Cardiovascular Assessment
Cardiovascular Assessment
Cardiovascular Assessment
LEARNING OBJECTIVES
Perform a cardiovascular assessment, including heart sounds; apical and
peripheral pulses for rate, rhythm, and amplitude; and skin perfusion (color,
temperature, sensation, and capillary refill time)
Identify S1 and S2 heart sounds
Differentiate between normal and abnormal heart sounds
Modify assessment techniques to reflect variations across the life span
Document actions and observations
Recognize and report significant deviations from norms
The evaluation of the cardiovascular system includes a thorough medical history
and a detailed examination of the heart and peripheral vascular system. Nurses
must incorporate subjective statements and objective findings to elicit clues of
potential signs of dysfunction. Symptoms like fatigue, indigestion, and leg swelling
may be benign or may indicate something more ominous. As a result, nurses must
be vigilant when collecting comprehensive information to utilize their best clinical
judgment when providing care for the patient.
BASIC CONCEPTS
While the cardiovascular assessment most often focuses on the function of the
heart, it is important for nurses to have an understanding of the underlying
structures of the cardiovascular system to best understand the meaning of their
assessment findings.
CARDIOVASCULAR ASSESSMENT
A thorough assessment of the heart provides valuable information about the
function of a patient’s cardiovascular system. Understanding how to properly
assess the cardiovascular system and identifying both normal and abnormal
assessment findings will allow the nurse to provide quality, safe care to the patient.
Before assessing a patient’s cardiovascular system, it is important to understand
the various functions of the cardiovascular system. In addition to the information
provided in the “Review of Cardiac Basics” section, the following images provide
an overview of the cardiovascular system. ( Figure 1) provides an overview of the
structure of the heart. Note the main cardiac structures are the atria, ventricles, and
heart valves. Figure 2demonstrates blood flow through the heart. Notice the flow
of deoxygenated blood from the posterior and superior vena cava into the right
atria and ventricle during diastole (indicated by blue coloring of these structures).
The right ventricle then pumps deoxygenated blood to the lungs via the pulmonary
artery during systole. At the same time, oxygenated blood from the lungs returns to
the left atria and ventricle via the pulmonary veins during diastole (indicated by red
coloring of these structures) and then is pumped out to the body via the aorta
during systole. . Figure 3 illustrates the arteries of the circulatory system,
and Figure 4 depicts the veins of the circulatory system. The purpose of these
figures is to facilitate understanding of the electrical and mechanical function of
the heart within the cardiovascular system.
Figure 2
Figure 3
Figure 4
Assessing the cardiovascular system includes performing several subjective and
objective assessments. At times, assessment findings are modified according to life
span considerations.
SUBJECTIVE ASSESSMENT
The subjective assessment of the cardiovascular and peripheral vascular system is
vital for uncovering signs of potential dysfunction. To complete the subjective
cardiovascular assessment, the nurse begins with a focused interview. The focused
interview explores past medical and family history, medications, cardiac risk
factors, and reported symptoms. Symptoms related to the cardiovascular system
include chest pain, peripheral edema, unexplained sudden weight gain, shortness of
breath (dyspnea), irregular pulse rate or rhythm, dizziness, or poor peripheral
circulation. Any new or worsening symptoms should be documented and reported
to the health care provider.
Table 1.3a outlines questions used to assess symptoms related to the cardiovascular
and peripheral vascular systems. Table 1.3b outlines questions used to assess
medical history, medications, and risk factors related to the cardiovascular system.
Information obtained from the interview process is used to tailor future patient
education by the nurse.
Table 1.3a
Interview Questions for Cardiovascular and Peripheral Vascular Systems.
Chest Pain Have you had any Review how to assess a patient’s chief
pain or pressure in complaint using the PQRSTU method in the
your chest, neck, or “Health History” chapter.
arm? “P-provocation or palliation—What brings
on the pain? What relieves the pain?
