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Focused Cardiovascular Assessment

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Acknowledgements
RN.comacknowledgesthevaluablecontributionsof
NadineSalmon,MSN,BSN,IBCLC,theClinicalContentSpecialistforRN.com.NadineisaSouthAfrican
trainedRegisteredNurse,MidwifeandInternationalBoardCertifiedLactationConsultant.Nadine
obtainedanMSNatGrandCanyonUniversity,withanemphasisonNursingLeadership.Herclinical
backgroundisinLabor&DeliveryandPostpartumnursing,andshehasalsoworkedinMedicalSurgical
NursingandHomeHealth.Nadinehasworkexperienceinthreecountries,includingtheUnitedStates,
theUnitedKingdomandSouthAfrica.SheworkedfortheinternationalnursedivisionofAmerican
MobileHealthcare,priortojoiningtheEducationTeamatRN.com.NadineisanurseplannerforRN.com
andisresponsibleforallclinicalaspectsofcoursedevelopment.Sheupdatescoursecontenttocurrent
standards,anddevelopsnewcoursematerialsforRN.com.
LoriConstantineMSN,RN,CFNP,theoriginalauthorofthiscourse.

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Purpose&Objectives
Thiscoursediscussesspecificcardiovascularhistoryquestionsandexamtechniquesforyouradult
patient.Physicalexamtechniquessuchasinspection,palpation,percussion,andauscultationwillbe
highlighted.Additionally,throughoutthecourseyouwilllearnhowalterationsinyourcardiovascular
assessmentfindingscouldindicatepotentialcardiovascularproblems.
Aftersuccessfulcompletionofthiscourse,youwillbeableto:
1. Outlineasystemicapproachtocardiovascularassessment.
2. Discusshistoryquestionsthatwillhelpyoufocusyourcardiovascularassessment.
3. Recognizeabnormalcardiovascularassessmentfindingsassociatedwithinspection,
auscultation,percussion,andpalpation.

Introduction
Cardiovasculardiseaseistheleadingkillerforbothmenandwomenamongallracialandethnicgroups
intheU.S.AccordingtotheCentersforDiseaseControl(CDC)studiesamongcoronaryheartdisease
patients,90%ofpatientshavehadpriorexposuretoatleastoneheartdiseaseriskfactorthat
contributedtotheirdisease.
Athoroughcardiovascularassessmentwillhelptoidentifysignificantfactorsthatcaninfluence
cardiovascularhealthsuchashighbloodcholesterol,cigaretteuse,diabetes,orhypertension(CDC,
2011).Therefore,acardiovascularexamshouldbeapartofeveryabbreviatedandcomplete
assessment.
Afocusedcardiovascularassessmentisusuallyindicatedafteracomprehensiveassessmentindicatesa
potentialcardiovascularproblem.Thefocusedcardiovascularassessmentisalsoindicatedwhenan
intervalorabbreviatedassessmentshowsachangeinstatusfromyourpreviousassessmentorthe
reportyoureceived,whenanewsymptomemerges,orthepatientdevelopsanydistress.
Anadvantageofthefocusedassessmentisthatitallowsyoutoaskaboutsymptomsandmovequickly
toconductingafocusedphysicalexam.Basedupontheresultsofyourassessment,youmaychoosehow
oftentoperformintervalassessmentstomonitorthepatientsidentifiedproblem.Keepinmindthatall
assessmentsshouldconsiderpatientsprivacyandfosteropen,honestpatientcommunication.

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History
Thepurposeofthecardiovascularhealthhistoryistoprovideinformationaboutyourpatients
cardiovascularsymptomsandhowtheydeveloped.Acompletecardiovascularhistorywillgiveyou
indicationstopotentialorunderlyingcardiovascularillnessesordiseasestates.Obtaininga
cardiovascularhistorywillguideyouthroughyourfocusedphysicalexam.Inadditiontoobtainingdata
aboutthepatientscardiovascularstatus,youshouldobtaininformationaboutotherfactorsthatcan
impactphysicalstatusincludingspiritualneeds,culturalidiosyncrasies,andfunctionallivingstatus.
PastHealthHistory
Itisimportanttoaskquestionsaboutyourpatientspasthealthhistory.Thepasthealthhistoryshould
elicitinformationaboutthefollowingissues:hypertension,elevatedbloodcholesterolortriglycerides,
heartmurmurs,congenitalheartdisease,rheumaticfeverorunexplainedjointpainsasachildoryouth,
recurrenttonsillitisandanemia.Youwillalsowanttoaskaboutthepatientshistoryofheartdisease,
whenandhowitwastreated,lastEKG,stresstests,andserumcholesterollevels.Askthepatientthe
reasonsforanyprevioushospitalizationsandthenatureofthetreatmentsreceivedwhileinthe
hospital.Askaboutcardiaccatheterizations,echocardiograms,stresstests,
andcardiacsurgeries(Kaplow&Hardin,2007).
CurrentLifestyleandPsychosocialStatus
Currentlifestyleandpsychosocialissuestoexplorewhenconductingyourfocusedcardiovascularhealth
historyinclude:

Nutrition:Haveyourpatientdescribetheirdailydiet.Askabouttheirusualweightandany
recentweightgainorweightloss.

