RESPIRATORY SYSTEM
ASSESSMENT PROCEDURE NORMAL FINDINGS
INSPECTION
Inspect for nasal flaring Nasal flaring is not observed.
and pursed lip breathing Normally, the diaphragm and the
external intercostal muscles do
most of the work of breathing.
This is evidenced by outward
expansion of the abdomen and
lower ribs on inspiration as well as
return to resting position on
expiration.
Observe color of face, The client has evenly colored skin
lips, and chest. tone, without unusual or
prominent discoloration.
Inspect color and shape of Pink tones should be seen in the
nails. nail beds. There is normally a 160-
degree angle between the nail
base and the skin.
Posterior Thorax
INSPECTION
Inspect configuration. Scapulae are symmetric and
While the client sits with nonprotruding. Shoulders and
arms at the sides, stand scapulae are at equal horizontal
behind the client and positions. The ratio of AP to
observe the position of transverse diameter is 1:2.
scapulae and the shape
and configuration of the
chest wall
ABNORMAL FINDINGS
Nasal flaring is seen with labored
respirations (especially in small
children) and is indicative of hypoxia.
Pursed lip breathing may be seen in
asthma, emphysema, or CHF as a
physiologic response to help slow
down expiration and keep alveoli
open longer.
Ruddy to purple complexion may be
seen in clients with COPD or CHF as a
result of polycythemia. Cyanosis may
be seen if client is cold or hypoxic.
Pale or cyanotic nails may indicate
hypoxia. Early clubbing (180-degree
angle) and late clubbing (>180-degree
angle) can occur from hypoxia.
Spinous processes that deviate
laterally in the thoracic area may
indicate scoliosis. Spinal
configurations may have respiratory
implications. Ribs appearing
horizontal at an angle >45 degrees
with the spinal column are frequently
the result of an increased (1:1) ratio
between the AP and transverse
diameter (barrel chest). This condition
is commonly the result of emphysema
due to hyperinflation of the lungs.
Trapezius, or shoulder, muscles are
used to facilitate inspiration in cases
of acute and chronic airway
obstruction or atelectasis.

