Focused Cardiac Assessment

7/29/2019 Focused Cardiac Assessment

1/23

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Focused Cardiovascular Assessment

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CourseExpires:October17,2014


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Acknowledgements

RN.comacknowledgesthevaluablecontributionsof

NadineSalmon,MSN,BSN,IBCLC,theClinicalContentSpecialistforRN.com.NadineisaSouthAfrican

trainedRegisteredNurse,MidwifeandInternationalBoardCertifiedLactationConsultant.Nadine

obtainedanMSNatGrandCanyonUniversity,withanemphasisonNursingLeadership.Herclinical

backgroundisinLabor&DeliveryandPostpartumnursing,andshehasalsoworkedinMedicalSurgical

NursingandHomeHealth.Nadinehasworkexperienceinthreecountries,includingtheUnitedStates,

theUnitedKingdomandSouthAfrica.SheworkedfortheinternationalnursedivisionofAmerican

MobileHealthcare,priortojoiningtheEducationTeamatRN.com.NadineisanurseplannerforRN.com

andisresponsibleforallclinicalaspectsofcoursedevelopment.Sheupdatescoursecontenttocurrent

standards,anddevelopsnewcoursematerialsforRN.com.

LoriConstantineMSN,RN,CFNP,theoriginalauthorofthiscourse.


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Purpose&Objectives

Thiscoursediscussesspecificcardiovascularhistoryquestionsandexamtechniquesforyouradult

patient.Physicalexamtechniquessuchasinspection,palpation,percussion,andauscultationwillbe

highlighted.Additionally,throughoutthecourseyouwilllearnhowalterationsinyourcardiovascular

assessmentfindings

could

indicate

potential

cardiovascular

problems.

Aftersuccessfulcompletionofthiscourse,youwillbeableto:

1. Outlineasystemicapproachtocardiovascularassessment.

2. Discusshistoryquestionsthatwillhelpyoufocusyourcardiovascularassessment.

3. Recognizeabnormalcardiovascularassessmentfindingsassociatedwithinspection,

auscultation,percussion,andpalpation.

Introduction

Cardiovasculardiseaseistheleadingkillerforbothmenandwomenamongallracialandethnicgroups

intheU.S.AccordingtotheCentersforDiseaseControl(CDC)studiesamongcoronaryheartdisease

patients,90%ofpatientshavehadpriorexposuretoatleastoneheartdiseaseriskfactorthat

contributedtotheirdisease.

Athoroughcardiovascularassessmentwillhelptoidentifysignificantfactorsthatcaninfluence

cardiovascularhealthsuchashighbloodcholesterol,cigaretteuse,diabetes,orhypertension(CDC,

2011).Therefore,acardiovascularexamshouldbeapartofeveryabbreviatedandcomplete

assessment.

Afocusedcardiovascularassessmentisusuallyindicatedafteracomprehensiveassessmentindicatesa

potentialcardiovascularproblem.Thefocusedcardiovascularassessmentisalsoindicatedwhenan

intervalorabbreviatedassessmentshowsachangeinstatusfromyourpreviousassessmentorthe

reportyoureceived,whenanewsymptomemerges,orthepatientdevelopsanydistress.

Anadvantageofthefocusedassessmentisthatitallowsyoutoaskaboutsymptomsandmovequickly

toconductingafocusedphysicalexam.Basedupontheresultsofyourassessment,youmaychoosehow

oftentoperformintervalassessmentstomonitorthepatientsidentifiedproblem.Keepinmindthatall

assessments

should

consider

patients

privacy

and

foster

open,

honest

patient

communication.


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History

Thepurposeofthecardiovascularhealthhistoryistoprovideinformationaboutyourpatients

cardiovascularsymptomsandhowtheydeveloped.Acompletecardiovascularhistorywillgiveyou

indicationstopotentialorunderlyingcardiovascularillnessesordiseasestates.Obtaininga

cardiovascularhistory

will

guide

you

through

your

focused

physical

exam.

In

addition

to

obtaining

data

aboutthepatientscardiovascularstatus,youshouldobtaininformationaboutotherfactorsthatcan

impactphysicalstatusincludingspiritualneeds,culturalidiosyncrasies,andfunctionallivingstatus.

PastHealthHistory

Itisimportanttoaskquestionsaboutyourpatientspasthealthhistory.Thepasthealthhistoryshould

elicitinformationaboutthefollowingissues:hypertension,elevatedbloodcholesterolortriglycerides,

heartmurmurs,congenitalheartdisease,rheumaticfeverorunexplainedjointpainsasachildoryouth,

recurrenttonsillitisandanemia.Youwillalsowanttoaskaboutthepatientshistoryofheartdisease,

whenandhowitwastreated,lastEKG,stresstests,andserumcholesterollevels.Askthepatientthe

reasonsfor

any

previous

hospitalizations

and

the

nature

of

the

treatments

received

while

in

the

hospital.Askaboutcardiaccatheterizations,echocardiograms,stresstests,

andcardiacsurgeries(Kaplow&Hardin,2007).

CurrentLifestyleandPsychosocialStatus

Currentlifestyleandpsychosocialissuestoexplorewhenconductingyourfocusedcardiovascularhealth

historyinclude:

Nutrition:Haveyourpatientdescribetheirdailydiet.Askabouttheirusualweightandany

recentweightgainorweightloss.

