ASSESSING THE HEART AND ABDOMEN  Centimeter Rule and Tape Measure
• Good morning, Sir! I’m a student nurse Charles Nathaniel Lozada from Jose Rizal University, I
will be your nurse for today and I’m here today to assess you.
● Alright, I have already read your medical records. Allow me to double check some pieces of
information for verification. Will that be okay sir?
● What’s your name? Your age and birthday?
● How are you doing?
● Before I start the assessment may I ask po how should I address you po? And what language do
you prefer to use po? Is it Tagalog po ba or English?
● That’s good to hear, Sir. So, to inform you, today I will assess your heart, central vessels,
peripheral vascular system, as well as your abdomen. The purpose of this examination is to
identify any sign of heart disease, to help to determine the status of the arteries and veins, and it
can also give diagnostic clues regarding most gastrointestinal pathologies and may also give
insight regarding abnormalities of other organ systems and to initiate any referral and treatment.
● This assessment encompasses inspection, palpation, and auscultation of the neck and especially
the anterior chest area and your extremities. By conducting different tests and later I will ask you
to do different positions like sitting up and leaning in a supine position, would that be, okay? I will
assure you that this will be a safe procedure.
● So, I would like to ask you if it’s okay with you that I touch some parts of your body? In that way,
you can participate in the assessment.
● Reassured that all information that will be documented after every assessment will remain
confidential between me and the attending physician that I will be going to refer to you. So, to
inform you I will be asking you some questions about your history so that I will be able to know.
Also please be informed that all your considerations that involve your ethnicity, religion, age, race,
and psychological development will be considered so please let me know if you have restrictions
in any of the following.
● Before proceeding to the assessment, I’ll wash my hands first to prevent the spread of microbes
while assessing you. And I will close the curtain so that you will not be uncomfortable displaying
your body, and when someone sees or hears you while doing the assessment. (In women drape
the anterior chest when it is not being examined.)
• Prior to assessment I already gather the supplies and materials that we will be using in the
following procedure I have here the:
 Disposable Gown
 Face Mask and Face Shield
 Examination Gloves
 Stethoscope
 Skin Marker
• I’ll be also asking you some questions before performing the assessment:
 Do you have a history of heart disease, high cholesterol levels, hypertension, stroke,
obesity, congenital heart disease, arterial heart disease, rheumatic fever, and heart
murmur?
 Have you experienced any treatment that may affect the heart like radiation therapy?
 Do you smoke or drink po ba?
 Do you have any exercise pattern po ba?
ASSESSING THE HEART AND THE CENTRAL VESSELS
“The nurse should also keep the client in the supine position with elevated at 15 to 45
degrees.”
• First, I will be inspecting and palpating your precordium which is the region on the chest wall that
overlays the heart area to check if there is any presence of abdominal pulsations, lifts, and heaves.
The inspection and palpation include your aortic, pulmonic, tricuspid, and the mitral area.
• I will now inspect and palpate your Aortic area on your right part and Pulmonic area on your left
which is both at second intercostal space near at sternal border in the base of your heart.
• Then the Tricuspid area on the fifth intercostal space at the left lower sternal border.
• Followed by the Apical area which is also in the fifth intercostal space but near the left mid-
clavicular line then lastly the epigastric area.
• Next, I will inspect and palpate your epigastric area at the base of the sternum for abdominal aortic
pulsations.
● Upon inspecting and palpating the Aortic and Pulmonic Area I observed that there is no
presence of pulsation, or any gentle flickers observed on the skin of the chest wall that
could cause conditions such as an enlarged heart.
● As well as the Tricuspid and Apical area which not also have pulsation and no presence of
heaves or lifts, or any more forceful movement observed on the skin over the chest wall.
(Adult patients may have 50% pulsation)
● Upon inspecting and palpating your epigastric area I observed that there is no Aortic
pulsation which is normal po. However, if the client is skinny or thin the aortic pulsation is
visible which is good and normal rin po.
● Okay sir I have observed po that all findings po are all normal and good.
• “In auscultating the heart, the nurse should eliminate all sounds in order for nurses to hear
it accurately as heart sounds are low intensity so noise may hinder the sounds.”
• For the next procedure, I’ll be auscultating your anatomic sites. Your aortic, pulmonic, tricuspid
and the apical or the mitral to check po your heart rate and heart rhythm.
• I’ll be auscultating you to identify if the S1 and the S2 which is the lub and dubb heart sounds
these two sounds make up the cardiac cycle of systole and diastole. S1 starts systole, and S2
starts diastole.
● Upon auscultating it appears normal because the heart rate is approximately 70 beats per
minute and the normal rate is up to 60-100 beats per minute.
● S1 and S2 are usually heard in all sites however it became louder as I auscultated the apical
area.
● S1 also corresponds with each carotid pulsation and is loudest at the apex of the heart.
While S2 immediately follows after S1 and is loudest at the base of the heart.
● A distinct sound is heard in each area but loudest at the apex and may become softer with
inspiration.
● S3 is usually in children and S4 is usually heard in older patients.
● Upon Auscultating your heart your results are all normal.
JUGULAR VEINS
● For the next part, I'll be inspecting for the jugular venous pressure by watching for distention of
the jugular vein.
● Okay, can you please turn your head slightly away from the side. For me to be able to clearly see
if there is any bulging present.
● Upon inspection I observed that your jugular veins are not visible, but this is normal po so
nothing to worry po.
• But if there is distention present, the nurse should assess the jugular venous pressure and locate
the highest visible point. In assessing the JVP measure the vertical height in centimeters from
sternal angle at the point which clavicles meet. The findings of distention should be less than
3cm.
• Document the findings of client to promote effective communication among multidisciplinary health
team members to facilitate safe and efficient client care.

