PRE INTRODUCTORY PHASE

1. 1st is to review the client’s medical record as well as the

doctor’s order for the assessment needed to perform.
2. Determine the scope of assessment and prepare the
necessary equipment. The following are the equipment
needed; Penlight, rectangular card, ruler, stethoscope)
THIS IS TO CONSERVE TIME AND ENERGY
3. Perform hand hygiene and wear gloves and observe
other appropriate infection prevention procedures. THIS
IS TO PREVENT THE SPREAD OF MICROORGANISMS.
INTRODUCTORY PHASE
4. Greet the client politely as well as his/her companion if
around. Introduce self and verify the client’s identity
using the agency protocol. Ask how the client would like
to be called during the assessment. Establish rapport.
Good day ma’am! I am your student nurse for today, my
name is Mary Joy Anne Guarin. Can you state your name
and birthday? How would you like to be called during the
assessment ma’am? Okay, ma’am Shai. How are you
feeling today?
5. Explain the procedure to the client and how he/she can
participate during the assessment. Provide the client’s
opportunity to ask for clarification or raise any concerns.
Ma’am Shai, for today, I am going to assess your
cardiovascular system which includes your neck vessels,
your heart, and your peripheral vascular system. I would
 like to ask for your full participation that I might ask you
to stand, sit, or bend later. Do you have any questions or
clarifications so far ma’am?
6. Ensure the client’s comfort, privacy, and confidentiality.
Drape the client’s body as needed throughout the
assessment. Ma’am Shai, are you okay with your sit?
How about the air conditioning? So, I’m going to close
the door and the curtain to make sure of your privacy
ma’am Shai. So, let me inform you that your information
for today’s assessment is confidential which is our
priority.
7. Inquire if the client has any existing history of
cardiovascular problems, as well as lifestyle h
8. abits that are risk factors for cardiac problems. Do you
have any specific complaints such as neck pain or chest
pain? Or in any of your extremities? Have you experience
shortness of breath, dizziness, or headache? Do you have
a history of hypertension or coronary heart disease? Do
you smoke? What are your daily activities? Do you
exercise?
WORKING PHASE
ASSESSMENT OF NECK VESSELS
Assessment of Jugular Veins
9. Stood on the right side of the patient and position
him/her supine with the head of the bed elevated
 between 30 and 45degrees, make sure that the head and
torso are on the same plane.
10. Instruct the client to turn the head slightly to the left
and shine tangential light source onto the neck,
suprasternal notch, and area around the clavicles to
observe for pulsations and shadows
11. If jugular distention is noted, assess the jugular
venous pressure by locating the highest visible point of
distention of the internal jugular vein. Emphasize the
distention with tangential lighting. NOTE! The jugular
vein should not be distended, bulging, or protruding at 45
degrees or greater. If so, it may indicate right-sided heart
failure.
12. As deemed necessary, raised or lowered the head of
the bed (30, 45, 60, and 90 degrees) until the highest
visible point of distention of the jugular vein is observed
13. Measure the vertical distance in centimeters above
the sternal angle by extending a long rectangular object
or card horizontally from this point and a centimeter
ruler vertically from the sternal angle making an exact
right angle.
14. Repeat on the other side
NORMAL- VEINS NOT VISIBLE WHICH INDICATES THAT
THE RIGHT SIDE OF HEART IS FUNCTIONING NORMALLY
Assessment of Carotid Arteries
 15. With head of the bed still slightly elevated at
30degrees, positioned the client’s head slightly towards
the side being examined. Palpate the carotid artery
avoiding too much pressure or massaging the area.
16. Repeat the steps of the other side
NORMAL- SYMMETRIC PULSE VOLUMES
- FULL PULSATION
- ELASTIC ARTERIAL WALL
17. Turn the client’s head slightly away from the side
being examined. Placed the bell of the stethoscope over
the carotid artery, and ask the client to hold his/her
breath for a moment and auscultate the carotid artery
listening for bruit.
18. Repeat steps on the other side
NORMAL- NO SOUND HEARD ON AUSCULTATION
(NEITHER BRUIT NOR THRILL)

ASSESSMENT OF THE HEART (PERICARDIUM)

