cardiovascular assessment
NURS 347
Towson University
structure and function
cardiovascular system
Blood flow through the Heart
Systole & Diastole
 Diastole: ventricles relax and fill with blood;
this takes up two thirds of cardiac cycle
 Systole: heart’s contraction, blood pumped
from ventricles fills pulmonary and systemic
arteries; this is one third of cardiac cycle
Systole
Ventricular pressure becomes higher than that in atria, so
mitral and tricuspid valves close
Closure of AV valves contributes to first heart sound (S1)
and signals beginning of systole
AV valves close to prevent any regurgitation of blood back
up into atria during contraction
For a very brief moment, all four valves are closed and
ventricular walls contract
Diastole
 Ventricles relaxed, and AV valves, tricuspid and mitral,
are open; opening of normal valve is silent
 Pressure in atria higher than that in ventricles, so blood
pours rapidly into ventricles
 Toward end of diastole, atria contract and push last
amount of blood into ventricles, known as pre-systole, or
atrial systole
Electrical Conduction System
Cardiac Conduction
 Heart has unique ability: automaticity
 Can contract by itself, independent of any signals or
stimulation from body
 Specialized cells in sinoatrial (SA) node, near
superior vena cava initiate an electrical impulse
 Because SA node has intrinsic rhythm, it is called the
pacemaker
PQRST
 P wave: depolarization of atria
 P-R interval: from beginning of P wave to beginning of
QRS complex (time necessary for atrial depolarization plus time for
impulse to travel through AV node to ventricles)
 QRS complex: depolarization of ventricles
 T wave: repolarization of ventricles

Blood Circulation
 In resting adult, heart normally pumps between 4 and 6 L of blood
per minute throughout body
Cardiac Cycle:
Complete
The Cardiovascular Assessment
Peripheral Assessment
Subjective Assessment
 Chest pain?
 Skin changes on arms or legs?
 Dyspnea?
 Swelling?
 Orthopnea?
 Lymph node enlargement?
 Cough?
 Personal habits and self-care
 Fatigue?
 Past cardiac history of self
 Cyanosis or pallor?
and family?
 Medications
 Edema?
 Nocturia?
 Leg pain or cramps?
Inspection
 Begin with the hands, noting:
 Color of skin and nail beds
 Temperature
 Texture
 Skin turgor
 Lesions & Scars
 Edema
 Hair growth
 Clubbing
 Symmetry of
extremities
Palpation
 Capillary refill:
 Depress and blanch the nail beds; release and note the time for color
return
 Color should return in less than 1-2 seconds
 Pulses: Note rate, rhythm, elasticity of vessel wall, equality, and
force:
 4+ Bounding
 3+ Increased
 2+ Normal
 1+ Weak
 0 Absent
Pulses
1.
2.
3.
4.
5.
6.
7.
8.
9.
Temporal
Carotid
Radial
Ulnar
Brachial
Femoral
Popliteal
Posterior tibial
Dorsalis pedal
carotid artery: palpation
 Palpate each separately medial to the sternomastoid muscle
of the neck
 Avoid excessive pressure, may slow heart rate
 Assess contour and amplitude of pulse;
 Generally:
 smooth contour
 rapid upstroke
 slower downstroke
 strength 2+
carotid artery: auscultation
 Middle-aged, older, or demonstrate signs and symptoms of
cardiovascular disease
 Listen with the bell to each side separately for a bruit
 Bruit: Blowing, swishing sound
Auscultation Locations:
 Angle of the jaw
 Midcervical area
 Base of neck
Homan’s Sign
 Assesses for DVT
 Signs and Symptoms of
DVT:
 Pain & cramps
 Unilateral edema
 Weakened pulse
1.
2.
3.
Bring leg up, allow
fluid to drain.
Dorsiflex foot while
squeezing the calf.
If pain is felt, positive
test.
 Has fallen out of favor in
comparison to diagnostic
imaging tests: ultrasound
cardiac exam
Straight to the Heart
Inspection: precordium
 Inspect for lifts, heaves, or visual pulsations:
 Apical impulse
 Continue to assess the integument
palpation
 Palpate for lifts, heaves, thrills, or pulsations
 Apical pulse (point of maximal impulse or PMI)




