Checklists for Clinical Nursing Skills

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Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

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.

Comments

Excellent

Satisfactory

Needs practice

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