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    Procedure Checklist Chapter 19: Assessing The Heart and Vascular System

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    jths
    Nursing Procedures

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    Procedure Checklist Chapter 19: Assessing The Heart and Vascular System

    Uploaded by

    jths
    16 views2 pages
    Nursing Procedures

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    pc_ch19-10

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    Nursing Procedures

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views2 pages

    Procedure Checklist Chapter 19: Assessing The Heart and Vascular System

    Uploaded by

    jths
    Nursing Procedures

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    PROCEDURE CHECKLIST

    Chapter 19: Assessing the Heart and Vascular System

    Check (9) Yes or No

    PROCEDURE STEPS Yes No COMMENTS


    1. Inspects the neck and chest.
    a. Positions patient supine.
    b. Observes carotid arteries.
    2. Assesses jugular flow by compressing jugular vein
    below the jaw and observing jugular wave.
    3. Assesses jugular filling by compressing jugular vein
    above the clavicle and observing for disappearance of
    jugular wave.
    4. Measures jugular venous pressure (JVP).
    a. Elevates the head of the bed to a 45º angle.
    b. Identifies the highest point of visible internal jugular
    filling.
    c. Places a ruler vertically at the sternal angle (where the
    clavicles meet).
    d. Places another ruler horizontally at the highest point of
    the venous wave.
    e. Measures the distance in centimeters vertically from
    the chest wall.
    5. Places patient supine with tangential lighting to inspect
    precordium for pulsations.
    6. Palpates the carotid arteries.
    a. Palpates each side separately.
    b. Avoids massaging the artery.
    c. Notes rate, rhythm, amplitude, and symmetry of pulse.
    d. Notes contour, symmetry, and elasticity of the arteries;
    notes any thrills.
    7. Palpates the precordium.
    a. Has patient sit up and lean forward; if lying down,
    turns patient to the left side.
    b. Palpates: apex, left lateral sternal border, epigastric
    area, base left, and base right.
    8. Works from patient’s right side to auscultate, if possible.
    9. Auscultates the carotids: uses bell of stethoscope, has
    patient hold his breath while listening.
    10. Auscultates jugular veins: uses bell of stethoscope, has
    patient hold his breath while listening.
    11. Auscultates the precordium:
    a. Identifies S1, S2, S3, and S4 sounds.
    b. Listens for murmurs.
    c. Listens with both bell and diaphragm at all four

    Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing
    locations.
    d. Listens at: base right (aortic valve), base left
    (pulmonic valve), apex (mitral valve), and left lateral
    sternal border (tricuspid valve).
    12. If murmur is heard, identifies variables affecting (e.g.,
    location, quality, pitch, intensity, timing, duration,
    configuration, radiation, and respiratory variation) and
    compares with previous findings. Refers to primary care if
    murmur is a new finding.
    13. Inspects the periphery for color, temperature, and
    edema.
    14. Palpates the peripheral pulses: radial, brachial, femoral,
    popliteal, dorsalis pedis, and posterior tibial.
    a. Uses distal pads of 2nd and 3rd fingers to firmly palpate
    pulses.
    b. Palpates firmly but does not occlude artery.
    c. Assesses pulses for rate, rhythm, equality, amplitude,
    and elasticity.
    d. Describes pulse amplitude on a scale of 0 to 4:
    0 = absent, not palpable
    1 = diminished, barely palpable
    2 = normal, expected
    3 = full, increased
    4 = bounding

    15. Inspects the venous system. If a client has varicosities,


    assess for valve competence with the manual compression
    test.

    Recommendation: Pass _____ Needs more practice _____

    Student: Date:

    Instructor: Date:

    Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing

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