College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
CARDIOVASCULAR SYSTEM ASSESSMENT
The cardiovascular assessment provides physiological and psychosocial information
that guides the physical assessment, the selection of diagnostic tests, and the choice of
treatment options.
Health History
Establishing the Interview Setting
Before taking a health history, make sure the setting is quiet and private and that the patient
is comfortable. Sit facing the patient, about 3' to 4' (about 1 m) from him.
Complete Health History
Unlike the medical health history, the nursing health history takes a holistic approach,
focusing on the patient's illness and his responses to it. During the health history, you'll
establish a rapport with your patient and collect important information on how the illness
affects him and his family and what educational needs they have. This information then helps
you direct your plan of care and initiate discharge planning. Frequently, you may find that
the subjective data you collect during the health history tells you more about the patient's
health status than the physical examination.
Components of the Health History
1- Biographical data
Begin by asking the patient his name, address, telephone number, birth date, age, birthplace,
Social Security number, race, nationality, religion, and marital status. Also find out the
names of anyone living with the patient, the name and telephone number of the person to
call in an emergency, and the patient's usual source of health care.
2- Chief Complaint and History of Present Illness
The nurse begins the history by investigating the patient’s chief complaint. The patient is
asked to describe in his or her own words the problem or reason for seeking care.
The nurse then asks for more information about the present illness, according to the
following manner:
 N Normal: Describe your normal baseline. What was it like before this symptom
developed?
 Onset: When did the symptom start? What day? What time? Did it start suddenly or
gradually?
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
 P Precipitating and palliative factors: What brought on the symptom? What seems
to trigger it—factors such as stress, position change, or exertion? What were you doing
when you first noticed the symptom? What makes the symptom worse? What measures
have helped relieve the symptom? What have you tried so far? What measures did not
relieve the symptom?
 Q Quality and quantity: How does it feel? How would you describe it? How much
are you experiencing now? Is it more or less than you experienced at any other time?
 R Region and radiation: Where does the symptom occur? Can you show me? In the
case of pain, does it travel anywhere such as down your arm or in your back?
 S Severity: On a scale of 1 to 10, with 10 being the worst ever experienced, rate your
symptom. How bad is the symptom at its worst? Does it force you to stop your activity
and sit down, lie down, or slow down? Is the symptom getting better or worse, or
staying about the same?
 T Time: How long does the symptom last? How often do you get the symptom? Does
it occur in association with anything, such as before, during, or after meals?
The following problems are refer to the most common chief complaint
associated with cardiovascular diseases:
1- Chest Pain
2- Dyspnea
3- Edema of the Feet and Ankles
4- Palpitations and Syncope
5- Cough and Hemoptysis
6- Nocturia
7- Cyanosis
3- Past Health History
When assessing the patient’s past health history, the nurse inquires about childhood illnesses
such as rheumatic fever as well as previous illnesses such as pneumonia, tuberculosis,
thrombophlebitis, pulmonary embolism, MI, diabetes mellitus, thyroid disease, or chest
injury. The nurse also asks about occupational exposures to cardiotoxic materials.
Finally, the nurse seeks information about previous cardiac or vascular surgeries and any
previous cardiac studies or interventions.
4- Current Health Status And Risk Factors
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
As part of the health history, the nurse queries the patient about use of prescription and
over-the-counter medications, vitamins, and herbs. It is essential to ask the patient about
drug allergies, food allergies, or any previous allergic reactions to contrast agents. The nurse
inquires about use of tobacco, drugs, and alcohol. The nurse also asks about dietary habits,
including usual daily food intake, dietary restrictions or supplements, and intake of caffeine
containing foods or beverages. The patient’s sleep pattern and exercise and leisure activities
also are noted.
Assessment of risk factors for cardiovascular disease is an important component of the
history. Risk factors are categorized as major uncontrollable risk factors; major risk factors
that can be modified, treated, or controlled; and contributing risk factors.
Major Uncontrollable Risk Factors
■ Age.
■ Heredity.
■ Gender.
■ Race.
Major Risk Factors That Can Be Modified, Treated, or Controlled
■ Tobacco smoking.
