ASSESSMENT OF THE CARDIOVASCULAR

PERFORMANCE SKILLS SCORE REMARKS

1. Explains the procedure.
2. Positions the patient supine
with head of the bed slightly
elevated.
PRECORDIUM
3. Inspects precordium for
pulsations.
In continuation of your assessment, I’ll be
assessing your cardiovascular status
through inspecting, palpating and
auscultating some parts of your chest, I’ll
be using some instruments and I’ll be
touching some parts of your body. Is that
all right with you?
Position client (low fowler’s)
Inspect – Pen light
No pulsations observed on the aortic,
pulmonic, and tricuspid area

Slight pulsation is observed in the mitral

area

Or no pulsation observed in all areas

*** Reports accurate findings
4. Identifies and palpates the
different cardiac regions:
a. Aortic Palpate (finger pads(pulsations),
b. Pulmonic palm(thrills), base of palm (heaves))
c. Tricuspid
d. Mitral No pulsations, thrills, or heaves on the
aortic, pulmonic, and tricuspid area.
AORTIC-
PULMONIC (2nd ICS)- Slight pulsation in the mitral area
RICUSPID (4th ICS)-
MIDCLAVI (5th ICS) Or no pulsations palpated on all of the areas

*** Reports accurate findings

5. Locates PMI Point of Maximal Impulse is located on the
5th ICS left midclavicular line

6. Auscultates:
a. Aortic Auscultate
b. Pulmonic
Diaphragm AORTIC-PULMONIC (2nd S1 and s2 sound is appreciated (base).
ICS)-RICUSPID (4th ICS)- However, s2 sound is much louder than the
MIDCLAVI (5th ICS)- Bell ERB’S
s1 sound in the Aortic and Pulmonic Area
(between Pulmonic and Tricuspid)

c. Tricuspid For the Tricuspid and Mitral Area (apex), S1

d. Mitral and s2 sound is heard. However, s1 is heard
louder in the area

e. Erb’s point For the Erb’s point: No abnormal heart

sound, particularly murmurs. S1 and s2
sound is audible in the area.
 PERFORMANCE SKILLS
*** Reports accurate findings
VASCULATURE
7. Assesses bruit
a. Temporal artery
b. Thyroid Artery
c. Abdominal Artery
8. Measures for jugular venous
distention
*** Reports accurate findings
TOTAL SCORE (21)
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ASSESSMENT OF THE BREAST AND AXILLA
PERFORMANCE SKILLS
8. Explains the procedure.
9. Inspects each breast in the
following positions:
a. Client’s hands are resting
on her side
b. Hands above the head /
raise overhead
c. Hands pressed into hips
d. Bend forward
Notes for the following:
i. Size
ii. Symmetry
iii. Color
iv. Contour
*** Reports accurate findings
10.Inspects the areola.
11.Inspects the nipples.
12.Inspects the axilla
SCORE REMARKS
Position patient, 30-45°
No bruit noted on all of the arteries
Measure (ruler)
Jugular vein measures to ______*3-6 cm
That’s all for this assessment, thank you for
participating ma’am
SCORE REMARKS
In continuation of your assessment, I’ll be
assessing your breast and axilla, and I’ll
be palpating and inspecting your breast. If
you feel uncomfortable during the
procedure, you just tell me. Is that all
right with you po ma’am?
Kindly please change into this gown
Upon assessment:
Inspect
ARMS ON THE SIDE
HANDS RAISED OVERHEAD
HANDS IN THE HIPS, PRESS IT OVER THEN
DOWN
BEND FORWARD
Breasts are appropriate for age and
developmental stage, both breasts are
symmetrical, no swelling, no tenderness
No discoloration and convex in contour
Smooth with no edema noted
Inspect
For the areola: No lesions, swelling or
discharges noted. Color is darker from the
skin of the breast
Nipples are protruding outward, no
swelling, no discharges, no lesions, and
 PERFORMANCE SKILLS SCORE REMARKS
has the same color of the areola

Axilla’s color is same of the skin color,

covered with slight fine coarse hair, no
swelling, no tenderness, and no
discoloration noted.

No rash/ infection noted

*** Reports accurate findings
on the areola, nipples, and
axilla
13.Identifies and palpates for the
lymph nodes
a. Brachial Palpate (RIGHT AND LEFT)
b. Central axillary Lymph nodes in the axillary area are
(midaxillary) nontender, no swelling, no complaints of
c. Pectoral (anterior) pain upon palpation
d. Subscapular (posterior)
There is discrete, nontender,
movable less than 1cm nodes in the
central area.
14.Positions patient correctly.
15.Drapes patient Cover side of breast that is not assessed
appropriately.

PROVIDE COMFORT
16.Palpates the breast Palpate (ASK PATIENT TO RAISE HAND
appropriately (perform breast OVER THE HEAD)
self-examination)
Upon palpation of the both breasts, there
was no palpable mass, no complaints of
pain during palpation, no tenderness and
there are no discharges from the nipples.

That’s all for this assessment, thank you

for participating, you can now change
back into your clothes ma’am
*** Reports accurate findings
TOTAL SCORE (22)