Use one fingerpad
4th or 5th intercostal space, midclavicular line
Normally 1cm x 2cm and feels like a short, gentle tap
Duration is short, generally occupies only the first half of systole
palpation
 General appraisal of precordium for additional pulsations:
 Use the carotid artery pulsation as a guide
 Use palmar aspect of four fingers and palpate:
 Apex
 Left sternal border
 Base
auscultate
 Rate & rhythm
 Identify S1 & S2
 Assess each separately
 Listen for extra heart sounds
 Listen for murmurs
 Diaphragm: High pitched sounds’
 Bell: Low pitched sounds
 Use a “Z-pattern” from base of the heart, right and left, and
over the apex.
 Aortic: 2nd right interspace
 Pulmonic: 2nd left interspace
 Tricuspid: Left lower sternal border
 Mitral: 5th interspace near midclavicular line
 Erb’s point: 3rd interspace, left sternal border
auscultate
 Heart Rate: 60-100 bpm
 Rhythm: Regular (normal sinus rhythm)
 Arrhythmia: varies with person’s breathing, increasing at the
peak of inspiration and slowing with expiration
 Pulse deficit: Auscultating apical beat and simultaneously
palpating radial pulse
heart sounds: “lub-dub”
 S1: “lub”
 Start of systole, caused by the close of AV valves
 Louder at apex
 Use diaphragm
 Carotid artery pulse
 Electrical conduction: R- wave
 S2: “dub”
 Closure of the semilunar valves
 Louder at the base
 Can auscultate with diaphragm
extra heart sounds
 Listen with the diaphragm, then the bell
 Cover all auscultatory areas
 Generally silent
 Most common extra sound is a mid-systolic click in systole
S3:
During diastole
Ventricular gallop
S4:
During diastole
Atrial gallop
murmurs
 Murmur: A blowing, swooshing sound related to turbulent blood
flow in the heart or great vessels
 Aside from that “innocent” murmur; murmurs are abnormal
Document findings by:
 Timing: During what part of the cardiac cycle?
Early, mid-, or late systole or diastole?
 Throughout cardiac cycle
 Muffles heart sounds?

murmur grading
 Loudness: Describe intensity with the following scale:
 Grade i: Barely audible, heard only in a quiet room and then with difficulty
 Grade ii: Clearly audible, but faint
 Grade iii: Moderately loud, easy to hear
 Grade iv: Loud, associated with a thrill palpable on the chest wall
 Grade v:Very loud, heard with one corner of the stethoscope lifted off the
chest wall
 Grade vi: Loudest, still heard with entire stethoscope lifted just off the
chest wall
murmurs
 Pitch: Describe as “high, medium, or low”
 Depends on the pressure and rate of blood flow producing the murmur
 Pattern: Does it follow a pattern through the cardiac phase?
 Crescendo: Grows louder
 Decrescendo: Tapers off
 Crescendo-decrescendo: Increases to a peak and then decreases
 Quality:
 Musical
 Blowing
 Harsh
 Rumbling
 Location:
 Describe the area where the murmur is best heard:
 Valve area
 Intercostal spaces
murmurs
 Radiation: May be transmitted in the direction of blood-flow:
Another precordial area
 Neck
 Back
 Axilla

 Posture: Some murmurs disappear or are enhanced by a change in
position.
Innocent: No valvular or other pathologic cause
 Generally soft, grade ii, midsystolic, short
 Crescendo-decrescendo, musical quality
 2nd or 3rd intercostal space, disappears with sitting
 No history of cardiac dysfunction
 Functional: Due to increased blood flow of the heart

physiologic splitting
 A split S1 means you are hearing the mitral and tricuspid components
separately, it is “normal”
 Very rapid; 0.03 seconds apart
 Auscultate over the tricuspid valve area
 A split S2 occurs toward the end of inspiration, is normal.
 “T-DUB”
 Auscultate over the pulmonic valve area, 2nd interspace
 Fixed split: Unaffected by respiration, always there
 Paradoxical split: Sounds fuse on inspiration;
split on expiration
Jugular Venous Distention (JVD)
 A technique used to assess central venous pressure (CVP)
 Judges the heart’s efficiency as a pump
 Position patient supine at a 30-45’ angle
 Remove pillow to decrease flexing the neck
 Turn head slightly from area being assessed
 Look for pulsating internal jugular veins near the suprasternal
notch, or origin of the sternomastoid muscle near the clavicle
 Be careful not to confuse the carotid pulse with the internal jugular
variations
 Infants
 Fetal shunt closure may take up to 48 hours
 Apical pulse may be palpable at 4th intercostal space, lateral to
midclavicular line.
 HR 100-180 bmp after birth; 120-140 bmp average
 Sinus arrhythmias with respirations
 Children




Apical pulse palpation changes
70-100 bmp
Venous hum
Innocent murmurs
variations
 Pregnant female:
 Increased resting heart rate
 Mild hyperemia (increased cutaneous blood flow to eliminate excess
heat)
 Increased volume of S1, exaggerated S1 split
 Heart murmurs
 Aging Adult:





Gradual rise in blood pressure
Orthostatic hypotension
Avoid pressure on carotid artery
Decreased visibility of JVD
Ectopic beats
sample charting
 Subjective:
 No chest pain, dyspnea, orthopnea, cough, or edema. No past history of
hypertension, abnormal blood tests, heart murmur, or rheumatic fever in self.
Last ECG 2 years. PTA, result normal. No stress ECG or other heart tests.
 Objective:
 Neck: Carotids 2+ and = bilaterally, internal jugular vein pulsations present
when supine, and disappear when elevated at a 45’ position.
 Precordium: Inspection. No visible pulsations, no heave or lift.
 Palpation: Apical pulse in 5th ics at left midclavicular line, no thrill
 Auscultation: Rate 68 beats per minute, rhythm regular. S1-S2 present, not
diminished or accentuated, no S3, no S4, no other extra heart sounds, no
murmurs.