Smoking:Askyourpatientiftheysmokecigarettesorothertobacco.Ascertainthepackperyear

smokinghistory.Thisisdonebymultiplyingthenumberofyearsyourpatienthassmokedwith

thenumberofpacksperdaytheyhavesmoked(CancerTreatmentCentersofAmerica,2011).

Alcohol:Askhowmuchalcoholthepatientnormallydrinksperdayorperweek.Askabout

whenthelastdrinkwasandtheusualnumberofdrinks

perepisode.

Exercise:Askaboutyourpatient'sactivitylevelandusualamountofexercisedonedailyor

weekly.Askwhattypeofexercisetheyparticipatein.

Drugs:

Ask

your

patient

about

all

medication

they

take

including

anti

hypertensives,

beta

blockers,calciumchannelblockers,digoxin,diuretics,aspirin,anticoagulants,overthecounter

drugs,herbalsupplements,orstreetdrugs.

SmokersPackPerDayHistory

2packsperdayx10years=20packyearhistory

1packperdayx20years=20packyearhistory

3packsperdayx7years=21packyearhistory


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FamilyHistory

Familyhistoryisanimportantfactorusedinidentifyingyourpatientsriskforcertaincardiovascular

diseases(Kaplow&Hardin,2007).

Askyourpatientaboutanycardiovascularfamilyhistorysuchashypertension,obesity,diabetes,

coronaryarterydisease,orsuddendeath.

TestYourself:

Whichofthefollowingdiseasesisassociatedwithcardiovasculardisease?

A. Hypothyroidism

B. LungCancer

C. Diabetes(correct)

D. InflammatoryBowelDisease

AssessmentofChestPainUsingPQRSTMnemonic

When examining the cardiovascular system, the mnemonic PQRST, is very useful inassessing chest pain. It provides a methodology in which communication to otherhealthcare providers will be most efficient and informative.

Assess the following characteristics with each new report of pain and following any

intervention:

(P) Provocative or Palliative: What makes the symptom(s) better or worse?

(Q) Quality: Describe the symptom(s).

(R) Region or Radiation: Where in the body does the symptom occur? Is there

radiation or extension of the symptom(s) to another area of the body?

(S) Severity: On a scale of 1-10, (10 being the worst) how bad is the symptom(s)?

(T) Timing: Does it occur in association with something else (e.g. eating, exertion,

movement)?


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ProvocativeorPalliativeFactors

Askthepatientaboutwhatstartsorworsensthepain.Chestdiscomfortprovokedbyexertionisaclassic

symptomofangina,althoughesophagealpaincanalsoresultfromexertion.Otherfactorsthatmay

provokeischemicpaininclude:

Cold

Emotionalstress

Sexualintercourse

Smoking

Meals

However,discomfortthatreliablyoccurswitheatingismostlikelyrelatedtoanuppergastrointestinal

disease.Painmadeworsebyswallowingislikelyofesophagealorigin.

Factorsthatinfluencepainshouldalsobeestablished.Painthatrespondstosublingualnitroglycerinor

cessationofactivitystronglysuggestsacardiacischemicetiology,whilepericarditispaintypically

improveswithsittingupandleaningforward.

PracticePearl

Patientswithahistoryofcoronaryheartdiseasetendtohavethesamequalityofchestpainwith

recurrentepisodes.

QualityofPain

Thepatient

with

myocardial

ischemia

often

denies

feeling

chest

pain

and

may

delay

seeking

treatment.Typicaldescriptionsofchestpainfrommyocardialischemiamayinclude:

Squeezing Abandlikesensationisfeltaroundthechest.

Tightness Thereisasensationofaknotbeingpresentinthecenterofthechest.

Pressure Asensationofalumpinthroatoraheavyweightonthechest.

ChestConstriction TheLevinesignisdisplayedbyapatientsufferingfromchestpaincausedbya

myocardialinfarction.Thepatienttypicallypressesaclenchedfistagainstthechesttoillustratethe

sensationofpressureandconstrictioninthechest.

Burning Infarctionpainisoftenmistakenforheartburnorindigestion,especiallyinwomen.


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RegionorRadiationofPainPainthatlocalizestoasmallareaofthechestismorelikelytoberelatedtoachestwallorpleuralorigin

ratherthantheheart.

Ischemiccardiacpainisadiffusetypeofnonlocalizedpain.

Thepainofmyocardialischemiaoftenradiatestotheneck,throat,lowerjaw,teeth,upperextremities,

orshoulder.

Ifthechestpainisradiatingtoseveralareas,thereisanincreasedchancethatthepatientishavinga

myocardialinfarction(MI).

SeverityandAssociatedSymptomsUsinga10pointnumericpainratingscaleorvisualanalogscaleoftenhelpspatientsdescribethe

intensityofpain.The10pointscoregradespaininseverityrangingfrom0(nopain)to10(most

excruciating).The

severity

of

pain

does

not

necessarily

correlate

with

the

degree

of

ischemia.

As

many

as1/3ofmyocardialinfarctionsmaygoundetectedbythepatient.Somepatientshavedifficultyputting

anumberonthepaininwhichcaseanadjectiveratingscalemaybemosthelpful.TheNumericPain

Scalebelowisarepresentationofonesuchnumericalscale.