Inspection and Palpation
19. Begin with a general inspection of the chest wall.
Looking for any pulsations, symmetry of movement,
retraction or heaves. For women, kept the right chest
draped, and gently lift the breast with the left hand or
ask your client to do this for assistance. Stood at the right
side of the client with the head of the bed elevated at 30
degrees and look for any abnormal pulsations.
 NORMAL- CHEST MOVEMENT IS SYMMETRICAL, NO
RETRACTIONS
20. Simultaneously inspect the pericardium for
pulsations while palpating all four anatomic sites: aortic,
pulmonic, tricuspid, and apical.
21. Palpate for heaves and lifts using the palm and/or
hold finger pads flat or obliquely against the chest
22. For thrills, pressed the ball of the hand firmly on the
chest to check for a buzzing or vibratory sensation caused
by underlying turbulent flow.
23. Palpate impulses using finger pads flatly or obliquely
on the body surface from the four anatomic sites: aortic,
pulmonic, tricuspid, and apicalError! Hyperlink reference
not valid.
NORMAL- NO PULSATIONS, NO LIFT OR HEAVE
24. Palpate the apical impulse using the palmar surfaces
of two to three middle fingers. For a finer assessment,
palpate with one finger alone to confirm characteristics
of the apical impulse noting for location, diameter, and
amplitude.
25. If unable to palpate the apical impulse with the
patient in a supine position, reposition the patient to roll
partly in the left lateral side. Palpate again, using the
palmar surfaces of several fingers. If still not able to
palpate, ask the patient to exhale fully and stop
breathing for a few seconds and palpate again while
he/she maintains to be partly facing left side.
 NORMAL- PULSATIONS VISIBLE IN 50% OF ADULTS AND
PALPABLE IN MOST
- DIAMETER OF 1-2CM
- NO LIFT OR HEAVE
26. Inspect and palpate the epigastric area at the base
of the sternum for abdominal aortic pulsations.
Auscultation
27. Assess heart rate and rhythm by placing the
diaphragm of the stethoscope at the apex and listening
closely to the rate and rhythm of the apical impulse.
Count the heartbeat for a full minute. (If an irregular
rhythm was detected, assess for a pulse rate deficit)
28. Using the diaphragm of the stethoscope first, then
the bell, auscultate the heart in all four anatomic sites
aortic, pulmonic, tricuspid, and apical (mitral) for heart
sounds, extra heart sounds, and murmurs. Then, ask the
client to breathe regularly while auscultating
29. Repeat the steps while the patient is in left lateral
position them at sitting position, leaning forward and
briefly stop after exhalation
NORMAL- Heart rate is _ per minute and have a regular
rhythm
ASSESSMENT OF THE PERIPHERAL VASCULAR SYSTEM
Examining Upper Extremities
30. Assess each arm for size, symmetry, skin color and
temperature from finger tips to shoulder. Note for any
presence of edema, lesion, changes in skin texture and
hair distribution
31. Inspect the peripheral veins in the arm for the arms
for the presence and/or appearance of superficial veins
when limbs are dependent and when limps are elevated.
32. Palpate for radial pulse, ulnar pulse, and brachial
pulse individually and bilaterally
33. Assess for capillary refill
34. Perform Allen Test
35. Repeat the steps on the other side
NORMAL- ARMS ARE BILATERALLY SYMMETRIC WITH
MINIMAL VARIATION IN SIZE AND SHAPE. NO EDEMA
AND LESIONS. SKIN TEMPERATURE IS WARM AND
CAPILLARY REFILL IS GOOD. RADIAL PULSE, ULNAR AND
BRACHIAL PULSE ARE BILATERALLY STRONG AND HAVE A
NORMAL RHYTHM. UPON ALLEN TEST, WHEN YOU WERE
OPENING AND CLOSING YOUR HANDS, THE RESULT IS
NORMAL.
Examining Lower Extremities
36. At the supine position, assess each leg for size,
symmetry, skin color and temperature from groin to toes.
So, I’m looking for any ulcerations, edema or swelling,
venous pattern or varicosities. Note for any presence of
lesion, changes in skin texture and hair distribution
37. Inspect the peripheral veins in the legs for the
presence and/or appearance of superficial veins when
limbs are dependent and when limbs are elevated
38. Palpate for a femoral pulse, popliteal pulse, dorsalis
pedis, and posterior tibialis individually and bilaterally
39. Assess the peripheral leg veins for veins signs of
ulcerations, varicosities, and thrombophlebitis:
Inspect the calves for ulcerations, varicosities, redness
and swelling over vein sites
40. Palpate the calves for firmness or tension of the
muscles, the presence of edema over the dorsum of the
foot, and areas of localized warmth. Push the calves from
side to side for tenderness
41. Firmly dorsiflexed the client’s foot while supporting
the entire leg in extension (Homans’ test) or had the
client stand or walk
42. Assess for capillary refill for both legs and repeat
steps with the other leg
NORMAL- UPON EXAMINING YOUR LEGS: HAIR IS
EVENLY DISTRIBUTED, SKIN TEMPERATURE IS WARM, NO
EDEMA, NO LESIONS AND NO SWELLING. FEMORAL
PULSE, POPLITEAL PULSE, DORSALIS PEDIS, AND
POSTERIOR TIBIALIS ARE NORMAL: EQUALLY STRONG
AND HAVE A NORMAL RHYTHM
SUMMARY AND CLOSING
43. Inform the client that the assessment was done. If
deemed, assist client to change clothes. Reposition the
client comfortably sitting on a chair.
44. Summarize the information obtained during the
working phase and discuss findings to the client. Discuss
the possible plans to resolve health concern. Assess for
client’s understanding of the plan and the need for
further teaching. Provide the client the opportunity to
clarify, raise any concern.
45. Thank the client for her cooperation and ended the
assessment politely. Done aftercare. Perform hand
hygiene.
46. Document findings in client record using printed or
electronic forms or checklists supplemented by narrative
notes when appropriate.