CAROTID ARTERIES

• For the next procedure, I’ll be palpating and auscultating your carotid arteries, the major blood
vessels that provide our brain's blood supply.

• Okay Sir pwede po ba kayong tumingin sa left side niyo as I will palpate your carotid arteries one
a time as the importance of this is to ensure that there is enough blood flowing onto our brain
through arteries. Sir, please tell me if my palpation puts pressure on your neck because putting
pressure on your artery may cause bradycardia or may cause a slower normal heart rate.

• Upon palpating I observed that your pulse is symmetric in volume and has full pulsation,
also your arterial wall din po si elastic which is all normal po.

• Then next I will auscultate your carotid arteries, so sir so this time can your turn your head po
away from me as this will facilitates po the placement of the stethoscope.

• Upon the auscultation, there is no presence of blowing or swishing or other sounds are
heard, also there is no presence of bruit caused by turbulent blood flow.
 ASSESSING THE PERIPHERAL VASCULAR SYSTEMS • Next is I’m going to inspect the peripheral leg veins to check if there is presence of phlebitis.
• Next po is I’m going to assess your peripheral vascular systems, this includes your
 Temporal: It is felt in the head. • First, I’m going to inspect your calves to check for redness and swelling on your vein sites.
 Carotid: It is felt in the neck.
 Branchial: It is felt in the elbow. • Then next is I’m going to palpate your calves to check for firmness or tension on the muscles,
 Femoral: It is felt at the groin. edema on dorsum part and I’m going to also check the temperature of your calves because any
 Radial: It is felt on the wrist. warmth may indicate that your vein has been damaged.
 Popliteal: It is felt on the knee.
 Dorsalis Pedis: It is felt on the foot. • Then next I’m going to push your calves’ side to side to check if there is tenderness that is present.

• Then last is I’m going to perform HOMANS TEST, or I will firmly dorsiflex your foot while supporting
and assisting your entire legs.

• Upon the assessment, I observed that your calves have

no sign of edema, no redness or swelling on your vein
sites. Then while palpating and pushing your calves I
observed that there is no tenderness present, and the
temperature is bilaterally equal and not warm. And you
do not feel any pain or discomfort while palpating and
when I’m performing the Homans test. Which is all
good and normal po.

• But before po I start the assessment I will ask one questions lang po prior to the assessment: • Now I’m going to inspect your hands and feet to check for
 Do you have past history of hearts disorders, hypertension, and arterial disease? color, edema, temperature, and skin changes.