Smoking:Askyourpatientiftheysmokecigarettesorothertobacco.Ascertainthepackperyear
smokinghistory.Thisisdonebymultiplyingthenumberofyearsyourpatienthassmokedwith
thenumberofpacksperdaytheyhavesmoked(CancerTreatmentCentersofAmerica,2011).

Alcohol:Askhowmuchalcoholthepatientnormallydrinksperdayorperweek.Askabout
whenthelastdrinkwasandtheusualnumberofdrinks
perepisode.

Exercise:Askaboutyourpatient'sactivitylevelandusualamountofexercisedonedailyor
weekly.Askwhattypeofexercisetheyparticipatein.

Drugs:Askyourpatientaboutallmedicationtheytakeincludingantihypertensives,beta
blockers,calciumchannelblockers,digoxin,diuretics,aspirin,anticoagulants,overthecounter
drugs,herbalsupplements,orstreetdrugs.
SmokersPackPerDayHistory
2packsperdayx10years=20packyearhistory
1packperdayx20years=20packyearhistory
3packsperdayx7years=21packyearhistory

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FamilyHistory
Familyhistoryisanimportantfactorusedinidentifyingyourpatientsriskforcertaincardiovascular
diseases(Kaplow&Hardin,2007).
Askyourpatientaboutanycardiovascularfamilyhistorysuchashypertension,obesity,diabetes,
coronaryarterydisease,orsuddendeath.
TestYourself:
Whichofthefollowingdiseasesisassociatedwithcardiovasculardisease?
A.
B.
C.
D.

Hypothyroidism
LungCancer
Diabetes(correct)
InflammatoryBowelDisease

AssessmentofChestPainUsingPQRSTMnemonic

When examining the cardiovascular system, the mnemonic PQRST, is very useful in
assessing chest pain. It provides a methodology in which communication to other
healthcare providers will be most efficient and informative.
Assess the following characteristics with each new report of pain and following any
intervention:
(P) Provocative or Palliative: What makes the symptom(s) better or worse?
(Q) Quality: Describe the symptom(s).
(R) Region or Radiation: Where in the body does the symptom occur? Is there
radiation or extension of the symptom(s) to another area of the body?
(S) Severity: On a scale of 1-10, (10 being the worst) how bad is the symptom(s)?
(T) Timing: Does it occur in association with something else (e.g. eating, exertion,
movement)?

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ProvocativeorPalliativeFactors
Askthepatientaboutwhatstartsorworsensthepain.Chestdiscomfortprovokedbyexertionisaclassic
symptomofangina,althoughesophagealpaincanalsoresultfromexertion.Otherfactorsthatmay
provokeischemicpaininclude:
Cold
Emotionalstress
Sexualintercourse
Smoking
Meals

However,discomfortthatreliablyoccurswitheatingismostlikelyrelatedtoanuppergastrointestinal
disease.Painmadeworsebyswallowingislikelyofesophagealorigin.

Factorsthatinfluencepainshouldalsobeestablished.Painthatrespondstosublingualnitroglycerinor
cessationofactivitystronglysuggestsacardiacischemicetiology,whilepericarditispaintypically
improveswithsittingupandleaningforward.
PracticePearl
Patientswithahistoryofcoronaryheartdiseasetendtohavethesamequalityofchestpainwith
recurrentepisodes.

QualityofPain
Thepatientwithmyocardialischemiaoftendeniesfeelingchestpainandmaydelayseeking
treatment.Typicaldescriptionsofchestpainfrommyocardialischemiamayinclude:
SqueezingAbandlikesensationisfeltaroundthechest.
TightnessThereisasensationofaknotbeingpresentinthecenterofthechest.
PressureAsensationofalumpinthroatoraheavyweightonthechest.
ChestConstrictionTheLevinesignisdisplayedbyapatientsufferingfromchestpaincausedbya
myocardialinfarction.Thepatienttypicallypressesaclenchedfistagainstthechesttoillustratethe
sensationofpressureandconstrictioninthechest.
BurningInfarctionpainisoftenmistakenforheartburnorindigestion,especiallyinwomen.

