NAME: DATE:

CN: C.I.:
Scoring: 1- Excellent 2- Very Good 3- Satisfactory 4- Needs Improvement 5- Failed
100=1.00 95=1.30 90=1.75 85=2.20 80=2.60 75=3.00 70=3.40 65=3.80 60=4.25 55=4.70
99=1.00 94=1.40 89=1.80 84=2.25 79=2.70 74=3.10 69=3.50 64=3.90 59=4.30 54=4.75
98=1.10 93=1.50 88=1.90 83=2.30 78=2.75 73=3.20 68=3.60 63=4.00 58=4.40 53=4.80
97=1.20 92=1.60 87=2.00 82=2.40 77=2.80 72=3.25 67=3.70 62=4.10 57=4.50 52=4.90
96=1.25 91=1.70 86=2.10 81=2.50 76=2.90 71=3.30 66=3.75 61=4.20 56=4.60 51=5.00

ASSESSING THE RESPIRATORY SYSTEM

CHECKLIST 1 2 3 4 5
1. Gather all equipment.
• Examination gown and drape
• Gloves
• Stethoscope
• Light source
• Mask
• Skin marker
• Metric ruler
2. Perform Hand hygiene and explain procedure to patient
3. Provide privacy and expose only the part to be examined.
INSPECTION
4. Anterior/Posterior/Lateral. Compare side to side. Work apex to
base
5. Assess respiratory rate and rhythm, depth, symmetry for chest
movement
6. Assess AP ratio, costal angle, spinal deformities muscles for
breathing and condition of skin
PALPATION
7. Anterior/Posterior/Lateral. Compare side to side. Work apex to
base
8. Palpate the trachea.
9. Palpate chest for tenderness and sensation.
10. Palpate the chest for crepitus and other abnormalities.
Crepitus- Use your fingers and follow the appropriate
sequence when palpating. Note if there is a crackling sensation
(like bones or hairs rubbing against each other) as you palpate.
11. Assess for tactile fremitus. Use the ball or ulnar edge of one
hand to assess for fremitus. As you move your hand to each
area, ask the client to say “ninety-nine.” Assess all areas for
symmetry and intensity of vibration.
12. Assess for chest expansion. Place your hands on the posterior
chest wall with your thumbs at the level of T9 or T10 and
pressing together a small skin fold. As the client takes a deep
breath, observe the movement of your thumbs
PERCUSSION
13. Percuss Anterior/Posterior/Lateral portion of chest.
14. Note general percussion sound of chest.
15. Percuss for diaphragmatic chest excursion.
• Ask the client to exhale forcefully and hold the
breath. Beginning at the scapular line (T7), percuss
the intercostal spaces of the right posterior chest
wall.
• Percuss downward until the tone changes from
resonance to dullness. Mark this level and allow the
client to breathe.
• Next ask the client to inhale deeply and hold it.
Percuss the intercostal spaces from the mark
downward until resonance changes to dullness.

Revised: January 2020

NAME: DATE:
CN: C.I.:
Scoring: 1- Excellent 2- Very Good 3- Satisfactory 4- Needs Improvement 5- Failed
100=1.00 95=1.30 90=1.75 85=2.20 80=2.60 75=3.00 70=3.40 65=3.80 60=4.25 55=4.70
99=1.00 94=1.40 89=1.80 84=2.25 79=2.70 74=3.10 69=3.50 64=3.90 59=4.30 54=4.75
98=1.10 93=1.50 88=1.90 83=2.30 78=2.75 73=3.20 68=3.60 63=4.00 58=4.40 53=4.80
97=1.20 92=1.60 87=2.00 82=2.40 77=2.80 72=3.25 67=3.70 62=4.10 57=4.50 52=4.90
96=1.25 91=1.70 86=2.10 81=2.50 76=2.90 71=3.30 66=3.75 61=4.20 56=4.60 51=5.00

• Mark the level and allow the client to breathe.

Measure the distance between the two marks.
AUSCULTATION
16. Use diaphragm of stethoscope. Have patient take slow, deep
breaths through mouth.
17. Assess Anterior/Posterior/Lateral. Compare side to side, apex
to base.
18. Assess breath sounds (bronchial, bronchovesicular, vesicular)
• Bronchial- heard over the trachea and thorax.
• Bronchovesicular- heard over the major bronchi—
posterior: between the scapulae; anterior: around the
upper sternum in the first and second intercostal spaces.
• Vesicular- heard over the peripheral lung fields.
19. Assess for voice sounds.
• Bronchophony: Ask the client to repeat the phrase
“ninety-nine” while you auscultate the chest wall.
• Egophony: Ask the client to repeat the letter “E” while
you listen over the chest wall.
• Whispered pectoriloquy: Ask the client to whisper the
phrase “one–two–three” while you auscultate the chest
wall.
20. After the assessment, make the patient comfortable and
perform hand hygiene. Do after care.
21. Document the data.

