What should you assess first when performing a cardiovascular assessment?
A cardiac assessment will be indicated on patients with a known cardiac history, suspected cardiac issue, and may even be conducted as part of a full physical assessment. While you do perform a basic cardiac assessment with the head-to-toe, note that a focused cardiac assessment will be much more in depth. You can learn more about performing a head-to-toe assessment here. Show
Review the following cardiac assessment tips on the go in episode 250 of the Straight A Nursing podcast. Listen wherever you get your podcast fix or straight from the website here. Note that if your patient is in acute distress, you will not be conducting this lengthy of an assessment. When your patient is experiencing an acute cardiac event such as acute coronary syndrome or cardiac arrest, you will follow ACLS guidelines and your facility’s protocols to get patients immediate treatment. Obtain vital signsThe key vital signs for a cardiac assessment are blood pressure, heart rate and oxygen saturation level. If the patient has heart failure with corresponding pulmonary congestion, then respiratory rate will be taken into account as well. In a patient with CHF, you would also do a full and focused respiratory assessment, which you can learn more about here.
When heart rate is elevated above 100 bpm, this is tachycardia and can be present for a wide variety of reasons such as fever, dehydration, anxiety, infection, hypoxia, use of stimulants, and pain, as well as in uncontrolled atrial fibrillation and other cardiac dysrhythmias. When we look at treating tachycardia, we almost always identify and address the underlying cause. When heart rate is below 60 bpm, this is bradycardia and it can be asymptomatic or symptomatic, depending on the patient. Many patients, especially athletes, will have asymptomatic bradycardia at baseline. So, when I have a patient with a low heart rate the first thing I do is correlate that against their blood pressure, their LOC, and any other associated signs/symptoms. If I see that my patient has a heart rate of 53, a blood pressure of 116/74 and is alert and oriented, then this patient has asymptomatic bradycardia. I’ll take a peek at the chart to see what the heart rate has been, and many times you’ll see this patient has a low heart rate at baseline. However, if the heart rate is 53, the blood pressure is 82/54 and the patient seems disoriented, then this is symptomatic bradycardia. Bradycardia related to a pathological process could also result in shortness of breath, pulmonary edema, chest pain and lightheadedness. Symptomatic bradycardia definitely warrants treatment. Oxygen saturation levels can be low with cardiac dysfunction, especially when bradycardia is severe or pulmonary edema is present in patients with heart failure. Interview the patientSome general questions to ask a patient with a known or suspected cardiac condition will be aimed at identifying risk factors and evaluating symptoms.
General observation of the patientObserve the patient noting any abnormalities that may be cardiac related. These include:
Assess for chest pain or tightnessA reliable and standardized way to assess chest pain is by using the PQRST format.
When evaluating chest pain, it’s important to understand that not all chest pain is cardiac related. For example, if the patient’s chest pain is worse with breathing, the cause is likely to be respiratory related. Anxiety and GERD are other common causes of non-cardiac chest pain as well. Additionally, ask about and observe for any associated symptoms of cardiac involvement such as palpitations, N/V, dyspnea, pallor and diaphoresis. Cardiac ischemia is a life-threatening emergency. Consider chest pain to be serious until proven otherwise! Assess for shortness of breath (SOB)Shortness of breath is a common symptom of heart failure due to pulmonary congestion. When assessing shortness of breath, ask the patient to rate their SOB on a 0-10 scale (much as you would use the standard numeric pain scale). Also observe how many words the patient can speak before pausing to take a breath. A patient who is speaking in short bursts due to the need to take a breath, is exhibiting signs of shortness of breath. You can also assess for orthopnea, which is worsening SOB when lying in the supine position. While you could lie the patient flat and observe for SOB, you can also simply ask them “How many pillows do you sleep on at night?” or “Do you sleep propped up or in a recliner?” Patients who have orthopnea will not be able to tolerate lying flat for sleep and will likely sleep propped up on pillows or even in a reclining chair. Ask the patient if they experience paroxysmal nocturnal dyspnea. This is an abrupt feeling of SOB that occurs during sleep. It wakes the patient with the sudden urge to sit upright. Once upright, the feelings of SOB resolve. Visual inspection and palpation of the precordiumLooking at the anterior chest, observe for any abnormal pulsations and locate the apical pulse, which should be present at the 5th ICS at the midclavicular line. The apical pulse is the point of maximal impulse. Lateral displacement of the apical pulse may be present in conditions such as cardiomegaly, right-sided tension pneumothorax and large right pleural effusions. If you are unable to palpate the pulse, you can try placing the patient on their left side which displaces the heart more anteriorly making it easier to palpate. In larger individuals, you may only be able to auscultate the apical pulse. Other abnormal findings are a thrill and heave/lift. A thrill feels like a cat’s purr and indicates turbulent blood flow which can be present in valve disease and congenital defects.. A heave or lift is a sustained forceful thrusting of the ventricle during the contraction and is associated with ventricular hypertrophy. Auscultation of the heartBefore you dive into listening to the heart, here are a few tips to ensure you get the most out of your stethoscope.
