11.10 Palpation of the Precordium

Palpation of the precordium involves palpating the chest wall and palpating the apical impulse.

Palpation of Chest Wall for Pulsations

Palpation of the chest wall provides information about the quality of cardiac blood flow.

Palpation for pulsations involves the following steps (see Video 7):

Step 1: Maintain the client in a supine position and continue to use draping as needed.

Step 2: Palpate the base of the heart, the left sternal border, and the apex.

Step 3: Use one of two techniques to palpate:

• Use the metacarpophalangeal surface of your fingers starting at the base of the heart. Leave them in place as long as you need to, but usually about two to three seconds, and then move onto the sternal border and then the apex. (This is the most common technique).

OR

• Use the ulnar surface of your hands starting at the base of the heart. Place your ulnar surface in several locations because its surface is smaller than your metacarpophalangeal surface. Leave them in place as long as you need to, but usually about two to three seconds and then move onto the sternal border and then the apex

Step 4: Identify presence of any pulsations that feel like a vibratory sensation.       

Tip: Place your fingertips over your trachea and stick your tongue out and say “ahhh.” The vibrations that you feel on your fingertips are similar to what a thrill feels like on the chest wall.

• Healthy blood flow does not produce a vibratory sensation.
• The presence of any vibratory sensations is abnormal; turbulent blood flow can create a vibratory sensation (typically referred to as a thrill) felt on the chest wall. If you feel a thrill, you should auscultate for a murmur and expect other subjective findings associated with an incompetent valve (not opening and closing correctly). You should conduct a full cardiac and vital sign assessment and notify the physician/nurse practitioner.

Step 5: Note the findings.

• Normal findings might be documented as: “Absence of vibratory sensations.”
• Abnormal findings might be documented (example): “Thrill palpated at second intercostal space left sternal border.”

Video 7: Palpation of precordium.

Palpation of Apical Impulse 

Palpation of the apical pulse provides information about the location and the workload of the heart. You are specifically palpating for a physical pulsation over the apex of the heart. This involves the following steps (Video 8):

Step 1: Maintain the client in a supine position and continue to drape.

Step 2: Physically landmark the expected location of the apex. In adults, this is the fifth intercostal space at the left midclavicular line or just midline to the midclavicular line; in children, it is the fourth intercostal space at the left midclavicular line.

Step 3: Place the finger pad of your index finger at this location in the intercostal space. Use the finger pad (not the fingertip) because it is more sensitive to pulsations. Thus, you will need to keep your hand/wrist/forearm low so that your hand/wrist/forearm are parallel to the client’s chest.

Step 4: Ask the client to hold their breath after taking a large breath in and out. You should feel the pulsation quite quickly if it is palpable.

Step 5: If you do not feel a pulsation, help the client into a left lateral position. This positioning rotates the apex of the heart and accentuates the impulse against the chest wall. Usually, you can leave your finger in place when re-positioning the client.

Step 5: Note the findings.

• Normal findings might be documented as: “Gentle tap of apical impulse, short duration, one smooth pulsation, 1–2 cm² at apex.” Also note that it is normal not to feel an apical impulse in many clients as well. In this case, note “No apical impulse felt after re-positioning client in left lateral position.”
• Abnormal findings might be documented as: “Double systolic impulse lateral to left midclavicular line with sustained forceful thrust lasting throughout systole.” (This is just one example of an abnormal finding.)

Video 8: Palpation of apical impulse (NOTE: Not clearly seen in the video, ensure that you place your index finger at the left mid-clavicular line).