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. 

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 signs

The 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.

• Normal blood pressure: SBP < 120 mmHg systolic with DBP < 80 mmHg
• Elevated blood pressure: SBP 120-129 mmHg with DBP < 80 mmHg
• Stage 1 hypertension: SBP 130-139 mmHg or DBP 80-89 mmHg
• Stage 2 hypertension: SBP > 140 mmHg or DBP > 90 mmHg
• Hypertensive crisis: SBP > 180 mmHg and/or DBP > 120 mmHg

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 patient

Some general questions to ask a patient with a known or suspected cardiac condition will be aimed at identifying risk factors and evaluating symptoms.

• Does the patient have a cardiac history?
• Has the patient ever had any previous cardiac diagnostic tests such as ECG, echocardiogram or a stress test?
• Does the patient have a family history of cardiac disease?
• Does the patient have unusual fatigue that has lasted longer than a week or two? Do they wake up in the morning still feeling tired? Do they fall asleep unintentionally during the day? These are all signs of unusual and extreme fatigue.
• Does the patient have nocturia? How many times do they get up to urinate at night? Frequent urination that interrupts sleep is associated with heart failure.
• Ask the patient about their risk factors and lifestyle. This includes diet, exercise, alcohol use and drug use. Inquire if they have ever been told they have obesity, hyperlipidemia, diabetes or hypertension.
• Ask the patient if they experience palpitations? If so, does anything specific trigger them? Have they ever been diagnosed with a dysrhythmia or received treatment for palpitations?
• Has the patient experienced sudden and unexplained weight gain? This could be due to fluid retention secondary to heart failure.
• Does the patient have chest pain? See below for detailed chest pain assessment tips.

General observation of the patient

Observe the patient noting any abnormalities that may be cardiac related. These include:

• LOC – With decreased cardiac output and decreased tissue perfusion, the patient may be confused, feel dizzy or lightheaded, or be difficult to rouse in severe cases.
• Skin signs – Cardiac dysfunction can cause abnormal skin signs such as paleness, cyanosis, cool and clammy skin, and diaphoresis.
• Capillary refill – Compress the fingertip or toe for a few seconds until it turns pale and then release. You’re assessing how long it takes for the color to return to normal, and a normal capillary refill time is less than three seconds. Usually the pressure is applied at the nail bed, but if your patient is wearing polish and you don’t have the means to remove it, use the tip of the finger or toe instead. This assessment tells you how well blood is flowing to the periphery and you’ll have increased capillary refill times in states of low cardiac output as well as in vascular disease. 
• Clubbing of fingers or toes – While lung cancer is the most common cause, it can be associated with congenital heart defects and infective endocarditis. To assess for clubbing, the angle between the nail bed and proximal nail fold is assessed. A normal angle is 160-degrees; with clubbing, this angle will be greater than 180-degrees. A quick way to evaluate the presence of clubbing is to assess for Schamroth’s sign. Have the patient place the index fingers together so they touch at the first joint down to the nail bed. In a normal assessment, you should be able to see a diamond-shaped window between the two nails as indicated in the image. If you don’t, this is an indicator that clubbing is present.
  

  Jajic, Zrinka & Jajic, Ivo & Nemčić, Tomislav. (2001)

• Edema – Congestive heart failure and heart disease can cause pitting edema in the feet and legs. When assessing for pitting edema, press on the area with your fingers and observe the depth of the temporary indentation. It is graded as +1 to +4, with +4 being the most severe and indicating an indentation of about 8 mm. 
• Abdominal distention – Right sided heart failure can cause congestion in the GI tract and liver, which can cause abdominal distention.
• Assess for cough – A chronic cough may be present with congestive heart failure and can indicate that the prescribed treatment isn’t effective, the condition is worsening, or that the patient is having a side effect related to ACE inhibitors. A “cardiac cough” will be wet and productive, meaning the patient brings up sputum that could possibly be blood-tinged. It may involve wheezing and the patient may describe a “bubbling” feeling in their chest. It is likely this patient will also experience SOB when lying down. The cough associated with ACE inhibitors is a dry cough and can be troublesome enough that it warrants changing treatment.
• Jugular vein distention (JVD) – When pressures in the superior vena cava are elevated, the congestion backs up to the jugular vein and presents as jugular vein distention. You’ll typically notice this bulging of the vessel more readily on the right side. To assess for JVD, place the patient in a supine position at 45-degrees and ask them to turn their head to the left. Observe for bulging of the vessel, which if present, will be measured and evaluated by the MD. 