■ High blood cholesterol.
■ Hypertension.
■ Physical inactivity.
■ Obesity.
■ Diabetes mellitus.
Other Contributing Factors
■ Stress.
■ Sex hormones.
■ Birth control pills
■ Excessive alcohol intake.
5- Family History
The nurse asks about the age and health, or age and cause of death, of immediate family
members, including parents, grandparents, siblings, children, and grandchildren.
The nurse also inquires about cardiovascular problems such as hypertension, elevated
cholesterol, coronary artery disease, MI, stroke, and peripheral vascular disease.
6- SOCIAL HISTORY
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Occupation:
- Occupational status (full-time, part-time, retired).
- Importance of work to his/her self image (mild, moderate, high).
Housing:
- Residence (Urban or Rural).
- House property (owns, rents).
- Home environment facilities (heating, cooling, lightening, cooking facilities, others).
Safety and security burden:
- Occupational exposure to health hazards (excessive noises, pollution, toxic
chemicals/vapors, injuries, infectious agents, others).
- Home exposure to health hazards (excessive noises, pollution, toxic chemicals/vapors,
injuries, infectious agents, others).
- Community exposure to health hazards (excessive noises, pollution, toxic
chemicals/vapors, injuries, infectious agents).
Socio-economic status:
note the adequacy of personal and/or family income to meet requirements for housing, food,
clothing, education, recreation in term of adequate, adequate to some extent, inadequate.
Diet:
- Nutritional status (body mass index**, condition of the mouth and teeth, ability to
swallowing, appetite, digestion, adequacy of food intake including basic four).
- Is there any health conditions/diseases influence the usual dietary practices (peptic ulcer, DM,
nausea and vomiting, hyperacidity, renal diseases, heart diseases, hypertension, loss of
consciousness, abnormal openings, others).
- Therapeutic diet (nothing by mouth, I.V. fluids, liquid diet, soft, low sodium, low protein,
low carbohydrate, high protein, low fat, high carbohydrate, prudent diet, tube feeding).
**: body mass index calculated through the following formula:
BMI= Weight/ Height (m)2
Exercises:
- Record the type, intensity, duration, frequency, factors affecting the patient participation
in regular exercises.
Sleep:
- Usual number of hours per 24-hour period
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
- Factors interfering with sleep (pain, orthopnia, others).
- Use of supportive aids (analgesics, sedatives, back rub, taking warm drinks, taking warm
bath, quite environment).
Drugs and alcohol use:
- Use of illicit drugs (type, amount, rout of administration, and how long).
- Smoking (type, how much, and how long).
- Alcohol (how much, and how long).
Social support:
 Is the patient receive social support? (In term of yes or no).
 Who/what are his/her primary sources of support? (Father, mother, brothers, sisters,
friends).
 To what extent does he/she want these individuals to be involved in his/her care?
Review of systems:
The nurse can asking the patient about all the body systems problems from general to
specific.
Physical Examination
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General approach to heart assessment:
Explain to the patient what you are going to do.
Ensure that the room is quite, warm, and well lit.
Expose the patient’s chest only as much as is needed for the assessment.
Position the patient in a supine position or sitting position.
Stand to the patient’s right side and the light should come from the opposite side of where
you are standing so that shadows can be accentuated.
Equipments:
Stethoscope.
Sphygmomanometer.
Watch.
Tape measure.
Ruler.
Torch.
Components of the cardiovascular system:
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
1- Assessment of precordium.
2- Assessment of the periphery.
Part one /Assessment of precordium
Inspection, palpation, percussion, and auscultation should be performed in a systematic
manner, using certain cardiac landmarks. The cardiac landmarks are defined as follows:
1- The aortic area is the second intercostals space to the right of the sternum.
2- The pulmonic area is the second intercostals space to the left of the sternum.
3- The midprecordial area, Erb,s point, is located in the third intercostals space to the left of
the sternum.
4- The tricuspid area is the fifth intercostals to the left of the sternum. Other terms for this
area are the right ventricular or septal area.
