Checklist For Cardiac Assessment

PILAR COLLEGE OF ZAMBOANGA CITY, INC
R.T. Lim Boulevard, Zamboanga City

Nursing Program
Physical Assessment of the Anterior Thorax

Focus: Cardiovascular System
RLE Performance Evaluation Checklist for BSN Students
Name: ______________________________________ Score: _____________
Year & Section: ______________________________________ Date: _____________
Direction: Put a check mark on the item that corresponds to the performance coded as follows:
2 – Done correctly and completely 1 – Done but incorrectly or incompletely 0 – NOT DONE
Assessing the Heart and Central Vessels

For most of the cardiac examinations, the client should be in supine position with the head elevated by 30°.
Two other positions are also needed: 1) turning to the left side, 2) leaning forward. The examiner should stand
at the client’s right.
Parameters 2 1 0
PREPARATION PHASE
1. Introduces self and verifies the client’s identity.
2. Explains to the client the purpose and how he/she can participate.
3. Discusses how the results will be used in planning further care or treatment
4. Performs hand hygiene and observes appropriate infection control procedures
5. Provides for client privacy. Drapes any body part when it is not being examined.
6. Removes the client’s upper clothing.
7. Assists the client to sit on the side of the examining table or bed.
(When examine in supine position, the client should lie comfortably with arms
somewhat abducted. A client who is having difficulty breathing should be
examined in the sitting position or with head of the bed elevated to a comfort
level).
8. Inquires if the client has any history of the following:
a. family history of illness, including cancer, allergies, tuberculosis;
b. lifestyle habits such as smoking and occupational hazards (e.g., inhaling fumes);
c. medications being taken (antihypertensive, aspirin, etc);
d. current problems (e.g., swellings, coughs, wheezing, pain).
Inspection: The Anterior Chest
9. Inspects the anterior chest for pulsation (observes for the apical impulse).
10. Notes any presence of abnormality on the skin (discoloration, scars, etc.).
Palpation: The Apical impulse (To detect some abnormal conditions)

11. Localizes the apical impulse by using one finger pad
12. Asks the client to “exhale and then hold his/her breath (aids the examiner in locating
the pulsation).
13. Asks the client to roll midway to the left side (notes location, size, amplitude, and
duration of the apical impulse).
Palpation: Across the Precordium
14. Using the palmer aspects of the four fingers, gently palpates the apex, the left sternal
border and the base
15. Detects for any other pulsations; if any present, notes the timing.
Auscultation: The Heart
16. Identifies the auscultatory areas where to listen. These include the four traditional valve
areas:
✔ Second right interspace – aortic valve area
✔ Second left interspace pulmonic valve area
✔ Left lower sternal border tricuspid valve area
✔ Fifth interspace at around left midclavicular line- mitral valve area
17. Places the stethoscope over the client’s chest.(Note: try closing eyes briefly to tune out
any distractions. Concentrate, and listen selectively to one sound at a time).
18. Identifies S1 and S2 sounds (the first heart sound is S1(“lub”) caused by closure of the
AV valves. S1 signals the beginning of systole while the second heart sound is S2
(“dup”), is associated with closure of the aortic and pulmonic valves).
19. Listens to S1 and S2. Focuses first on the systole, then diastole. Listens for any extra
heart sounds (notes murmurs if any and describes it by indicating its characteristics:
timing, loudness, pitch, pattern, quality, location, radiation and posture).
20. Counts the number of apical heart rate for one full minute.
POST EXAMINATION PHASE

21. Thanks client for his/her cooperation, shares feedback and gives any further
instructions.
22. Collects all materials used. Tidies the client’s room.
23. Washes hands, cleans and returns all materials properly in their places.
24. Documents results of assessment correctly, timely and accurately.
25. Refers any abnormal results (if any) for further care.
Total
Comments:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Evaluated by: _________________________________________________ Date: _____________________

Name and Signature of Clinical Instructor
Shown to me: _________________________________________________ Date: _____________________

Name and Signature of BSN Student
Note: This form shall be used for rating by the Clinical Instructor assigned.

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PILAR COLLEGE OF ZAMBOANGA CITY, INC

R.T. Lim Boulevard, Zamboanga City

Physical Assessment of the Anterior Thorax

RLE Performance Evaluation Checklist for BSN Students

Name: __________________________ Score: _

Year & Section: __________________________ Date: _

Assessing the Heart and Central Vessels

Inspection: The Anterior Chest

Palpation: The Apical impulse (To detect some abnormal conditions)

POST EXAMINATION PHASE

Evaluated by: _____________________________ Date: _

Shown to me: _____________________________ Date: _

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