NumericalPainScale

SeverityandAssociatedSymptomsOthersymptomsthatmaybeassociatedwithmyocardialischemiamayinclude:

Nausea

Vomiting

Diaphoresis Syncope

Palpitations

Exertionaldyspnea

Fatigue

Weakness

Dizziness

Lightheadedness


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Timing

Knowingtheonsetofchestpainisimportanttohelptodeterminethecauseandtreatmentofthepain.

Ischemicpainismostoftengradualwithanincreasingintensityovertime.Acrescendopatternofpain

canalsobecausedbyesophagealdisease.Painassociatedwithpneumothorax,aorticdissection,or

acutepulmonary

embolism

typically

has

an

abrupt

onset

with

the

initial

sensation

being

the

most

intense.

Understandingthedurationofpainandanypatternsarealsohelpful.Thepainfrommyocardial

ischemiagenerallylastsforafewminuteswhereasthepainfromanMImaybemoreprolonged.Chest

discomfortthatonlylastsforafewsecondsorpainthatisconstantfordaysorweeksisnotgenerally

duetoischemia.Myocardialischemiamayhaveacircadianpattern.Itismorelikelytooccurinthe

morningthanintheafternoon,correlatingwithanincreaseinsympathetictone.However,thispattern

maynotbeexhibitedinpatientswithdiabetesorpatientstakingbetablockersasthepatients

sympathetictoneisaltered.

Ifthe

patient

is

unable

to

qualify

and

quantify

their

pain,

the

following

questions

may

be

useful

in

gettingneededinformationregardingtheirpain.

Whatgetsthepainstarted?

Whathelpsthepainstop(rest,sittingupandleaningforward)?

Wouldyoudescribeitasmoreofadullpressureorsqueezingormoreofasharp,stabbing,or

rippingfeeling?

Doesthispainfeelsimilartowhenyouhadyourpreviousheartattack?

Isthepainmostlyinoneareaordoyoufeelitupintoyourneckandarms?

With0beingnopainand10beingthemostexcruciatingpainever,whatnumberwouldyou

givethepaintodescribetheseverity?

Whenapplying

anumber

is

difficult:

Would

you

describe

the

pain

as

mild,

moderate,

or

severe?

Areyoufeelingnauseous,dizzy,lightheaded,shortofbreath,ortired?

Doesthepainstartoffgraduallyandgetworse,orviceversa?

Howlongdoesthepainlast?

Whendoesthepainusuallyoccurmorning,afternoon,ornight?

ChestPainintheElderly

Itshouldbenoted,however,thattypicalclinicalmanifestationssuchaschestpainoccurinonly50%of

elderlypatientswithcoronaryarterydisease(CAD)(Milner,2001).Whenpainispresentinanolder

patientitisfrequentlyvagueandpoorlylocalizedorlocalizedtotheabdomenorepigastricarearather

thanthesubsternalarea.Elderlypatientsexperiencinganginaormyocardialischemiamaydescribetheir

symptomssimplyas:exertionaldyspnea(mostcommon),fatigue,syncope,nausea,anorexia,confusion,

ordyspneaatrest.


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TestYourself:

Chestpainintheelderlyisusuallywelldefined.

A. True

B. False(Correct)

OtherSymptoms:Dyspnea

Dyspnea(shortnessofbreath)thataccompanieschestpainmayalsobeduetoanumberofpulmonary

disorders.

Askyourpatientthefollowingquestionsrelatedtodyspnea:

Doyouevergetshortofbreath?

What

types

of

activity

and

how

much

activity

brings

on

the

shortness

of

breath?

Doestheshortnessofbreathcomeonsuddenlyorunexpectedly?

Doesthedyspneacomeandgoorisitconstant?

Istheshortnessofbreathassociatedwithchangeinposition?

Doestheshortnessofbreathwakeyouupatnight?

Doestheshortnessofbreathinterferewithactivitiesofdailyliving?

PracticePearl

Paroxysmalnocturnaldyspnea(PND)occursatnightwithcongestiveheartfailure.Layingdown

increasesthevolumeofthoracicblood.Theweakenedheartcannotaccommodatethisgreater

volume.Your

patient

will

complain

of

sleeping

for

about

two

hours

and

then

arising

suddenly

needingfreshair.

OtherSymptoms:OrthopneaandCoughing

Orthopnea

Askyourpatienthowmanypillowsheorshesleepsonatnight.Orthopneaistheinabilitytobreathe

wheninalyingposition.

CoughDoesyourpatienthaveaconsistentcough?Havethepatientdescribethefrequency,timing,severityof

cough,andanysputumproduction.Ifthepatientdoeshavesputumproductionaskaboutthecolorof

thesputum,ifithasanodor,andifitisbloodtinged.

PracticePearl

Hemoptysisisoftenpulmonaryinnature,butmayoccurwithcardiogenicpulmonaryedema.


10/23


OtherSymptoms:Fatigue,Edema,CyanosisandPallor

Fatigue

Askyourpatientiftheytireeasily.Ifso,askaboutwhenthefatiguestarted.Wasitsuddenorgradual?