5- The mitral area is the fifth intercostals space to the left midclavicular line. Other terms used
for this area are left ventricular or apical area.
Inspection:
When assessing the pericardial firstly the examiner should be observe the pericardial for
symmetry, color, skin lesions, rash, and scars.
Aortic area:
No pulsation should be visible. A pulsation at the aortic area is abnormal. A pulsation at the
aortic area indicates that an aortic root aneurysm.
Pulmonic area:
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
No pulsation should be visible. A pulsation is abnormal finding. A pulsation at the pulmonic
area indicates a pulmonary valve stenosis.
Midprecordial area:
No pulsation should be visible. A pulsation or retraction at the midprecordial area is
considered abnormal findings. A left ventricular aneurysm cause mid precordial pulsation.
While the precordial diseases may cause midprecordial retraction.
Tricuspid area:
No pulsation should be visible. A pulsation at the tricuspid area is considered abnormal
finding. A right ventricular enlargement can cause tricuspid pulsation.
Mitral area:
Normally there is a pulsation in the mitral area this point also knows as a point of maximum
impulse. A hypokinetic(decreased movement) pulsations at the mitral area are considered
abnormal. Hypokinetic pulsation can be caused by a certain conditions that put a more fluids
between the left ventricle and the chest wall such as pericardial effusion and cardiac
tamponade. Also the obesity, low - output states , decreased myocardial contractility can
caused this type of pulsation. Hyperkinetic pulsations (increased movement) are always
abnormal when located at the mitral area. High – output states such as mitral regurgitation
, thyrotoxicosis, severe anemia, and left to right shunt can caused this type of pulsations.
Palpation:
The nurse may feel a thrill (vibrations that feel similar to what one feels when a hand is
placed on a purring cat), heaves(lifting of the cardiac area secondary to an increased
workload and force of the left ventricle contraction, or pulsation. The patient should be in
a supine position for this portion of the assessment.
Palpate the cardiac landmarks for:
1- Pulsation: using the fingers pads, locate the cardiac landmarks and palpate the area for
pulsation.
2- Thrills: using the palmar surface of the hand at the base of the fingers, locate the cardiac
landmarks and palpate the area for thrills.
3- Heaves: follow step 2 and palpate the area for heaves.
Aortic area:
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
No pulsation, thrills, or heaves should be palpated. Aortic regurgitation or stenosis can
caused a turbulent blood flow in the left ventricle , which may be palpated as a thrills.
Pulmonic area:
No pulsation, thrills, or heaves should be palpated. pulmonic regurgitation or stenosis can
caused a turbulent blood flow in the right ventricle , which may be palpated as a thrills.
Midprecordial area:
No pulsation, thrills, or heaves should be palpated. Both left ventricular aneurysm and right
ventricular enlargement can produce a pulsation in the midprecordial area.
Tricuspid area:
No pulsation, thrills, or heaves should be palpated. tricuspid regurgitation or stenosis can
caused a turbulent blood flow in the right atrium , which may be palpated as a thrills. Right
ventricular enlargement can produce heaves at the tricuspid area secondary to the increases
ventricular workload.
Mitral area:
Palpate the mitral area for pulsation, thrills, or heaves. If a pulsation (apical impulses) is not
palpable, turn the patient to the left side and palpate in this position.
The apical impulse can be palpate at approximately half of the adult population, 1-2 cm in
diameter, and the amplitude is small and can be felt directly after the first heart sounds.
Mitral stenosis or mitral regurgitation may produce a thrills from the turbulent of the blood
at the left atrium.
Left ventricular hypertrophy produced a laterally displaced apical impulse to the sixth
intercostals space. In addition, the hypertrophied muscles works harder during a contraction
to produce a heaves or sustained apical beats. This occurs in many cases such as aortic
stenosis, systemic hypertension, sub-aortic stenosis, hypertrophied cardiomyopathy.
A hypokinetic pulsation less than 1-2 cm in diameter can caused by the same cause listed
under the hypokinetic pulsation in inspection of the mitral area.
A hyperkinetic pulsation , greater than 1-2 cm in diameter can caused by the same cause
listed under the hyperkinetic pulsation in inspection of the mitral area.
