Goal: The assessment is completed without causing the patient to experience anxiety or discomfort, the findings are documented, and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Close curtains around bed and close the door to the room, if possible. Explain the purpose of the cardiovascular examination and what you are going to do. Answer any questions.
4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a supine position with the head elevated about 30 to 45 degrees and expose the anterior chest. Use the bath blanket to cover any exposed area other than the one being assessed.
5. Inspect and palpate the left and then the right carotid arteries. Only palpate one carotid artery at a time. Use the bell of the stethoscope to auscultate the arteries.
6. Inspect the neck for jugular vein distention, observing for pulsations.
7. Inspect the precordium for contour, pulsations, and heaves. Observe for the apical impulse at the fourth to fifth intercostal spaces (ICS).
8. Use the palmar surface with the four fingers held together and palpate the precordium gently for pulsations. Remember that hands should be warm. Palpation proceeds in a systematic manner, with assessment of specific cardiac landmarks— the aortic, pulmonic, tricuspid, and mitral areas and Erb’s point. Palpate the apical impulse in the mitral area. Note size, duration, force, and location in relationship to the midclavicular line.
9. Use systematic auscultation, beginning at the aortic area, moving to the pulmonic area, then to Erb’s point, then to the tricuspid area, and finally to the mitral area. Ask the patient to breathe normally. The stethoscope diaphragm is first used to listen to high-pitched sounds, followed by use of the bell to listen to low-pitched sounds. Focus on the overall rate and rhythm of the heart and the normal heart sounds.
10. Assist the patient in replacing the gown. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems as appropriate or indicated. Initiate appropriate referral to other healthcare practitioners for further evaluation, as indicated.
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