Chapter objectives: At the end of this chapter, the learner will:
- Obtain health history related to the heart and peripheral vascular systems.
- Perform physical assessment of the heart and the peripheral vascular system using correct techniques.
- 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.
III. Medial Terminology
| Angina pectoris | chest pain, a result of myocardial ischemia |
| Arteriosclerosis (Atherosclerosis) | formation of plaques of fatty material within arterial walls |
| Bradycardia | slow heart rate |
| Bruit | a blowing sound heard in auscultation over a peripheral vessel or an organ. |
| Capillary Refill Time (CRT) | time required for return of color after application of blanching pressure to a distal capillary bed |
| Cyanosis | bluish-gray discoloration of the skin |
| Diastole | period of time within the cardiac cycle in which ventricles are relaxed |
| Ecchymosis | discoloration of skin caused by leakage of blood into the subcutaneous tissue |
| Embolus | blood clot or foreign object in the circulatory system |
| Hypertension | high blood pressure |
| Korotkoff Sounds | series of sounds that correspond to changes in blood flow through an artery as pressure is relasesed |
| Myocardial infarction | heart attack |
| Palpitation | sensation of pounding or racing of the heart |
| Pitting Edema | an indentation remains after the swollen skin is pressed |
| Pulse Pressure | difference between systolic and diastolic pressure |
| Prehypertension | an elevated systolic blood pressure of 120-139 mmHg and diastolic 80-89 mmHg |
| Systole | period of time within the cardiac cycle in which ventricles contract |
| Tachycardia | rapid heart rate |
| Thrombus | blood clot |
| Deep Venous Thrombosis (DVT) | formation of a blood clot in a deep vein |
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:
|
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.
|
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:
|
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.
|
| 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.
VII. Learning Exercises
While you are obtaining the health history, your patient says to you, “I normally got up 4 or 5 times a night to pee.”
- What does this statement mean to you?
- What additional questions will you ask?
- What and how will you assess?
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