Assessment of

Cardiovascular System
Reymond Bicariato,RN

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Objectives
1. describe the structure and function of the cardiovascular
system, including the peripheral vascular system
2. explain developmental variations a nurse considers when
assessing the heart & neck vessels & peripheral vascular
system
3. state the specific areas considered essential in gathering
subjective data pertaining to the cardiovascular system & the
peripheral vascular system
4. demonstrate assessment of the heart, neck vessels & the PV
system

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Anatomy of the Heart
 Four Valves:
 Four Chambers:  Two atrioventricular
 Right atrium (AV)
 Left atrium
1. tricuspid
 Right ventricle
 Left ventricle
2. mitral

 Two semilunar (SL)

1. pulmonic
2. aortic

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Blood
Blood FlowFlow
through the
Heart

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Cardiac Cycle

It has two phases:

(A) Diastole – ventricles relax & fill with

blood (This is 2/3 of the
cardiac cycle.)
(B) Systolic – heart contracts & pushes
blood out of the ventricles to:
(i) the lungs
(ii) systemic arteries

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Heart Sounds
 S1 – when closure of the AtrioVentricular valves
(tricuspid & mitral) & ventricles
contract

 S2 – when closure of the semilunar

valves ( pulmonic & aortic) &
the ventricles relax

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Extra Heart Sounds
S3 – This occurs immediately after S2
Why? Resistance to filling of ventricles
Note: also called a ventricular gallop
*It is caused by overload.
* use diaphragm (it is a high sound)
S4 - This occurs at the end of diastole, just
before the next S1.
Why? The atrium contract & push blood into
a non-compliant ventricles.
Note: also called an atrial gallop
*caused by Hypertension,Aortic stenosis, cardiomyopathy
* Use bell to listen as it is a low sound.

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Murmurs
 Caused by “turbulence”
Therefore we hear a gentle blowing, swooshing sound.
 Why?

1. Velocity of blood increases

(eg. exercise)
2. Velocity of blood decreases (eg. anemia)
3. Structural defect in the valves or an unusual
opening occurs in the chambers

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Grading of Murmurs
Use VI point grading scale & record as a fraction
(ie. I/VI or II/VI)

Grades:
Grade I – barely audible, heard only in a quiet room & then with
difficulty
Grade II – clearly audible, but faint
Grade III – moderately loud, easy to hear
Grade IV – loud, associated with a thrill palpable on the chest wall
Grade V – very loud, heard with one corner of the stethoscope lifted
off the chest wall
Grade VI – loudest, still heard with the entire stethoscope lifted off
the chest

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The Neck Vessels
 The Carotid Artery

 The Jugular Venous Pulse & Pressures

2 components: (a) internal jugular
(b) external jugular

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Subjective Data
1. chest pain
2. dyspnea
3. Orthopnea
4. Cough
5. Fatique
6. cyanosis or pallor
7. edema
8. nocturia
9. past cardiac history
10. family cardiac history
11. personal habits
12. environment

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Preparation for Assessment
 Room that is warm & “quiet”
 Examining table positioned so you can
stand on the patient’s right side
 Patient Gown
 A watch with a second hand
 Stethoscope with diaphragm & bell
 Tape measure

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Recommended Sequence
for assessing cardiovascular system
1. Pulses & BP
2. Extremities
3. Neck Vessels
4. Precordium

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The Neck Vessels
A. Carotid Arteries
 Palpate low in neck to avoid the sinus
 Be gentle
 Palpate only one side at a time to avoid
compromising blood flow to the head
 Auscultate using the bell
 Listen in 3 places: angle of jaw
midcervical area
base of neck

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Assessment of the Jugular Vein
 Purpose: To measure the
“central venous pressure”
 Method: Position patient @ 45 degree
angle at the hip
Turn head slightly away
Use a strong light tangentially
Observe the external jugular over the
sternomastoid muscle

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 Specific Process for Central Venous
Pressure Measurement
 Locate the internal jugular pulsation
 Mark the highest point of pulsation
 Locate the “angle of Louis”
 Make a “T square” with 2 index cards
 Read the level of intersection

Note: The normal jugular venous pressure is

2 cm or less above the sternal angle.