Hastherebeenanyrecentchangeinenergylevel?Alsoaskaboutthetimeofthedaythefatigueis

related

to,

e.g.

all

day,

morning

or

evening

to

establish

the

presence

of

a

circadian

rhythm,

which

may

indicateischemia.

PracticePearl

Cardiacrelatedfatigueisworseintheevening.Fatiguetoanxietyordepressionoccursalldayoris

worseinthemorning.

Edema,Cyanosis,andPallor

Doesyourpatienthaveanyswellingorskincolorchanges?Cyanosisorpalloroccurswithmyocardial

infarctionorlowcardiacoutput.Ifthepatienthasswelling,askaboutitslocation.Isitinthefeetand

legs?

If

so,

when

was

it

first

noticed?

Ask

about

any

recent

change

in

the

swelling,

if

it

is

unilateral

or

bilateral,andiftheswellingsubsidesaftersleepingorrestingwithfeetup.Alsoaskaboutany

associatedsymptomswiththeswellingsuchasdyspnea.

PracticePearl

Cardiacrelatededemaisworseintheeveningandbetterinthemorningafterrestingwiththefeet

up.

OtherSymptoms:Nocturia

Doesyourpatientgetupatnighttourinate?Askhowlongthishasbeenoccurringandiftherehave

beenanyrecentchangesinthispattern.

PracticePearl

Recumbencypromotesfluidreabsorptionandexcretion.Nocturiaoccurswithheartfailureinthe

patientwhoisambulatoryduringtheday.


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Pediatric,Pregnant,andAgingPatients

Additionalhistoryquestionsyoumaywishtoaskregardingyourinfant,pediatric,pregnant,oraging

patientarelistedontheleftsidebuttons.

ContentadaptedfromJarvis,1996.

AdditionalHistoryforInfants

Mothershealthduringpregnancy? Unexplainedfeverorrubellainthefirsttrimester? Other

infections,hypertension,drugstaken?

Evernoticedanycyanosiswhilefeeding,nursingorcrying?

Doesthebabyeatorplaywithouttiring?

Isthebabygrowingaccordingtonormalforageandgender?

Werethebabysmotormilestonesachievedasexpected

Howmanynapsperdayandlengthofnaps?

AdditionalHistoryforChildren

Activity Isthechildabletokeepupwithsameagedplaymates? Isthechildwillingorreluctant

toplay? Doesthechildpreferquietplay? Doesthechildeverhavebluespells?

Anyunexpectedjointpainorunexplainedfever?

Doesthechildhavefrequentheadachesornosebleeds?

Doesthechildhavefrequentrespiratoryinfections? Anyproventobestrepinfections?

Anyfamilyhistoryofcongenitaldiseases?

Anyoneinthefamilywithchromosomalabnormalities?

AdditionalHistory

for

Pregnant

Patients

BloodPressure Didyouhavehighbloodpressureinthisorotherpregnancies?Whatwasyour

bloodpressurebeforeyourpregnancy?

Hasyourpressurebeenmonitoredinthispregnancy?

Anyproteinintheurine?

Anyexcessiveweightgain?

Haveyouhadanyswellinginthefeet,legsorface?

Haveyouexperiencedanyfaintnesswiththispregnancy?

Haveyouexperiencedanydizzinesswiththispregnancy?

AdditionalHistory

for

Elderly

Patients

HeartandLungdisease Isthereahistoryofheartdisease,hypertension,coronaryartery

disease,emphysema,bronchitis?

Doyoutakeanymedicationsforyourillness?

Whatarethesideeffectsofthemedication(s)?

Haveyourecentlystoppedtakinganyofyourmedications? Ifso,whichonesandwhy?


12/23


Doyourillnessesinterferewithyouractivitiesofdailyliving?

Doesyourhomehaveanystairs? Howoftendoyouneedtoclimbthem?

ThePhysicalExamWhenassessingthecardiovascularsystem,othersystems,suchasthecirculatoryandrespiratory

systems,alsoneedtobeevaluatedtoprovideacomprehensiveandholisticpicture.

Inperformingacardiacassessment,avisualunderstandingoftheheartmaybeuseful:

A:AortaB:LeftventricleC:RightventricleD:Pulmonaryartery

ThecoronaryarteryRamusinterventricularisanteriorcanbeseeninthegroove(sulcus

interventricularis)between

the

ventricles.

(wikimedia.org,2007)

AssessmentofTheNeckVessels:InspectionWheninspectingtheneckvessels,lookforanyabnormalitiesyoucanobservewithyoureyes,ears,or

nose.

Themostimportantobservationtobemadeintheneckregionistheassessmentofjugularvenous

pulse.From

the

jugular

veins

you

can

estimate

central

venous

pressure

(CVP)

and

estimate

the

hearts

efficiencyasapump.

Ataglance,ifthepatientissittinginthesupinepositionat45degreesorhigher,youshouldnotbeable

toseejugularvenouspulsationsunlessthereisunderlyingpathology.


13/23


AssessmentofTheNeckVessels: Auscultation

Whenauscultating,ensureyourroomisquiet,auscultateoverbareskin,andlistentoonesoundata

time.Yourbellordiaphragmshouldbeplacedonyourpatientsskinfirmlyenoughtoleaveaslightring

ontheirskinwhenremoved. Beawarethatyourpatientshairmayalsointerferewithtrue

identificationof

certain

sounds.