• Sir, is it okay that I'm the one going to palpate your peripheral pulses or you're the one who will
assess yourself and I will instruct you which part to touch or need to palpate then after po tell me
if you feel any pulse?
• Upon the assessment, as you (client) verbalized po that you felt pulse on the peripheral
pulses, it is normal because you all pulse that you feel po is in symmetric volume which
mean all your pulses po are equal bilaterally.
• I will use the dorsal part of my hand to check the temperature
of your hands putting it over the palm or palmar part of your hands.
• And I’m going to Assess the adequacy of arterial flow on
your nails by doing the capillary refill test by gently pinching your
nails to check the blood flow and if arterial insufficiency is
suspected, also to monitor dehydration or hydration.

• Next is I’m going to the peripheral veins on your arms and legs to check if there are any
presence of veins when your limbs are elevated.
• Okay sir I will assist you po to place your legs into dorsum recumbent with knees flexed or your
legs po into elevated position.
• Upon inspecting, I observed that your hands are color pinkish, the temperature is
bilaterally equal and neither warm nor cold, no edema and the skin texture is resilient and
moist which normal po.
• And upon doing the capillary refill test I observed that after I pinch your nails the color
returns to its original within 2-3 seconds or less which is normal rin po.

• Upon the assessment, I observed that there are no peripheral veins present in your arms • Document the findings of client to promote effective communication among multidisciplinary health
and legs which is normal po as when the limbs po are elevated the veins also collapse team members to facilitate safe and efficient client care. Upon documenting I have observed that
which is normal lang po. all finding from assessing your heart to peripheral vascular systems are all normal and good.
 ASSESSING THE ABDOMEN
• Before I start the assessment, I will adjust first the bed as the you (patient) need to be in a
supine position po, and your arms should be comfortable placed on your side when
assessing the abdomen to accurately check po your abdomen.
• Nilalamig po ba or giniginaw po ba kayo? (if nilalamig or giniginaw po kayo I will cover po
other parts of the body except the chest to pubic area to avoid chilling and shivering to
make sure that the abdomen was not getting tense.)
• Followed by putting pillows under the knee or do the dorsum recumbent with knees flex to
reduce tension in the abdominal muscles.
• Before I start po the assessment I ask few questions land po related to abdominal history
po
 Do you have a history of having abdominal pain?
 Can you describe the type of pain you’ve experienced?
 Can you please tell me or point to the location where you feel the pain before?
 Does the pain stay or shift in one specific area?
 Is the pain constant or does it come and go?
 How would you rate the severity of your abdominal pain that you’ve experienced?
 Have you also experienced any nausea or vomiting, changes in appetite, or fever
chills when you experienced abdominal pain before?
 Have you also experienced being ingested when you have abdominal pain before?
 Have your had history of getting treatment like stomach ulcer? Gallbladder surgery?
Or history of jaundice?
• In assessing the abdomen, it includes four techniques, Inspection, Auscultation, Percussion, and
Palpation, the patterns of IIPA technique becomes different and palpation becomes last when
assessing the abdomen because palpate can alter the frequency and intensity of bowel sounds
and may affect the results of your abdominal assessment po.
• So, I’ll be standing on this side as I’ll be first observing the
skin integrity, contour, and symmetry of your abdomen, and
could you please take a deep breath and hold it to as I’m
going to observed if there are enlarged organ that is bulging
on your abdomen.
• Then, I’ll be inspecting the symmetry of contour while
standing at the foot of the bed.
Okay sir, you don’t have abdominal distension po but is it okay lang po ba na I will perform the
test po or just measure na lang po as I will place the tape measure po around the abdomen at the
level po of umbilicus?
• Can you please raise po your back while I’m assisting you to put the tape measure po, I will be
placing it po gently to avoid po magkaron kayo ng scratches from the measuring tools.
“In putting the tape measure make sure that
centimeters are the measure of length that you
are going to use. “
• I’ll also be observing the abdomen
movements associated with the respiration,
peristalsis, or aortic pulsation as well as the vascular
pattern.
