ASSESSMENT OF HEART AND VASCULAR SYSTEM

PROCEDURES RATIONALE/FINDINGS
1. Introduce self and verify the clients identity. Explain the To be sure that you are administering the procedure to the
procedure right person to lessen anxiety and fear, thus promoting
cooperation
2. Perform hand hygiene and observe appropriate infection For infection control
prevention procedure
3. Provide client privacy To show respect
4. Inquire if the client has family history of incident of heart To ensure accurate health assessment
disease  Do you have family history of heart problems, high
cholesterol levels or hypertension?
 Any present symptoms like fatigue, chest pain,
shortness of breath (dyspnea), or palpitations?
 How about diabetes, lung diseases, endocrine
disorders?
 Do you have any vice like smoking or drinking
alcohol?
5. Inspect and palpate the precordium Findings:
a) Inspect and palpate the aortic and pulmonic areas No pulsations felt in the aortic and pulmonic areas
b) Inspect and palpate the tricuspid area No pulsation in the tricuspid area
c) Inspect and palpate the apical area Pulsation visible in 50% of adults and palpable in most Point of
Maximal Impulse (PMI) in the 5 th intercostal spaces (ICS) at/or
medial to mid-clavicular line (MCL) diameter of 1-2cm
6. Auscultate the heart in all four anatomic sites. S1 sounds can be heard at all sites, louder at apical area
S2 sounds can be heard at all sites , louder at the base of the
heart
S3 in children and young adults
7. Palpate the carotid artery There is symmetric pulse volume, full pulsation and also elastic
arterial wall
8. Auscultate the carotid artery No sounds heard on auscultation
9. Inspect the jugular veins Veins visibly distended indicating advanced cardiopulmonary
10. Assess the jugular venous pressure, if jugular distention is disease
present
11. Document and evaluate findings To serve as baseline data for health care provider

ASSESSMENT OF ABDOMEN
PROCEDURES RATIONALE/FINDINGS
1. Gather all the equipment needed to promote efficiency of health care provider

2. Introduce self and verify clients identity. Explain the To make sure that you are administering the procedure to the
procedure right person. To alleviate fear and anxiety thus promoting
cooperation
3. Perform hand hygiene and observe other appropriate For infection control
infection prevention procedure
4. Provide client privacy To show respect
5. Inquire about the client’s history related to the abdomen To ensure accurate health assessment
 Any incidence of abdominal pain?
 Do you experience nausea, vomiting or diarrhea?
 Changes in appetite or food tolerance?
6. Assist client to supine position, placing the arms at the side. To avoid chilling and shivering, which can tense the abdominal
Place small pillows underneath knees and head to reduce muscles
tension on abdominal muscles. Expose the client’s abdomen
until chest line to pubic area.
7. Inspect the abdomen for skin integrity Unblemished skin and uniform color
8. Inspect the abdomen for contour and symmetry Flat, evidence of enlargement of liver or spleen, symmetric
contour
9. Observe abdominal movements associated with respiration, Symmetric movements caused by respiration
peristalsis, or aortic pulsations Visible peristalsis in lean people
Aortic pulsations in thin people at epigastric area
10. Observe the vascular pattern No visible vascular pattern
11. Auscultate the abdomen for bowel sounds, vascular Audible bowel sounds
sounds, and peritoneal friction rubs (WARM THE HANDS)
12. Percuss several areas in each four quadrants to determine Tympany over the stomach and gas-filled bowels. Dull over
presence of tympany and dullness. Use a systematic pattern: liver and spleen
begin in the lower right quadrant, then proceed to the upper
right quadrant, the upper left quadrant, and the lower left
quadrant.
13. Perform light palpation to detect areas of tenderness No tenderness; relaxed abdomen with smooth, consistent
and/or muscle guarding. Systematically explore all four tension
quadrants. Ensure that the client’s position is appropriate for
relaxation of the abdominal muscles (WARM HANDS)
14. Palpate the area above the pubic symphysis if the client’s
history indicates possible urinary retention
15. Document findings in the client’s record using printed or To provide client with quality care and to help health care
electronic form or checklist supplemented by narrative notes providers evaluate the patient’s plan of treatment
when appropriate