The

diaphragm

is

used

to

listen

to

high

pitched

sounds

and

the

bell

is

bestusedtoidentifylowpitchedsounds(Kaplow&Hardin,2007).Also,remembertocleanyour

stethoscopebetweenpatients.

Auscultatethecarotidarteriesinpersonsmiddleagedorolder,orthosewithahistoryofcardiovascular

disease.Youarelisteningforthepresenceofabruit,whichisablowingorswishingsound,indicating

turbulentbloodflow.Youmayneedtoaskyourpatienttoholdtheirbreathforashorttimesothatyou

donotconfusetrachealbreathsoundswithabruit.Typically,abruitisabsent.

TestYourself:

Abruitisoftenconfusedwith:

A. Rales

B. Crackles

C. Wheezes

D. Trachealbreathsounds(Correct)

AssessmentofTheNeckVessels:Palpation

Palpation,anothercommonlyusedphysicalexamtechnique,requiresyoutotouchyourpatientwith

differentpartsofyourhandusingdifferentstrengthpressures.Duringlightpalpation,youpresstheskin

aboutinchto3/4inchwiththepadsofyourfingers.Whenusingdeeppalpation,useyourfingerpads

andcompresstheskinabout1inchesto2inches.Palpationallowsyoutoassesstheneckfor

tenderness,abnormaltemperature,excessivemoisture,pulsations,ormasses.

Palpatethecarotidarteriesverygentlyandneveratthesametime.Feelthecontourandamplitudeof

thepulse.Normally,thecontourissmoothwitharapidupstrokeandnormalstrength(+2).Findings

shouldbesimilarbilaterally.

Therightbundlebranchspreadsthewaveofdepolarizationtotherightventricle.Likewise,theleft

bundlebranchspreadsthewaveofdepolarizationtoboththeinterventricularseptumandtheleft

ventricle.Theleftbundlefurtherdividesintothreebranchesorfasicles.Thebundlebranchesfurther

divideintoPurkinjefibers.


14/23


CirculatoryAssessment:Inspection

Performingavisualassessmentofthecirculatorysystemisanimportantcomponentofa

comprehensivecardiovascularassessment.Areasforevaluationyoumayinspectincludeskincolor,

locationofanylesions,bruisesorrash,symmetryofmotion,sizeofbodyparts,andanyabnormal

findings,sounds,

and

odors.

Beginbyinspectingthepatientsskinforcolor,warmth,andmoisture.Cool,clammyskinresultsfrom

vasoconstriction.Warm,moistskinresultsfromvasodilation.Flushingofapatientsskinmaybedueto

medications,excessheat,anxiety,orfear.Pallorcanresultfromanemiaorincreasedperipheralvascular

resistancecausedbyatherosclerosis.Dependentrubor(redness)maybeasignofchronicarterial

insufficiency.Peripheralcyanosismaycauseabluishdiscolorationtothelipsandextremities.Inspect

theoralmucousmembranesforcyanosisthatmaynotbereadilyapparentontheskin.Examine

underneaththetongue,insidethecheeks,andthenailbedsforsignsofperipheralcyanosis.

Therearetwotypesofcyanosisthatmayoccurincompromisedpatients:centralandperipheral.Central

cyanosisis

consistent

with

reduced

oxygen

intake

or

transport

from

the

lungs.

Peripheral

cyanosis

suggestsconstrictionoftheperipheralarteries.Thisisusuallyfromstress,cold,oranxiety.Itmayalso

befromhypovolemia,shock,orvasoconstrictivediseases.

Notethepresenceofanyedema.Inspectyourpatientshairdistributionontheirskin.Lackofhairmay

alsoindicatearterialinsufficiency.

Next,assessarterialperfusiontothelowerextremities.Haveyourpatientliesupineonaflatsurface

andelevateoneofhislegsabovehisheartforaboutoneminute.Youmayneedtoassistwiththis

movement.Thenaskhimtositupanddanglehislegsoverthebedandinspectthecolorofbothlegs.

The

leg

that

was

elevated

should

show

slight

pallor

in

comparison

to

the

other

leg.

The

color

of

both

legs

shouldbeaboutthesameinabouttenseconds,oncetheveinshavehadtimetofill.

Edemacanresultfrommanydiseaseprocessesincludingheartfailure,liverfailure,orbyvenous

insufficiency,varicosities,andthrombophlebitis.

CirculatoryAssessment:Auscultation

Auscultateyourpatientsbloodpressure.Thesystolicreadingreflectsthepressureexertedbytheleft

ventricleduringcontraction.Thediastolicreadingreflectsthepressureinthearterieswhentheheartis

atrest.

Bloodpressure

is

lowest

in

the

newborn,

and

rises

with

age,

weight

gain,

stress,

anxiety,

and

during

exercise.


15/23


CirculatoryAssessment:Auscultation

Whenauscultatingbloodpressure,besuretochooseanappropriatesizecufftoavoidfalsereadings.

Somehelpfulhintswhenassessingbloodpressureinclude:

Nevertakeabloodpressureinanarmonthesamesideasamastectomy.