Some clinicians prefer to
inspect the entire thorax
first, followed by palpation
of the anterior and
posterior thorax, then
percussion and
auscultation of the
anterior and posterior
thorax.
Observe use of accessory
muscles. Watch as the
client breathes and note
use of muscles.
Inspect the client’s
positioning. Note the
client’s posture and ability
to support weight while
breathing comfortably.
PALPATION
Palpate for tenderness
and sensation. Palpation
may be performed with
one or both hands, but the
sequence of palpation is
established. Use your
fingers to palpate for
tenderness, warmth, pain,
or other sensations. Start
toward the midline at the
level of the left scapula
(over the apex of the left
lung) and move your hand
left to right, comparing
findings bilaterally. Move
systematically downward
and out to cover the
Spinous processes appear
straight, and thorax appears
symmetric, with ribs sloping
downward at ~45-degree angle in
relation to the spine.
OLDER ADULT CONSIDERATIONS
Kyphosis (an increased curve of
the thoracic spine) is common in
older clients It results from a loss
of lung resiliency and a loss of
skeletal muscle. It may be a
normal finding.
The client does not use accessory
(trapezius/shoulder) muscles to
assist breathing. The diaphragm is
the major muscle at work. This is
evidenced by expansion of the
lower chest during inspiration.
Client should be sitting up and
relaxed, breathing easily with
arms at sides or in lap.
Client reports no tenderness,
pain, or unusual sensations.
Temperature should be equal
bilaterally.
Client leans forward and uses arms to
support weight and lift chest to
increase breathing capacity, referred
to as the tripod position (This is often
seen in COPD (EvidenceBased Practice
19-1).
Tender or painful areas may indicate
inflamed fibrous connective tissue.
Pain over the intercostal spaces may
be from inflamed pleurae. Pain over
the ribs, especially at the costal
chondral junctions, is a symptom of
fractured ribs.
Muscle soreness from exercise or the
excessive work of breathing (as in
COPD) may be palpated as
tenderness. Increased warmth may
be related to local infection.
lateral portions of the
lungs at the bases.
Palpate for crepitus.
Crepitus, also called
subcutaneous
emphysema, is a crackling
sensation (like bones or
hairs rubbing against each
other) that occurs when
air passes through fluid or
exudate.
Palpate surface
characteristics. Put on
gloves and use your
fingers to palpate any
lesions that you noticed
during inspection. Feel for
any unusual masses.
Palpate for fremitus.
Following the sequence
described previously, use
the ball or ulnar edge of
one hand to assess for
fremitus (vibrations of air
in the bronchial tubes
transmitted to the chest
wall). As you move your
hand to each area, ask the
client to say “ninety-nine.”
Assess all areas for
symmetry and intensity of
vibration.
CLINICAL TIP The ball of
the hand is best for
assessing tactile fremitus
because the area is
especially sensitive to
vibratory sensation.
Assess chest expansion.
Place your hands on the
posterior chest wall with
The examiner finds no palpable
crepitus.
Skin and subcutaneous tissue are
free of lesions and masses.
Fremitus is symmetric and easily
identified in the upper regions of
the lungs. If fremitus is not
palpable on either side, the client
may need to speak louder. A
decrease in the intensity of
fremitus is normal as the
examiner moves toward the base
of the lungs. However, fremitus
should remain symmetric for
bilateral positions.
When the client takes a deep
breath, the examiner’s thumbs
should move 5 to 10 cm apart
Crepitus can be palpated if air
escapes from the lung or other
airways into the subcutaneous tissue,
as occurs after an open thoracic
injury, around a chest tube, or
tracheostomy. It also may be
palpated in areas of extreme
congestion or consolidation. In such
situations, mark margins and monitor
to note any decrease or increase in
the crepitant area.
A physician or other appropriate
professional should evaluate any
unusual palpable mass
Unequal fremitus is usually the result
of consolidation (which increases
fremitus) or bronchial obstruction, air
trapping in emphysema, pleural
effusion, or pneumothorax (which all
decrease fremitus). Diminished
fremitus even with a loud spoken
voice may indicate an obstruction of
the tracheobronchial tree.
Unequal chest expansion can occur
with severe atelectasis (collapse or
incomplete expansion), pneumonia,
your thumbs at the level
of T9 or T10 and pressing
together a small skin fold.
As the client takes a deep
breath, observe the
movement of your thumbs
PERCUSSION
Percuss for tone. Start at
the apices of the scapulae
and percuss across the
tops of both shoulders.
Then percuss the
intercostal spaces across
and down, comparing
sides. Percuss to the
lateral aspects at the
bases of the lungs,
comparing sides.
Percuss for diaphragmatic
excursion. Ask the client
to exhale forcefully and
hold the breath. Beginning
at the scapular line (T7),
percuss the intercostal
spaces of the right
posterior chest wall.
Percuss downward until
the tone changes from
resonance to dullness.
Mark this level and allow
the client to breathe. Next
ask the client to inhale
deeply and hold it. Percuss
the intercostal spaces
from the mark downward
until resonance changes to
dullness. Mark the level
and allow the client to
breathe. Measure the
symmetrically.
Resonance is the percussion tone
elicited over normal lung tissue.
Percussion elicits flat tones over
the scapula.
Excursion should be equal
bilaterally and measure 3– 5 cm in
adults.
The level of the diaphragm may
be higher on the right because of
the position of the liver. In well-
conditioned clients, excursion can
measure up to 7 or 8 cm.
chest trauma, or pneumothorax (air
in the pleural space). Decreased chest
excursion at the base of the lungs is
characteristic of COPD. This is due to
decreased diaphragmatic function.
Hyperresonance is elicited in cases of
trapped air, such as in emphysema or
pneumothorax.
Dullness is present when fluid or solid
tissue replaces air in the lung or
occupies the pleural space, such as in
lobar pneumonia, pleural effusion, or
tumor.
Diaphragmatic descent may be
limited by atelectasis of the lower
lobes or by emphysema, in which
diaphragmatic movement and air
trapping are minimal. The diaphragm
remains in a low position on
inspiration and expiration. Other
possible causes for limited descent
can be pain or abdominal changes
such as extreme ascites, tumors, or
pregnancy. Uneven excursion may be
seen with inflammation from
unilateral pneumonia, damage to the
distance between the two phrenic nerve, or splenomegaly.
marks. Perform this
assessment technique on
both sides of the posterior
thorax.

AUSCULTATION

Auscultate for breath
sounds. To best assess
lung sounds, you will need
to hear the sounds as
directly as possible. Do not
attempt to listen through
clothing or a drape, which
may produce additional
sound or muffle lung
sounds that exist. To
begin, place the
diaphragm of the
stethoscope firmly and
directly on the posterior
chest wall at the apex of
the lung at C7. Ask the
client to breathe deeply
through the mouth for
each area of auscultation
(each placement of the
stethoscope) in the
auscultation sequence so
that you can best hear
inspiratory and expiratory
sounds. Be alert to the
client’s comfort and offer
times for rest and normal
breathing if fatigue is
becoming a problem.
Three types of normal breath
sounds may be auscultated—
bronchial, bronchovesicular, and
vesicular
CLINICAL TIP Breath sounds are
considered normal only in the
area specified. Heard elsewhere,
they are considered abnormal
sounds. For example, bronchial
breath sounds are abnormal if
heard over the peripheral lung
fields. Sometimes breath sounds
may be hard to hear with obese or
heavily muscled clients due to
increased distance to underlying
lung tissue.
Diminished or absent breath sounds
often indicate that little or no air is
moving in or out of the lung area
being auscultated. This may indicate
obstruction within the lungs as a
result of secretions, mucus plug, or a
foreign object. It may also indicate
abnormalities of the pleural space
such as pleural thickening, pleural
effusion, or pneumothorax. In cases
of emphysema, the hyperinflated
nature of the lungs, together with a
loss of elasticity of lung tissue, may
result in diminished inspiratory
breath sounds. Increased (louder)
breath sounds often occur when
consolidation or compression results
in a denser lung area that enhances
the transmission of sound.

Auscultate from the

apices of the lungs at C7
to the bases of the lungs
at T10 and laterally from
the axilla down to the
seventh or eighth rib.
Listen at each site for at
least one complete
respiratory cycle.

Auscultate for No adventitious sounds, such as Adventitious lung sounds, such as

adventitious sounds. crackles (discrete and crackles (formerly called rales) and
Adventitious sounds are discontinuous sounds) or wheezes wheezes (formerly called rhonchi)
sounds added or (musical and continuous), are are evident.
superimposed over auscultated.
normal breath sounds and CLINICAL TIP If you hear an abnormal
heard during auscultation. sound during auscultation, always
Be careful to note the have the client cough, then listen
location on the chest wall again and note any change. Coughing
where adventitious sounds may clear the lungs.
are heard as well as the
location of such sounds
within the respiratory
cycle.

Auscultate voice
sounds.
Bronchophony: Ask the Voice transmission is soft, The words are easily understood and
client to repeat the muffled, and indistinct. The sound louder over areas of increased
phrase “ninety-nine” of the voice may be heard through density. This may indicate
while you auscultate the the stethoscope, but the actual consolidation from pneumonia,
chest wall with the
stethoscope if you suspect
an abnormality.
Egophony: Ask the client
to repeat the letter “E”
while you listen over the
chest wall.
Whispered pectoriloquy:
Ask the client to whisper
the phrase “one-two-
three” while you
auscultate the chest wall.
Anterior Thorax
INSPECTION
Inspect for shape and
configuration. Have the
client sit with arms at the
sides. Stand in front of the
client and assess shape
and configuration.
Inspect position of the
sternum. Observe the
sternum from an anterior
and lateral viewpoint.
Watch for sternal
retractions.
Inspect slope of the ribs.
Assess the ribs from an
anterior and lateral
viewpoint.
Observe quality and
pattern of respiration.
phrase cannot be distinguished.
Voice transmission will be soft and
muffled, but the letter “E” should
be distinguishable and heard as
“eeeee” through the stethoscope.
Transmission of sound is very faint
and muffled. It may be inaudible.
The AP diameter is less than the
transverse diameter. The ratio of
AP diameter to the transverse
diameter is 1:2.
Sternum is positioned at midline
and straight. CLINICAL TIP The
sternum and ribs may be more
prominent in the older client
because of loss of subcutaneous
fat.
Retractions not observed.
Ribs slope downward with
symmetric intercostal spaces.
Costal angle is within 90 degrees.
Respirations are relaxed,
effortless, and quiet. They are of a
atelectasis, or tumor.
Over areas of consolidation or
compression, the sound is louder and
sounds like a bleating “aaaa” sound.
Over areas of consolidation or
compression, the sound is
transmitted very clearly and distinctly.
In such areas, it sounds as if the client
is whispering “one, two, three”
directly into the stethoscope.
AP equals transverse diameter,
resulting in a barrel chest. This is
often seen in emphysema because of
hyperinflation of the lungs.
Pectus excavatum is a markedly
sunken sternum and adjacent
cartilages (often referred to as funnel
chest). It is a congenital malformation
that seldom causes symptoms other
than self-consciousness. Pectus
carinatum is a forward protrusion of
the sternum causing the adjacent ribs
to slope backward (often referred to
as pigeon chest). Both conditions may
restrict expansion of the lungs and
decrease lung capacity.
Sternal retractions are noted, with
severely labored breathing.
Barrel-chest configuration results in a
more horizontal position of the ribs
and costal angle of >90 degrees. This
often results from long-standing
emphysema.
Labored and noisy breathing is often
seen with severe asthma or chronic
Note breathing regular rhythm and normal depth bronchitis. Abnormal breathing
characteristics as well as at a rate of 10–20 per minute in patterns include tachypnea,
rate, rhythm, and depth. adults. Tachypnea and bradypnea bradypnea, hyperventilation,
may be normal in some clients. hypoventilation, Cheyne– Stokes
respiration, and Biot respiration.
CLINICAL TIP When
assessing respiratory
patterns, it is more
objective to describe the
breathing pattern, rather
than just labeling the
pattern.

