COLLEGE OF NURSING AND ALLIED HEALTH PROFESSIONS

NHA-HEALTH ASSESSMENT
SKILLS LABORATORY

PERFORMANCE EVALUATION TOOL

PROCEDURE:
ASSESSING HEART AND NECK MUSCLE

NAME OF STUDENT:______________________________________ Score:

Block :______ Date:______________

NO. PROCEDURE ABLE TO UNABLE REMARKS

PERFORM TO
PERFORM
1 To identify significant factors that can influence cardiovascular
health such as high blood cholesterol, cigarette use, diabetes,
or hypertension.

2 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
“Good morning ma’am/sir, I am ______, a student nurse from
GSC and I will take care of you from (Shift). For safety
purposes may I hold your hand as I check your ID band. I am
here to (Explain the procedure)
3 Close the curtains around the bed and close the door to the
room, if possible.
4 Perform hand hygiene and observe other appropriate
infection-prevention procedures
5 A heart examination is usually performed while the client is in
a semi-reclined position. The practitioner usually stands at
the client’s right side and auscultates and palpates with the
right hand, but this may be reversed if the nurse is left-handed.
6 HEART
Inspect for any pulsations on the anterior chest over the heart
Palpate for any pulsations or the apical impulse
Auscultate the heart rate and rhythm
Normal Findings
• -visible on the mitral area (LMCL, 4th or 5th ICS)
• -Aortic area- no pulsation
• -Pulmonic area- no pulsation
• -Apical area- pulsation is palpable
• -Epigastric- not palpable
• Auscultation
• -Two heart sounds are audible in all areas but loudest
at the apical area.
• -CR: 75
• -No murmur, thrill and heave
7 JUGULAR VEINS
Inspect the jugular veins for distention while the client is placed
in the semi-Fowler’s position (15° to 45° angle), with the head
supported on a small pillow.

ALDC-2024
 COLLEGE OF NURSING AND ALLIED HEALTH PROFESSIONS
8 If jugular distention is present, assess the jugular venous
pressure (JVP).
9 Locate the highest visible point of distention of the internal
jugular vein. Although either the internal or the external jugular
vein can be used, the internal jugular vein is more reliable
10 Measure the vertical height of this point in centimeters from the
sternal angle, the point at which the clavicles meet. Repeat the
preceding steps on the other side
11 Document findings in the client record

● The following rating scale shall be used in grading student’s performance:

ABLE TO PERFORM
Perform the procedure safely and accurately consistently and independently without supportive
assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on the client while giving care
UNABLE TO PERFORM
Unable to perform the procedure even under close supervision of guidance
Require continuous, supportive, and directive cues
Takes a longer time to complete the procedure.
Performs in an unskilled manner
REMARKS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

EXPECTED LEVEL OF PERFORMANCE:

7 to 11 items done: PASSED

6 items below done: REPEAT DEMONSTRATION

Student’s Signature:_______________
Date:__________

Instructor’ Signature:________________
Date:__________

ALDC-2024