25
Comments
Excellent
Satisfactory
Needs practice
Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
skill 2-6
Assessing the cardiovascular system
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
Goal:
The assessment is completed accurately and without
causing the patient to experience anxiety or discomfort, the
findings are documented and the appropriate referral is made to
other healthcare professionals, as needed, for further evaluation.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
stethoscope, alcohol wipes.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), if indicated.
8. Ensure patient privacy is maintained and that
interruptions are minimal. Ensure adequate lighting and
a quiet environment in order to hear during auscultation.
9. Undertake a health history, as per Skill 2-1.
10. Help the patient to undress, if needed, and provide a
patient gown. Assist the patient to a supine position
with the head elevated about 30–45 degrees and expose
the anterior chest. Use a blanket or drape to cover any
exposed area other than the one being assessed.
11. Inspect and palpate the left and then the right carotid
arteries.
Palpate one carotid artery at a time.
Use the
bell of the stethoscope to auscultate the arteries.
12. Inspect the neck for jugular vein distension, observing for
pulsations.
13. Inspect the praecordium
for contour, pulsations and
heaves. Observe for the apical impulse at the fourth to
fifth intercostals spaces (ICS).
14. Using the palmar surface with four fingers held together,
palpate the praecordium gently for pulsations. Remember
that your hands should be warm. Palpation proceeds in
a systematic manner, with assessment of specific cardiac
landmarks: the aortic, pulmonic, tricuspid and mitral
areas and Erb’s point. Palpate the apical impulse in the
mitral area. Note its size, duration, force and location in
relationship to the midclavicular line.
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