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RegionorRadiationofPain
Painthatlocalizestoasmallareaofthechestismorelikelytoberelatedtoachestwallorpleuralorigin
ratherthantheheart.
Ischemiccardiacpainisadiffusetypeofnonlocalizedpain.
Thepainofmyocardialischemiaoftenradiatestotheneck,throat,lowerjaw,teeth,upperextremities,
orshoulder.
Ifthechestpainisradiatingtoseveralareas,thereisanincreasedchancethatthepatientishavinga
myocardialinfarction(MI).
SeverityandAssociatedSymptoms
Usinga10pointnumericpainratingscaleorvisualanalogscaleoftenhelpspatientsdescribethe
intensityofpain.The10pointscoregradespaininseverityrangingfrom0(nopain)to10(most
excruciating).Theseverityofpaindoesnotnecessarilycorrelatewiththedegreeofischemia.Asmany
as1/3ofmyocardialinfarctionsmaygoundetectedbythepatient.Somepatientshavedifficultyputting
anumberonthepaininwhichcaseanadjectiveratingscalemaybemosthelpful.TheNumericPain
Scalebelowisarepresentationofonesuchnumericalscale.
NumericalPainScale

SeverityandAssociatedSymptoms
Othersymptomsthatmaybeassociatedwithmyocardialischemiamayinclude:

Nausea
Vomiting
Diaphoresis
Syncope
Palpitations
Exertionaldyspnea
Fatigue
Weakness
Dizziness
Lightheadedness

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Timing
Knowingtheonsetofchestpainisimportanttohelptodeterminethecauseandtreatmentofthepain.
Ischemicpainismostoftengradualwithanincreasingintensityovertime.Acrescendopatternofpain
canalsobecausedbyesophagealdisease.Painassociatedwithpneumothorax,aorticdissection,or
acutepulmonaryembolismtypicallyhasanabruptonsetwiththeinitialsensationbeingthemost
intense.
Understandingthedurationofpainandanypatternsarealsohelpful.Thepainfrommyocardial
ischemiagenerallylastsforafewminuteswhereasthepainfromanMImaybemoreprolonged.Chest
discomfortthatonlylastsforafewsecondsorpainthatisconstantfordaysorweeksisnotgenerally
duetoischemia.Myocardialischemiamayhaveacircadianpattern.Itismorelikelytooccurinthe
morningthanintheafternoon,correlatingwithanincreaseinsympathetictone.However,thispattern
maynotbeexhibitedinpatientswithdiabetesorpatientstakingbetablockersasthepatients
sympathetictoneisaltered.
Ifthepatientisunabletoqualifyandquantifytheirpain,thefollowingquestionsmaybeusefulin
gettingneededinformationregardingtheirpain.

Whatgetsthepainstarted?
Whathelpsthepainstop(rest,sittingupandleaningforward)?
Wouldyoudescribeitasmoreofadullpressureorsqueezingormoreofasharp,stabbing,or
rippingfeeling?
Doesthispainfeelsimilartowhenyouhadyourpreviousheartattack?
Isthepainmostlyinoneareaordoyoufeelitupintoyourneckandarms?
With0beingnopainand10beingthemostexcruciatingpainever,whatnumberwouldyou
givethepaintodescribetheseverity?
Whenapplyinganumberisdifficult:Wouldyoudescribethepainasmild,moderate,or
severe?
Areyoufeelingnauseous,dizzy,lightheaded,shortofbreath,ortired?
Doesthepainstartoffgraduallyandgetworse,orviceversa?
Howlongdoesthepainlast?
Whendoesthepainusuallyoccurmorning,afternoon,ornight?

ChestPainintheElderly
Itshouldbenoted,however,thattypicalclinicalmanifestationssuchaschestpainoccurinonly50%of
elderlypatientswithcoronaryarterydisease(CAD)(Milner,2001).Whenpainispresentinanolder
patientitisfrequentlyvagueandpoorlylocalizedorlocalizedtotheabdomenorepigastricarearather
thanthesubsternalarea.Elderlypatientsexperiencinganginaormyocardialischemiamaydescribetheir
symptomssimplyas:exertionaldyspnea(mostcommon),fatigue,syncope,nausea,anorexia,confusion,
ordyspneaatrest.

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TestYourself:
Chestpainintheelderlyisusuallywelldefined.
A. True
B. False(Correct)

OtherSymptoms:Dyspnea
Dyspnea(shortnessofbreath)thataccompanieschestpainmayalsobeduetoanumberofpulmonary
disorders.
Askyourpatientthefollowingquestionsrelatedtodyspnea:

Doyouevergetshortofbreath?
Whattypesofactivityandhowmuchactivitybringsontheshortnessofbreath?
Doestheshortnessofbreathcomeonsuddenlyorunexpectedly?
Doesthedyspneacomeandgoorisitconstant?
Istheshortnessofbreathassociatedwithchangeinposition?
Doestheshortnessofbreathwakeyouupatnight?
Doestheshortnessofbreathinterferewithactivitiesofdailyliving?
PracticePearl
Paroxysmalnocturnaldyspnea(PND)occursatnightwithcongestiveheartfailure.Layingdown
increasesthevolumeofthoracicblood.Theweakenedheartcannotaccommodatethisgreater
volume.Yourpatientwillcomplainofsleepingforabouttwohoursandthenarisingsuddenly
needingfreshair.