Q-Quality or quantity—Characteristics,
duration
R-Region or Radiation—Where is the pain?
Does it radiate anywhere?
S- Severity—How would you rate the pain
on a scale of 0-10?
T-Timing—When did the pain start? How
long does the pain last? Anything relieve
the pain?
U-Understanding—What do you think is
causing the pain?”
Calf Pain Do you currently Can you point to the area of pain with one
have any constant finger?
pain in your lower
legs?
Table 1.3b
Interview Questions Exploring Cardiovascular Medical History, Medications, and
Cardiac Risk Factors
Topic Questions
Cardiac Risk Have your parents or siblings been diagnosed with any heart
Factors conditions?
INSPECTION
Skin color to assess perfusion. Inspect the face, lips, and fingertips
for cyanosis or pallor. Cyanosis is a bluish discoloration of the skin, lips, and
nail beds and indicates decreased perfusion and oxygenation. Pallor is the loss
of color, or paleness of the skin or mucous membranes, as a result of reduced
blood flow, oxygenation, or decreased number of red blood cells. Patients with
light skin tones should be pink in color. For those with darker skin tones, assess
for pallor on the palms, conjunctiva, or inner aspect of the lower lip.
Jugular Vein Distension (JVD). Inspect the neck for JVD that occurs when the
increased pressure of the superior vena cava causes the jugular vein to bulge,
making it most visible on the right side of a person’s neck. JVD should not be
present in the upright position or when the head of bed is at 30-45 degrees.
Precordium for abnormalities. Inspect the chest area over the heart (also
called precordium) for deformities, scars, or any abnormal pulsations the
underlying cardiac chambers and great vessels may produce.
Extremities:
o Upper Extremities: Inspect the fingers, arms, and hands bilaterally noting
Color, Warmth, Movement, Sensation (CWMS). Alterations or bilateral
inconsistency in CWMS may indicate underlying conditions or injury. Assess
capillary refill by compressing the nail bed until it blanches and record the
time taken for the color to return to the nail bed. Normal capillary refill is less
than 3 seconds.
o Lower Extremities: Inspect the toes, feet, and legs bilaterally, noting
CWMS, capillary refill, and the presence of peripheral edema, superficial
distended veins, and hair distribution. Document the location and size of any
skin ulcers.
Edema: Note any presence of edema. Peripheral edema is swelling that
can be caused by infection, thrombosis, or venous insufficiency due to an
accumulation of fluid in the tissues. (See Figure 5 )for an image of pedal
edema.)
Deep Vein Thrombosis (DVT): A deep vein thrombosis (DVT) is a
blood clot that forms in a vein deep in the body. DVT requires
emergency notification of the health care provider and immediate follow-
up because of the risk of developing a life-threatening pulmonary
embolism. Inspect the lower extremities bilaterally. Assess for size,
color, temperature, and for presence of pain in the calves. Unilateral
warmth, redness, tenderness, swelling in the calf, or sudden onset of
intense, sharp muscle pain that increases with dorsiflexion of the foot is
an indication of a deep vein thrombosis (DVT). See Figure 6 for an image
of a DVT in the patient’s right leg, indicated by unilateral redness and
edema.
Figure 5
Figure 6
AUSCULTATION
HEART SOUNDS
Auscultation is routinely performed over five specific areas of the heart to listen
for corresponding valvular sounds. These auscultation sites are often referred to by
the mnemonic “APE To Man,” referring to Aortic, Pulmonic, Erb’s point,
Tricuspid, and Mitral areas (see Figure 7 for an illustration of cardiac auscultation
areas). The aortic area is the second intercostal space to the right of the sternum.
The pulmonary area is the second intercostal space to the left of the sternum. Erb’s
point is directly below the aortic area and located at the third intercostal space to
the left of the sternum. The tricuspid (or parasternal) area is at the fourth intercostal
space to the left of the sternum. The mitral (also called apical or left ventricular
area) is the fifth intercostal space at the midclavicular line.