Assess for chest pain or tightness

A reliable and standardized way to assess chest pain is by using the PQRST format. 

• P: Provocation and palliation – What causes the pain to start? What makes the pain better?
• Q: Quality – What is the quality of the pain? Chest pain may be described as sharp, tightness and pressure.
• R: Radiate – Does the pain radiate anywhere? Angina pain can radiate to the arm, leg, jaw or back. Sometimes, the pain is felt in the epigastric region.
• S: Severity – How severe is the pain? 
• T: Timing – Does the pain get better or worse over time? 

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 precordium

Looking 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 heart

Before you dive into listening to the heart, here are a few tips to ensure you get the most out of your stethoscope. 

• Use the bell side of the stethoscope for lower frequency sounds such as S3, S4 and some murmurs.
• Use the diaphragm side of the stethoscope for higher frequency sounds including S1, and S2.
• Not all stethoscopes have two sides and you will adjust the pressure to pick up different sounds. Lighter pressure will be pressure against the skin to pick up lower-frequency sounds, while higher pressure will pick up higher frequency sounds.
• Reduce environmental noise when possible by asking the patient not to speak, turning off the television and closing the door.

Normal heart sounds

• S1: Heard at the onset of systole when the mitral and tricuspid valves close (often referred as the atrioventricular valves). This is the “lub” in “lub-dub” and it is typically louder than S2.
• S2: Heard at the onset of diastole when the aortic and pulmonary valves close (often referred as the semilunar valves). This is the “dub” in “lub-dub.”

Abnormal heart sounds

• S3: This is an abnormal heart sound also referred to as a “gallop.” It occurs during periods of rapid ventricular refilling and is associated with heart failure in middle-age or older adults. Note that S3 can be a normal sound in children and young healthy adults. You can hear a sample of it here.
• S4: This is an abnormal heart sound sometimes referred to as “atrial gallop” that occurs when the atria push blood into a hypertrophic or stiff ventricle. You can hear a sample of it here.
• Murmurs: Murmurs cause a swishing or whooshing sound caused by turbulent blood flow through a faulty valve or an atrial-septal defect.  Murmurs can also be due to exercise, endocarditis, anemia, hypertrophic cardiomyopathy and hyperthyroidism.
• Pericardial friction rub: When the layers of the pericardium are inflamed (pericarditis), the movement of the heart causes a pericardial friction rub. The sound has a grating quality and is best heard with the diaphragm of the stethoscope. Note that your patient will also be complaining of chest pain associated with the inflammation that is often described as a sharp or stabbing pain. You can hear a sample here.
• Prosthetic heart valves: If your patient has had heart valves replaced with a prosthesis, you are likely to hear a clicking sound or a sound that is louder than normal. You can hear some examples here.

Assess for a pulse deficit

A 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 sounds

Finally, 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.

• A: Aortic valve – Listen at the right sternal border, 2nd intercostal space. You are listening for S2 here.
• P: Pulmonic valve – Listen at the left sternal border, 2nd intercostal space. You are listening for S2 here.
• E: Erb’s Point – Listen at the left sternal border, 3rd intercostal space. You are listening for S1 and S2 here.
• T(o): Tricuspid valve – Listen at the left sternal border, 4th intercostal space. You are listening for S1 here. 
• M(an): Mitral valve – Listen at the midclavicular line, 5th intercostal space. You are listening for S1 here. S3 and S4 are most easily auscultated at this point.

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:

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What is the correct order of assessment for the cardiovascular system?

What assessment findings are important in determining cardiovascular disorders?

What should you ask from the patient for a cardiac assessment?