Cardiovascular System Assessment

Cardiovascular   Assessment

            Cardiovascular nursing assessment involves:

·         Careful, systematic evaluation of a patient

·         Medical, family, social, cultural, psychological, and occupational history

·         Examination of the heart and vascular system.

Cardiovascular assessment should be conducted in an organized manner.  

·         It begins with an overall evaluation of the patient, assessing the skin, nails, and extremities for general signs of circulatory compromise.

·         Palpating the pulses, evaluating the major arteries and veins, measuring the blood pressure. Assessing the heart by palpation and auscultation.

History Collection

·         Chief Complaint:

·         Do you ever have chest pressure, heaviness, or pain?

·         Do you ever feel fatigued? Tired?

·         Swelling in ankles, feet or hands? How long?

·         Experience confusion?

·         Noticed a Bluish tinge to skin, lips, and mucous membranes?

·         Experience palpitations?

·         Experience shortness of breath?

·         Felt dizzy or have fainted?

·         Any of above adversely affected your life?

·         Past Medical History:

v  Childhood and  Infectious diseases such as

(a) Rheumatic Fever

(b) Severe Streptococcal Infection

v  Major Illnesses and  Hospitalizations

Presence of co-morbidities such as DM, COPD, Kidney disease, anaemia, Hypertension Stroke, Gout, Thrombophlebitis, bleeding disorders.

·         Medications: Need to evaluate prescription as well as OTC medications. (Over the counter)

Specific drugs to ask patient about:

• Antihypertensives

• Vasodilators (Nitroglycerine)

• Cardiotonic drugs (Digoxin)

• Anticoagulants

• Bronchodilators

• Contraceptives

Diuretics

·         .Psychosocial History- Smoking and Alcohol- amount, duration.

·         Diet history/Nutrition- Cholesterol levels, Caffeine. Stress

·          Exercise Occupation- Past, Present, Job related stress.

·          Geographical Location- where one lives

·         H/o chest pain, palpitation or dizziness, swelling in the ankles and feet

·         H/o heart defect, rheumatic fever or heart surgery

·         Family h/o hypertension, MI, CAD, DM

·         H/o smoking, alcohol intake

·         Type and amount of exercise, usual food pattern

·         Evidence of changes in colour or temperature of extremities

·         H/o edema of the lower extremities

Assessment

Inspection- Inspect visible pulsation, exaggerated lifts,

Palpate apical impulse, thrills

Begin assessment from base of heart to apex

Observe the neck and precordium (aortic, pulmonic, tricuspid, apical areas and Erb’s point)

Usually no visible pulsations, except for apical impulse/ PMI. Observe for dilated neck veins

Simultaneously inspect and palpate the precordium for abnormal pulsations, lifts, or heaves.

Locate the valve areas of the heart: Locate the angle of Louis. It is felt as a prominence on the sternum.  Move fingertips down each side of the angle until can feel the second intercostal spaces.

 The client's right second intercostal space is the aortic area, and the left second intercostal space is the pulmonic area,

Skin-

Colour- Pallor

Cyanosis-bluish colour, best observed at the nail beds, lips and inside the mouth caused by increased amount of deoxygenated hemoglobin.

Temperature and Moisture- An extremity that is cooler and drier than other body surfaces suggest arterial insufficiency.

Inspection of Nails- Nails should be assessed for colour, shape and clubbing. Peripheral Vascular Disease can produce nail depression, pitting, and longitudinal striations.

Koilonychia- spoon shaped nail is associated with several conditions, including Raynaud’s disease.

Clubbing- of the fingers accompanies long standing cyanosis and is associated with decreased oxygen.

Inspection of Extremities-

            The upper and lower extremities should be evaluated for Signs and symptoms of acute and chronic changes due to arterial or venous disorders

Chronic arterial insufficiency- can over time lead changes such as uneven hair distribution or hair loss and atrophy of the skin, which becomes smooth, shiny and thin.

-Severe ischemia of the lower extremity results in varying degrees of tissue loss, including ulceration or gangrene.

Pre-gangrene signs can be recognized by a deep cyanosis or purple-black colour that is not affected by pressure or changes in position.

Redness, thickening and tenderness along a superficial vein suggest thrombophlebitis. -Deep vein thrombosis (DVT) cannot be confirmed on physical exam alone, but should be suspected if swelling, pain, and tenderness appear over a vein.