Normal heart sounds
Abnormal heart sounds
Assess for a pulse deficitA pulse deficit can exist in heart failure when the ventricles are too weak to propel the blood adequate through systemic circulation. To assess for a pulse deficit, listen at the apical pulse with your stethoscope while another nurse palpates the radial pulse. Begin your counts at the same time and count for a full 60 seconds. A normal finding is that the counts will be the same. If the counts are not the same, subtract the radial pulse from the apical pulse to arrive at the pulse deficit. Auscultate heart soundsFinally, we get to the part where you learn where to listen for the various heart sounds. We do this through a systematic method called “APE TO MAN.” Note that the locations for auscultation do not represent where the valves themselves are located. Rather, the locations represent where the sound from the valve closure is best transmitted.
I hope this review of cardiac assessment helps you feel confident at the bedside. For more cardiac tips, click this handy link. Want to get a study guide that goes with this lesson? Check out the Power Guide here. References: Cleveland Clinic. (n.d.-a). Edema: Causes, Symptoms & Treatment. Cleveland Clinic. Retrieved September 17, 2022, from https://my.clevelandclinic.org/health/diseases/12564-edema Cleveland Clinic. (n.d.-b). Heart Murmur: Causes, Symptoms, Treatment. Cleveland Clinic. Retrieved September 17, 2022, from https://my.clevelandclinic.org/health/diseases/17083-heart-murmur Gupta, J. I., & Shea, M. J. (2021, April). Cardiovascular Examination – Cardiovascular Disorders. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/cardiovascular-disorders/approach-to-the-cardiac-patient/cardiovascular-examination Heart.org. (n.d.-a). Types of Heart Failure | American Heart Association. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure Heart.org. (n.d.-b). Understanding Blood Pressure Readings. Www.Heart.Org. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings Ignatavicius, D., Workman, L., & Rebar, C. (2017). Medical-surgical nursing concepts for interprofessional collaborative care (9th ed.). Incontinence Institute. (2015, February 17). The Link Between Nighttime Urination and Heart Health. Incontinence Institute. https://myconfidentlife.com/blog/the-link-between-nighttime-urination-and-heart-health Jajic, Z., Jajic, I., & Nemcic, T. (2001). Primary hypertrophic osteoarthropathy: Clinical, radiologic and scintigraphic characteristics. Archives of Medical Research, 32, 136–142. https://doi.org/10.1016/S0188-4409(01)00251-X Jarvis, C. (2020). Physical Examincation & Health Assesment (8th ed.). Elsevier Health Sciences. Lippincott Procedures. (2022, February 18). Pulse Assessment. Lippincott Procedures. https://procedures.lww.com/lnp/view.do?pId=2958589&hits=assessment,cardiac&a=true&ad=false&q=cardiac%20assessment Meyer, T. (2022, June 30). Auscultation of heart sounds. UpToDate. https://www.uptodate.com/contents/auscultation-of-heart-sounds?csi=e1cd832d-2762-4601-80f4-ec748e8f7b32&source=contentShare Mount Sinai Health System. (n.d.). Clubbing of the fingers or toes Information | Mount Sinai – New York. Mount Sinai Health System. Retrieved September 17, 2022, from https://www.mountsinai.org/health-library/symptoms/clubbing-of-the-fingers-or-toes Precordial Movements in the Cardiac Exam. (n.d.). Stanford Medicine 25. https://stanfordmedicine25.stanford.edu/the25/precordial.html Rosenberg, J. H., & Saxena, S. K. (2017, September 2). Digital Clubbing: An Easily Overlooked Sign Associated With Systemic Disease. Consultant360. https://www.consultant360.com/articles/digital-clubbing-easily-overlooked-sign-associated-systemic-disease Rutherford, J. D. (2013). Digital Clubbing. Circulation, 127(19), 1997–1999. https://doi.org/10.1161/CIRCULATIONAHA.112.000163 Specialists, O. (2018, July 23). Pitting Edema VS Non-Pitting Edema: What’s the Difference? Louisville Bones. https://louisvillebones.com/pitting-edema-non-pitting-edema/ UpToDate. (n.d.-a). Epidemiology and pathophysiology of benign prostatic hyperplasia – UpToDate. https://www.uptodate.com/contents/epidemiology-and-pathophysiology-of-benign-prostatic-hyperplasia?csi=30893ddd-69ec-453a-b66a-cbebd74de454&source=contentShare UpToDate. (n.d.-b). Schamroth sign – UpToDate. Retrieved September 17, 2022, from https://www.uptodate.com/contents/image?imageKey=DERM%2F126120 Williams, E. S. (1990). The Fourth Heart Sound. In H. K. Walker, W. D. Hall, & J. W. Hurst (Eds.), Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). Butterworths. http://www.ncbi.nlm.nih.gov/books/NBK344/ Wisconsin Technical College System. (2021). 9.3 Cardiovascular Assessment. Wisconsin Technical College System. https://wtcs.pressbooks.pub/nursingskills/chapter/9-3-cardiovascular-assessment/ What is the correct order of assessment for the cardiovascular system?The cardiac examination consists of evaluation of (1) the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous pulse and auscultation for cervical venous hums; (3) the precordial impulses and palpation for heart sounds and murmurs; and (4) auscultation of the heart.
What assessment findings are important in determining cardiovascular disorders?Blood Pressure, Heart Rate, SpO2
Baseline vital signs are important in any assessment.
What should you ask from the patient for a cardiac assessment?You will also want to ask about the patient's history of heart disease, when and how it was treated, last EKG, stress tests, and serum cholesterol levels. Ask the patient the reasons for any previous hospitalizations and the nature of the treatments received while in the hospital.
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