PREPARATIONS
PERFORMED
YES
1. Assemble equipment:
● Stethoscope
● Centimeter ruler
PROCEDURE
1. Introduce yourself, and
verify the client’s identity.
Explain to the client what
you are going to do, why it
is necessary, and how the
client can cooperate.
2. Perform hand hygiene, and
observe other appropriate
infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any
history of the following:
● Family history of
incidence and age of
heart disease, high
cholesterol levels, high
blood pressure, stroke,
obesity, congenital
heart disease, arterial
disease, hypertension
and rheumatic fever.
● Client’s past history of
rheumatic fever, heart
murmur, heart attack,
varicosities or heart
failure.
● Present symptoms
indicative of heart
disease.
● Presence of disease
that affect the heart.
NO
SCORES
COMMENTS
50
●
Lifestyle habits that are
risk factors for cardiac
disease
ASSESSMENT
5. Simultaneously inspect
and palpate the
precordium for the
presence of abnormal
pulsation, lifts or heaves.
Inspect and palpate the aortic and
pulmonic areas, observing them at
an angle and to the side, to note
the presence or absence of
pulsation.
Inspect and palpate the tricuspid
area of pulsation and heaves or
lifts.
Inspect and palpate the apical area
for pulsation, noting its specific
location (it may be displaced
laterally or lower) and diameter. If
displaced laterally, record the
distance between the apex and the
MCL in centimeters.
Inspect and palpate the epigastric
area at the base of the sternum for
abdominal aortic pulsations.
6. Auscultate the heart in all
four anatomic sites: aortic,
pulmonic, tricuspid and
apical (mitral)
CAROTID ARTERIES
7. Palpate the carotid artery.
8. Auscultate the carotid
artery
JUGULAR VEINS
9. Inspect the jugular veins
for distention.
The client is placed in a semi
-fowler’s position, with the head
supported on small pillows.
10. If jugular distention is
present, assess the jugular
venous pressure.
Locate the highest visible point in
centimeters from the sternal angle,
the point at which the clavicles
meet.
Repeat the steps above on the
other side.
11. Document findings in the
client record
TOTAL SCORE=