Inspect intercostal spaces. No retractions or bulging of Retraction of the intercostal spaces

Ask the client to breathe
normally and observe the
intercostal spaces.
intercostal spaces are noted.
indicates an increased inspiratory
effort. This may be the result of an
obstruction of the respiratory tract or
atelectasis. Bulging of the intercostal
spaces indicates trapped air, such as
in emphysema or asthma.

Observe for use of Use of accessory muscles Neck muscles (sternomastoid,

accessory muscles. Ask
the client to breathe
normally and observe for
use of accessory muscles.
PALPATION
(sternomastoid and rectus
abdominis) is not seen with
normal respiratory effort. After
strenuous exercise or activity,
clients with normal respiratory
status may use neck muscles for a
short time to enhance breathing.
scalene, and trapezius) are used to
facilitate inspiration in cases of acute
or chronic airway obstruction or
atelectasis. The abdominal muscles
and the internal intercostal muscles
are used to facilitate expiration in
COPD.

Palpate for tenderness, No tenderness or pain is palpated Tenderness over thoracic muscles can
sensation, and surface over the lung area with result from exercising (e.g., pushups),
masses. Use your fingers respirations. especially in a previously sedentary
to palpate for tenderness client.
and sensation. Start with
your hand positioned over
the left clavicle (over the
apex of the left lung) and
move your hand left to
right, comparing findings
bilaterally. Move your
hand systematically
downward toward the
midline at the level of the
breasts and outward at
the base to include the
lateral aspect of the lung.
The established sequence
for palpating the anterior
thorax.

CLINICAL TIP Anterior and

anterolateral thoracic
palpation is best for
assessing the right lung’s
middle lobe.
Palpate for tenderness at Palpation does not elicit OLDER ADULT CONSIDERATIONS
costochondral junctions tenderness. Tenderness or pain at the
of ribs. costochondral junction of the ribs is
seen with fractures, especially in
older clients with osteoporosis.

Palpate for crepitus as No crepitus is palpated. In areas of extreme congestion or

you would on the consolidation, crepitus may be
posterior thorax palpated, particularly in clients with
(described previously). lung disease.

Palpate for any surface No unusual surface masses or Surface masses or lesions may
masses or lesions. lesions are palpated. indicate cysts or tumors.

Palpate for fremitus.
Using the sequence for the
anterior chest described
previously, palpate for
fremitus using the same
technique as for the
posterior thorax.
Fremitus is symmetric and easily
identified in the upper regions of
the lungs. A decreased intensity of
fremitus is expected toward the
base of the lungs. However,
fremitus should be symmetric
bilaterally.
Diminished vibrations, even with a
loud spoken voice, may indicate an
obstruction of the tracheobronchial
tree. Clients with emphysema may
have considerably decreased fremitus
as a result of air trapping.

CLINICAL TIP When you

assess for fremitus on the
female client, avoid
palpating the breast.
Breast tissue dampens the
vibrations.

