Calayan Educational Foundation, Inc.

Office of the College of Nursing

PACUCOA Level II Accredited

Assessment of the Heart

DEFINITION: An assessment of the heart is a way to assess the cardiovascular

system function. Cardiovascular assessment includes the survey of the
vascular structures in the neck - - the carotid artery and jugular veins.

PURPOSE: To identify areas requiring intervention while establishing a

baseline for measuring improvement or deterioration in condition of patient.

CONSIDERATIONS:

1. Key elements of a comprehensive cardiovascular assessment include

a patient history.

2. The physical examination involves inspection, palpation and

auscultation.

3. Common symptoms of heart problems include chest pain,palpitations,

easy fatigability, dyspnea, nocturia, dizziness, swelling of lower
extremities,heart burn.

EQUIPMENT:

Personal protective equipment

Stethoscope

Small Pillow

Penlight

Watch with second hand


Office of the College of Nursing
PROCEDURE
1. Perform hand hygiene
2. Introduce yourself to patient
3. Confirm patient ID using two
patient identifiers (e.g., name
and date of birth).
4. Explain process to patient.
5. Determine the need for
assessment of the heart &
obtain a stethoscope
6. Have the patient sit up, if able
7. Remove the patient’s gown or
pajama top if not already done
8. Auscultate the patient’s heart.
a. Warm the diaphragm of
the stethoscope
b. Listen for the first and
second heart sound
c. Count the cardiac rate
d. Evaluate the cardiac
rhythm
e. Wash hands
9. Document and report
appropriately
Calayan Educational Foundation, Inc.
PACUCOA Level II Accredited
RATIONALE
1. Reduces transmission of
microorganisms
2. Information facilitates acceptance of &
compliance with the assessment
3. Ensures that the right client will receive
right Management & care
4. Allays anxiety of the client
5.Promotes efficiency of actions
6.Provides adequate exposure & provides
comfort
7.Prevents unnecessary exposure of other
body parts
8. Comprehensive assessment provides a
baseline data for measuring improvement
or deterioration in condition. Ensure
comfort on patient’s part.
To determine whether there is an abnormal
findings or “extra heart” sounds heard
Evaluates underlying structures.
To detect /differentiate the heart sounds
heard using the diaphragm of a
stethoscope
Prevents transmission of microorganisms
Records information for evaluation
 Calayan Educational Foundation, Inc.
Office of the College of Nursing
PACUCOA Level II Accredited
Notes: Heart

 If you have difficulty hearing the heart, have the supine patient roll partially over to
the left or have the sitting patient lean slightly forward… this way, the sound should
be easier to hear because the heart has moved closer to the chest wall.
 Heart sounds that are very difficult to hear are termed distant.
 Heart sounds that are easily heard are termed clear.
 Heart sounds are often difficult to hear in obese or barrel-chested patients.
 Patients who are receiving a digitalis preparation have an apical pulse taken prior to
the administration of the digitalis, to ensure an accurate heart rate count that is
within the parameters for giving that drug.
 Digitalis = drug used exclusively in cardiac conditions to strengthen and slow the
heartbeat. Useful in auricular fibrillation and congestive heart failure
 S1 = first heart sound. It is more easily heard in the area of the 5 th left intercostal
space near the nipple line (apex) using the bell of the stethoscope.
 S2 = second heart sound. It is more easily heard in the 2nd intercostal space
immediately to the right of the sternum (base) using the diaphragm of the
stethoscope.
 Heart sounds are created by closing the valves in the heart
 Systole = occurs between the first and second heart sounds
 Diastole = occurs between the second and first sounds.
 Carotid pulse = occurs simultaneously with the first heart sound. If it is difficult to
distinguish the sound, identify the carotid pulse while you listen to the heart.