OtherSymptoms:OrthopneaandCoughing
Orthopnea
Askyourpatienthowmanypillowsheorshesleepsonatnight.Orthopneaistheinabilitytobreathe
wheninalyingposition.
Cough
Doesyourpatienthaveaconsistentcough?Havethepatientdescribethefrequency,timing,severityof
cough,andanysputumproduction.Ifthepatientdoeshavesputumproductionaskaboutthecolorof
thesputum,ifithasanodor,andifitisbloodtinged.
PracticePearl
Hemoptysisisoftenpulmonaryinnature,butmayoccurwithcardiogenicpulmonaryedema.

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OtherSymptoms:Fatigue,Edema,CyanosisandPallor
Fatigue
Askyourpatientiftheytireeasily.Ifso,askaboutwhenthefatiguestarted.Wasitsuddenorgradual?
Hastherebeenanyrecentchangeinenergylevel?Alsoaskaboutthetimeofthedaythefatigueis
relatedto,e.g.allday,morningoreveningtoestablishthepresenceofacircadianrhythm,whichmay
indicateischemia.
PracticePearl
Cardiacrelatedfatigueisworseintheevening.Fatiguetoanxietyordepressionoccursalldayoris
worseinthemorning.
Edema,Cyanosis,andPallor
Doesyourpatienthaveanyswellingorskincolorchanges?Cyanosisorpalloroccurswithmyocardial
infarctionorlowcardiacoutput.Ifthepatienthasswelling,askaboutitslocation.Isitinthefeetand
legs?Ifso,whenwasitfirstnoticed?Askaboutanyrecentchangeintheswelling,ifitisunilateralor
bilateral,andiftheswellingsubsidesaftersleepingorrestingwithfeetup.Alsoaskaboutany
associatedsymptomswiththeswellingsuchasdyspnea.
PracticePearl
Cardiacrelatededemaisworseintheeveningandbetterinthemorningafterrestingwiththefeet
up.

OtherSymptoms:Nocturia
Doesyourpatientgetupatnighttourinate?Askhowlongthishasbeenoccurringandiftherehave
beenanyrecentchangesinthispattern.
PracticePearl
Recumbencypromotesfluidreabsorptionandexcretion.Nocturiaoccurswithheartfailureinthe
patientwhoisambulatoryduringtheday.

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Pediatric,Pregnant,andAgingPatients
Additionalhistoryquestionsyoumaywishtoaskregardingyourinfant,pediatric,pregnant,oraging
patientarelistedontheleftsidebuttons.
ContentadaptedfromJarvis,1996.
AdditionalHistoryforInfants

Mothershealthduringpregnancy?Unexplainedfeverorrubellainthefirsttrimester?Other
infections,hypertension,drugstaken?
Evernoticedanycyanosiswhilefeeding,nursingorcrying?
Doesthebabyeatorplaywithouttiring?
Isthebabygrowingaccordingtonormalforageandgender?
Werethebabysmotormilestonesachievedasexpected
Howmanynapsperdayandlengthofnaps?

AdditionalHistoryforChildren

ActivityIsthechildabletokeepupwithsameagedplaymates?Isthechildwillingorreluctant
toplay?Doesthechildpreferquietplay?Doesthechildeverhavebluespells?
Anyunexpectedjointpainorunexplainedfever?
Doesthechildhavefrequentheadachesornosebleeds?
Doesthechildhavefrequentrespiratoryinfections?Anyproventobestrepinfections?
Anyfamilyhistoryofcongenitaldiseases?
Anyoneinthefamilywithchromosomalabnormalities?

AdditionalHistoryforPregnantPatients

BloodPressureDidyouhavehighbloodpressureinthisorotherpregnancies?Whatwasyour
bloodpressurebeforeyourpregnancy?
Hasyourpressurebeenmonitoredinthispregnancy?
Anyproteinintheurine?
Anyexcessiveweightgain?
Haveyouhadanyswellinginthefeet,legsorface?
Haveyouexperiencedanyfaintnesswiththispregnancy?
Haveyouexperiencedanydizzinesswiththispregnancy?

AdditionalHistoryforElderlyPatients

HeartandLungdiseaseIsthereahistoryofheartdisease,hypertension,coronaryartery
disease,emphysema,bronchitis?
Doyoutakeanymedicationsforyourillness?
Whatarethesideeffectsofthemedication(s)?
Haveyourecentlystoppedtakinganyofyourmedications?Ifso,whichonesandwhy?