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Hepatojugular Reflux
 This is measured if the CVP is elevated or CHF is
suspected.
 Patient is supine
 Instruct patient to breathe quietly with mouth open
 With rt. hand on the patient’s RUQ of abdomen,
just below the rib cage, exert firm consistent
pressure for 30 seconds
 Watch the level of the jugular pressure
 Note: Normally the jugular rises but recedes back.
 Abnormally, the pressure elevates & stays.

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The Heart ( Precordium)
 Inspection: Check pulsations, heaves, lifts
(You may see the apical pulse.)
Note: The apical is located in the 4th or 5th
Intercostal space @ the left Midclavicle
level.
 Palpate: Feel the apical impulse . Use 1 finger
pad.
Use palmar side of 4 fingers to feel for
other pulsations on the chest.
(eg. “thrills”

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Heart Assessment (continued)
Percussion: To check for heart
enlargement
(Note:often done by chest X-ray)
Auscultation: Start at the base of the heart.
“APE to Man”
Aortic - 2nd Rt. ICS
Pulmonic – 2nd left ICS
Erb’s Point
Tricuspid – left sternal border
Mitral – 5th ICS @ left Midclavicle level.

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Sequence for Auscultating
A. Begin with the diaphragm.
 Note at each area:

1. rate & rhythm

2. identify S1 and S2
3. assess S1 and S2 separately
4. listen for extra heart sounds (ie. S3,S4)
5. listen for murmurs
B. Repeat above using the bell.

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What do you hear?
 S1 and S2 sound like “lub-dup”
 S1 is louder than S2 at the apex
 S2 is louder than S1 at the base
 S1 coincides with the carotid pulsation

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Assessment of the
Peripheral Vascular System
 Arteries assessed in cephalocaudal direction:

 Head – temporal
carotid
 Arms – brachial
ulnar
radial
 Legs – femoral
poplitial
 Feet - dorsalis pedis
posterior tibialis

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Assessment of Veins
 Neck – Jugular veins
 Arms – Superficial
Deep
 Legs - Deep veins – femoral, popliteal
Superficial veins:-
great saphenous (inside of leg)
small saphenous (outside of leg)
Perforators – join the above 2 sets
 Note: The veins have valves that keep blood moving toward
the heart. However, you need exercise too.

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Lymph Nodes
Superficial nodes available for palpation:
1. Cervical nodes
2. Axillary nodes
3. Epitrochlear Nodes
4. Inguinal nodes

Also organs –
 Spleen - assessed in abdomenal exam
 Tonsils – assessed with head & neck
 Thymus (behind sternum)

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Subjective Data for Peripheral
Vascular System
 Leg pain
 Skin changes
 Swelling in arms & legs
 Lymph node enlargement
 Medications
 Smoking

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Techniques used to assess the
Peripheral Vascular System
Arms: Inspection
Palpation – radial, ulnar, brachial,
epitrochlear lymph nodes
* perform the Allen Test
The Allen Test
1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds.
2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the
finger nails).
4) Ulnar pressure is released and the color should return in 7 seconds.
Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial
If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not
sufficient and the radial artery therefore cannot be safely pricked/cannulated.

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Techniques used to assess the
Peripheral Vascular System( Cont.)
Legs: Inspection
* If calf pain, check the Homan’s sign
Palpation – femoral, poplitial, dorsalis
pedis, posterior tibialis
* If pretibial edema, press over tibia or
medial malleolas for 5 seconds
* Use rating scale

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 An Additional Test
If there is a color change in the lower
extremities…
 Elevate the legs 30 cms (12 inches)
 Have patient wag feet to drain blood
 Sit patient up with legs over side of table
 Note the time it takes for color to return.
 Normally, the color returns in 10 seconds.

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 Thank You…..

The end
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