cardiac

NURS 1544 – Cardiac Assessment Skill Competency Demonstration (SCD)

INTRODUCTION

  • Preparation Steps:
    1. Review the patient’s chart for details regarding cardiac and peripheral vascular system.
    2. Perform hand hygiene.
    3. Complete introduction of self, including name and designation.
    4. Confirm positive patient identity using two identifiers (name and date of birth).
    5. Explain the procedure to the patient using techniques represented by I, P, A (Introduction, Purpose, Anticipation).
    6. Discuss confidentiality, collection of data, and ask for consent.
      • Remind the patient of their right to revoke consent.
    7. Ask the patient if they have any questions.
  • Evaluation Criteria:
    • A score of 7/7 indicates satisfactory performance.
    • A score of 6 or less is considered unsatisfactory.

SUBJECTIVE ASSESSMENT

  • Key Components of Inquiry:

    • Must ask questions related to cardiac symptoms using patient-friendly terms: CCCODFEN

      • Chest pain/discomfort/tightness.
      • Cough.
      • Cyanosis or pallor.
      • Orthopnea.
      • Dyspnea.
      • Fatigue.
      • Edema.
      • Nocturia.

    • A score of 7/8 indicates satisfactory performance; 6 or less is unsatisfactory.

    • Relevant Cardiac History Inquiry:

      • Cardiac history (e.g., select 2 or 3 from murmurs, hypertension, heart disease, heart attack, stroke, heart surgeries).
      • Family cardiac history (same categories as above).
      • Personal habits (must inquire about all four: smoking, alcohol, exercise, dietary practices).

    • Complete Symptom Assessment using OPQRSTUV:

      • Onset: Inquire when symptoms started.
      • Provoked & Palliation: Determine what alleviates or exacerbates symptoms.
      • Quality: Ask the patient to describe the symptom in their words.
      • Radiate: Establish where symptoms are located and if they radiate elsewhere.
      • Severity: Use a 0-10 scale (0 = no pain/symptom, 10 = worst pain/symptom).
      • Timing: Inquire if symptoms are constant or intermittent and their duration.
      • Understanding: Ask what the patient thinks is causing the symptoms.
      • Values: Query the perceived impact of the symptoms on quality of life.

    • A score of 7/8 indicates satisfactory performance; 6 or less is unsatisfactory.

OBJECTIVE ASSESSMENT

  • Preparation for Assessment:
    1. Explain the assessment to the client and obtain consent to proceed. Position the patient at a 30-degree semi-Fowler’s position.
    2. Perform hand hygiene and clean the stethoscope.
      • A score of 2/2 indicates satisfactory performance; 1 or less is unsatisfactory.
Inspection
  • Key Areas for Inspection:
    • Face/Central (3/3):
      • Inspect for signs of cyanosis, anxiety, or diaphoresis.
    • Neck (1/1):
      • Check for jugular venous distention (JVD) at a 30-degree angle; remove pillow, have the patient face away, and shine a light at the jugular vein.
    • Chest (2/2):
      • Inspect for heaves, lifts, and pulsations at the Point of Maximum Impulse (5th Intercostal Space, Midclavicular Line).
    • Arms/Legs (3/4):
      • Look for edema, color, lower extremity hair distribution, skin lesions, or ulcers.
      • A score of 4/4 indicates satisfactory performance; 3 or less is unsatisfactory.
Palpation
  1. Capillary Refill:
    • Palpate capillary refill and state the normal finding (<2 seconds).
      • Procedure: Depress and blanch nailbeds of fingers and toes.
  2. Temperature of Limbs:
    • Palpate temperature using the dorsal surface of the hand; compare bilaterally from distal to proximal in all four limbs.
      • State that cool limbs can indicate poor perfusion.
  3. Pitting Edema:
    • Palpate the feet and pretibial area for edema; state grading of pitting edema:
      • 1+ = mild pitting (slight indentation).
      • 2+ = moderate pitting (indentation subsides rapidly).
      • 3+ = deep pitting (indentation remains for a short time).
      • 4+ = very deep pitting (indentation lasts a long time).
Pulse Assessment
  1. Pulses:
    • Palpate the following pulses bilaterally, indicating strength (0= absent, 1+ = weak, 2+ = normal, 3+ = bounding) and regularity (regular vs irregular):
      • Radial.
      • Brachial.
      • Femoral.
      • Posterior Tibial.
      • Dorsalis Pedis.
      • A score of 5/5 indicates satisfactory performance; 4 or less is unsatisfactory.
Auscultation
  1. Auscultate Bruits:
    • Identify three landmarks: Angle of jaw, midcervical area, base of the neck.
      • State that bruits are abnormal sounds indicating turbulent flow & narrowing of the carotid artery (e.g., atherosclerosis).
      • Procedure: Auscultate left carotid artery with the bell at 3 locations, then right carotid artery with the bell in 3 locations.
  2. Auscultate Normal Heart Sounds:
    • Landmark locations and auscultation for S1 and S2 sounds:
      • Aortic Valve = Right Sternal Border (RSB), 2nd Intercostal Space (ICS), S2 is loudest.
      • Pulmonic Valve = Left Sternal Border (LSB), 2nd ICS, S2 is loudest.
      • Erb’s Point = LSB, 3rd ICS, S1 & S2 sound equal.
      • Tricuspid Valve = LSB, 4th ICS, S1 is loudest.
      • Mitral Valve = Left Midclavicular Line (MCL), 5th ICS, S1 is loudest.
      • Reposition patient upright and leaning forward to assess murmurs using the diaphragm:
        • Aortic Valve = RSB, 2nd ICS.
        • Pulmonic Valve = LSB, 2nd ICS.
  3. Auscultate Murmurs:
    • Identify and auscultate APETM for murmurs using the bell:
      • State that murmurs are blowing/swooshing sounds caused by turbulent blood flow in the heart or great vessels.
        • Aortic Valve = RSB, 2nd ICS.
        • Pulmonic Valve = LSB, 2nd ICS.
        • Tricuspid Valve = LSB, 4th ICS.
        • Mitral Valve = Left MCL, 5th ICS.
  4. Auscultate Heart Failure Sounds:
    • Reposition the patient in a left lateral position. Landmark and auscultate at the 5th ICS, MCL for S3 & S4 using the bell:
      • S3: Occurs just after S2.
      • S4: Occurs just before S1.

CLOSING/ADDITIONAL CONSIDERATIONS

  • Thank the patient for their time.
  • Adjust the bed to the lowest position and keep the table within reach of the patient.
  • Ensure the call bell is within reach of the patient.
  • Perform hand hygiene.

REPORT/SUMMARY (SBAR)

  • Situation:
    • State your name, role, patient’s name, age/date of birth, and reason for the call.
  • Background:
    • Provide at least three relevant details from the patient's profile or subjective data.
  • Assessment:
    • Report on OPQRSTUV of the presenting symptom (need 6/8 reported).
    • Report vital signs.
    • Report on inspection, palpation, and auscultation.
  • Recommendation:
    • Provide one relevant recommendation to the scenario.
  • Time Limit:
    • A reasonable time limit for completing the procedure is 20 minutes.

GRADING

  • 16/16 for first attempt with no errors.
  • 12/16 for first attempt with 3 or fewer errors; more than 3 errors require a second attempt.
  • 8/16 for second attempt with 3 or fewer errors.
  • 0/16 for unsuccessful second attempt.
  • Additional Note:
    • Students who are unsuccessful must continue to be assessed in open lab until skill mastery is obtained for their course marks to be released.