We're going to be doing the heart and neck vessel assessment. First we're going to start out by doing the carotid assessment and we're going to do this sitting up with the head midline. We're going to be auscultating first, we're going to be listening three areas - where I listen to the angle of the jaw, mid cervical and the base of the neck. I'm going to get you to take a big deep breath, exhale and hold every time I move the spots and then we'll get you to breathe normal and then we'll get you to do it again. For this we're going to be using the bell, so let's take a big deep breath exhale and hold. Breathe normal, deep breath exhale and hold. No bruit present so that's good. Now we're going to palpate your carotid artery - we're just going to palpate one area and bilaterally. We will start with the mid cervical just here by the base of the neck. Then we're gonna note 4 findings - so I felt a rapid upstroke, slower down stroke, smooth contour, it was equal bilateral and it had a plus two force and that is perfect. What we're going to do now is we're going to get you into bed and we're going to assess your jugular vein. I'm gonna put them at a 45 degree angle so that we're able to see the distension of the vein. I'm going to remove the pillow, I'm going to get my client to turn their head to the side, I'm going to shine my tangential lighting. I'm going to note that my external jugular it's over my sternomastoid muscle, my internal jugular is that my sternal notch or the base of the neck. I'm going to note two findings - there are two visible waves per cycle, it's undulant diffuse, it varies with respiration, if I sat my client up or laid them flat that it would disappear and any sort of gentle pressure will obliterate the pulse. So that's essentially that so now we're gonna get back to pillow and we're going to inspect their precordium. So we're going to look at their precordium - the area from the right sternal border over to their left midclavicular line, we're going to identify their sternal border, the apex of their heart, and we see no heaves our lifts, no apical pulse present. Then we're going to palpate the area using our palmar aspect of our fingers or ulnar aspect we're going to feel the base of the precordium, the sternal border - left sternal border all the way to their apex. No thrills felt and no apical pulse felt. Now, we're gonna feel for our apical pulse so we're going to landmark our second intercostal space at our angle of Louie. We're gonna come down to our fifth intercostal space about seven to nine centimeters over midclavicular line, we're going to use one finger we're gonna palpate for our apical impulse. I'm not able to feel it if you're not able to feel it then we're going to turn our client to the left side and you can turn your sideways here and when I do that I'm gonna get you to take a deep breath exhale and hold. We're gonna move over and we're gonna palpate so now I'm able to feel it there in a one to two centimeter area. I was able to feel a short gentle tap however in about 50% of the population we're not able to feel that. We're going to auscultate your apical pulse. We are going to use the diaphragm for this. We're going to land mark your fifth intercostal space, left sternal border. If you have breast tissue or your clients have breasts you can get your client to displace the breast to the medial and then you can landmark it using your diaphragm we're gonna place it over there and we're gonna listen for a full minute and we're gonna note rate and rhythm. So a minute has passed - rate is 68 and rhythm is regular. No now we are going to landmark your valves and we are going to auscultate those - at your second intercostal space, right sternal border we have our aortic valve. Left sternal border second intercostal space as our pulmonic valve, our fourth or fifth intercostal space left sternal border is our tricuspid and then our fifth intercostal space we're left midclavicular line is our mitral valve. First we're going to use our diaphragm and we're going to listen to those valves for one full cardiac cycle. So s1 s2 present, no abnormal or split sounds heard, no murmurs heard, s1 was louder at the apex, s2 was louder at the base. Now we're going to switch that over to our bell and we're going to listen to those same areas again. So again s1 s2 heard, no abnormal or split sounds heard, and no murmurs heard. So that concludes our assessment any questions?