Assessing the Cardiovascular System

Skill 3-6

Assessing the Cardiovascular System

The cardiovascular system transports oxygen, nutrients, and other substances to the body tissues and removes metabolic waste products to the kidneys and lungs. Careful assessment of this vital system is essential. In this skill, assessment data associated with the heart will be presented. The peripheral vascular system assessment is included in Skill 3-10, because peripheral vascular, neurologic, and musculoskeletal systems are usually combined when performing a head-to-toe assessment. Assessment of the carotid pulses is included in Skill 3-4, because this assessment is commonly included while assessing the neck as part of a head-to-toe assessment.

While assessing the heart, careful auscultation is important. Identifying heart sounds takes practice. Table 3-3 provides a review of normal heart sounds in relation to the cardiac cycle and information about abnormal heart sounds.

Delegation Considerations

Assessment of the patient's cardiovascular system should not be delegated to assistive personnel (AP). However, the AP may notice some items while providing care. The nurse must then validate, analyze, document, communicate, and act on these findings, as appropriate. Depending on the state's nurse practice act and the organization's policies and procedures, the licensed practical/vocational nurses (LPN/LVNs) may perform some or all the parts of assessment of the patient's cardiovascular system. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Bath blanket or other drape
Examination gown
Stethoscope
Centimeter ruler
PPE, as indicated

Assessment

Complete a health history, focusing on the heart. Identify risk factors for altered health by asking about the following:

History of chest pain, tightness, palpitations, dizziness, or fatigue
Swelling in the ankles and feet
Number of pillows used to sleep
Type and amount of medications taken daily
History of heart defect, rheumatic fever, or chest or heart surgery
Personal or family history of hypertension (high blood pressure), myocardial infarction (heart attack), coronary artery disease, high blood cholesterol levels, or diabetes mellitus
History of smoking (including pack-years)
Alcohol use
Type and amount of exercise
Usual foods eaten each day

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Impaired Cardiac Output
Activity Intolerance
Risk for Impaired Cardiac Function

Outcome Identification and Planning

The expected outcome to achieve in performing an examination of the cardiovascular structures is that the assessment is completed without causing the patient to experience anxiety or discomfort, the findings are documented, and the appropriate referral is made to other health care professionals, as needed, for further evaluation. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Close the curtains around the bed and close the door to the room, if possible. Explain the purpose of the cardiovascular examination and what you are going to do. Answer any questions.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a supine position with the head elevated about 30 to 45 degrees, if possible, and expose the anterior chest. Use the bath blanket to cover any exposed area other than the one being assessed.	Having the patient wear a gown facilitates examination of the cardiovascular system. Use of a bath blanket provides for comfort and warmth.
5. If not performed previously with the assessment of the head and neck, inspect and palpate the left and then the right carotid arteries. Palpate only one carotid artery at a time. Note the strength of the pulse and grade it as with peripheral pulses.	Palpation of this area evaluates circulation through the arteries. Palpating both arteries at once can reduce blood flow to the brain, potentially causing dizziness or loss of consciousness (Jensen, 2019).
6. Inspect the neck for distention of the jugular veins.	Jugular venous distention (fullness) is associated with heart failure and fluid volume overload.
7. Inspect the precordium for contour, pulsations, and heaves (Figure 1). Observe for the apical impulse at the fourth to fifth intercostal space (ICS) at the left midclavicular line.	Precordium inspection helps detect pulsations. There are normally no pulsations, except for the apical impulse.
8. Using the palmar surface, with the four fingers held together, gently palpate the precordium for pulsations. Remember that hands should be warm. Palpation proceeds in a systematic manner, with assessment of specific cardiac landmarks—the aortic, pulmonic, tricuspid, and mitral areas and Erb's point (see Figure 1). Palpate the apical impulse in the mitral area (Figure 2). Note size, duration, force, and location in relationship to the midclavicular line.	Normal findings include no pulsation palpable over the aortic and pulmonic areas, with a palpable apical impulse. Abnormal findings include precordial thrills, which are fine, palpable, rushing vibrations over the right or left second ICS, and any lifts or heaves, which involve a rise along the border of the sternum with each heartbeat.
9. Auscultate heart sounds at the cardiac landmarks (Figure 1). Ask the patient to breathe normally. Use the diaphragm of the stethoscope first to listen to high-pitched sounds. Then use the bell to listen to low-pitched sounds. Focus on the overall rate and rhythm of the heart and the normal heart sounds (Table 3-3). Begin at the aortic area, move to the pulmonic area, then to Erb's point, then the tricuspid area, and finally listen at the mitral area (Figure 3).	Auscultation evaluates heart rate and rhythm and assesses for normal sounds (the lub, S₁; the dub, S₂) and abnormal heart sounds. The normal heart sounds (S₁ and S₂) are generated by the closing of the valves (the aortic, pulmonic, tricuspid, mitral). Extra heart sounds are often heard when the patient has anemia or heart disease. A wide variety of conditions may alter the normal heart rate or rhythm, including serious infections, diseases of the heart muscle or conducting system, dehydration or overhydration, endocrine disorders, respiratory disorders, and head trauma. Extra heart sounds may be S₃, S₄, or murmurs.
10. Assist the patient in replacing the gown. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems as appropriate or indicated. Initiate appropriate referral to other health care providers for further evaluation, as indicated.	Replacing the gown ensures patient comfort. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Additional assessments should be completed as indicated to evaluate the patient's health status. Intervention by other health care providers may be indicated to evaluate and treat the patient's health status.

Evaluation

The expected outcomes have been met when the patient has participated in the assessment of the cardiovascular system; the patient has verbalized understanding of these assessment techniques as appropriate; the assessment has been completed without the patient experiencing anxiety or discomfort; the findings have been documented; and the appropriate referrals have been made to the other health care professionals, as needed, for further evaluation.

Documentation

Guidelines

Document assessment techniques performed, along with specific findings. Note assessment data related to color and temperature of the skin. Record inspection findings related to the carotid arteries, jugular veins, and anterior chest wall area. Document findings related to palpation of anterior chest wall for presence of pulsations, thrills, lifts, and heaves. Note auscultation findings, including rate, rhythm, pitch, and location of sounds. Record the normal heart sounds (S₁ and S₂) as well as the presence of any extra (abnormal) sounds.

Sample Documentation

Practice documenting assessment techniques and findings in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Special Considerations

General Considerations

Warm equipment, such as a stethoscope, before using it to prevent chilling the patient.

Infant and Child Considerations

The presence of abnormal heart sound S₃ is considered normal in children and young adults.
The presence of abnormal heart sound S₄ is considered abnormal in children.

Older Adult Considerations

The presence of abnormal heart sound S₃ is considered abnormal in middle-aged and older adults.
The presence of abnormal heart sound S₄ is considered normal in older adults.

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Skill 3-6