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Doyourillnessesinterferewithyouractivitiesofdailyliving?
Doesyourhomehaveanystairs?Howoftendoyouneedtoclimbthem?

ThePhysicalExam
Whenassessingthecardiovascularsystem,othersystems,suchasthecirculatoryandrespiratory
systems,alsoneedtobeevaluatedtoprovideacomprehensiveandholisticpicture.
Inperformingacardiacassessment,avisualunderstandingoftheheartmaybeuseful:
A:Aorta
B:Leftventricle
C:Rightventricle
D:Pulmonaryartery

ThecoronaryarteryRamusinterventricularisanteriorcanbeseeninthegroove(sulcus
interventricularis)betweentheventricles.
(wikimedia.org,2007)

AssessmentofTheNeckVessels:Inspection
Wheninspectingtheneckvessels,lookforanyabnormalitiesyoucanobservewithyoureyes,ears,or
nose.
Themostimportantobservationtobemadeintheneckregionistheassessmentofjugularvenous
pulse.Fromthejugularveinsyoucanestimatecentralvenouspressure(CVP)andestimatethehearts
efficiencyasapump.
Ataglance,ifthepatientissittinginthesupinepositionat45degreesorhigher,youshouldnotbeable
toseejugularvenouspulsationsunlessthereisunderlyingpathology.

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AssessmentofTheNeckVessels:Auscultation
Whenauscultating,ensureyourroomisquiet,auscultateoverbareskin,andlistentoonesoundata
time.Yourbellordiaphragmshouldbeplacedonyourpatientsskinfirmlyenoughtoleaveaslightring
ontheirskinwhenremoved.Beawarethatyourpatientshairmayalsointerferewithtrue
identificationofcertainsounds.Thediaphragmisusedtolistentohighpitchedsoundsandthebellis
bestusedtoidentifylowpitchedsounds(Kaplow&Hardin,2007).Also,remembertocleanyour
stethoscopebetweenpatients.
Auscultatethecarotidarteriesinpersonsmiddleagedorolder,orthosewithahistoryofcardiovascular
disease.Youarelisteningforthepresenceofabruit,whichisablowingorswishingsound,indicating
turbulentbloodflow.Youmayneedtoaskyourpatienttoholdtheirbreathforashorttimesothatyou
donotconfusetrachealbreathsoundswithabruit.Typically,abruitisabsent.

TestYourself:
Abruitisoftenconfusedwith:
A.
B.
C.
D.

Rales
Crackles
Wheezes
Trachealbreathsounds(Correct)

AssessmentofTheNeckVessels:Palpation
Palpation,anothercommonlyusedphysicalexamtechnique,requiresyoutotouchyourpatientwith
differentpartsofyourhandusingdifferentstrengthpressures.Duringlightpalpation,youpresstheskin
aboutinchto3/4inchwiththepadsofyourfingers.Whenusingdeeppalpation,useyourfingerpads
andcompresstheskinabout1inchesto2inches.Palpationallowsyoutoassesstheneckfor
tenderness,abnormaltemperature,excessivemoisture,pulsations,ormasses.
Palpatethecarotidarteriesverygentlyandneveratthesametime.Feelthecontourandamplitudeof
thepulse.Normally,thecontourissmoothwitharapidupstrokeandnormalstrength(+2).Findings
shouldbesimilarbilaterally.
Therightbundlebranchspreadsthewaveofdepolarizationtotherightventricle.Likewise,theleft
bundlebranchspreadsthewaveofdepolarizationtoboththeinterventricularseptumandtheleft
ventricle.Theleftbundlefurtherdividesintothreebranchesorfasicles.Thebundlebranchesfurther
divideintoPurkinjefibers.

