Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [55], C).
2. 2.Show
   Gain the patient's verbal consent.
   Consent must be gained before any procedure takes place (NMC [55], C).
3. 3.Show
   Check that the patient has an empty bladder.
   A full bladder will interfere with the examination (Walsh [86], E).
4. 4.Show
   Make sure the patient is warm and comfortable and ideally have them in the supine position, with their head at 30–45° and their arms by their sides.
   This is the optimum position from which to assess the jugular venous pressure (JVP) (Talley and O'Connor [82], E).
5. 5.Show
   Expose the patient from head to waist while maintaining privacy and dignity. You will also need access to their legs.
   To allow a thorough examination (Talley and O'Connor [82], E).

Procedure

1. 6.Show
   Wash and dry hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).

General inspection

1. 7.Show
   Take a global view of the patient.
   See ‘Inspection’ above.
2. 8.Show
   Look at the patient's skin and nails. Feel the texture, temperature and turgor of the skin.
   Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example heart disease, endocarditis, hypercholesterolaemia and/or anaemia (Bickley and Szilagyi [9], Tidman [84]). Also look for tobacco staining. E
3. 9.Show
   Press the patient's fingernail (on the first digit) firmly between your finger and thumb for 5 seconds and then let go. Count how many seconds it takes for the colour to return to the nail.
   To assess the capillary refill; this can give an indication of the status of circulation (Paterson and Dover, [23]). Normal return is 2 seconds. E
4. 10.Show
   Look at the patient's eyes.
   To assess for any abnormalities, particularly looking for any signs of hypercholesterolaemia or anaemia (Talley and O'Connor [82], E).
5. 11.Show
   Look at and in the patient's mouth.
   The mouth can give a snapshot of the patient's general state of health. Look for signs of malnutrition, infection, central cyanosis and any sores (Innes et al. [39], E).
6. 12.Show
   Ask the patient to turn their head to the left, use tangential lighting and locate the highest pulsation point of the internal jugular vein (see Figure 2.15). Place a ruler vertically from the sternal angle, then use a tongue depressor placed horizontally to make a right angle from the pulsation to the ruler. The JVP is measured in centimetres and the measurement is where the tongue depressor meets the ruler.
   To assess the JVP (Bickley and Szilagyi [9], E).
7. 13.Show
   Inspect the precordium.
   To assess for scars, deformities, heaves, lifts and the apical impulse (Bickley and Szilagyi [9], E).
8. 14.Show
   Inspect the legs.
   To assess for signs of venous disease and ischaemic changes (Mills et al. [50], E).

Palpation

1. 15.Show
   Palpate the pulses.
   To assess cardiac output (Rushforth [74], E).
2. 16.Show
   Palpate the chest.
   To assess for tenderness, heaves, lifts and thrills (Bickley and Szilagyi [9], Rushforth [74], E).
3. 17.Show
   Palpate with the finger tips the fifth intercostal space, inside the mid‐clavicular line.
   To assess the apical impulse (Bickley and Szilagyi [9], Rushforth [74], E).

Auscultation

1. 18.Show
   Listen with the bell of the stethoscope to the carotid pulse.
   To assess for bruits (Bickley and Szilagyi [9], E).
2. 19.Show
   Auscultate at the aortic, pulmonary, tricuspid and mitral valves (see Figure 2.16) with the diaphragm of the stethoscope.
   To assess S1 and S2 (Bickley and Szilagyi [9], Camm and Camm [13], E).
3. 20.Show
   Auscultate at the aortic, pulmonary, tricuspid and mitral valves (see Figure 2.16) with the bell of the stethoscope.
   To assess for S3, S4 and murmurs (Bickley and Szilagyi [9], Camm and Camm [13], E).
4. 21.Show
   Ask the patient to roll partially onto their left side and listen with the bell of the stethoscope to the apical impulse.
   To assess for a mitral murmur (Bickley and Szilagyi [9], Camm and Camm [13], E).
5. 22.Show
   Ask the patient to sit up and lean forward, exhale completely and hold their breath. Listen with the diaphragm of the stethoscope to the apical impulse and along the left sternal border. Make sure to tell the patient to start breathing normally again.
   To assess for an aortic murmur and pericardial friction rubs (Bickley and Szilagyi [9], Camm and Camm [13], Rushforth [74], E).
6. 23.Show
   Ask the patient to sit up and listen to the lung bases with the diaphragm of the stethoscope.
   To assess for lung congestion, which can be caused by heart failure (Rushforth [74], E).

Post‐procedure

1. 24.Show
   Document fully.
   Accurate records should be kept of all discussions and/or assessments made (NMC [55], C).
2. 25.Show
   Report any abnormal findings to a senior nurse or to medical staff.
   Patients should be cared for as part of a multidisciplinary team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC [55], C).
3. 26.Show
   Clean the equipment used and wash hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).
4. 27.Show
   Explain findings to the patient.
   The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC [55], C).
5. 28.Show
   Discuss plan of care with the patient.
   Where possible, patients should be involved in planning their care (NMC [55], C).