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Auscultation of Precordium:
Data obtained by careful and thorough auscultation of the heart are essential in planning and
evaluating care of the critically ill patient.
To facilitate accurate auscultation, the patient should be relaxed and comfortable in a quiet,
warm environment with adequate lighting. The patient should be in a recumbent position
with the trunk elevated 30 to 45 degrees. To help hear abnormal sounds, the patient may
be asked to roll partly onto the left side (left lateral decubitus position). This position helps
bring the left ventricle closer to the chest wall.
In each area auscultated, the nurse should identify S1, noting the intensity of the sound,
respiratory variation, and splitting. S2 should then be identified and the same characteristics
assessed. After S1 and S2 are identified, the presence of extra sounds is noted—first in
systole, then in diastole. Finally, each area is auscultated for the presence of murmurs and
friction rubs.
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Part two /Assessment of periphery
General Inspection
During your general inspection, record your initial impressions of the patient's body type,
posture, gait, and movement, as well as his overall health and basic hygiene. Be alert for
clues about the patient's cardiovascular status. For example, head jerking (Musset's sign)
may indicate severe aortic insufficiency. Also, note observable cardiac risk factors, such as
cigarette smoking, obesity, and fatty tissue deposits (xanthomas). Observe facial expressions
for signs of pain or anxiety. During conversation, assess mental status, particularly the
appropriateness of responses and the clarity of speech. Determine his apparent mood. Is he
cooperative or withdrawn, fearful, or depressed?
New York Heart Association (NYHA) Functional Classification Class Function
I ordinary physical activity does not evoke symptoms (fatigue, palpitation, dyspnea, or
angina)
II slight limitation of physical activity; comfortable at rest; ordinary physical activity results
in symptoms
III marked limitation of physical activity; less than ordinary physical activity results in
symptoms
IV inability to carry out any physical activity without discomfort; symptoms may be present
at rest
Head
To help determine the adequacy of cardiac output, assess the skin color of the patient's face,
mouth, and earlobes. Note any deep creases or folds in the earlobes (McCarthy's sign),
which may indicate CAD. Check the condition of the mucous membranes; moistness
indicates adequate hydration.
Note the color of the conjunctivae (normally pink) and the sclerae (normally white). Look
for an opaque ring around the cornea (corneal arcus) and yellow fatty nodules on the eyelids
(xanthelasma).
Inspect the neck
Your inspection of the neck focuses on the jugular vein and the carotid artery. First, inspect
jugular vein pulsations. Place the patient in semi-Fowler's position. (In this position, his neck
veins shouldn't be prominent if his heart function is normal.) Turn his head slightly away from
you to relax the sternocleidomastoid muscle so it doesn't obstruct your view of the veins. Next,
arrange the lighting to cast small shadows along the neck. Then, observe the pulsations of the
internal jugular vein. Noting the force of these pulsations helps you to indirectly evaluate the
amount of pressure in the right atrium.
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
You can estimate a patient's central venous pressure (CVP) indirectly by determining the height
from the right atrium to the highest level of visible pulsation in the jugular vein. First, note the
highest level of visible pulsation. Next, locate the angle of Louis, or sternal notch. To do this,
palpate the clavicles where they join the sternum (the suprasternal notch). Place your first two
fingers on the suprasternal notch and slide them down the sternum until you feel a bony
protuberance. This is the angle of Louis. The right atrium lies about 2" (5 cm) below this point.
To estimate CVP, measure the vertical distance between the highest level of visible pulsation
and the angle of Louis. Normally, this distance is less than TVs" (2.9 cm). Add 2" to this figure
to estimate the total distance between the highest level of visible pulsation and the right atrium.
A total distance that exceeds 4" (10 cm) may indicate elevated CVP and right ventricular failure.
If the patient has a central venous line connected to a hemodynamic monitoring system, you
can observe jugular vein pulsations to obtain information about the dynamics of the right side
of the heart. As you assess, use the carotid pulse or heart sounds to time the venous pulsations
with the cardiac cycle. Finally, inspect the carotid arteries, noting whether the pulsations are
weak (hypokinetic) or strong and bounding (hyperkinetic).