Nevertakeabloodpressureinanarmwithanarteriovenousfistulaorshunt,orinanarmwitha

peripherallyinsertedcentralcatheter.

IfeitherthesystolicBPisover140orthediastolicpressureisover90onrepeated

measurements,thepatientisconsideredtohaveStage1Hypertension(highbloodpressure).

Hypertensionisriskfactorforheartdisease,stroke,andkidneydisease.

Diet,exercise,and,whennecessary,medicationscancontrolbloodpressure.

BloodPressureClassificationinAdults

Category

Normal

PreHypertension

StageIHypertension

StageIIHypertension

Systolic

160

Diastolic

And100

ClassificationandManagementofBloodPressureinAdults.NationalInstituteofHealth(2003).

CirculatoryAssessment:Palpation

Thenextpartofthecirculatorysystemexaminationispalpation.

Beginbypalpatingtheperipheralarteries.Theseincludethebrachial,radial,femoral,popliteal,dorsalis

pedis,andposteriortibial.

Notethecontourandamplitudeofeachpulsation.Theseshouldfeelsimilarbilaterally.

Asyoumoveawayfromthecoreofthebody,youmaynoticethatthecontourorupstrokeofthe

pulsationislessrapid.Thisisnormal,butitisimportanttoassessthatthearterieshavesimilarstrength

bilaterally.


16/23


TestYourself:

Whenassessingnormalcirculationintheextremities,youanticipatefindingthat:

A. Bloodflowissimilarbilaterally.(Correct)

B. Thecontourandamplitudeofpulsationsaregreaterontheleftsideofthebody.

C. Thecontourandamplitudeofpulsationsaregreatontherightsideofthebody.

D. Asyoumovefurtherawayfromthecoreofthebody,thecontourpulsationsaremorerapid.

ThePrecordium:InspectionandAuscultation

Inspection

Inspecttheanteriorchestforpulsations.Youmayormaynotseetheapicalpulse.Ifitisvisible,youwill

seeitinthefourthorfifthintercostalsspace.

Auscultation

Beforeyoubeginyourauscultationoftheprecordium,prefaceyourexambytellingthepatientyouwill

belisteninginmanydifferentplacesforwhatmightbeawhile.Then,youmustidentifytheareasyou

needtoausculate.YoumaywanttoinchyourstethoscopeinaZpatternacrosstheprecordium,from

thebaseofthehearttotheapex.Concentratetothesoundofthelubandthedub.Theluborfirst

heartsoundisknownasS1.TheduborthesecondheartsoundisknownasS2.

HeartSounds:S1

S1,thelubofthelubdub,isproducedbytheclosureoftricuspidandmitralvalves.

Alterationsyou

may

auscultate

that

involve

S1

are

as

follows:

S1isaccentuatedinexercise,anemia,hyperthyroidism,andmitralstenosis.

S1isdiminishedinfirstdegreeheartblock.

S1splitismostaudibleintricuspidarea(Tlubdub)

(Kaplow&Hardin,2007)

HeartSounds:S2

S2,thedubofthelubdub,isproducedbytheclosureofaortic&pulmonicvalves.

Alterationsyou

may

auscultate

that

involve

S2

are

as

follows:

NormalphysiologicalsplittingofS2isbestheardatpulmonicarea.Itoccursoninspiration(lub

Tdub,lubdub).

SplittingofS2soundcanoccurwhentheaorticandpulmonaryvalvesdonotcloseatthesame

time(Kaplow&Hardin,2007).Thiscanindicatepulmonicstenosis,atrialseptaldefect,right

ventricularfailure,orleftbundlebranchblock.


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HeartSounds

ListentoactualheartsoundsusingtheAuscultationAssistant

http://www.wilkes.med.ucla.edu/intro.html

Thisgreattoolwillexposeyoutomanydifferentnormalandabnormalheartsounds.

HeartSounds:S3

Thethirdheartsoundisproducedbytherapidfillingoftheventricle(thatisnotcompletelyempty)

duringearlydiastole(Kaplow&Hardin,2007).S3isalsoknownasaventriculargallop(lubDUBtaor

Kentucky).

S3isnormalinpregnancy,children,adultslessthanthirtyyearsold,duringexercise,anxiety,oranemia.

Itisheardbestattheapexintheleftlateraldecubitusposition,usingthebell.

PathologicS3occursinpeopleovertheageof40,usuallyduetomyocardialfailure.

HeartSounds:S4

ThefourthheartsoundistypicallyheardinlatediastolebeforeS1,asaresultofincreasedventricular

resistancetoatrialfilling,duetoeitherdecreasedventricularcomplianceorincreasedventricular

volume.Itislowpitchedandbestheardwiththebell.S4isalsoknownasanatrialgallop(talubDUB

orTennessee).

S4isoftennormalinolderadultsandisheardbestattheapexintheleftlateraldecubitusposition.

PathologicalS4maybecausedbycoronaryarterydisease,hypertension,cardiomyopathy,oraortic

stenosis.

TestYourself:

Whichheartsoundisknownastheatrialgallop?

A. S1

B. S2

C. S3

D. S4(Correct)


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AbnormalHeartSoundsSummationGallop&OpeningSnap

SummationGallop

AsummationgallopisproducedwhenS3&S4mergeintoonesound.Itoftenoccursatratesgreater

than100beatsperminute.Itmayoccurinheartfailureandpericarditis.Summationgallopsoccurin

15%

of

all

myocardial

infarctions

and

are

common

following

cardiac

surgery.