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CirculatoryAssessment:Inspection
Performingavisualassessmentofthecirculatorysystemisanimportantcomponentofa
comprehensivecardiovascularassessment.Areasforevaluationyoumayinspectincludeskincolor,
locationofanylesions,bruisesorrash,symmetryofmotion,sizeofbodyparts,andanyabnormal
findings,sounds,andodors.
Beginbyinspectingthepatientsskinforcolor,warmth,andmoisture.Cool,clammyskinresultsfrom
vasoconstriction.Warm,moistskinresultsfromvasodilation.Flushingofapatientsskinmaybedueto
medications,excessheat,anxiety,orfear.Pallorcanresultfromanemiaorincreasedperipheralvascular
resistancecausedbyatherosclerosis.Dependentrubor(redness)maybeasignofchronicarterial
insufficiency.Peripheralcyanosismaycauseabluishdiscolorationtothelipsandextremities.Inspect
theoralmucousmembranesforcyanosisthatmaynotbereadilyapparentontheskin.Examine
underneaththetongue,insidethecheeks,andthenailbedsforsignsofperipheralcyanosis.
Therearetwotypesofcyanosisthatmayoccurincompromisedpatients:centralandperipheral.Central
cyanosisisconsistentwithreducedoxygenintakeortransportfromthelungs.Peripheralcyanosis
suggestsconstrictionoftheperipheralarteries.Thisisusuallyfromstress,cold,oranxiety.Itmayalso
befromhypovolemia,shock,orvasoconstrictivediseases.
Notethepresenceofanyedema.Inspectyourpatientshairdistributionontheirskin.Lackofhairmay
alsoindicatearterialinsufficiency.
Next,assessarterialperfusiontothelowerextremities.Haveyourpatientliesupineonaflatsurface
andelevateoneofhislegsabovehisheartforaboutoneminute.Youmayneedtoassistwiththis
movement.Thenaskhimtositupanddanglehislegsoverthebedandinspectthecolorofbothlegs.
Thelegthatwaselevatedshouldshowslightpallorincomparisontotheotherleg.Thecolorofbothlegs
shouldbeaboutthesameinabouttenseconds,oncetheveinshavehadtimetofill.
Edemacanresultfrommanydiseaseprocessesincludingheartfailure,liverfailure,orbyvenous
insufficiency,varicosities,andthrombophlebitis.
CirculatoryAssessment:Auscultation
Auscultateyourpatientsbloodpressure.Thesystolicreadingreflectsthepressureexertedbytheleft
ventricleduringcontraction.Thediastolicreadingreflectsthepressureinthearterieswhentheheartis
atrest.
Bloodpressureislowestinthenewborn,andriseswithage,weightgain,stress,anxiety,andduring
exercise.

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CirculatoryAssessment:Auscultation
Whenauscultatingbloodpressure,besuretochooseanappropriatesizecufftoavoidfalsereadings.
Somehelpfulhintswhenassessingbloodpressureinclude:

Nevertakeabloodpressureinanarmonthesamesideasamastectomy.
Nevertakeabloodpressureinanarmwithanarteriovenousfistulaorshunt,orinanarmwitha
peripherallyinsertedcentralcatheter.
IfeitherthesystolicBPisover140orthediastolicpressureisover90onrepeated
measurements,thepatientisconsideredtohaveStage1Hypertension(highbloodpressure).
Hypertensionisriskfactorforheartdisease,stroke,andkidneydisease.
Diet,exercise,and,whennecessary,medicationscancontrolbloodpressure.

BloodPressureClassificationinAdults
Category

Systolic

Diastolic

Normal

<120

And<80

PreHypertension

120139

Or8089

StageIHypertension

140159

Or9099

StageIIHypertension

>160

Or>100

ClassificationandManagementofBloodPressureinAdults.NationalInstituteofHealth(2003).

CirculatoryAssessment:Palpation
Thenextpartofthecirculatorysystemexaminationispalpation.
Beginbypalpatingtheperipheralarteries.Theseincludethebrachial,radial,femoral,popliteal,dorsalis
pedis,andposteriortibial.
Notethecontourandamplitudeofeachpulsation.Theseshouldfeelsimilarbilaterally.
Asyoumoveawayfromthecoreofthebody,youmaynoticethatthecontourorupstrokeofthe
pulsationislessrapid.Thisisnormal,butitisimportanttoassessthatthearterieshavesimilarstrength
bilaterally.

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TestYourself:
Whenassessingnormalcirculationintheextremities,youanticipatefindingthat:
A.
B.
C.
D.

Bloodflowissimilarbilaterally.(Correct)
Thecontourandamplitudeofpulsationsaregreaterontheleftsideofthebody.
Thecontourandamplitudeofpulsationsaregreatontherightsideofthebody.
Asyoumovefurtherawayfromthecoreofthebody,thecontourpulsationsaremorerapid.

ThePrecordium:InspectionandAuscultation
Inspection
Inspecttheanteriorchestforpulsations.Youmayormaynotseetheapicalpulse.Ifitisvisible,youwill
seeitinthefourthorfifthintercostalsspace.
Auscultation
Beforeyoubeginyourauscultationoftheprecordium,prefaceyourexambytellingthepatientyouwill
belisteninginmanydifferentplacesforwhatmightbeawhile.Then,youmustidentifytheareasyou
needtoausculate.YoumaywanttoinchyourstethoscopeinaZpatternacrosstheprecordium,from
thebaseofthehearttotheapex.Concentratetothesoundofthelubandthedub.Theluborfirst
heartsoundisknownasS1.TheduborthesecondheartsoundisknownasS2.
HeartSounds:S1
S1,thelubofthelubdub,isproducedbytheclosureoftricuspidandmitralvalves.
AlterationsyoumayauscultatethatinvolveS1areasfollows:

S1isaccentuatedinexercise,anemia,hyperthyroidism,andmitralstenosis.
S1isdiminishedinfirstdegreeheartblock.
S1splitismostaudibleintricuspidarea(Tlubdub)

(Kaplow&Hardin,2007)
HeartSounds:S2
S2,thedubofthelubdub,isproducedbytheclosureofaortic&pulmonicvalves.
AlterationsyoumayauscultatethatinvolveS2areasfollows:

NormalphysiologicalsplittingofS2isbestheardatpulmonicarea.Itoccursoninspiration(lub
Tdub,lubdub).
SplittingofS2soundcanoccurwhentheaorticandpulmonaryvalvesdonotcloseatthesame
time(Kaplow&Hardin,2007).Thiscanindicatepulmonicstenosis,atrialseptaldefect,right
ventricularfailure,orleftbundlebranchblock.