Figure 7
Auscultation usually begins at the aortic area (upper right sternal edge). Use the
diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will
make a “lub-dub” sound. Note that when listening over the area of the aortic and
pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1). Move the
stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point
(left third intercostal space at the sternal border), and tricuspid area (fourth
intercostal space. When assessing the mitral area for female patients, it is often
helpful to ask them to lift up their breast tissue so the stethoscope can be placed
directly on the chest wall. Repeat this process with the bell of the stethoscope. The
apical pulse should be counted over a 60-second period. For an adult, the heart rate
should be between 60 and 100 with a regular rhythm to be considered within
normal range. The apical pulse is an important assessment to obtain before the
administration of many cardiac medications.
The first heart sound (S1) identifies the onset of systole, when the atrioventricular
(AV) valves (mitral and tricuspid) close and the ventricles contract and eject the
blood out of the heart. The second heart sound (S2) identifies the end of systole
and the onset of diastole when the semilunar valves close, the AV valves open, and
the ventricles fill with blood. When auscultating, it is important to identify the S1
(“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen
for any extra heart sounds.
AUSCULTATING HEART SOUNDS
To effectively auscultate heart sounds, patient repositioning may be required.
Ask the patient to lean forward if able, or position them to lie on their left
side.
It is common to hear lung sounds when auscultating the heart sounds. It may
be helpful to ask the patient to briefly hold their breath if lung sounds impede
adequate heart auscultation. Limit the holding of breath to 10 seconds or as
tolerated by the patient.
Environmental noise can cause difficulty in auscultating heart sounds.
Removing environmental noise by turning down the television volume or
shutting the door may be required for an accurate assessment.
Patients may try to talk to you as you are assessing their heart sounds. It is
often helpful to explain the procedure such as, “I am going to take a few
minutes to listen carefully to the sounds of blood flow going through your
heart. Please try not to speak while I am listening, so I can hear the sounds
better.”
CAROTID SOUNDS
The carotid artery may be auscultated for bruits. Bruits are a swishing sound due
to turbulence in the blood vessel and may be heard due to atherosclerotic changes.
PALPATION
Palpation is used to evaluate peripheral pulses, capillary refill, and for the presence
of edema. When palpating these areas, also pay attention to the temperature and
moisture of the skin.
PULSES
Compare the rate, rhythm, and quality of arterial pulses bilaterally, including the
carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. Review
additional information about obtaining pulses in the “General Survey” chapter.
Bilateral comparison for all pulses (except the carotid) is important for determining
subtle variations in pulse strength. Carotid pulses should be palpated on one side at
a time to avoid decreasing perfusion of the brain. The posterior tibial artery is
located just behind the medial malleolus. It can be palpated by scooping the
patient’s heel in your hand and wrapping your fingers around so that the tips come
to rest on the appropriate area just below the medial malleolus. The dorsalis pedis
artery is located just lateral to the extensor tendon of the big toe and can be
identified by asking the patient to flex their toe while you provide resistance to this
movement. Gently place the tips of your second, third, and fourth fingers adjacent
to the tendon, and try to feel the pulse.
The quality of the pulse is graded on a scale of 0 to 3, with 0 being absent pulses, 1
being decreased pulses, 2 is within normal range, and 3 being increased (also
referred to as “bounding”). If unable to palpate a pulse, additional assessment is
needed. First, determine if this is a new or chronic finding. Second, if available,
use a doppler ultrasound to determine the presence or absence of the pulse. Many
agencies use doppler ultrasound to document if a nonpalpable pulse is present. If
the pulse is not found, this could be a sign of an emergent condition requiring
immediate follow-up and provider notification. See Figure 8 and Figure 9. for
images of assessing pedal pulses.