They

are

best

heard

with

patientleaningforward,holdingbreathafterfullexpiration.

OpeningSnap

Attheendofventricularsystole,whentheaorticandpulmonicvalvesclose,S2isproduced.

ImmediatelyafterS2,theheartrelaxes,andventricularpressurefallsbelowthatofatrialpressure.This

allowstheatrioventricularvalvestoopen.Thisisthestartofdiastole.Normally,youcannothearthese

valvesopen.However,ifthemitralvalvebecomesstenoticorabnormallynarrowedtheywillcreatean

openingsnap.Thissoundusuallyprecedesthedevelopmentofadiastolicmurmurassociatedwith

mitralstenosis.Oncethevalvebecomesseriouslyimpairedandinflexible,theopeningsnapdisappears

(Kowalak,Johnson&Sussman,2002).

AnOpeningSnapisanabnormalheartsoundduetoastenoticvalveopening.Whenanormalcardiac

valveopens,thereisnosoundcreated.

AbnormalHeartSounds:EjectionClick&MidSystolicClick

EjectionClick

Similartoanopeningsnap,anejectionclickiscausedbystenoticvalveleaflets.Thissoundisproduced

whentheaorticorpulmonicvalvesopenatthebeginningofsystole.Itisabriefhighfrequencysound

bestheard

with

the

diaphragm

over

the

aortic

or

pulmonary

artery

or

Erbs

point,

or

near

the

apex

over

themitralarea(Kowalak,Johnson&Sussman,2002).

MidSystolicClick

Amidsystolicclickoccurswhenthemitralvalvesleafletsandcordaetendenaetense.Theanterioror

posteriororbothleafletscanprolapse.Everyonceinawhilemultipleclicksoccur.Theyareheardinmid

tolatesystole.Theyarebestheardoverthetricuspidareaandtowardsthemitralarea.Theyarecrisp,

highfrequencysounds(Kowalak,Johnson&Sussman,2002).

AbnormalHeartSounds:PericardialFrictionRub&MediastinalCrunch

PericardialFriction

Rub

Apericardialfrictionrubisusuallyheardbestandissometimespalpableoverthetricuspidandxyphoid

areas.Itoccurswheninflamedpericardialsurfacesrubtogether.Therubbingofthesesurfacesproduce

thecharacteristic,highpitched,gratingnoises.Todifferentiateapericardialfrictionrubfromapleural

frictionrub,havethepatientholdhisorherbreath.Whentheydothis,apericardialfrictionrubwill

continue,apleuralfrictionrubwillcease(Kowalak,Johnson&Sussman,2002).


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MediastinalCrunch

Amediastinalcrunchisproducedduetodisplacedairunderthesurfaceoftheskinnearthe

mediastinum.Patientswithmediastinalcrunchoftenhavesubcutaneousemphysema.Youcanassess

forthisbypalpatingcrepitationintheneck.Thenoisehasacrunchingqualityandisheardbestalong

theleftsternalborder.Itmaybelouderoninspiration(Kowalak,Johnson&Sussman,2002).

AbnormalHeartSounds:Murmurs

Amurmurisanabnormalheartsoundcausedbyturbulentbloodflow.Thesoundmayindicatethat

bloodisflowingthroughadamagedoroverworkedheartvalve,thattheremaybeaholeinoneofthe

heart'swalls,orthatthereisanarrowinginoneoftheheart'svessels.

Someheartmurmursareaharmlesstypecalledinnocentheartmurmurswhicharecommoninchildren

andusuallydonotrequiretreatment.

AuscultationofMurmurs

Ifyouauscultateamurmur,itisimportanttoassessanddocumentthefollowingqualitiesofthe

murmur:

Timing: Aretheysystolicordiastolic?

Anatomicallocationofmaximumintensity: Whereisthemurmurbestheard?

Frequency: Whatisthepitchofthemurmur?

Radiation: Canyouhearthemurmurinotherlocationssuchastheneckorupperchest?

Quality: Isthemurmurharsh,soft,orblowing?

Intensity: Describetheloudnessofthemurmuronascaleof1to6,asindicatedbyLevine's6point

gradingscale:

Grade Intensity

1 VeryFaint EasilyMissed

2 QuietBarelyAudible

3 ModeratelyloudbuteasilyheardsameintensityasS1orS2

4 Loud,butusuallynothrillpresent

5

Veryloud,

thrill

present

6 HeardwithstethoscopeoffchestThrillpresent

(Lippincott,Williams&Wilkins,2005)


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TimingandQualityofCommonMurmurs

Thefollowingtabledepictsthetimingandqualityofcommonmurmurs.

ThePrecordium:PalpitationandPercussion

Palpation

Palpate

the

apical

pulse,

normally

in

the

fourth

or

fifth

intercostal

space,

mid

clavicular

line.

It

should

be

feltasashort,gentletap.Itcanbepalpatedinabouthalfofpeople.Itismoredifficulttopalpatein

obesepatientsorthosewiththickchestwalls.Stress,fever,anxiety,hyperthyroidism,andanemiamay

increasetheamplitudeanddurationoftheapicalpulse.Whentheapicalpulseispalpatedlowerinthe

thoraciccageandhasagreateramplitudethanexpected,itisoftenduetocardiacpathology.

Percussion

Youmayusepercussiontooutlinethecardiacborder.Typically,however,achestxraycanrevealthe

sameresults.Therearetimes,however,thatchestxraysarenotavailableandpercussionmaybeone

ofyouronlytoolstoassesscardiacsize.

Toperform

effective

percussion,

press

the

distal

part

of

the

middle

finger

of

your

non

dominant

hand

firmlyonthebodypart,keepingtherestofthehandoffthebodysurface.Usingthemiddlefingerofthe

dominanthand,tapquicklyanddirectlyoverthepointwheretheothermiddlefingermakescontact

withthepatientsskin.Dullnessshouldbeheardovertheareawheretheheartislocated.


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RecordingFindings

Itisimportanttoaccuratelyandthoroughlyrecordanddocumentyourfindingsfromthecardiovascular

exam.

Standarddocumentationensuresthatallmembersofthehealthcareteaminterpretthefindings

accurately.

In

documenting

murmurs,

Levine's

six

point

grading

scale

is

the

most

accurate

way

to

record

findings,asistheuseofastandard4pointscaletoassessanddocumentedema.

Rememberthatyourrecordingsarepartofthemedicalrecord,andshouldbeasobjectiveandaccurate

aspossible.

Conclusion

Integratingthecardiovascularhealthhistoryandphysicalexamtakespractice.Itisnotenoughtosimply

asktherightquestionsandperformthephysicalexam.Asthepatientsnurse,youmustcriticallyanalyze

allofthedatayouareobtaining,synthesizethedataintorelevantproblemfocus,andidentifyaplanof

care

for

your

patient

based

upon

this

synthesis.

As

the

plan

of

care

is

being

carried

out,

reassessments

mustoccuronaperiodicbasis.Howoftenthesereassessmentsoccurisuniquetoeachpatient,based

upontheirphysicaldisorder.

IMPORTANTINFORMATION:

Thispublicationisintendedsolelyfortheeducationaluseofhealthcareprofessionalstakingthiscourse

fromRN.cominaccordancewithRN.comtermsofuse.Theguidanceprovidedinthispublicationis

generalinnature,andisnotdesignedtoaddressanyspecificsituation.Asalways,inassessingand

respondingtospecificpatientcaresituations,healthcareprofessionalsmustusetheirjudgment,aswell

asfollowthepoliciesoftheirorganizationandanyapplicablelaw.Organizationsusingthispublicationas

apart

of

their

own

educational

program

should

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Healthcareproviders,hospitalsandhealthcareorganizationsthatusethispublicationagreetohold

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22/23


References

AmericanAssociationofCriticalCareNurses(1998).TheCardiovascularSystem.InJ.Alspach

(Ed.),Corecurriculumforcriticalcarenursing

(5thed.,Rev.,pp.137338).Philadelphia:Saunders.

AuscultationAssistant.(2004).Availableathttp://www.wilkes.med.ucla.edu/intro.html.

BlumJ,SchadlerA,PrushCooperS.(2001).AssessmentandManagementofAcuteCardiac

ChestPain.CritCareNursClinofNorthAm.13(2):25969.

CancerTreatmentCentersofAmerica.(2011).Riskfactorsforlungcancer.RetrievedMay4,

2011,fromhttp://www.cancercenter.com/lungcancer/lungcancerriskfactors.cfm

CentersforDiseaseControl.(2006).HeartDiseasefactSheet.RetrievedOctober10,2007from:

http://www.cdc.gov/dhdsp/library/pdfs/fs_heart_disease.pdf

Jarvis,C.(1996).Physicalexaminationandhealthassessment.Philadelphia:W.B.Saunders.

Kaplow,RandHardin,S.(2007).CriticalCareNursing:SynergyforOptimalOutcomes.MA.Jones

andBartlett.

Kowalak,J.;Johnson,P.&Sussman,T.(Eds.).(2002).Auscultationskills:Heartandbreath

sounds.(2nded). (pp.2694). Springhouse,PA: Springhouse.

Lippincott,Williams&Wilkins(2005).

HeartSounds

Made

Incredibly

Easy.

PA.

McCaffery,M.&Pasero,C.(Eds.).(1999).Pain:ClinicalManual(2nded.).

(pp1718,63,108113). St.Louis: Mosby.

MilnerKA,FunkM,RichardsS,VaccarinoV,KrumholzHM.(2001).Symptompredictorsofacute

coronarysyndromesinyoungerandolderpatients.NursRes,50(4):233241.

NationalInstituteofHealth(NIH),2003.NationalHighBloodPressureEducationProgram

(2003).Part oftheSeventhReportoftheJointCommitteeonPrevention,Detection.

Evaluation,andTreatmentofHighBloodPressure.U.S.DepartmentofHealthandHuman

services,National

Institutes

of

Health,

National

Heart,

Lung

and

Blood

Institute.

Retrieved

and

updatedMay5,2011from:http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

Shaw,M.(1998)Assessmentmadeincrediblyeasy!Springhouse,PA:Springhouse.


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