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HeartSounds
ListentoactualheartsoundsusingtheAuscultationAssistant
http://www.wilkes.med.ucla.edu/intro.html
Thisgreattoolwillexposeyoutomanydifferentnormalandabnormalheartsounds.
HeartSounds:S3
Thethirdheartsoundisproducedbytherapidfillingoftheventricle(thatisnotcompletelyempty)
duringearlydiastole(Kaplow&Hardin,2007).S3isalsoknownasaventriculargallop(lubDUBtaor
Kentucky).
S3isnormalinpregnancy,children,adultslessthanthirtyyearsold,duringexercise,anxiety,oranemia.
Itisheardbestattheapexintheleftlateraldecubitusposition,usingthebell.
PathologicS3occursinpeopleovertheageof40,usuallyduetomyocardialfailure.
HeartSounds:S4
ThefourthheartsoundistypicallyheardinlatediastolebeforeS1,asaresultofincreasedventricular
resistancetoatrialfilling,duetoeitherdecreasedventricularcomplianceorincreasedventricular
volume.Itislowpitchedandbestheardwiththebell.S4isalsoknownasanatrialgallop(talubDUB
orTennessee).
S4isoftennormalinolderadultsandisheardbestattheapexintheleftlateraldecubitusposition.
PathologicalS4maybecausedbycoronaryarterydisease,hypertension,cardiomyopathy,oraortic
stenosis.
TestYourself:
Whichheartsoundisknownastheatrialgallop?
A.
B.
C.
D.

S1
S2
S3
S4(Correct)

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AbnormalHeartSoundsSummationGallop&OpeningSnap
SummationGallop
AsummationgallopisproducedwhenS3&S4mergeintoonesound.Itoftenoccursatratesgreater
than100beatsperminute.Itmayoccurinheartfailureandpericarditis.Summationgallopsoccurin
15%ofallmyocardialinfarctionsandarecommonfollowingcardiacsurgery.Theyarebestheardwith
patientleaningforward,holdingbreathafterfullexpiration.
OpeningSnap
Attheendofventricularsystole,whentheaorticandpulmonicvalvesclose,S2isproduced.
ImmediatelyafterS2,theheartrelaxes,andventricularpressurefallsbelowthatofatrialpressure.This
allowstheatrioventricularvalvestoopen.Thisisthestartofdiastole.Normally,youcannothearthese
valvesopen.However,ifthemitralvalvebecomesstenoticorabnormallynarrowedtheywillcreatean
openingsnap.Thissoundusuallyprecedesthedevelopmentofadiastolicmurmurassociatedwith
mitralstenosis.Oncethevalvebecomesseriouslyimpairedandinflexible,theopeningsnapdisappears
(Kowalak,Johnson&Sussman,2002).

AnOpeningSnapisanabnormalheartsoundduetoastenoticvalveopening.Whenanormalcardiac
valveopens,thereisnosoundcreated.
AbnormalHeartSounds:EjectionClick&MidSystolicClick
EjectionClick
Similartoanopeningsnap,anejectionclickiscausedbystenoticvalveleaflets.Thissoundisproduced
whentheaorticorpulmonicvalvesopenatthebeginningofsystole.Itisabriefhighfrequencysound
bestheardwiththediaphragmovertheaorticorpulmonaryarteryorErbspoint,orneartheapexover
themitralarea(Kowalak,Johnson&Sussman,2002).
MidSystolicClick
Amidsystolicclickoccurswhenthemitralvalvesleafletsandcordaetendenaetense.Theanterioror
posteriororbothleafletscanprolapse.Everyonceinawhilemultipleclicksoccur.Theyareheardinmid
tolatesystole.Theyarebestheardoverthetricuspidareaandtowardsthemitralarea.Theyarecrisp,
highfrequencysounds(Kowalak,Johnson&Sussman,2002).
AbnormalHeartSounds:PericardialFrictionRub&MediastinalCrunch
PericardialFrictionRub
Apericardialfrictionrubisusuallyheardbestandissometimespalpableoverthetricuspidandxyphoid
areas.Itoccurswheninflamedpericardialsurfacesrubtogether.Therubbingofthesesurfacesproduce
thecharacteristic,highpitched,gratingnoises.Todifferentiateapericardialfrictionrubfromapleural
frictionrub,havethepatientholdhisorherbreath.Whentheydothis,apericardialfrictionrubwill
continue,apleuralfrictionrubwillcease(Kowalak,Johnson&Sussman,2002).

