Chapter objectives: At the end of this chapter, the learner will:

1. Obtain health history related to the heart and peripheral vascular systems.
2. Perform physical assessment of the heart and the peripheral vascular system using correct techniques.
3. Document findings of cardiac and peripheral-vascular assessment.

I. Overview of the Cardiovascular System

The assessment of the cardiovascular system will include examinations of the peripheral vascular system by assessing the color, temperature, edema, capillary refills, and peripheral pulses and examinations of the heart by inspecting, palpating and auscultating the landmarks of the heart.

II. Anatomy and Physiology

Click the link below to review anatomy and physiology of the circulatory system. In the assessment process, you will need to apply your knowledge of the A & P to the heart and peripheral vascular system.

• Circulatory system and the heart

III. Medial Terminology

IV. Step by Step Assessment

• Perform hand hygiene.
• Check room for contact precautions.
• Introduce yourself to patient.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain process to patient.
• Assemble equipment prior to starting exam.
• Be organized and systematic in your assessment.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Apply principles of asepsis and safety.
• Check vital signs.

Steps	Additional Information
1. Conduct a focused interview related to cardiovascular and peripheral vascular disease.	Ask relevant questions related to chest pain, palpitations, shortness of breath (dyspnea), cough, edema, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes.
2. Inspect: Face, lips, and ears for cyanosis Chest for deformities, scars, visible pulsations Bilateral arms/hands, noting color, warmth, movement, sensation (CWMS), edema, color of nail beds, nail shape, and capillary refill Bilateral legs, noting CWMS, hair distribution, edema to lower legs and feet, color of nail beds, and capillary refill, numbness/tingling calf size/pain for signs of deep venous thrombosis (DVT)	Cyanosis is an indication of decreased perfusion and oxygenation. To check capillary refill, squeeze nails or pads of fingers until they blanche; release compression and observe how many seconds the original color returns. Normal is 2 seconds or less. Assess capillary refill Assess bilateral lower legs. Alterations and bilateral inconsistencies in CWMS may indicate underlying conditions or injury. While checking for capillary refill, inspect the nail base angle. The normal angle of the nail base is 160 degrees. Assessing for Clubbing Fingers  However, if the angle of nails become greater than 160 degrees, they are called clubbing fingers. Clubbing fingers are related to chronic hypoxemia.   Sudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of DVT, as is increased warmth, redness, tenderness, and swelling in the calf.   Note: DVT requires emergency referral because of the risk of developing a pulmonary embolism.
3. Auscultate: Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral Auscultate apical pulse for one minute. Note the rate and rhythm.     Heart Sounds (text and video)	Have the patent breathe normally. Use the diaphragm side of the stethoscope to hear the five landmark areas: Aortic Area – 2nd ICS on the right sternal border. Pulmonic Area – 2nd left ICS ERB’s Point – 3rd left ICS Tricuspid Area – 5th left ICS. Mitral Area (Apical) – 5th left ICS medial to the MCL Auscultate for rate, rhythm, and pitch (the quality of the sound). Auscultate apical pulse at the fifth intercostal space and midclavicular line. Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.
4. Palpate: Inspect and palpate of the heart Bilateral radial, brachial, dorsalis pedis, and posterior tibialis pulses. Skin turgor edema	The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills.Inspect and palpate for: Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow. The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded). Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place.   To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing Edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema.  Documenting Pitting Edema
5. Report and document assessment findings and related health problems according to agency policy.	Accurate and timely documentation and reporting promote patient safety.

V. Documentation of Assessment Findings

A sample of the narrative documentation:

A & Ox4, patient appears comfortable in bed. Chest is symmetrical expansion with respiration, no scars. No cardiac heaves or lifts. No thrills is palpated. PMI noted at fifth intercostal space and midclavicular line. Normal S1 and S2 with regular rate and rhythm. No rashes, swelling, color change, or cyanosis in arms or legs. No clubbing in fingernails. Capillary refill is < 2 sec. Hands and feet pink and warm to touch. No pitting edema in feet.

VI. Related Laboratory Values and Diagnostic Findings

Some blood tests related to the cardiovascular system are seen frequently, for example, cholesterol tests which measure the levels of fat and cholesterol in the bloodstream. When serum cholesterol are high, the patient will be at risk for cardiovascular problems.  When there is an abnormal finding in the physical assessment,  the patient may need to have additional diagnostic procedure(s) to further identify a potential cardiovascular disease. These diagnostic cardiac tests could be non-invasive, such as electrocardiogram (ECG or EKG), uses to record the electrical activity of the heart; Holter Monitoring (or Ambulatory ECG), can record the electrical activity during daily activity; chest X-ray, examines the size of the heart; echocardiogram, uses high-frequency sound waves to view the size/structure/motion of the heart; exercise stress test (or treadmill test), can be used to examine the heart function while exercise on treadmill. Diagnostic tests could be invasive, such as  cardiac catheterization or coronary angiogram to check heart abnormalities or coronary artery problems.

• Cardiac Diagnostic Test

VII. Learning Exercises

VIII. Attributions and References

• Khan Academy https://www.khanacademy.org/science/health-and-medicine/circulatory-system/circulatory-system-introduction/v/circulatory-system-and-the-heart author by Sal Khan
• Step by Step Checklist adapted from https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ by authors Glynda Rees Doyle and Jodie Anita McCutcheon
• Chandrasekhar, A. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep75.htm
• File:Acopaquia.jpg. (2014, March 4). Wikimedia Commons, the free media repository. Retrieved 23:54, August 29, 2019 from https://commons.wikimedia.org/w/index.php?title=File:Acopaquia.jpg&oldid=118072980.
• Anthony J. Busti (2016). https://www.ebmconsult.com/articles/pitting-edema-assessment
• https://www.textbookofcardiology.org/wiki/Physical_Examination%23Cardiac_Auscultation
• Heart Sounds  https://vault.lumc.edu/videos/videojump.cfm?hd=1&ID=128F2A83-7ECB-43E2-8F33-32DA6F6C3F36 by Drs. Michael Gibson & Cafer Zorkun
• Cardiac Diagnostic Tests https://medlineplus.gov/hearthealthtests.html