Respiratory Cardiovascular Assessment Script

Perform Hand Hygiene

Putting Routine

Explain procedure

Inspect anterior chest

Verbalize: No visible abnormalities

Breathing even and unlabored

Pt denies respiratory distress

Auscultate

12 spots on the front

Verbalize: Lung sounds even, regular and clear bilaterally

Auscultate respiratory rate

Listen for 1 minute or 30 secs x2 if respirations are even and regular

Verbalize: rate bpm

Palpate Cap refill

Press a nail on each hand

Verbalize: Cap refill is less than 3 secs bilaterally

Inspect posterior chest

Verbalize No visible abnormalities

Breathing even and unlabored

Inspect thoracic chest expansion

Place hands with thumbs touching below the costal vertebral angle

Verbalize: Expansion is equal bilaterally

Auscultate posterior chest

10 spots on the back

Verbalize: Lungs sounds even, regular and clear bilaterally

Auscultate heart sounds

 Aortic - Right sternal border 2nd intercostal space

Pulmonic – Left sternal border 2nd intercostal space

Erb’s point – Left sternal border 3rd intercotal space

Tricuspid – Left sternal border 5th intercostal space

Mitral (Apex, PMI) – 5th intercostal space midclavicular line.

Verbalize: Heart sounds regular and even. S1 and S2 clearly heard . No adventitious
sounds noted.

Palpate apical pulse

Mitral – 5th intercostal space midclavicular line

Verbalize: pulse is palpable, regular and even.

Inspect jugular vein

Verbalize: Within normal limits. No distention noted.

Palpate: carotid pulse (one at a time)

brachial pulses

Radial pulses

Take radial heart rate

Verbalize: heart rate bpm

verbalize femoral pulses

popliteal pulses

posterior tibialis

dorsalis pedis

Verbalize: Pulses present, 3+, regular and even bilaterally.

Palpate cap refill of feet

Press a nail on each foot

Verbalize: Cap refill less than 3 secs bilaterally