XAVIER UNIVERSITY

PERFORMANCE RATING SCALE

ASSESSING THE HEART & NECK VESSELS

SCALE DESCRIPTION INDICATORS

4 Very Good Student performs behaviors/tasks reflecting the highest level of

performance: consistent, independent, effective
3 Good Student performs behaviors/tasks reflecting mastery of performance with
minimal supervision
2 Fair Student performs behaviors/tasks reflecting development and movement
towards mastery of performance with help or direct supervision in some
aspect
1 Needs Student performs behaviors/tasks reflecting beginning level of
Improvement performance; tasks not done properly majority of the time but demonstrate
understanding of concepts involved with tasks

PROCEDURE 4 3 2 1 REMARKS
1. Perform hand hygiene and put on PPE, if indicated.
2. Iden9fy the pa9ent.
3. Explain the procedure to the client/pa9ent.
Neck Vessels: Inspec?on
4. Observe the jugular venous pulse. Inspect the jugular venous
pulse by standing on the right side of the client. The client should be
in a supine posi9on with the torso elevated 30 to 45 degrees. Make
sure the head and torso are on the same plane. Ask the client to turn
the head slightly to the leJ. Shine a tangen9al light source onto the
neck to increase visualiza9on of pulsa9ons as well as shadows. Next
inspect the suprasternal notch or the area around the clavicles for
pulsa9ons of the internal jugular veins.
5. Evaluate jugular venous pressure. Evaluate jugular venous
pressure by watching for disten9on of the jugular vein. It is normal
for the jugular veins to be visible when the client is supine; to
evaluate jugular vein disten9on, posi9on the client in a supine
posi9on with the head of the bed elevated 30, 45, 60, and 90
degrees. At each increase of the eleva9on, have the client’s head
turned slightly away from the side being evaluated. Using tangen9al
ligh9ng, observe for disten9on, protrusion, or bulging.
Ausculta?on and Palpa?on
6. Auscultate the caro?d arteries. Aus- cultate the caro9d arteries if
the client is middle-aged or older or if you suspect cardiovascular
disease. Place the bell of the stethoscope over the caro9d artery and
ask the client to hold his or her breath for a moment so breath
sounds do not conceal any vascular sounds.
7. Palpate the caro?d arteries. Palpate each caro9d artery
alternately by placing the pads of the index and middle fingers medial
to the sternocleidomastoid muscle on the neck. Note amplitude and
contour of the pulse, elas9city of the artery, and any thrills.

8. Palpate the caro?d arteries individually because bilateral

palpa9on could result in reduced cerebral blood flow.
 PROCEDURE 4 3 2 1 REMARKS
Heart (Precordium)
17. Inspect pulsa?ons. With the client in supine posi9on with the
head of the bed elevated between 30 and 45 degrees, stand on the
client’s right side and look for the apical impulse and any abnormal
pulsa9ons.
Palpa?on
18. Palpate the apical impulse. Remain on the client’s right side and
ask the client to remain supine. Use the palmar surfaces of your hand
to palpate the apical impulse in the mitral area (4th or 5th intercostal
space at the midclavicular line). AJer loca9ng the pulse, use one
finger pad for more accurate palpa9on.
19. Palpate for abnormal pulsa?ons. Use your palmar surfaces to
palpate the apex, leJ sternal border, and base.
Ausculta?on
20. Auscultate heart rate and rhythm. Place the diaphragm of the
stethoscope at the apex and listen closely to the rate and rhythm of
the apical impulse.
21. If you detect an irregular rhythm, auscultate for a pulse rate
deficit. This is done by palpa9ng the radial pulse while you auscultate
the apical pulse. Count for a full minute.
22. Auscultate to iden?fy S1 and S2. Auscultate the first heart sound
(S1 or “lub”) and the second heart sound (S2 or “dubb”). Remember
these two sounds make up the cardiac cycle of systole and diastole.
S1 starts systole, and S2 starts diastole. The space, or systolic pause,
be- tween S1 and S2 is of short dura9on (thus S1 and S2 occur very
close together), whereas the space, or diastolic pause, between S2
and the start of another S1 is of longer dura9on.
23. Listen to S1. Use the diaphragm of the stethoscope to best hear
S1
24. Listen to S2. Use the diaphragm of the stethoscope. Ask the client
to breath regularly.
25. Auscultate for extra heart sounds. Use the diaphragm first then
the bell to aus- cultate over the en9re heart area. Note the
characteris9cs (e.g., loca9on, 9ming) of any extra sound heard.
Auscultate during the systolic pause (space heard between S1 and S2).
26. Auscultate during the diastolic pause (space heard between end
of S2 and the next S1).
27. Auscultate for murmurs. A murmur is a swishing sound caused by
turbulent blood flow through the heart valves or great vessels.
Auscultate for murmurs across the en9re heart area. Use the di-
aphragm and the bell of the stethoscope in all areas of ausculta9on
because murmurs have a variety of pitches. Also auscultate with the
client in different posi9ons as described below because some
murmurs occur or subside accord- ing to the client’s posi9on.
28. Auscultate with the client assuming other posi?ons. Ask the
client to assume a leJ lateral posi9on. Use the bell of the
stethoscope and listen at the apex of the heart.
29. Ask the client to sit up, lean forward, and exhale. Use the
diaphragm of the stethoscope and listen over the apex and along the
leJ sternal border
21. Document findings & refer if necessary.

Actual Score/Total Score x 100

A (92 – 100)
A- (84 – 91.99)
B (76 – 83.99)
B- (68 – 75.99)
C (60 – 67.99)
F (< 60 Student’s Signature: _____________________
C.I.’s Signature: _____________________