Palpate anterior chest
expansion. Place your
hands on the client’s
anterolateral wall with
your thumbs along the
costal margins and
pointing toward the
xiphoid process. As the
Thumbs move outward in a
symmetric manner from the
midline.
Unequal chest expansion can occur
with severe atelectasis, pneumonia,
chest trauma, pleural effusion, or
pneumothorax. Decreased chest
excursion at the bases of the lungs is
seen with COPD.
client takes a deep breath,
observe the movement of
your thumbs.
PERCUSSION
Percuss for tone. Percuss
the apices above the
clavicles. Then percuss the
intercostal spaces across
and down, comparing
sides.
Resonance is the percussion tone
elicited over normal lung tissue.
Percussion elicits dullness over
breast tissue, the heart, and the
liver. Tympany is detected over
the stomach, and flatness is
detected over the muscles and
bones.
Hyperresonance is elicited in cases of
trapped air, such as in emphysema or
pneumothorax. Dullness may
characterize areas of increased
density such as consolidation, pleural
effusion, or tumor.
AUSCULTATION

Auscultate for anterior Refer to text in the posterior adventitious breath sounds.
breath sounds, thorax section for normal voice
adventitious sounds, and sounds.
voice sounds. Place the
diaphragm of the
stethoscope firmly and
directly on the anterior
chest wall. In cases of lobe consolidation, a dull
sound is heard in the affected lobe. In
obstructive atelectasis, the trachea
Auscultate from the shifts to affected (ipsilateral) side, and
apices of the lungs slightly there are decreased breath sounds. In
above the clavicles to the a pneumothorax, the trachea shifts to
bases of the lungs at the other (contralateral) side, and breath
sixth rib. Ask the client to sounds are absent on affected side. In
breathe deeply through pleural effusion or hemothorax (fluid
the mouth in an effort to or blood pooling in pleural cavity), the
avoid transmission of trachea
sounds that may occur
with nasal breathing. Be
alert to the client’s
comfort and offer times
for rest and normal
breathing if fatigue is
becoming a problem,
particularly for the older
client. Listen at each site
for at least one complete
respiratory cycle.

CLINICAL TIP Again, do not

attempt to listen through
clothing or other
materials. However, if the
client has a large amount
of hair on the chest and/or
back, listening through a
thin T-shirt can decrease
extraneous sounds that
may be misinterpreted as
crackles.
CARDIOVASCULAR SYSTEM
ASSESSMENT
Neck Vessels
INSPECTION
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.
CLINICAL TIP Be careful not to
confuse pulsations of the carotid
arteries with pulsations of the
internal jugular veins.
Evaluate jugular venous
pressure. Evaluate jugular
venous pressure by watching for at 45 degrees or greater.
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
NORMAL FINDNKGS
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.
The jugular vein should not be
distended, bulging, or protruding
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. Distention of jugular
vein on one side may be caused
by a kink or aneurysm
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.
bulging.

CLINICAL TIP Jugular venous

pressure is often omitted and
replaced by a medical order for
pulmonary artery catheter
placement. However, when
performed correctly, this
assessment is low cost and
effective.

AUSCULTATION AND
PALPATION

Auscultate the carotid arteries if No blowing, swishing, or other A bruit, a blowing or swishing
the client is middle-aged or sounds are heard. sound caused by turbulent blood
older or if you suspect flow through a narrowed vessel,
cardiovascular disease. Place is indicative of occlusive arterial
the bell of the stethoscope over disease. However, if the artery is
the carotid artery and ask the more than two-thirds occluded,
client to hold their breath for a a bruit may not be heard.
moment so that breath sounds
do not conceal any vascular
sounds (Fig. 21-11). CLINICAL TIP
Always auscultate the carotid
arteries before palpating
because palpation may increase
or slow the HR, changing the
strength of the carotid impulse
heard.

