Name : Theresia Ine Diaz

NRP : 9103020022

INSPECTION ON CARDIOVASCULAR SYSTEM

Purpose of inspection:
1. Knowing abnormal heart rate
2. Knowing the size and shape of the heart roughly
3. Knowing normal and abnormal heart sounds
4. Detect cardiovascular disorders

Procedure of action

COMPETENCE
No. ASSESSMENT COMPONENTS
4 3 2 1 0
A SKILL
TOOLS PREPARATION
1. Stethoscope
2. Small flashlight
NURSE AND ENVIRONMENT
PREPARATION:
3. Identify the client and his situation
4. Explain the action to be taken and
the goal to the client
5. Advise the client to stay relaxed/relaxed
5. Maintain client privacy during examination
ACTION PROCEDURE
A. INSPECTION and PALPATION
1. Position the client supine with the examiner on
the client's right
2. localization in the chest, first with palpate the
angle of Louis or the angle of the sternum a
palpable, flat, elongated bulge on the sternum ±5
cm below the sternal notch
3. Move the fingers along the corners on each side
 of the sternum to feel the 2nd rib close by
4. Palpate the right 2nd intercostal space for
determine the aortic area and the 2nd intercostal
space left for pulmonary area
5. Inspect and then palpate the area of the aorta and
the pulmonary to determine the presence or
absence of pulsation
6. Observe the left 5th intercostal space for
Identify the tricuspid/ventricular area. Observe
presence of pulsation
7. From the tricuspid area, move your hands lateral
5-7 cm to the left midclavicular line for
determine the apical area or point of maximal
pulse
B. PERCUSSION
1. Performed to determine the limits of the
heart,help client in lying position
2. Place the middle finger of the non-dominant
hand examiner at ICS 5 on the left anterior
axillary line.
3. Finger tapping on the distal phalanx with Use
the fingers of the dominant hand. Examiner have
to listen to the resonance because the examiner
above the lung tissue
4. Continue percussion at ICS 5 above the
midclavicular left and left sternal border. The
sound will change becomes "dullnes" on
percussion over the heart
5. Repeat the percussion technique over ICS 3 and
2 on the side left thorax. Resonant sound of the
heart above the lungs turns into "dullnes" above
the heart
C. AUSCULTATION
1. Instruct the client to breathe normally
2. Auscultate the client's chest with a stethoscope
diaphragm:
1.)start auscultation with the client sitting
 2.) move/place the stethoscope slowly while
listen to it over “five key landmarks”.
The first heart sound is low-pitched, soft, and
relatively old, often said to sound like "lub".
The second heart sound has a higher pitch,
more short, and sharp, often said to sound like
"dump".
3. Listen above the right sternal border at ICS 2.
In this position the heart sound (S2) can be
louder compared to heart sound 1 (S1) because
on this side just above the pulmonary valve.
4. Listen above the left sternal border at ICS 3
(called also Erb's point). The examiner must
listen both heart 1 and heart 2 sounds are relative
balanced intensity. At this location the sound
1st heart sound is louder than 2nd heart sound.
This occurs due to closure of the tricuspid and
valves is the best place for auscultation.
5. Listen above the apex on ICS 5 and
midclavicular, at this location the 1st heart sound
can be louder than heart sound 2. This is occurs
due to closure of the mitral valve and is the best
place for auscultation.
6. Compare the apex beat with the carotid beat, the
two pulses should be in sync
7. Check the heart rate, that is, after both sounds
heart sounds clear like “lub dup”, count each
combination of S1 and S2 as one beat heart.
Count the number of beats for 1 minute
SCORE = ∑ score obtained x 100 = …..
∑ total score

B ATTITUDE
1. Therapeutic Communication
2. Be careful
3. Empathy
 4. Polite
5. Sensitive to client response
SCORE = ∑ score obtained x 100 = …..
∑ total score

C KNOWLEDGE
Value Range 0 -100

TOTAL PRACTICUM VALUE

(15%x N.Cognitive)+ (15%x N.Affective)+ (70%xN.Psychomotor) = .............
Information:
4: Perform all actions independently
3: take action with 25% help
2: Take action with 50% assistance
1: Take action with 75% assistance
0 : Takes action with full assistance / unable to take action