Christian University of Thailand

College of Nursing
INUR3302: Nursing Process and Basic Health Assessment

Performing Cardiovascular System Assessment


1. ID No. .... Name. Score ...


2 = Performed satisfactorily 1 = Needs practice 0 = No Performance


Procedure Rationale Evaluation
1. Identify the patient. Identification of the patient
ensures that the assessment will be
performed on the right patient.

2. Explain the purpose of the
cardiovascular
examination and answer
any questions.
Explanation helps to alleviate
anxiety, promotes cooperation,and
facilitates the examination.

3. Perform hand hygiene. Hand hygiene deters the risk of
microorganism transmission.


4. Assist the patient to a
supine position with the
head elevated about 30 to
45 degrees and expose
anterior chest.
Having the patient wear a gown
facilitates examination of the
chest. Provide privacy when
exposing the chest of the female
patient.

5. Inspect and palpate the left
and the right carotid
arteries. Only palpate one
carotid artery at a time.
Use the bell of the
stethoscope to auscultate
the arteries.
Palpation of this area evaluates
circulation through the arteries.
Palpating both arteries at once
can obstruct blood flow to the
brain. Auscultation can detect a
bruit.

6. Inspect the neck for
jugular distention,
observing for pulsations.
This technique helps to detect
pulsations.There are normally no
pulsations, except for a slight
apical impulse.

7. Inspect the precordium for
contour, pulsations, and
heaves. Observe for the
apical impulse at the 4
th
to
5
th
intercostal spaces
(ICS).
Precordium inspection helps
detect pulsations. There are
normally no pulsations, except for
a slight apical impulse.







8. Using the palmar surface
of your fingers held
together, palpate the
precordium gently for
pulsations. Remember the
hands should be warm.
Palpation proceeds in a
systematic manner, with
assessment of specific
cardiac landmarksthe
aortic, pulmonic,
tricuspid, and mitral areas
and Erbs point. Palpate
the apical impulse in the
mitral area. Note size
duration, force,and
location in relationship to
the midclavicular line.
This helps identify any precordial
thrills, which are fine, palpable,
rushing vibrations over the right
or left second intercostal space,
and any lifts or heaves, which
involve a rise along the border of
the sternum with each heartbeat.
Normal findings include no
pulsation palpable over the aortic
and pulmonic areas, with a
palpablr apical impulse.




9. Use systematic
auscultation, beginning at
the aortic area, moving to
the pulmonic area, then to
Erbs point, then to the
tricuspid area, and finally
to the mitral area. Ask the
patient to breathe
normally. The stethoscope
diaphragm is first used to
listen to high-pitched
sounds. Focus on the over-
all rate and rhythm of the
heart and the normal heart
sounds.
Auscultation evaluates heart rate
and rhythm and assesses for
normal sounds. The normal heart
sounds are generated by the
closing of the valves ( aortic,
pulmonic, tricuspid, mitral).

10. Replace the patients
gown and assist the patient
to a comfortable position.
This ensures the patients comfort.
11. Perform hand hygiene. This deters the spread of
microorganisms.

12. Document findings and
the procedure done.
Documentation prevents clinical
errors during the practice.



Recommendations: ..


Instructor..
././.