Figure 8
Figure 9
CAPILLARY REFILL
The capillary refill test is performed on the nail beds to monitor perfusion, the
amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it
pales, indicating that the blood has been forced from the tissue under the nail. This
paleness is called blanching. Once the tissue has blanched, pressure is removed.
Capillary refill time is defined as the time it takes for the color to return after
pressure is removed. If there is sufficient blood flow to the area, a pink color
should return within 2 to 3 seconds after the pressure is removed.
EDEMA
Edema occurs when one can visualize visible swelling caused by a buildup of fluid
within the tissues. If edema is present on inspection, palpate the area to determine
if the edema is pitting or nonpitting. Press on the skin to assess for indentation,
ideally over a bony structure, such as the tibia. If no indentation occurs, it is
referred to as nonpitting edema. If indentation occurs, it is referred to as pitting
edema. See Figure 10 for images demonstrating pitting edema.
Figure10
1010101
Note the depth of the indention and how long it takes for the skin to rebound back
to its original position. The indentation and time required to rebound to the original
position are graded on a scale from 1 to 4. Edema rated at 1+ indicates a barely
detectable depression with immediate rebound, and 4+ indicates a deep depression
with a time lapse of over 20 seconds required to rebound. See Figure 11 for an
illustration of grading edema. Additionally, it is helpful to note edema may be
difficult to observe in larger patients. It is also important to monitor for sudden
changes in weight, which is considered a probable sign of fluid volume overload.
Figure 11
HEAVES OR THRILLS
You may observe advanced practice nurses and other health care providers
palpating the anterior chest wall to detect any abnormal pulsations the underlying
cardiac chambers and great vessels may produce. Precordial movements should be
evaluated at the apex (mitral area). It is best to examine the precordium with the
patient supine because if the patient is turned on the left side, the apical region of
the heart is displaced against the lateral chest wall, distorting the chest movements.
[24]
A heave or lift is a palpable lifting sensation under the sternum and anterior
chest wall to the left of the sternum that suggests severe right ventricular
hypertrophy. A thrill is a vibration felt on the skin of the precordium or over an
area of turbulence, such as an arteriovenous fistula or graft.
Table 12
Expected Apical Pulse by Age
Preterm 120-180
Table 13
Expected Versus Unexpected Findings on Cardiac Assessment
Unexpected Findings
(Document and notify the
Assessment Expected Findings
provider if this is a new
finding*)
breath
Table 14
Expected Versus Unexpected Peripheral Vascular Assessment Findings
Unexpected Findings
Assessment Expected Findings (Document or notify provider if
new finding*)
Cyanosis
Absent pulse (and not heard using
Doppler device)
*CRITICAL
Capillary refill time greater than 3
CONDITIONS to
seconds
report immediately
Unilateral redness, warmth, and
edema, indicating a possible deep
vein thrombosis (DVT)
SAMPLE FORMAT OF CARDIOVASCULAR ASSESSMENT SHEET
Date S ample
Patient Name Gender
DOB/Age
Cardiovascular History
Review of Systems/Symptoms
Social History
Postmenopausal _______
Physical Activity - Weight History ___________________
Initial diet - None AHA DASH Vegetarian Other
Alcohol Use-
Thyroid Dis - Stress Source/Mgmt
No _________________________________________
Liver Dis - Yes _________ Cancer No Yes
No ________
Yes _________ Bleeding Dis No Yes
________
LIFESTYLE & PAST MEDICAL HISTORY
Allergies
CVS EXAMINATION:
INSPECTION
Colour and texture of skin-
Any suture marks-
Any dilated engorged superficial veins-
Inspected precordium-
Visible pulsations (Apex beat)-
PALPATION
Any local rise of temperature and tenderness-
Locate apex beat-
Parasternal heave-
Thrill
PERCUSSION
Borders of heart:
Right border-
Left border-
Upper border-
Lower border-
AUSCULTATION
Cardiac areas:
Mitral areas-
Tricuspid areas-
Aortic areas-
Pulmonary area-