Neck Vessels

Palpate the carotid arteries.
Palpate each carotid artery
alternately by placing the pads of
the index and middle fingers
medial to the
sternocleidomastoid muscle on
the neck . Note amplitude and
contour of the pulse, elasticity of
the artery, and any thrills (that
feel similar to a purring cat).
Palpate the carotid arteries
individually because bilateral
palpation could result in reduced
cerebral blood flow. If you detect
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 4 as follows: Pulse
Amplitude Scale 0 = Absent 1+ =
Weak, diminished (easy to
obliterate) 2+ = Normal
(obliterate with moderate
pressure) 3+ = Strong (obliterate
Pulse inequality may indicate
arterial constriction or occlusion
in one carotid artery. Weak
pulses may indicate
hypovolemia, shock, or
decreased CO. 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
problem. A delayed upstroke
may indicate aortic stenosis. Loss
of elasticity may indicate
occlusion during auscultation,
palpate very lightly to avoid
blocking circulation or triggering
vagal stimulation and
bradycardia, hypotension, or
even cardiac arrest.
with firm pressure) 4+ = arteriosclerosis. Thrills may
Bounding (unable to obliterate) indicate a narrowing of the
Arteries are elastic and no thrills artery.
are noted.

OLDER ADULT CONSIDERATIONS

Be cautious with older clients
because atherosclerosis may
have caused obstruction and
compression may easily block
circulation.

Heart (Precordium),
Anterior Chest
INSPECTION

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.
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.
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.

CLINICAL TIP The apical impulse

was originally called the point of
maximal impulse (PMI).
However, this term is no longer
used because a maximal impulse
may occur in other areas of the
precordium as a result of
abnormal conditions.

PALPATION
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)
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 clients who are obese or in
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.
You may ask the client to roll to
the left side to better feel the
impulse using your finger pads
CLINICAL TIP If this apical
pulsation cannot be palpated,
have the client assume a left
lateral position. This displaces
the heart toward the left chest
wall and relocates the apical
impulse farther to the left.
Palpate for abnormal
pulsations. Use your palmar
surfaces to palpate the apex, left
sternal border, and base.
AUSCULTATION
Auscultate HR and rhythm.
Place the diaphragm of the
stethoscope at the apex and
listen closely to the rate and
rhythm of the apical impulse.
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.
Auscultate to identify S1 and
S2 . Auscultate the first heart
sound (S1 or “lub”) and the
second heart sound (S2 or
“dub”). Remember these two
clients with large breasts, the
apical impulse may not be
palpable.
OLDER ADULT CONSIDERATIONS
In older clients, the apical
impulse may be difficult to
palpate because of increased
anteroposterior chest diameter.
No pulsations or vibrations are
palpated in the areas of the
apex, left sternal border, or base.
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
with age, gender, and
ethnic/racial factors (Hart, 2015).
Adult female RPRs are a few
beats faster than male RPRs.
The radial and apical pulse rates
should be identical.
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
A thrill or a pulsation is usually
associated with a grade IV or
higher murmur
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
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.
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.
CLINICAL TIP If you are
experiencing difficulty
differentiating S1 from S2 ,
palpate the carotid pulse: the
harsh sound that you hear from
the carotid pulse is S1
Listen to S1 . Use the diaphragm
of the stethoscope to best hear
S1
Listen to S2 . Use the diaphragm
of the stethoscope. Ask the
client to breathe regularly
CLINICAL TIP Do not ask the
client to hold their breath.
Breath holding will cause any
normal or abnormal split to
subside.
Auscultate for extra heart
sounds. Use the diaphragm first,
then the bell 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 ).
heart.
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.
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
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
wellconditioned athletes and in
Accentuated, diminished,
varying, or split S1 are all
abnormal findings (
Any split S2 heard in expiration is
abnormal. The abnormal split
can be one of three types: wide,
fixed, or reversed.
Ejection sounds or clicks (e.g., a
midsystolic click associated with
mitral valve prolapse) are heard.
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.
 adults older than age 40 or 50
with no evidence of heart
disease, especially after exercise.

Heart (Precordium),
Anterior Chest
CLINICAL TIP While auscultating, A pathologic S3 (ventricular
keep in mind that development gallop) may be heard with
of a pathologic S3 may be the ischemic heart disease,
earliest sign of heart failure. 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

Auscultate for murmurs. A Normally, no murmurs are Pathologic midsystolic,

murmur is a swishing sound heard. However, innocent and pansystolic, and diastolic
caused by turbulent blood flow physiologic midsystolic murmurs murmurs.
through the heart valves or great may be present in a healthy
vessels. Auscultate for murmurs heart.
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.
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
S1 and S2 heart sounds are An S3 or S4 heart sound or a
normally present. murmur of mitral stenosis that
was not detected with the client
in the supine position may be
revealed when the client
assumes the left lateral position.
S1 and S2 heart sounds are Murmur of aortic regurgitation
normally present. may be detected when the client
assumes this position.