Homan’s sign: which is used to test for DVT, involves having the patient quickly dorsiflex  the foot while the knee is slightly flexed.  Calf pain is a (+) sign and usually indicated thrombosis.

            The lower extremities should be evaluated for Edema which is a sign of increased interstitial fluid. Bilateral edema of the lower extremities can be a sign of heart failure or venous insufficiency.

Check for arterial pulses:

Carotid artery- Never palpate both sides simultaneously to avoid a reduction in cerebral blood flow or vagal bradycardia.

Assessment of jugular veins:

            Assessment of jugular veins provides information regarding the volume and pressure in the right side of the heart. The external jugular vein is visible above the clavicle. Because palpation obliterates the jugular pulse, veins are assessed by visual inspection. Not usually visible when sitting upright; assessment should be done with the patient reclining 30-45 degree angle. Use sternal angel as reference point. Using centimeter ruler, measure the vertical distance between sternal angle and the point of highest venous pulsation.

Normal value  < 3-4cm with Head of bed elevated 30-45 Degrees.

 > 4 indicates (a) increased RA {right atrium} or RV {right ventricle} pressure as in RV failure.

(b)Tricuspid regurgitation or

© Pericordial tamponade

Flat Jugular Vein - when patient lying down may suggest vascular volume depletion.

Unilateral distension- may indicate vessel obstruction on that side.

Carotid artery: sitting or lying supine with 30 degree -Using fingertips gently palpate carotid arteries one side at a time, comparing rate, rhythm. Auscultate for bruits (blowing sound).

Do not palpate or massage the carotid arteries vigorously because carotid sinus is located at the bifurcation of common carotid artery- cause’s syncope

Thrill: vibrating sensation. Palpate artery lightly for thrill.

Bruit: indicative of turbulence-blood flowing under pressure.  Place bell of stethoscope over carotid artery at lateral end of clavicle and posterior margin of sternocleidomastoid muscle

Turn head slightly away from side being examined. Have patient hold breath, listen for bruits or murmurs

Grading intensity of thrill

Grade 1: barely audible in quite room

Grade 2: clearly audible but quiet

Grade 3: moderately loud

Grade 4: loud

Grade 5: very loud

Grade 6: louder can be heard without stethoscope

Palpation

Hands should be warm, are used to palpate the precordium gently, using palmar surface with four fingers. Palpate in a systematic manner i.e. aortic, pulmonic, tricuspid, mitral. Use proximal halves of the four fingers together and alternate with ball of hand.

PMI {point of maximal impulse} - Ask patient to turn left side. Check for apical impulse.

Cardiac Auscultation: Anatomical Landmarks of Heart - each area corresponds to a specific valvular outflow tract.

Aortic area = Right 2nd intercostal space (component of S2).

Pulmonic area = Left 2nd intercostal space (component of S2).

Erb’s Point = left 3rd Intercostal space (S1 S2).

PMI/Apical Impulse = 5th Intercostal space, mid clavicular line (MCL).

Tricuspid or Right Ventricular = Left sternal border (5th ICS).

Epigastric = just below tip of sternum.

Mitral = at apex of Left Lower Sternal border (5th ICS).

Normal heart sounds: AV valve closure generates the “lubb” sound (S1).

Closing of the aortic and pulmonic valves is the “dubb” sound (S2).

            Use a systemic approach beginning with the diaphragm of the stethoscope at the apex, moving to the lower sternal border, and then ascending along the left sternal border to the right and left base.

Note: Diaphragm of stethoscope detects high pitched sounds.

Bell of stethoscope detects low pitched sounds/murmurs.

Heart Sounds: Normal (Lub-dub, Lub-dub). S1 Lub (Closure of AV Valves at start of systole).

 S2 Dub – (Closure of pulmonic and aortic valves upon end diastole).

3rd Heart Sound – Middle 3rd of diastole.

4th Heart Sound – Atrial.

S1 is the 1st heart sound: produced by closure of the triscupid and mitral valves and marks the beginning of systole. [Ventricular contraction] Best heard at the apex and 5th ICS at left sternal border. Corresponds with upswing of carotid pulse.

S1 more intense in high output states and with mitral valve stenosis.

A decreased intensity occurs in systemic or pulmonary HTN and valve fibrosis or calcification.

Obesity, emphysema, and excess pericardial fluid can obscure S1. A varying intensity of S1 suggests severe dysrhythmia or complete heart block. S1 > S2 at apex.

