Skill: Assessing the Heart and Central Vessels

Performed
Preparation Yes No Mastered Comments
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 diseases that affect
heart
• Lifestyle habits that are risk
factors for cardiac disease
Assessment
5. Simultaneously inspect and palpate
the precordium for the presence of
abnormal pulsations, 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 pulsations.
Inspect and palpate the tricuspid area
for pulsations 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.
Use extreme caution.
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 head
supported on a small pillow.
10. If jugular distention is present,
assess the jugular venous pressure
(JVP).
Locate the highest visible point of
distention of the internal jugular vein.
Measure the vertical height of this
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.