The University of Jordan
Faculty of Nursing
Evaluation Form
Day/Date: ……………………............
Student Name: ……………………………………..
Section: ……………….……………...
Course Name: ………………………………………
Evaluator Name:…………………….
Instructor Name: …………………………………..
Procedure: Assessment: Neck and Heart.
Task
1. Performed hand hygiene.
2. Verified the correct patient using
two identifiers.
3. Ensured that the examination area
was adequately lighted, quiet,
private, and sufficiently warm.
4. Assessing the Neck Vessels
Had the patient remain in a
sitting position.
5. Inspected neck on both sides for
obvious artery pulsations.
6. To assess jugular venous
pressure, had the patient assume a
supine position and then raised
the head of the bed 45 degrees.
a. Located the highest point along
the internal jugular vein where a
pulsation could be seen
b. Located the sternal angle with a
centimeter ruler and measured
the vertical distance between the
sternal angle and the meniscus
of the internal jugular vein.
7. Assisted the patient to a semiFowler or supine position that
was as relaxed and comfortable as
possible.
8. Assessing the Heart
Formed a mental image of the
Score
Student
Score
Comments
exact location of the heart.
9. Found the angle of Louis at the
manubriosternal junction. Slipped
fingers down each side of angle to
feel adjacent ribs.
10. Found the following anatomic
landmarks:
The aortic area
The pulmonic area
The second pulmonic area
The tricuspid area
The mitral area
The epigastric area
11. Stand to the patient's right,
inspect and the precordium.
Noted any visible pulsations at
point of maximum impulse
(PMI).
12. Inspect for pulsations at all
anatomic landmarks. Note no
other pulsation. (heave if visible
pulsation)
13. Inspected the epigastric area and
palpated the abdominal aorta.
Noted a localized strong beat.
14. Palpate the PMI with fingertips
along the 4th or 5th intercostal
space (ICS) in the midclavicular
line (MCL). Noted a soft, short,
and gentle tap pulsation at the
apex. If difficult to feel, turned
the patient onto the left side.
15. Palpate Across precordium using
the palmar aspect of the fingers or
ulnar side, gently palpate the apex,
the left sterna border, and the base,
searching for other pulsation
(thrill).Note no pulse
16. Percussion to outlines the heart
borders.
a. Place the stationary finger in the
5th ICS over on the left side of the
chest near the anterior axillary
line (AAL). Slide the stationary
hand, while percussing as note the
change of the sound from
resonance to dull.
b. Then percuss upward to the 2nd
ICS, move toward left sterna
border and percuss the right
sterna border.
17. Auscultated heart sounds. Began
by having the patient sit up and
lean slightly forward; then
flowers. Ended the examination
with the patient in a left lateral
recumbent position.
18. Auscultate sounds at each
anatomic landmark, asked the
patient not to speak but to breathe
comfortably. Began with the
diaphragm of the stethoscope and
then alternated with the bell.
Inched the stethoscope in a rough
Z pattern
19. Began at the PMI medially to the
left sternal border, superiorly to
the 2nd ICS, then across the
sternum to the 2nd ICS at the right
sternal border.
Or
Began at the right 2nd ICS close to
the sternum, move along the left
sternal border in each intercostal
space from the 2nd through the 5th,
and then to the apex.
20. Assess apical pulse rate, rhythm,
and volume
21. Assessing pulse deficit by
auscultating the apical pulse,
while palpating the radial pulse. If
irregular heart rate.
22. Performed hand hygiene.
23. Documented the findings in the
patient's record.