1.

Gathers equipment (stethoscope with bell diaphragm, small pillow, penlight or movable exam light,
watch with second hand, two centimetre rulers, clean gown, and wrist watch).

 IDENTIFY THE CLIENT

Jhaz: Hello sir, I am Jhaztene your nurse for today. May I know]

2. Explains procedure to the client.

3. Assists client to put on gown.

NECK VESSELS

1. Inspects for jugular venous pulse.

2. Measures jugular venous pressure.

3. Auscultates carotid arteries for bruits.

4. Palpates each carotid artery for amplitude and contour of the pulse, elasticity of the vessel, and thrills.

HEART (Precordium)

1. Inspects for visible pulsations with the client in supine position with HOB elevated between 309 and
459

2. Palpates apical pulse for location, size, strength and duration of pulsation

3. Palpates for abnormal pulsation or vibrations at apex, left sternal border and base.

4. Auscultates heart sounds for rate and rhythm (apical and radial pulses, pulse rate deficit, si and s2) if
irregular rhythm is detected.

5. Auscultates sl and s2 heart sounds for sound location and strength pattern (louder/softer at locations
and with respiration, splitting of s2).

6. Auscultates for extra heart sounds (clicks, rubs) and murmurs (systolic or diastolic, intensity grade,
pitch, quality, shape or pattern, location, transmission, effect of ventilation and position)

7. Auscultates with the client in the left lateral position and with the client sitting up, leaning forward,
and exhaling.

ANALYSIS OF DATA

1. Formulates nursing diagnoses (wellness, risk actual)

2. Formulates collaborative problems.

3. Makes necessary referrals.