast 1.​ Position the client supine, gradually
upward and to the side to raising the head of the bed to 30, 45, 60,
and 90 degrees. Procedure:
improve sound clarity during
2.​ Turn the client's head slightly away from 1.​ Use the pads of the index and middle
auscultation.
the side being assessed. fingers.
3.​ Observe for distention, protrusion, or 2.​ Palpate each carotid artery separately to
ASSESSMENT OF THE NECK VESSELS
bulging of the jugular veins. prevent cerebral ischemia.
3.​ Assess pulse amplitude, contour, and
A. INSPECTION OF THE JUGULAR VENOUS PULSE elasticity.
Normal Findings:
●​ Jugular veins should not be distended,
bulging, or protruding at 45 degrees or Normal Findings:
greater. ●​ Pulses equal bilaterally.
●​ 2+ (normal) amplitude.
Abnormal Findings: ●​ No thrills or murmurs.
●​ Distention at 45, 60, or 90 degrees -›
Suggests right-sided heart failure. Abnormal Findings:
●​ Kussmaul's Sign (JVP increases during ●​ Weak pulse -> Indicates shock or
inspiration) -› Suggests constrictive decreased cardiac output.
pericarditis. ●​ Bounding pulse -> Suggests increased
cardiac output or hypervolemia.
Procedure: C. AUSCULTATION OF THE CAROTID ARTERIES ●​ Thrills (vibration-like purring) -> Suggests
1.​ Stand on the right side of the client. Procedure: narrowing of the artery.
2.​ Position the client supine with head 1.​ Place the bell of the stethoscope over the
elevated 30-45 degrees. carotid artery. ASSESSMENT OF THE HEART (PRECORDIUM)
3.​ Ensure the head and torso are on the 2.​ Ask the client to hold their breath
same plane. momentarily to prevent breath sounds A. INSPECTION OF THE ANTERIOR CHEST
4.​ Ask the client to turn their head slightly to from masking vascular sounds.
the left.
5.​ Shine a tangential light onto the neck to Normal Findings:
visualize pulsations. ●​ No blowing, swishing, or murmuring
sounds are heard.
Normal Findings:
●​ The jugular venous pulse is not visible Abnormal Findings:
when the client is sitting upright. ●​ Bruit (blowing or swishing sound) ->
●​ The vein distends in the supine position Indicates occlusive arterial disease.
but should collapse at 45 degrees or
greater. D. PALPATION OF THE CAROTID ARTERIES

Abnormal Findings:
●​ Fully distended jugular veins at 45 degrees
or higher May indicate right ventricular
failure, pulmonary hypertension,

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HEALTH ASSESSMENT (RLE)

Procedure:
1.​ Position the client supine at 30-45 degrees.
2.​ Look for the apical impulse in the mitral
area (left midclavicular line, 4th or 5th
intercostal space).

Normal Findings: a.​ Aortic (2nd right ICS)

●​ Apical impulse may or may not be visible. b.​ Pulmonic (2nd left ICS)
c.​ Erb's Point (3rd left ICS)
Abnormal Findings: d.​ Tricuspid (4th left ICS, lower
sternal border)
●​ Heaves or lifts
e.​ Mitral (5th left ICS, MCL)
-​ Suggest ventricular
enlargement.
2. Use diaphragm for high-pitched sounds (SI, S2)
and bell for low-pitched sounds (murmurs).
B. PALPATION OF THE APICAL IMPULSE
Procedure:
1.​ Use one or two finger pads to palpate the
mitral area.
2.​ Ask the client to turn to the left lateral
position if the impulse is difficult to locate.

Normal Findings:
●​ Size: 1-2 cm (nickel-sized). HEART SOUNDS:
●​ Amplitude: Small, gentle tap. [Link]

Abnormal Findings:
●​ Strong impulse
-​ Suggests hypertension or left
ventricular hypertrophy.
●​ Displaced impulse
-​ Suggests ventricular dilation.
Normal Findings:
●​ SI (lub) and S2 (dub) sounds present.
C. AUSCULTATION OF HEART SOUNDS
Procedure:
Abnormal Findings:
1. Listen at all five cardiac landmarks:
●​ Murmurs
-​ Indicate valvular disease.

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