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MediastinalCrunch
Amediastinalcrunchisproducedduetodisplacedairunderthesurfaceoftheskinnearthe
mediastinum.Patientswithmediastinalcrunchoftenhavesubcutaneousemphysema.Youcanassess
forthisbypalpatingcrepitationintheneck.Thenoisehasacrunchingqualityandisheardbestalong
theleftsternalborder.Itmaybelouderoninspiration(Kowalak,Johnson&Sussman,2002).
AbnormalHeartSounds:Murmurs
Amurmurisanabnormalheartsoundcausedbyturbulentbloodflow.Thesoundmayindicatethat
bloodisflowingthroughadamagedoroverworkedheartvalve,thattheremaybeaholeinoneofthe
heart'swalls,orthatthereisanarrowinginoneoftheheart'svessels.
Someheartmurmursareaharmlesstypecalledinnocentheartmurmurswhicharecommoninchildren
andusuallydonotrequiretreatment.
AuscultationofMurmurs
Ifyouauscultateamurmur,itisimportanttoassessanddocumentthefollowingqualitiesofthe
murmur:
Timing:Aretheysystolicordiastolic?
Anatomicallocationofmaximumintensity:Whereisthemurmurbestheard?
Frequency:Whatisthepitchofthemurmur?
Radiation:Canyouhearthemurmurinotherlocationssuchastheneckorupperchest?
Quality:Isthemurmurharsh,soft,orblowing?
Intensity:Describetheloudnessofthemurmuronascaleof1to6,asindicatedbyLevine's6point
gradingscale:

Grade

Intensity

VeryFaintEasilyMissed

QuietBarelyAudible

ModeratelyloudbuteasilyheardsameintensityasS1orS2

Loud,butusuallynothrillpresent

Veryloud,thrillpresent

HeardwithstethoscopeoffchestThrillpresent

(Lippincott,Williams&Wilkins,2005)

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TimingandQualityofCommonMurmurs
Thefollowingtabledepictsthetimingandqualityofcommonmurmurs.

ThePrecordium:PalpitationandPercussion
Palpation
Palpatetheapicalpulse,normallyinthefourthorfifthintercostalspace,midclavicularline.Itshouldbe
feltasashort,gentletap.Itcanbepalpatedinabouthalfofpeople.Itismoredifficulttopalpatein
obesepatientsorthosewiththickchestwalls.Stress,fever,anxiety,hyperthyroidism,andanemiamay
increasetheamplitudeanddurationoftheapicalpulse.Whentheapicalpulseispalpatedlowerinthe
thoraciccageandhasagreateramplitudethanexpected,itisoftenduetocardiacpathology.
Percussion
Youmayusepercussiontooutlinethecardiacborder.Typically,however,achestxraycanrevealthe
sameresults.Therearetimes,however,thatchestxraysarenotavailableandpercussionmaybeone
ofyouronlytoolstoassesscardiacsize.
Toperformeffectivepercussion,pressthedistalpartofthemiddlefingerofyournondominanthand
firmlyonthebodypart,keepingtherestofthehandoffthebodysurface.Usingthemiddlefingerofthe
dominanthand,tapquicklyanddirectlyoverthepointwheretheothermiddlefingermakescontact
withthepatientsskin.Dullnessshouldbeheardovertheareawheretheheartislocated.

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RecordingFindings
Itisimportanttoaccuratelyandthoroughlyrecordanddocumentyourfindingsfromthecardiovascular
exam.
Standarddocumentationensuresthatallmembersofthehealthcareteaminterpretthefindings
accurately.Indocumentingmurmurs,Levine'ssixpointgradingscaleisthemostaccuratewaytorecord
findings,asistheuseofastandard4pointscaletoassessanddocumentedema.
Rememberthatyourrecordingsarepartofthemedicalrecord,andshouldbeasobjectiveandaccurate
aspossible.
Conclusion
Integratingthecardiovascularhealthhistoryandphysicalexamtakespractice.Itisnotenoughtosimply
asktherightquestionsandperformthephysicalexam.Asthepatientsnurse,youmustcriticallyanalyze
allofthedatayouareobtaining,synthesizethedataintorelevantproblemfocus,andidentifyaplanof
careforyourpatientbaseduponthissynthesis.Astheplanofcareisbeingcarriedout,reassessments
mustoccuronaperiodicbasis.Howoftenthesereassessmentsoccurisuniquetoeachpatient,based
upontheirphysicaldisorder.
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