● So, upon inspecting and observing, the abdominal skin is unblemished as your abdomen
po has no marks nor spots po, uniform in color, have no silver-white striae or stretch marks
and no surgical scars which is all normal po.
● Abdomen has no evidence of enlargement liver and spleen, has symmetric contour, and
the abdomen is convex or round which is all normal po.
● There is no abdominal distention that is present po but the measurement po of your
abdominal girth is 82cm which is normal rin po.
● The abdomen has symmetric movements caused by respiration, has no aortic pulsation
which is normal lang po. If the client po is malaman there is a slight chance of seeing aortic
pulsation however if the client is thin a slight pulsation of the abdominal aorta is visible in
the epigastrium.
• Next po is I’m going to warm po my hands and the diaphragm of my stethoscope as I will
auscultate po your abdomen because cold temperature may cause your abdominal muscles to
contract that can be heard during auscultation.
• I will place my stethoscope first on right lower quadrant, followed by the right upper quadrant, then
left upper quadrant, last is left lower quadrant. The reason for this is I don’t want to disrupt the
airflow in your abdomen and once I disrupt the flow the results and findings will not be accurate
as I alter already the flow of air.
• Upon auscultating, there are 5-30 presence of audible bowel sounds per minute on each
quadrant. There are no Hyperactive bowel sounds are heard or referred to as
“borborygmus” which means there are no presence of loud, prolonged gurgles
characteristic of one’s “stomach growling.”
• Absence of arterial bruits and absence of friction rubs which is all normal po
• Next is I’ll be percussing several areas on each quadrant to ● I’ll be also palpating for the liver. I'll be placing my left
determine presence of tympany that indicates there is gas in hand on your back, parallel to and supporting the right 11th
stomach and intestines and to determine presence of and 12th ribs and your right hand lateral to the rectus
dullness which indicate decrease, absence, or flatness of muscle with my fingertips below the liver border.
resonance over solid masses or fluid.
● Could you please take a deep breath?
• I will use again the systematic pattern and start percussing
over lower right quadrant of abdomen,
• Last is I’ll be palpating your bladder. I’ll start with symphysis pubis
• Upon percussing, generalized tympany predominates over the abdomen because of air in and move upward and outward to estimate bladder borders.
the stomach and intestines.
• Dullness is heard over the liver and spleen. • Upon assessing, Abdomen is nontender and soft. There is no
guarding, and the abdomen is relaxed with smooth consistent
• Next is I’m going to instruct tension.
you to inhale and hold your • Upon deep palpation, normal (mild) tenderness is possibly felt
breath as I’ll be percussing your over the xiphoid, aorta, cecum, sigmoid colon, and ovaries.
liver to determine its size. • When I perform the palpation of your liver, it is not palpable but
it normal since your abdomen po is convex and malaman po.
• I will start percussing on the However, although it may be felt in some thin client and if the lower edge is felt, it should
3rd intercostal space down until I be firm, smooth, and even, and mild tenderness may be normal.
hear changes from resonance to • Upon palpation, the area above the pubic symphysis is not palpable which indicates that
dullness between the 5th and 7th you have no urinary retention.
intercostal space.
• Document the findings of client to promote effective communication among multidisciplinary health
• Next is I’ll start percussing from the right part at the level of umbilicus area and upward until I hear team members to facilitate safe and efficient client care. Upon documenting I have observed that
changes from tympany turns to dullness. all findings from assessing your heart, peripheral veins to abdomen are all normal and good.

● Upon percussing I observed that the lower border of liver dullness is located at the costal
margin is 1 to 2 cm below and the size of your liver is 6-12 cm which is normal po.

• For the next procedure, I’ll be performing light palpation first

to detect areas of tenderness and or muscle guarding. Then, I’ll
be proceeding to perform the deep palpation over all four
quadrants.

• I’ll be placing the palmar aspect of my fingers on your

abdomen. Using a light, gentle, dipping motion, palpates for
abnormalities, such as muscle guarding, rigidity, or superficial
masses.

• Then proceeding to the deep palpation. Using the

palmar surface of non-dominant hand being pushed by
my dominant hand. I’ll compress the maximum depth of
(5–6 cm).