TOTAL SCORE = ______ = ______ %

21

Revised: January 2020

NAME: DATE:
CN: C.I.:
Scoring: 1- Excellent 2- Very Good 3- Satisfactory 4- Needs Improvement 5- Failed
100=1.00 95=1.30 90=1.75 85=2.20 80=2.60 75=3.00 70=3.40 65=3.80 60=4.25 55=4.70
99=1.00 94=1.40 89=1.80 84=2.25 79=2.70 74=3.10 69=3.50 64=3.90 59=4.30 54=4.75
98=1.10 93=1.50 88=1.90 83=2.30 78=2.75 73=3.20 68=3.60 63=4.00 58=4.40 53=4.80
97=1.20 92=1.60 87=2.00 82=2.40 77=2.80 72=3.25 67=3.70 62=4.10 57=4.50 52=4.90
96=1.25 91=1.70 86=2.10 81=2.50 76=2.90 71=3.30 66=3.75 61=4.20 56=4.60 51=5.00

ASSESSING THE CARDIOVASCULAR SYSTEM

CHECKLIST 1 2 3 4 5
1. Assemble equipment
2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may
remain in place.
3. Introduce yourself, and verify the client’s identity. Explain to the procedure to the
client and how the client can cooperate.
4. Perform hand hygiene, and observe other appropriate infection control procedures.
Provide for client privacy.
5. 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, 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 the heart
- Lifestyle habits that are risk factors for cardiac disease
NECK VESSELS
INSPECTION
6. Inspect the jugular veins for distention. The client is placed in a semi-Fowler’s
position, with the head supported on a small pillow.
7. If jugular vein 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.
AUSCULTATION
8. Auscultate the carotid arteries.
- Always auscultate the carotid artery first before palpating because palpation
may increase or slow the heart rate, changing the strength of the carotid impulse
heard
- Place the bell of the stethoscope over the carotid artery and ask the client to
hold his or her breath for a moment so that breath sounds do not conceal any
vascular sounds.
- Auscultate for bruit.
PALPATION
9. If occlusion is detected during auscultation, palpate very lightly to avoid blocking
circulation or triggering vagal stimulation and bradycardia, hypotension, or even
cardiac arrest.
10. Palpate the carotid arteries.
- Palpate each carotid artery alternately.
- Bilateral palpation could result in reduced cerebral blood low.
- Place the pads of the index and middle fingers medial to the
sternocleidomastoid muscle on the neck.
- Note amplitude and contour of the pulse, elasticity of the artery, and any thrills.

Revised: January 2020

NAME: DATE:
CN: C.I.:
Scoring: 1- Excellent 2- Very Good 3- Satisfactory 4- Needs Improvement 5- Failed
100=1.00 95=1.30 90=1.75 85=2.20 80=2.60 75=3.00 70=3.40 65=3.80 60=4.25 55=4.70
99=1.00 94=1.40 89=1.80 84=2.25 79=2.70 74=3.10 69=3.50 64=3.90 59=4.30 54=4.75
98=1.10 93=1.50 88=1.90 83=2.30 78=2.75 73=3.20 68=3.60 63=4.00 58=4.40 53=4.80
97=1.20 92=1.60 87=2.00 82=2.40 77=2.80 72=3.25 67=3.70 62=4.10 57=4.50 52=4.90
96=1.25 91=1.70 86=2.10 81=2.50 76=2.90 71=3.30 66=3.75 61=4.20 56=4.60 51=5.00

HEART (PRECORDIUM)
INSPECTION
11. Inspect the aortic and pulmonic areas, observing them at an angle and to the side, to
note the presence or absence of pulsations
12. Inspect for Apical Impulse.
- This represents the brief early pulsation of the left ventricle as it moves
anteriorly during contraction and through the chest wall located at 4 th or 5th
intercostal Space (ICS).
- If displaced laterally, record distance between the apex and the MCL in
centimeters
13. Inspect epigastric area at the base of the sternum for abdominal aortic pulsations
PALPATION
14. Palpate the aortic and pulmonic areas, observing them at an angle and to the side, to
note the presence or absence of pulsations
15. Palpate Apical Impulse. You may ask the client to roll to the left side to better feel the
impulse using palmar surfaces of the hand.
16. Palpate epigastric area at the base of the sternum for abdominal aortic pulsations.
PERCUSSION
17. Percussion estimates cardiac border.
- Determine size and location of heart, note displacement or enlargement.
- There should be dullness at 3rd, 4th and 5th ICS to the left sternum at left mid-
clavicular line.
- Begin at the anterior axillary line and percuss to the sternum at the 5 th ICS.
- There should be a change of sound from resonance to dullness as you reach the
left sternal border of the heart.
AUSCULTATION
18. Auscultate for S1, S2, S3, S4 and murmurs.
19. Auscultate from apex to base; mitral, tricuspid, Erb’s point, pulmonic and aortic areas,
noting for murmurs, rate, rhythm, pitch and intensity, duration, timing, quality and
location.
LOCATION:
• Aortic area: Second ICS at the right sternal border—the base of the heart
• Pulmonic area: Second or third ICS at the left sternal border—the base of the
heart
• Erb point: Third ICS at the left sternal border
• Mitral (apical): Fifth ICS near the left MCL—the apex of the heart
• Tricuspid area: Fourth or fifth ICS at the left lower sternal border
20. After the assessment, make the patient comfortable. Perform hand hygiene and do
after care.
21. Document findings in the client record.

TOTAL SCORE = ______ = ______ %

21

Revised: January 2020