Inspect the hepatojugular reflux
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
hepatojugular (Abdominojugular) reflux occurs in right ventricular failure. It can be
demonstrated by pressing the periumbilical area firmly for 30 to 60 seconds and observing
the jugular venous pressure. If there is a rise in the jugular venous pressure by 1 cm or more
that is sustained throughout pressure application, abdominojugular reflux is present.
Kussmaul's sign is a paradoxical elevation of jugular venous pressure during inspiration and
may occur in patients with chronic constrictive pericarditis, heart failure, or tricuspid
stenosis.
Assessment of arterial circulation
Carotid pulse
Lightly place your fingers just medial to the trachea and below the jaw angle.
Femoral pulse
Press relatively hard at a point inferior to the inguinal ligament. For an obese patient, palpate
in the crease of the groin halfway between the pubic bone and the hip bone.
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Popliteal pulse
Press firmly against the popliteal fossa at the back of the knee.
Posterior tibial pulse
Apply pressure behind and slightly below the malleolus of the ankle.
Dorsalis pedis pulse
Place your fingers on the medial dorsum of the foot while the patient points the toes down.
In this site, the pulse is difficult to palpate and may seem to be absent in healthy people.
Brachial pulse
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Position your fingers medial to the biceps tendon.
Radial pulse
Apply gentle pressure to the medial and ventral de of the wrist just below the thumb.
Arterial pulses
Weak pulses indicate low cardiac output or increased peripheral vascular resistance, as
occurs in arterial atherosclerotic disease. Weak pedal pulses are common in elderly patients.
A strong bounding pulse occurs in patients with hypertension and in high cardiac output
states, such as exercise, pregnancy, anemia, and thyrotoxicosis. Arterial pulse scale:
+ 4 Significantly elevated
+ 3 Moderately elevated
+ 2 Normal
+ 1 Normal but weak
0 Absent.
Identifying arterial pulse abnormalities
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Blood pressure measurement: assess the blood pressure for both hands and with supine
and upright position.
Assessment Of Venous Circulation
Edema.
Evaluating edema: When you detect edema, determine the degree, using a scale of +1
to + 4. Press your fingertip firmly for 5 to 10 seconds over a bony surface, such as the
subcutaneous tissue over the patient's tibia, fibula, sacrum, or sternum. Then, note the
depth of the imprint your fingertip leaves on the skin. A slight imprint indicates +1 edema.
If the imprint is deep and the skin is slow to return to its baseline shape, the edema is a +4.
With severe edema, the skin swells so much that fluid can't be displaced. Called brawny
edema, this condition resists pitting but makes the skin appear distended.
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
College Of Nursing / Nursing Sciences Department
Second Stage / Health Assessment
Varicose Veins. Varicose veins are tortuous dilations of the superficial veins that result
from defective venous valves, intrinsic weakness of the vein wall, high intraluminal pressure,
or arteriovenous fistulas.
Chronic Venous Insufficiency. Chronic venous insufficiency (incompetence of venous
valves) may follow deep venous thrombosis or may occur without previous thrombosis. It
may be unilateral, but more commonly is bilateral. Patients complain of a dull ache in the
legs that is present with standing and relieved by elevation. Physical examination reveals
increased leg circumference, edema, and superficial varicose veins. Erythema, dermatitis,
and hyperpigmentation may develop in the distal lower extremity.
Others:
Temperature and Moistness. Temperature and moistness are controlled by the
autonomic nervous system. Normally, hands and feet are warm and dry. Under stress, the
periphery may be cool and moist. In cardiogenic shock, skin becomes cold and clammy.
Capillary Refill Time. Capillary refill time provides an estimate of the rate of peripheral
blood flow. When the tip of the fingernail is depressed, the nail bed blanches. When the
pressure is released quickly, the area is reperfused and becomes pink. Normally, reperfusion
occurs almost instantaneously. More sluggish reperfusion indicates a slower peripheral
circulation, such as in heart failure.