Republic of the Philippines

PALAWAN STATE UNIVERSITY

COLLEGE OF NURSING AND HEALTH SCIENCES

PERFORMANCE CHECKLIST
Assessment of the Heart, Neck Vessels, and Abdomen
Name Score /52
Year and Block Date

DIRECTIONS:
While the student performs the procedure, the Clinical Instructor (CI) must evaluate the student
using the following parameters:
Qualitative Point
Definition
description system
Meets expectations, possess full depth and breadth of
Done 2 points skill knowledge, performs skill completely and with
confidence.
Requires assistance/reminder from CI, or
does not meet expectations, or
Needs
1 points possess limited depth and breadth of skill knowledge,
improvement
or
performs skill incomplete and/or without confidence
Step was not performed, even with CI’s reminder
Not done 0 point
and/or assistance.

ASSESSMENT D NI ND REMARKS
1. Prepare the equipment:
• Stethoscope with bell and diaphragm
• Small pillow
• Penlight
• Watch with second hand
• 2 centimeter rulers
2. Explain the purpose of the examination of the heart, neck
vessels and abdomen and what you are going to do.
• Answer any questions
3. Perform hand hygiene and put on PPE if indicated
4. Help the patient undress, if needed, and provide a patient
gown.
• Assist the patient to a supine position with the head
elevated about 30 to 45 degrees and expose the anterior
chest.
• Use the bath blanket to cover any exposed area other than
the one being assessed
Heart and Neck Vessels
5. Inspect the neck for jugular vein distention, observing for
pulsations.
6. Evaluate jugular venous pressure.
7. The auscultate and palpate the carotid arteries.
8. Inspect the precordium for contour, pulsations, and heaves.
• Observe for the apical impulse at the fourth to fifth
intercostals spaces (ICS).

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 ASSESSMENT D NI ND REMARKS
9. Use the palmar surface with the four fingers held together
and palpate the precordium gently for pulsations.
• Remember that 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 size, duration, force, and location in relationship to the
midclavicular line.
10. Use systematic auscultation, beginning at the aortic area,
moving to the pulmonic area, then to Erb’s point, then to the
tricuspid area, and finally to the mitral area.
• Ask the patient to breathe normally.
• The stethoscope diaphragm is first used to listen to high-
pitched sounds, followed by use of the bell to listen to low-
pitched sounds.
• Focus on the overall rate and rhythm of the heart and the
normal heart sounds.
Abdomen
11. Assist the patient to a supine position and expose the
abdomen.
• Use the bath blanket to cover any exposed area other than
the one being assessed.
12. Inspect the abdomen for skin color, contour, pulsations, the
umbilicus, and other surface characteristics (rashes, lesions,
masses, scars)
13. Auscultate all four quadrants of the abdomen for bowel
sounds by using the diaphragm of the stethoscope. • Use a
systematic method
14. Auscultate the abdomen for vascular sounds by using the
bell of the stethoscope
15. Percuss the abdomen for tones.
16. Percuss the span or height of the liver by determining its
lower and upper borders.
17. Palpate the abdomen lightly in all four quadrants and then
palpate using deep palpation technique.
• If the patient complains of pain or discomfort in a particular
area of the abdomen, palpate that area last
18. Deeply palpate all quadrants to delineate abdominal organs
and detect subtle masses.
• Using the palmar surface of the fingers, compress to a
maximum depth (5–6 cm).
• Perform bimanual palpation if you encounter resistance
or to assess deeper structures
19. Palpate for the kidneys on each side of the abdomen.
• Palpate the liver at the right costal border.
• Palpate for the spleen at the left costal border.
20. Test for shifting dullness and fluid wave test.
21. Assess for rebound tenderness over appendix area
(Blumberg’s Sign)
• If the client has abdominal pain or tenderness, test for
rebound tenderness by palpating deeply at 90 degrees
into the abdomen in the RLQ. Then suddenly release
pressure.
• Test for referred rebound tenderness (Rovsing’s sign).
Palpate deeply in the LLQ and quickly release pressure.
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 ASSESSMENT D NI ND REMARKS
22. Assess for Psoas sign by hyper-extending the right leg of the
client.
23. Assess for obturator sign by flexing the hip and knee, and
rotating the leg internally and externally.
24. Assess for Murphy’s sign.
25. Assist the patient in replacing the gown.
• Remove PPE, if used.
• Perform hand hygiene.
26. Document the findings, and report any abnormal ones in to
the Attending Physician
SUB TOTAL:
TOTAL: Highest possible
score: 52

Evaluated by:

(CI’s signature over printed name)

Date:

Conformed by (must be signed after RD):

(Student’s signature over printed name)

Date: