24.3: Nursing Assessment
By the end of this section, you will be able to:
- Describe how to collect subjective data when performing cardiovascular and peripheral vascular assessments
- Explain how to collect objective data when performing cardiovascular and peripheral vascular assessments
- Discuss how to identify abnormalities identified during cardiovascular and peripheral vascular assessments
The initial assessment performed by the nurse is instrumental in the care of a patient and provides vital information for the provider and collaborative healthcare team. Data collected during the assessment allow the nurse to make critical decisions about short- and long-term care and address immediate emergencies as needed. When assessing a patient’s cardiovascular and peripheral vascular systems, having a full understanding of the components of both systems is important in determining how information provided by the patient provides signs of dysfunction.
Subjective data that come from the patient include information such as pain, nausea, and experiences that cannot be seen or measured. In comparison, objective data collected include empirical data such as blood pressure and oxygen levels. Objective data also include anthropometric data (systematic measurement of the physical properties of the human body, primarily dimensional descriptors of body size and shape). Anthropometric data reflect health and nutritional status and predicts performance, health, and survival of a person or group of people. It is the responsibility of the nurse to collect both types of data, ask follow-up inquiry-based questions, and form a plan based on clinical judgment and critical-thinking skills.
Proficiency in assessment includes knowledge in performing inspection , palpation , percussion , and auscultation of each body system. These techniques are used to auscultate heart sounds and assess perfusion through areas of the body, palpate for masses, and inspect irregularities in the skin including discoloration and edema. The nurse will perform many of these techniques to determine cardiovascular diseases (e.g., hypertension, arrhythmias, coronary artery disease, heart failure, valvular diseases) and peripheral vascular disease s (e.g., deep vein thrombosis (DVT) , lymphedema, chronic venous insufficiency, Raynaud phenomenon, varicose veins ).
Nursing Assessment
A thorough assessment of the cardiovascular system starts with a full history of the patient’s current and past medical experiences as well as family history, especially related to heart disease. This along with a complete examination of the cardiovascular system, including peripheral vascular function, will help the nurse create a patient-specific nursing care plan with a comprehensive plan of action. Information gathered during the assessment such as subjective data and objective findings are critical to accurately recognizing and analyzing cues that could potentially be attributed to dysfunction.
Collecting Subjective Data
Subjective data are information that comes from the patient, the “subject.” This is information that cannot be measured empirically and is often based on the perception of the patient. This information includes past and present medical history, family history, cardiac risk factors, symptoms, and current medications including vitamins, herbal remedies, and over-the-counter (OTC) medications. New or worsening symptoms should be documented and reported to the provider. Symptoms can include chest pain, shortness of breath (dyspnea), irregular pulse rate, dizziness, fatigue, peripheral edema, poor peripheral circulation, decreased pulses in the lower extremities, fluttering in the chest, and pain in the upper back, neck, or abdomen. Additional symptoms, such as heartburn, indigestion, nausea, or vomiting may be benign; however, they can also be indicative of a myocardial infarction. Therefore, it is imperative that the nurse ask appropriate inquiry-based questions to clarify subjective information provided by the patient (Centers for Disease Control and Prevention, n.d.).
When conducting the interview and assessment, clarifying questions should first address any immediate need for intervention (e.g., severe chest pain, shortness of breath) that may be indicative of a serious problem (e.g., myocardial infarction). When the situation is determined not to be urgent, the nurse should continue asking clarifying questions to further assess the patient’s condition (Table 24.5).
| Complaint/Symptom | Initial Questions | Follow-Up Clarifying Questions |
|---|---|---|
| Palpitations |
|
|
| Shortness of breath (dyspnea) |
|
|
| Swelling (edema) |
|
|
| Dizziness (syncope) |
|
|
| Poor peripheral circulation |
|
|
| Calf pain |
|
|
When assessing pain, the nurse may want to use the multidimensional PQRSTU Pain Assessment Model.
- Provocation/Palliation: What brings on the pain? What relieves the pain?
- Quality/Quantity (characteristics and duration): Please describe the pain. How often has it been occurring?
- Region/Radiation: Where is the pain? Does it radiate anywhere?
- Severity: How would you rate the pain on a scale of zero to ten, where zero is no pain and ten is the worst possible pain you could ever imagine?
- Timing: When did the pain start? How long does the pain last?
- Understanding: What do you think is causing the pain?
Scenario: A 72-year-old male presents to an urgent care center with complaints of chest pain. The patient doesn’t have any family or friends present. During the initial assessment, the triage nurse, Samantha, measured the patient’s vital signs, initiated oxygen therapy, and determined that the patient was stable at this time. Another nurse walks into the patient’s room to complete an assessment.
Nurse: Hi, my name is Richard. I am going to be your nurse today. Do you mind verifying your name and date of birth for me?
Patient: Sure, I am Abraham Cohen. My date of birth is September 23, 1952.
Nurse: Thank you. So, you mentioned to Samantha, the first nurse, that you’ve been experiencing some chest pain. Can you tell me what’s going on?
Patient: I woke up this morning with really bad chest pain. It seems to have eased a bit but it’s still bad.
Nurse: I’m sorry to hear about that. What makes it worse?
Patient: Well, nothing really, it’s just sort of steady pain.
Nurse: Can you tell me if anything makes it feel better?
Patient: Um, sitting upright in a chair and not exerting any energy seems to help.
Nurse: How would you describe your pain?
Patient: Well, it’s right here [patient pointing at the center of the chest] and its real sharp.
Nurse: On a scale of zero to ten, zero being no pain at all and ten being the worst possible pain you could ever imagine, how would you rate your pain?
Patient: I’d probably say about a seven.
Nurse: When did this begin?
Patient: Well, it started with what I thought was heartburn and it’s been coming and going for a couple of days but seemed much worse this morning.
Nurse: Is it constant?
Patient: No.
Nurse: Where were you when it began?
Patient: This time I was in bed sleeping and it woke me up.
Nurse: I see. Have you used anything to treat it, any medications?
Patient: No.
Nurse: Can you tell me what you think might be causing this?
Patient: I’m not real sure. I was hoping it would go away but when it kept coming back I was afraid it might be a heart attack so thought I should come get it checked out.
Nurse: That was a good decision. So, now we’re going to do a physical assessment. Hopefully this will give us a better understanding of what’s going on. If you remember anything else while I’m examining you, please feel free to just speak up and tell me. And, if you have any questions, don’t hesitate to ask. Most important, if you start to feel worse, tell me immediately.
Patient: Okay, great. Thank you.
Nurse: No problem. We’ll start working to figure this out.
Obtaining Health History
The goal of obtaining a health history is to gain insight into the overall health status of the patient. Relevant information related to chronic illness can be revealed through patient interviews as well as discovery of prior illnesses that the patient has not been treated for resulting in lingering effects. In general, the health history will include the patient’s medical history, allergies, surgeries, medications, and social history, and the patient’s family history.
When gathering a comprehensive medical history as it pertains to cardiovascular health, there are several key points for the nurse to consider. This includes an in-depth exploration of existing medical conditions, ongoing treatments, and any lingering effects from previous illnesses. Recognizing chronic or pervasive symptoms will help the nurse identify areas that require further evaluation.
For example, current symptoms such as shortness of breath, palpitations, chest pain, and edema may point to a cardiovascular origin. The nurse should ask if the patient has a history of any cardiac conditions, including short-term infections or illnesses (e.g., endocarditis, rheumatic fever, heart attacks) and long-term or chronic conditions (e.g., heart failure, high blood pressure, valvular disease). The nurse should also ask if the patient has a family history of heart disease—for example, a sibling or parent who had a heart attack or sudden cardiac death. It’s important to find out, if possible, the age at which family members experienced these events.
The nurse also needs to assess cardiovascular disease risk factors that may be present in the patient’s lifestyle, such as their diet, smoking status, substance use, alcohol use, sleep habits, stress levels, and physical activity. In taking a social history, the nurse should also consider whether the patient’s job or leisure activities (such as travel) could be risk factors for heart disease.
Asking a patient about their current medication use is also important, not just to ascertain whether they are being treated for a cardiovascular condition (and are complying with treatment) but also to determine whether they are taking any medications that could have cardiovascular contraindications or side effects. For example, popular OTC supplements that contain stimulating substances such as caffeine or ginseng may cause palpitations. Certain prescription drugs (e.g., erythromycin) can cause QT prolongation.
In taking a detailed medication history, particularly in older patients or those with multiple chronic conditions, the nurse should be aware of an increasing number of medications that patients may be taking and the potential for drug-to-drug interactions. This relates not just to prescriptions, but to OTC drugs, herbs, supplements, and vitamins as well.
Allergies are of utmost importance for all patients because of the potential for life-threatening consequences. Clear communication is key when asking about medication allergies, ensuring a thorough understanding of the patient’s reactions. Questions regarding allergies should cover more than just medications. The nurse should also inquire about allergies, sensitivities, or reactions to other substances (e.g., latex, medical/bandage tape, antiseptic solutions) as well as any herbs and vitamins.
Certain aspects of the medical history may be tailored to specific situations. Age and gender often guide healthcare professionals in determining when to inquire about additional details. For infants, parents should be asked about complications during pregnancy and delivery, and prematurity. Immunization status is crucial for pediatric patients, and it remains relevant for older adults with an increasing array of vaccination options making it an integral part of medical history assessments.
Definition: Integrate current evidence regarding best practices with clinical expertise; also incorporate patient/family preferences and values for delivery of optimal health care.
Knowledge: Demonstrate knowledge of basic scientific methods and processes
Skill: Participate effectively in appropriate data collection and other research activities. The nurse will ask questions such as:
- Have you ever been diagnosed with any heart or circulation conditions, such as high blood pressure, coronary artery disease, peripheral vascular disease, high cholesterol, heart failure, or valve problems?
- Have you ever had a heart attack or stroke?
- Have you had any procedures performed to improve your heart function, such as ablation or stent placement?
Attitude: Appreciate strengths and weaknesses of the scientific basis for practice.
Past History
Identifying both acute and chronic illnesses for which the patient has been treated in the past, as well as any untreated illness, is instrumental in recognizing current risk factors and symptoms that may contribute to current and future health status. A history of chronic respiratory illness, diabetes, obesity, and kidney disease can adversely affect the patient’s overall health and place the patient at risk for cardiovascular disease. Surgical history is also considered, encompassing all invasive procedures the patient has undergone. Information collected from the past history can often direct treatment, identify areas in need of further evaluation, and avoid potential harm to the patient.
Family history plays a crucial role, offering insights into potential genetic predispositions to certain diseases. It is important to gather information related to parents and siblings to determine risk factors and genetic disposition for heart disease.
Social History
Social history is a broad category that covers the patient’s lifestyle factors, such as smoking or tobacco use, alcohol and drug history, spirituality, mental health, and relationship aspects. Occupational details, hobbies, and sexual activity are also part of this inquiry. Further probing may be necessary if there are concerns about health risks or a connection to the current disease state.
Asking about smoking or tobacco use as well as alcohol and drug use should include how much, how often, and how long. If the patient has smoked in the past, the questions should be centered around when stopped and how long the patient smoked at that time. Alcohol-related questions should include type of alcohol (beer, wine, liquor), how many drinks per day/week/month, and any history of alcohol dependency. Drug usage, abuse, and dependency should include both prescribed and recreational or illegal drugs. The type of medication, medication name, how often, and any adverse effects should be documented.
Identify Risk Factors
To mitigate any potential cardiac dysfunction, it is important to identify risk factors that may contribute to cardiovascular disease. Some risk factors may be attributed to social history such as smoking, alcohol, and drug use. Other risk factors may include information from the past medical history and family history.
Name:
Jess, RN
Clinical setting:
OB-GYN office
Years in practice:
8
Facility location:
A small clinic in the Midwest
I recently had a patient; her name was Lisa. She came in with her partner, Cole, for her first prenatal visit. She was new to the practice, so we were going through her medical history. Lisa and Cole were both teachers in their early 30s who had moved to the area to take jobs at the local high school. This was Lisa’s first pregnancy, and she hadn’t had any trouble getting pregnant. Actually, she said they got pregnant a lot quicker than they thought they would, so she was nervous that “things were happening so fast.”
When we started talking about her medical history, which was pretty unremarkable because she was young and healthy, I noticed that she started to get tearful. Her parents were in great health, she told me, but her younger brother . . . she started to cry, and Cole stepped up to fill me in.
When Lisa was a teen, her brother Scotty had died suddenly during a soccer game. He had just “passed out and died” on the field without warning. It was very traumatic for everyone, but especially Lisa because they had been so close. Scotty was a healthy, athletic kid, and Lisa’s family thought that him dying of sudden cardiac arrest “didn’t make sense.”
Lisa told me that since Scotty died, she’d always had a fear in the back of her mind that she could die the same way—without warning, and “from some unknown heart thing.” But since she’d found out she was pregnant, she’d become consumed with anxiety that “whatever killed Scotty might be passed on to my baby.”
I started by acknowledging her concern and making sure she felt heard and that her feelings were valid. I also reassured her that the doctor would be able to answer questions and address her fears. They would be able to discuss things such as genetic screenings and prenatal testing, and because technology has come so far, we can even spot some congenital heart problems in utero today.
I also asked her if she had someone to talk to about Scotty, and she admitted that she “probably needed therapy.” I offered to connect her with the social worker who is part of our office team, and she seemed relieved.
I remember the next time she came in, she stopped me in the hallway and thanked me. The prenatal and genetic tests had come back negative. But she said that the biggest thing was that after she “spoke up about the fear” it was like a weight had been lifted from her shoulders—or maybe, her heart.
The nurse will follow through with additional questions related to any potential risk factors to analyze the severity and potential impact on overall health (Table 24.6).
| Question | Follow-Up Questions |
|---|---|
| Have your parents or siblings been diagnosed with any heart conditions? |
|
| Do you smoke or vape? |
|
| If you do not currently smoke, have you smoked in the past? |
|
| Are you physically active during the week? |
|
| What does your diet look like on a typical day? |
|
| Do you drink alcoholic drinks? |
|
| Would you say you experience stress in your life? |
|
| How many hours of sleep do you normally get each day? |
|
Although some risk factors cannot be changed, such as genetic predisposition, other factors are modifiable. Globally, CVDs (heart and blood vessel diseases) are a significant health challenge. CVD is influenced by factors such as high blood sugar, high blood pressure, high cholesterol, and obesity. Evidence suggests that having multiple modifiable risk factors can make the condition more severe. From 1990 to 2019, the number of CVD cases almost doubled, with about 523 million people affected and 18.6 million deaths in 2019 (Kumma, 2022). According to the American Heart Association (n.d.), major modifiable risk factors for CVD include smoking, high blood pressure, high cholesterol, physical inactivity, obesity, and diabetes. These factors can occur individually or in combination with other factors. Factors such as age, gender, residence, altitude, education, and socioeconomic status are associated with having multiple modifiable CVD risk factors.
Validated risk assessment tools are available to help estimate an individual’s likelihood of experiencing a stroke or heart attack in the next ten years. These tools, such as the BE-FAST and RACE assessments, use general practice data and consider factors such as age, gender, family history, smoking, atrial fibrillation , chronic kidney disease, body mass index, blood pressure, and lipid levels. The BE-FAST (Balance-Eyes-Face-Arms-Speech-Time) is an easy to administer, quick assessment tool that can be conducted by both licensed and unlicensed health professionals (El Ammar et al., 2020). The RACE (Rapid Arterial Occlusion Evaluation) is a longer assessment tool that can identify larger vessel occlusion (American Heart Association, 2019). Other assessment tools such as the Cincinnati Pre-Hospital Stroke Scale (CPSS), the Los Angeles Motor Scale (LAMS), and the Miami Emergency Neurological Deficit (MEND) are also used to assess for stroke activity (Fussner & Velasco, n.d.). If an individual’s estimated CVD risk score is 10 percent or more, pharmacological therapies targeting blood pressure and/or lipid levels are recommended. Lifestyle advice is offered to individuals at all risk levels, including those with a risk score below 10 percent, based on their specific needs, as per the hypertension clinical guideline from the National Institute for Care and Health Excellence, or NICE (2023).
Comprehensive graded recommendations for screening tests across cultures and the life span are provided by the U.S. Preventive Services Task Force.
After completing a risk assessment, the focus often shifts to managing factors closely tied to CVD risk (e.g., hypertension, dyslipidemia, smoking). According to NICE, hypertension is suspected if clinic blood pressure is 140/90 mm Hg or more, with home readings of 135/85 mm Hg or greater (NICE, 2023). Treatment decisions depend on comorbid conditions or CVD risk scores. If diagnosed with stage 1 hypertension, lifestyle changes are recommended, and medication may be offered for those with pre-existing conditions or a risk score of 10 percent or more. In stage 2 hypertension, medication is always recommended.
Dyslipidemia, another critical risk factor, is managed based on patient profiles or an overall CVD risk score of 10 percent or more (NICE, 2023). Statins are recommended for those with established CVD. When calculating CVD risk, the ratio of total cholesterol to HDL cholesterol is used, and the non-HDL cholesterol should be 2.5 mmol/mol or less.
Detecting atrial fibrillation (AF) is vital for reducing stroke risk. Manual pulse checks should be part of a CVD assessment, and if AF is diagnosed, stroke risk should be assessed, and anticoagulants may be prescribed.
Definition: Describe reliable sources for locating evidence reports and clinical practice guidelines.
Knowledge: Nurses must distinguish between clinical opinion-based reports and those referencing clinical evidence and research summaries. Because nurses provide most patient education on CVD and associated conditions and risk factors, they must continually review recommendations that guide clinical practice. Focusing on guidelines from the American Heart Association, reviewing evidence-based reports on new treatment options, and familiarizing themselves with outcome goals gives nurses an advantage in providing the most up-to-date care for their patients.
Skill: Nurses can be alert for progressive changes in biomarkers such as serum lipid tests, blood pressure changes, edema, and subtle chest pain. The nurse can empower their patients to pursue lifestyle modification by providing clinical education based on evidence-based data that clearly shows the benefit of these actions. Depending on patient motivation and health literacy, nurses can adjust the level and depth of teaching while still promoting evidence-based practice. The nurse focuses on patient needs and concerns while incorporating contemporary treatment guidelines to fit the patients’ circumstances.
Attitude: A focus on evidence-based practice enhances the nurse’s professional presence, promotes the best outcomes for patients, and guides patient-centered care.
Nursing Assessment: Collecting Objective Data
The physical assessment of the cardiovascular system involves collecting data and interpreting findings related to vital signs; inspection, palpation, and percussion of the CVS; and auscultation (e.g., heart sounds, bruits). Collection of objective data also includes assessing heart rate and rhythm and gathering and reviewing diagnostic test results.
During the assessment, the nurse evaluates for sufficient perfusion and cardiac output. Tools such as a sphygmomanometer or blood pressure cuff (an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff that is applied to the arm), a stethoscope, penlight, tape measure, and pulse oximeter are used to collect data related to blood flow, blood pressure, edema, and oxygenation.
The first step in a physical assessment is to Identify the patient’s level of consciousness (LOC). Is the patient conscious and able to follow simple instructions and answer basic questions? The patient should be alert and cooperative. If not, assessment should be geared toward why the patient’s LOC is diminished including obtaining vital signs and testing for cardiac activity. Blood pressure, pulse readings, and oxygenation are interpreted to verify that the patient is stable before proceeding with the physical assessment. During this phase of the assessment, perfusion is evaluated. Several cardiac conditions can adversely affect cardiac output and perfusion in the body. There are several medications used to enhance a patient’s cardiac output and maintain adequate perfusion to organs and tissues throughout the body.
Assessing a patient’s oxygenation status is commonly accomplished using pulse oximetry (the saturation of peripheral oxygen [SpO 2 ]), which measures the saturation of hemoglobin with oxygen in peripheral blood. The target SpO 2 range for adults is 94 to 98 percent, but for individuals with chronic conditions such as chronic obstructive pulmonary disease (COPD), the target may be lower at 88 to 92 percent. Although SpO 2 is a convenient and noninvasive method, it may not always be entirely accurate. Conditions such as severe anemia, reduced extremity perfusion, or exposure to substances (e.g., carbon monoxide) can affect SpO 2 readings, leading to potential inaccuracies.
Inspection
Visual observation of areas of the body to assess for symmetry, color, movement, swelling, and obvious alterations in body function is called inspection (Table 24.7). For example, using the acronym CWMS (color-warmth-movement-sensation) helps the nurse efficiently and thoroughly inspect the extremities noting edema, numbness, and capillary refill . Alterations and bilateral inconsistencies in CWMS may indicate underlying conditions or injury. The face, lips, and ears are inspected for cyanosis or pallor , which may be caused by reduced blood flow, abnormal oxygenation levels, or a decreased number of red blood cells.
| Area/What/Reason | Abnormal Findings |
|---|---|
|
Skin: Color
Assess for perfusion by inspecting the face, lips, and fingertips for cyanosis or pallor. |
|
|
Neck: Jugular vein
Assess for distention. |
|
|
Chest: Precordium
Inspect the chest area over the heart for abnormalities, scars, or any abnormal pulsations that the underlying cardiac chambers and great vessels may produce. |
|
|
Extremities: Legs, feet, toes, arms, hands, and fingers
Inspect bilaterally for changes in color, warmth, movement, and sensation (CWMS). |
|
Palpation
Using the fingers or hand to assess size, consistency, texture, location, and tenderness of an organ, body part, or body area is called palpation . It is a method used to evaluate peripheral pulses, capillary refill, and lymph nodes and to look for the presence of edema. When palpating these areas, also pay attention to the temperature and moisture of the skin.
Capillary Refill
The capillary refill test is performed on the nail beds to monitor perfusion. Pressure is applied to a fingernail or toenail until it pales, indicating that the blood has been forced from the tissue under the nail. This paleness is called blanching. After the tissue has blanched, the pressure is removed. Capillary refill time is defined as the time it takes for the color to return after pressure is removed. If there is sufficient blood flow to the area, a pink color should return within two seconds or less after the pressure is removed. However, some research indicates that a capillary refill time of less than three seconds may be considered normal in some patients (e.g., pediatric patients).
This nurse provides a walk-through instruction on capillary refill that you can review and practice to ensure understanding.
Edema
Edema occurs when visible swelling of the extremities is seen, which is caused by a buildup of fluid within the tissues. If edema is present on inspection , palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as non pitting edema . If indentation occurs, it is referred to as pitting edema (Figure 24.20).
The nurse should note the depth of the indention and how long it takes for the skin to rebound back to its original position. The depth of the indentation and time required to rebound to the original position are graded on a scale from 1 to 4 (Table 24.8). Additionally, it is helpful to note that edema may be difficult to observe in a patient with a higher weight. It is also important to monitor for any sudden increase in weight, which is considered a probable sign of fluid volume overload.
| Grade | Description | Depth of Indentation |
Time to
Return to Normal |
|---|---|---|---|
| +1 |
Trace:
|
0–2 mm |
Rapidly
(< 2 seconds) |
| +2 |
Mild:
|
3–4 mm | Up to 15 seconds |
| +3 |
Moderate:
|
5–6 mm | More than 1 minute |
| +4 |
Severe:
|
7 mm or more | More than 2 minutes |
Peripheral Pulses
During the palpation phase of a nursing assessment, the nurse should compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. Bilateral comparison for all pulses (except the carotid) is important for determining subtle variations in pulse strength. Carotid pulses should be palpated on one side at a time to avoid decreasing perfusion of the brain. The posterior tibial artery is located on the medial aspect of the foot just behind the medial malleolus (Figure 24.21). It can be palpated by placing your fingertips on the area just behind and slightly below the medial malleolus.
The dorsalis pedis artery is located just lateral to the extensor tendon of the big toe on the top of the foot and can be identified by asking the patient to flex the toe while you provide resistance to this movement (Figure 24.22). Gently place the tips of your second, third, and fourth fingers adjacent to the tendon, and try to feel the pulse.
The quality of the pulse is graded on a scale of 0 to 4. Absent (0), weak (+1), normal (+2), strong (+3), full and bounding (+4). If unable to palpate a pulse, additional assessment is needed. First, determine if this is a new or chronic finding. Second, if available, use a Doppler ultrasound to determine the presence or absence of the pulse. An absent pulse could be a sign of an emergent condition requiring immediate follow-up and provider notification.
Percussion
The term percussion involves tapping the chest wall with the fingers to assess sound that may indicate an abnormality or dysfunction. This method of examination involves hyperextending the fingers of one hand with the middle distal finger placed firmly on the chest wall. Holding the opposite hand close to the hand on the patient, the middle finger of the second hand is retracted and the distal finger is firmly struck.
Resonant sounds can be heard when percussing the precordial area of the chest, which indicates normal tissue beneath the fingers used. When percussing over the lungs, the resonant sounds will be a semihollow, medium-pitched sound. Denser tissue, such as the heart will yield a flat or dull sound. Percussion is most often used to determine masses and blockages so it has a limited use in nursing. Auscultation will yield more accurate results and is much easier to conduct.
Auscultating Heart Sounds
The process of using a stethoscope to listen for normal and abnormal sounds (e.g., components of the heartbeat, murmurs, valvular sounds, bruits) is known as auscultation . When assessing the heart, auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic APE To Man, referring to the Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral areas (Figure 24.23). The aortic area is the second intercostal space to the right of the sternum. The pulmonic area is the second intercostal space to the left of the sternum. Erb’s point is directly below the pulmonic area and located at the third intercostal space to the left of the sternum. The tricuspid (or parasternal) area is at the fourth intercostal space to the left of the sternum. The mitral area (also called the apical or left ventricular area) is the fifth intercostal space at the midclavicular line.
Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds, which make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1). Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and tricuspid area (fourth intercostal space). When assessing the mitral area for female patients, it is often helpful to ask them to lift up their breast tissue so the stethoscope can be placed directly on the chest wall.
Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a sixty-second period. For an adult, the heart rate should be between sixty and one hundred with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.
The first heart sound (“lub”) is designated as S1 , which identifies the onset of systole , when the atrioventricular (AV) (mitral and tricuspid) valves close and the ventricles contract and eject the blood out of the heart. The second heart sound (“dub”) is designated as S2 , which identifies the end of systole and the onset of diastole when the semilunar (pulmonic and aortic) valves close, the AV valves open, and the ventricles fill with blood. S1 corresponds to the palpable pulse. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds. Nurses should listen to a normal S1/S2 sound and then compare them to abnormal sounds. It may be helpful to use earbuds or a headphone.
Extra heart sounds include clicks, murmurs, S3 and S4 sounds, and pleural friction rubs. These extra sounds can be difficult for a novice to distinguish, so if any new or different sounds are noticed, consult an advanced practitioner or notify the provider. A midsystolic click, associated with mitral valve prolapse, may be heard with the diaphragm at the apex or left lower sternal border.
A click may be followed by a murmur . A murmur is a blowing or whooshing sound that signifies turbulent blood flow often caused by a valvular defect. New murmurs not previously recorded should be immediately communicated to the healthcare provider. In the aortic area, listen for possible murmurs of aortic stenosis and aortic regurgitation with the diaphragm of the stethoscope. In the pulmonic area, listen for potential murmurs of pulmonic stenosis and pulmonary and aortic regurgitation. In the tricuspid area, at the fourth and fifth intercostal spaces along the left sternal border, listen for the potential murmurs of tricuspid regurgitation, tricuspid stenosis, or a ventricular septal defect.
If present, S3 and S4 sounds are often heard best by asking the patient to lie on their left side and listening over the apex of the heart with the bell of the stethoscope. An S3 sound, a ventricular gallop , occurs after the S2 and sounds like “lub-dub-dah,” or a sound similar to a horse galloping. An S3 can occur when a patient is experiencing fluid overload, such as during an acute exacerbation of heart failure. It can also be a normal finding in pregnancy due to increased blood flow through the ventricles.
The S4 sound, an atrial gallop , occurs immediately before the S1 and sounds like “ta-lub-dub.” An S4 sound during diastole may be created by the movement of blood out of the atria flowing against a stiff ventricular wall caused by hypertension, pulmonary hypertension, ventricular outflow obstruction, or ischemic heart disease.
A pericardial friction rub is a grating, to-and-fro sound or creaky-scratchy noise generated as the parietal and visceral membranes rub together, which is caused by inflammation of the pericardium . It is best heard with the diaphragm of the stethoscope at the apex or left lower sternal border as the patient sits up, leans forward, and holds their breath.
The carotid artery may be auscultated for bruit , a swishing sound caused by turbulence in the blood vessel. Bruits may be heard because of atherosclerotic changes.
Assessing Heart Rate and Rhythm
Pulses can be found at many points on the body and all could theoretically be used to assess heart rate. When palpating pulses, use moderate pressure, because too much pressure can impair blood flow and occlude the vessel. In some facilities, scales are used to document the quality of the pulse, such as absent (0), weak (+1), normal (+2), strong (+3), and full and bounding (+4).
If a pulse is regular, a thirty-second count multiplied by two is generally acceptable. If a pulse is irregular, the nurse should count for a full sixty seconds. A common pulse for assessment is the radial pulse (Figure 24.24).
The apical pulse is another common pulse and should be auscultated for rate and regularity (Figure 24.25). For accuracy, an apical heart rate should be taken for a full minute especially when giving medications that are dependent on the heart rate.
It is suggested that beginner nurses concentrate on rate and regularity. With practice, and depending on work location, skill level with specific heart sounds may improve, at which point the nurse will document in greater detail.
A carotid pulse may be taken when the radial pulse is not present or is difficult to palpate (Figure 24.26). It is important that the nurse NOT palpate both bilateral carotid arteries at the same time, to avoid decreasing perfusion of the brain.
Diagnostic Testing
Cardiovascular diagnostic and screening tests offer comprehensive insights into the heart’s electrical activity, heartbeat rhythm, and efficiency of blood pumping through the heart’s chambers and valves into the coronary arteries and to the heart muscle. Other tests help providers identify the presence of tumors or other abnormalities in the structure of the cardiovascular system.
There are numerous types of diagnostic tests for cardiovascular disease including blood laboratory tests; electrocardiograms; echocardiograms; stress tests; electrophysiology studies; cardiac catheterization; and magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography (CT), and positron emission tomography (PET) scans. New tests are continually being developed and tested to ensure the safest avenues to obtain the most accurate results. It is important to recognize patient needs and abilities to perform some diagnostic tests as well as identify allergies or adverse events that may be associated with using a contrast medium.
Basic blood panels with complete blood counts and prothrombin platelet times are tested to evaluate blood components for blood clotting, anemia, diabetes, and other contributing factors to CVD. The D-dimer test measures fragments of protein that a body releases when a blood clot dissolves. It can help diagnose and monitor blood-clotting conditions such as DVT. Electrolytes can be used to screen for imbalances in potassium, sodium, or calcium, which may affect cardiac function and conduction. Increased cardiac enzymes (e.g., troponin, creatine kinase-MB [CK-MB]) can indicate ischemia , myocardial damage, or infarction. The antinuclear antibody profile is used to help diagnose autoimmune disorders, which may indicate an increased risk for CVD. Another important blood test is the B-type natriuretic peptides (BNP), which measures the levels of BNP protein in the bloodstream. High levels of BNP can be a sign of heart failure. Additional blood tests include testing for cholesterol and triglyceride levels to monitor for hyperlipidemia, which may suggest a risk of atherosclerosis or coronary artery disease.
Healthcare providers may use arterial blood gas (ABG) measurements, a more specific evaluation of oxygen and carbon dioxide levels, particularly in emergency situations involving deteriorating respiratory status. An ABG involves drawing blood from the radial artery, and provides insights into oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen (PaO 2 ) in arterial blood measures the pressure of oxygen dissolved in the blood, offering a more accurate assessment than SpO 2 because it is not influenced by hemoglobin levels. The normal PaO 2 level for a healthy adult ranges from 80 to 100 mm Hg. Additionally, ABGs provide information about the partial pressure of carbon dioxide (PaCO 2 ) in arterial blood and how well carbon dioxide can move out of the body; this assesses ventilation efficiency at the alveolar level. The normal PaCO 2 level is 35 to 45 mm Hg. The results of an ABG test also include pH levels (7.35–7.45), bicarbonate levels (22–26 mEq/L), and the calculated arterial oxygen saturation level (SaO 2 ). Nurses need to become versed with the normal values for common blood test values (Table 24.9).
| Complete Blood Count | |
| Laboratory Test | Reference Range |
| Red blood cell count |
Male: 4.7–6.1 million cells/mcL
Female: 4.2–5.4 million cells/mcL |
| Hemoglobin (Hgb) | 12–16 g/dL or 7.4–9.9 mmol/L |
| Hematocrit (Hct) | 37–47% or 0.37–0.47 volume fraction |
| Mean corpuscular volume (MCV) | 80–95 fL |
| Mean corpuscular hemoglobin (MCH) | 27–31 pg |
| Mean corpuscular hemoglobin concentration (MCHC) | 32–36 g/dL or 320–360 g/L |
| White blood cell count | 5,000–10,000/mm 3 or 5–10 × 10 9 /L |
| Neutrophils | 55–70% or 2,500–8,000/mm 3 |
| Lymphocytes | 20–40% or 1,000–4,000/mm 3 |
| Monocytes | 2–8% or 100–700/mm 3 |
| Eosinophils | 1–4% or 50–500/mm 3 |
| Basophils | 0.5–1% or 25–100/mm 3 |
| Platelet count | 150,000–400,000/mm 3 or 150–400 × 10 9 /L |
| Electrolytes | |
| Laboratory Test | Reference Range |
| Calcium (electrolyte) | 9.0–10.5 mg/dL or 2.25–2.62 mmol/L |
| Chloride (electrolyte) | 98–106 mEq/L or 98–106 mmol/L |
| Cholesterol, serum | < 200 mg/dL or < 5.20 mmol/L (SI units) |
| CO 2 | 23–30 mEq/L or 23–30 mmol/L |
| Glucose | 74–106 mg/dL or 4.1–5.9 mmol/L |
| Potassium (electrolyte) | 3.5–5 mEq/L or 3.5–5 mmol/L |
| Sodium (electrolyte) | 136–145 mEq/L or 136–145 mmol/L |
| Magnesium | 1.3–2.1 mEq/L |
| Phosphate | 3–4.5 mg/dL |
| Total bilirubin | 0.3–1.0 mg/dL or 5.1–17 µmol/L |
| Total protein | 6.4–8.3 g/dL or 64–83 g/L |
| Cardiac Biomarkers | |
| Laboratory Test | Reference Range |
| Troponin | < 0.04 ng/ml |
| Creatinine kinase-MB (CK-MB) | < 4% (Women < 4 mg/mL; Men < 7.8 ng/mL) |
| Antinuclear antibody profile | Negative at 1:40 dilution |
| B-type natriuretic peptides (BNP) | < 100 pg/mL |
| D-Dimer | < 0.4 mcg/mL |
| Lipid Profile | |
| Laboratory Test | Reference Range |
|
Fasting cholesterol
Low risk for coronary heart disease (CHD) Borderline risk for CHD High risk for CHD |
< 200 mg/dL 200–239 mg/dL > 240 mg/dL |
|
Triglycerides
Low risk for CHD Borderline risk for CHD High risk for CHD |
< 149 mg/dL 150–199 mg/dL > 200 mg/dL |
| High-density lipoprotein (HDL) | > 40 mg/dL |
|
Low-density lipoprotein (LDL)
Low risk for CHD Borderline risk for CHD High risk for CHD |
< 100 mg/dL 100–159 mg/dL > 160 mg/dL |
| Arterial Blood Gases | |
| Laboratory Test | Reference Range |
| pH |
Adult/child: 7.35–7.45
2 months to 2 years: 7.34–7.46 Newborn: 7.32–7.49 pH (venous): 7.31–7.41 |
| PaCO 2 |
Adult/child: 35–45 mm Hg
Child < 2 years: 26–41 mm Hg PCO 2 (venous): 40–50 mm Hg |
| HCO 3 |
Adult/child: 22–26 mEq/L
Newborn/infant: 16–24 mEq/L |
| PaO 2 |
Adult/child: 80–100 mm Hg
Newborn: 60–70 mm Hg PO 2 (venous): 40–50 mm Hg |
| O 2 sat |
Adult/child: 95–100%
Older adults: 95% Newborn: 40–90% |
| O 2 content |
Arterial: 15–22 vol %
Venous: 11–16 vol % |
| Base excess | 0 ± 2 mEq/L |
Testing for heart rhythm and stability are electronic evaluations that assess for arrhythmias such as ventricular fibrillation , myocardial infarction, ischemia , and valvular dysfunction. An echocardiogram provides detailed images of the heart’s structure and function, identifying abnormalities in chambers, valves, or wall motion. An ECG can determine current electrical activity and can identify issues such as arrhythmias (e.g., ventricular tachycardia, atrial fibrillation, sinus-node arrhythmia , heart blockage), ischemia, and other cardiac dysfunction. Prior myocardial infarction and ischemia will also show up on ECG tracings through altered QRS complexes and inverted P waves.
Other diagnostic tests identify various types of heart dysfunction including partial or complete blockage, congenital heart disease, peripheral vascular disease , and risk factors for stroke. Such tests include the following:
- Stress test: The patient is placed on a treadmill to evaluate heart function during physical stress, uncovering abnormalities that may not be apparent at rest. A chemical stress test, or the use of medication to simulate the patient’s heart response to exercise, may be used to replace a treadmill stress test if the patient is unable to perform a regular stress test.
- Tilt table test: The patient is connected to an ECG and blood pressure monitor and is strapped to a table that tilts the patient from a lying to standing position. This test is used to determine if the patient is likely to have sudden drops in blood pressure (orthostatic hypotension) while standing, or slow pulse rates with position changes. This test might be performed if the patient is experiencing frequent fainting spells.
- Electrophysiology study: For this test, insulated electric catheters are placed through the femoral vein and threaded into the heart. It is used to test the heart’s electrical system. It helps healthcare providers identify causes of abnormal heart rhythms.
- Cardiac catheterization (coronary angiogram): During this test, a small catheter is guided through the femoral artery, or sometimes the wrist or arm, into the patient’s heart. Dye is injected through the catheter, and fluoroscopy (continuous x-rays) are taken as the dye travels through the heart arteries and heart chambers. This comprehensive test shows narrowing in the arteries, heart chamber size, heart pump efficiency, and the efficiency of valves opening and closing. It also measures the pressures within the heart chambers, arteries, and veins. This invasive procedure visualizes coronary arteries and identifies blockages or abnormalities.
- Cardiac MRI: This procedure uses a combination of large magnets, radiofrequencies, and a computer to make detailed images of organs and structures in the body. An MRI of the heart may be ordered to assess the heart valves and major vessels. It can also detect coronary artery disease and resultant damage caused. Tumors and congenital heart conditions can also be evaluated.
- Cardiac MRA: This is a special type of MRI procedure used to evaluate blood vessels in the heart. Contrast dye is used to help highlight blood flow.
- Cardiac CT scan: This imaging procedure uses X-rays and a computer to create a 3-dimensional images of the heart. Sometimes dye is injected into a vein so that the heart arteries can be seen as they uptake the dye. Sometimes medicine is administered to lower the patient’s heart rate so it captures a better image. A CT scan can also be used to find out how much calcium is in the heart arteries. Calcium is a marker for coronary artery disease.
Read how one nurse’s myocardial infarction affected how she educates patients on heart health and teaches patients to listen to their bodies.
Identifying Abnormalities in Findings
Typically, diagnosing a heart problem involves a combination of blood tests, heart monitoring, and imaging studies. Recognizing normal and abnormal results is instrumental in quality and safe patient care. Based on diagnostic test findings, the nurse must adapt the care plan according to the patient’s needs as well as when providing instructions and orders. In scenarios where abnormalities in cardiovascular findings are identified, the nurse plays a critical role in further assessment, communication, and collaboration with the healthcare team. The following examples help define what the nurse may do in these situations:
- Immediate Response: If the abnormalities indicate a critical condition (e.g., severe arrhythmias, acute myocardial infarction), the nurse initiates emergency response protocols. The immediate goals are to ensure the patient’s safety, administer appropriate interventions, and call for assistance if needed.
- Communication: The nurse must communicate findings promptly to the healthcare team, including the primary care provider, cardiologist, or other specialists. Reporting critical values and changes in the patient’s condition helps ensure swift decision-making.
- Patient monitoring: Simultaneously, the nurse is continuously monitoring the patient’s vital signs and cardiac parameters to track any dynamic changes. Implementing continuous cardiac monitoring is crucial for patients at risk of arrhythmias or other acute events.
- Symptom management: The nurse is responsible for assisting with pain management and providing comfort measures. Administering medications as prescribed for symptom relief or to address acute issues is one of the first steps. Nitroglycerin, initially sublingual and then intravenously, is one option because it provides vasodilation, which helps oxygenate cardiac muscle, thus easing chest pain. The sympathetic nervous system’s response to cardiac pain causes or worsens lightheadedness, weakness, diaphoresis, and palpitations. This, in turn, increases cardiac workload. Therefore, another cardiac pain management option is morphine, which helps to mitigate the sympathetic nervous system response.
- Collaboration: Treating CVD is a collaborative effort of healthcare professionals in many disciplines. In addition to nurses, physicians, respiratory therapists, pharmacists, and radiology technicians are needed to provide comprehensive care. Nurses work closely with the interdisciplinary team to create and implement a tailored care plan.
- Education: Nurses play a pivotal role in educating the patient and family members about the identified cardiovascular abnormalities, explaining the significance and potential implications. The nurse must be prepared to provide information on prescribed medications, lifestyle modifications, and follow-up care.
- Documentation: As in any healthcare situation, nurses are responsible for maintaining accurate and detailed documentation of the patient’s cardiovascular assessment, interventions, and responses. The nurse must meticulously document any changes in the patient’s condition and the effectiveness of interventions.
- Advocacy: Patients often feel overwhelmed and afraid when diagnosed with a CVD. Nurses are the primary advocate for the patient’s needs, ensuring they receive timely and appropriate diagnostic tests, consultations, and interventions. Nurses can and should advocate for the patient to receive necessary resources and support to address the identified cardiovascular issues.
- Follow-up care: Part of advocating for the patient includes facilitating and coordinating follow-up appointments with specialists for further evaluation and management. The nurse should reinforce the importance of the patient adhering to prescribed medications and lifestyle modifications.
- Emotional support: Providing emotional support to the patient and family includes addressing concerns, fears, and questions. The nurse should encourage open communication and involve the patient in decision-making regarding their care.
Refer back to Chapter 15 General Survey, Anthropometric Measurement, and Vital Signs, Chapter 17 Nutrition Assessment, Chapter 18 Oxygenation and Perfusion, and Chapter 19 Fluids, Electrolytes, and Elimination for Unfolding Case Study Parts 1 to 11 to review the patient data. Mrs. Ramirez, a 68-year-old female, is brought to the emergency room by her husband. The patient reports shortness of breath with exertion and feeling “off” for the last three days. She has been admitted to the medical-surgical unit for observation. Assessment findings indicate she is experiencing an exacerbation of heart failure causing fluid excess. She has been given one dose of IV furosemide and reports an improvement in dyspnea. However, she just pressed the call light because she feels “like my chest is tight and feels sharp.”
| Nursing Notes | Patient reports chest tightness and sharp pain. Patient is mildly diaphoretic and appears anxious. S1 and S2 heart sounds present, lungs clear. Sinus tachycardia with occasional PVCs noted on the monitor. |
| Flow Chart |
2215: Assessment
Blood pressure: 145/82 mm Hg Heart rate: 116 beats/minute Respiratory rate: 29 breaths/minute Temperature: 99.6°F (37.5°C) Oxygen saturation: 93 percent on 2L nasal cannula Pain: 7/10 in the chest |
Abnormalities in Cardiovascular Findings
Recognizing abnormal findings in cardiovascular health is critical for healthcare professionals in order to provide timely and effective care. Cardiovascular abnormalities can manifest through various signs and symptoms that could have catastrophic and life-altering results. Therefore, it is of utmost importance to conduct a comprehensive assessment to identify underlying issues. One key aspect is understanding the patient’s symptoms (complaints) related to potential cardiovascular problems (e.g., shortness of breath, chest pain, palpitations, dizziness, sweating, numbness, weakness). Clinical signs (e.g., edema, cyanosis , abnormal pulsations) can provide visual cues that may indicate cardiovascular issues.
In nursing practice, continuous monitoring and prompt recognition of deviations from baseline cardiovascular parameters are essential. Timely identification of abnormal findings empowers healthcare professionals to initiate appropriate interventions, collaborate with interdisciplinary teams, and guide patients toward optimal cardiovascular health outcomes. Using an algorithm for stroke assessment helps the nurse act quickly to minimize tissue injury:
Within sixty minutes of symptom onset:
- Transport to ER
Within five minutes of arrival at ER:
- Vital signs
- ECG
Within ten to twenty-five minutes of arrival at ER:
- Neurological assessment
- CT scan
- Laboratory tests
- Doppler ultrasonography (if necessary)
Within forty-five minutes of arrival at the ER:
- Administration of thrombolysis (clot buster), if eligible
Within three hours of stroke onset:
- Decision/administration of thrombolysis
- Admission to a specialized stroke unit
Continuous:
- Administration of nonglucose fluids to maintain hydration
As needed:
- Care for individual patient needs (e.g., insulin, aspirin, blood thinners, blood pressure medications, antibiotics)
Follow-up:
- Close monitoring and ongoing care for recovery
Education and awareness among healthcare providers plays a pivotal role in recognizing abnormal cardiovascular findings and delivering patient-centered care (Figure 24.27).
Abnormalities in Peripheral Vascular Findings
Abnormal findings on peripheral examination may include edema, cellulitis, cool or warm skin, changes in the color of skin, reduced peripheral pulses, and ulcerations. Identifying these changes and how they correlate to the function of the peripheral vascular system is instrumental in creating an accurate nursing diagnosis and care plan. Venous stasis dermatitis, vasculitis, peripheral artery disease (PAD), and mixed venous and arterial insufficiency are common peripheral vascular system disorders (Table 24.10).
| Disorder | Description | Signs | Treatment |
|---|---|---|---|
| Venous stasis dermatitis | Skin inflammation caused by chronic edema |
|
|
| Vasculitis | Group of inflammatory conditions damaging the blood vessels |
|
|
| Peripheral artery disease | Vascular disorder demonstrated by abnormal narrowing of peripheral arteries |
|
|
| Mixed venous and arterial insufficiency | Combination of chronic venous insufficiency (CVI) and peripheral arterial occlusive disease (PAOD) | Ulceration of lower extremities, especially around ankles and feet |
|