S2.  The second heart sound:  is produced by closure of the pulmonic and Aortic Valves [semi-lunar valves] and marks the beginning of diastole [ventricular filling]

“Dup” shorter and higher pitched than S1. Higher in pitch and shorter duration than S1. Aortic valve closure is at the 2nd right ICS and pulmonic valve closure is best heard at the 2nd left ICS.

A decreased intensity of S2 occurs in severe arterial hypotension and in immobile, thickened, calcified, or stenotic valves. Overlying tissue, fat, or fluid also mutes S2. S2 > S1 at base.

S3 [Ventricular gallop] – Vibration of the ventricular walls during a rapid passive filling in early diastole produces the 3rd heart sound (also referred to as ventricular gallop).  Occurs after closure of semilunar valves. Occurs in early diastole during passive rapid ventricular filling of ventricles. Best heard with the stethoscope bell at the apex or left lower sternal border the patient is in left lateral position. S3 immediately follows S2 (Lub-dupp-a)

An accentuated S3 sound can result from conditions that cause more rapid filling, including exercise and elevation of the legs, or any factors that increase the heart rate. S3 is commonly heard in children and young adults and is considered normal (physiologic S3). In adults  > 30, S3 gallop signal left sided heart failure.

S4-Atrial Gallop-

Occurs in late diastole during atrial contraction and active filling of ventricles [ventricles resistant to filling when almost full].  Heard late diastole just before S2.  Auscultated at apex or Sternal border. S4 gallop is caused by loss of ventricular wall compliance from HTN or CAD or from increased stroke volume in high cardiac output states.

Murmurs

Caused by increased blood flow through valve. Auscultate mitral, tricuspid, pulmonic, aortic valve area. If murmur occur betweenS1 and S2 it is systolic murmur. If murmur occur between S2 and next S1-diastolic murmur. Mitral murmurs best heard at apex.

 Crescendo murmur- starts softly and builds in loudness.

Decrescendo murmur starts loudly and become less intense.

Inspect the Extremities

- Skin of the extremities for colour, temperature, lesions, venous pattern, scar, pigmentation, ulcer, edema.

Abnormal Findings

-  Skin of the patients with peripheral vascular disease is typically pale and cool, shiny with brown discolorations and hairless

Palpation of Peripheral pulses

- Using finger pads of the index and middle fingers palpate pulses for amplitude of the symmetry

·         Carotid

·         Brachial

·         Radial

·         Femoral

·         Popliteal

·         Dorsalis pedis

·         Posterior tibial

Pulse should be strong and equal bilaterally. Amplitude can be documented as:

 Absent = 0               

Weak = 1+

Normal = 2+

Increased = 3+

Bounding = 4+

Abnormal findings:

- Absent, weak, thready pulse

-Bounding pulse

-Asymmetric pulse

-Phlebitis 

Peripheral Perfusion: Inspect the skin of the hands and feet for colour, temperature, edema, and skin changes. Assess the adequacy of arterial flow. Inspect the fingernails for changes. Blue lips, earlobes, nail beds –signs of peripheral cyanosis

Assess 5 Ps

·         Pain

·         Pallor

·         Pulselessness

·         Paraesthesia

·         Paralysis 

Assessing the arterial blood flow

ü  Buerger's Test

ü  Capillary Refill Test

Buerger's   Test

• Assist the client to a supine position. Ask the client to raise one leg or one arm about 30 cm (1 ft.) above heart level, move the foot or hand briskly up and down for about 1 minute  then sit up and dangle the leg or arm. Observe the time elapsed until return of original colour and vein filling.

Normal findings: Buerger's test: Original colour returns in 10 seconds; veins in feet or hands fill in about 15 seconds.

Capillary Refill Test
Squeeze the client's fingernail and toenail between your fingers sufficiently to cause blanching (about 5 seconds).  Release the pressure, and observe how quickly normal colour returns. Colour normally returns immediately (less than 2 seconds).

Peripheral veins- Inspection and palpation for varicosities. Dependent edema around area of feet and ankles is sign of venous insufficiency

Asses for pitting edema: Use index finger to press firmly for several seconds and release over medial malleolus. Depression left in skin indicate edema

Lymphatic system

Supine position- palpate area of superficial inguinal nodes in groin area.

Infection -Enlarged, hardened, tender nodes