Cardiovascular assessment

Performed correctly, cardiovascular assessment can help to identify and evaluate changes in the patient’s cardiac function. Complete cardiovascular assessment of a patient consists of obtaining an accurate, thorough history and performing a physical examination, including assessing the patient’s heart and vascular system.

Obtaining a health history

To obtain a health history of a patient’s cardiovascular system, begin by introducing yourself and explaining what will occur during the health history and physical examination. To take an effective history, you’ll need to establish rapport with the patient. Ask open-ended questions and listen carefully to responses. Closely observe the patient’s nonverbal behavior.

Chief complaint

You’ll find that a patient with a cardiovascular problem typically cites specific complaints, such as:

chest pain
irregular heartbeat or palpitations
shortness of breath on exertion, lying down, or at night
cough
cyanosis or pallor
weakness
fatigue
unexplained weight change
swelling of the extremities (see Pregnancy and vein changes)
dizziness
headache
high or low blood pressure
peripheral skin changes, such as decreased hair distribution, skin color changes, or a thin, shiny appearance to the skin
pain in the extremities, such as leg pain or cramps.

Ask the patient how long he has had the problem, when it began, and how it affects his daily
routine. Find out about any associated signs and symptoms. Ask about the location, radiation, intensity, and duration of any pain and any precipitating, exacerbating, or relieving factors. Ask him to rate the pain on a scale of 1 to 10, in which 1 means negligible pain and 10 means the worst pain imaginable. (See Understanding chest pain, pages 26 and 27.)

Let the patient describe his problem in his own words. Avoid leading questions. Use familiar expressions rather than medical terms whenever possible. If the patient isn’t in distress, ask questions that require more than a yes-or-no response. Try to obtain as accurate a description as possible of any chest pain.

Because elderly patients have a higher risk of developing life-threatening conditions—such as a myocardial infarction (MI), angina, and aortic dissection—carefully evaluate chest pain in these patients. (See Key questions for assessing cardiac function, page 28.)

Abnormal findings

Orthopnea or dyspnea that occurs when the patient is lying down and improves when he sits up suggests left ventricular heart failure or mitral stenosis. It can also accompany obstructive lung disease. Fatigue in elderly patients may mask a more serious underlying condition.

Health history

Ask the patient about any history of cardiac-related disorders, such as hypertension, rheumatic fever, scarlet fever, diabetes mellitus, hyperlipidemia, congenital heart defects, and syncope. Other questions to ask include:

Have you ever had severe fatigue not caused by exertion?
Are you taking any prescription, over-the-counter, or illicit drugs?
Are you allergic to any drugs, foods, or other products? If yes, describe the reaction you experienced.

In addition, ask the female patient:

Have you begun menopause?
Do you use hormonal contraceptives or estrogen?
Have you experienced any medical problems during pregnancy? Have you ever had gestational hypertension?

Understanding chest pain

This chart outlines the different types of chest pain, including their location, exacerbating factors, and causes as well as measures used to alleviate them. Use this chart to accurately assess chest pain in a patient.

Description	Location	Exacerbating factors	Causes	Alleviating measures
Aching, squeezing, pressure, heaviness, burning pain; usually subsides within 10 minutes	Substernal; may radiate to jaw, neck, arms, and back	Eating, physical effort, smoking, cold weather, stress, anger, hunger, lying down	Angina pectoris	Rest, nitroglycerin (Nitro-Dur) (Note: Unstable angina appears even at rest.)
Tightness or pressure; burning, aching pain; possibly accompanied by shortness of breath, diaphoresis, weakness, anxiety, or nausea; sudden onset; lasts ½ to 2 hours	Typically across chest but may radiate to jaw, neck, arms, or back	Exertion, anxiety	Acute myocardial infarction	Opioid analgesics such as morphine (Duramorph), nitroglycerin
Sharp and continuous; may be accompanied by friction rub; sudden onset	Substernal; may radiate to neck or left arm	Deep breathing, supine position	Pericarditis	Sitting up, leaning forward, anti-inflammatory drugs
Excruciating, tearing pain; may be accompanied by blood pressure difference between right and left arm; sudden onset	Retrosternal, upper abdominal, or epigastric; may radiate to back, neck, or shoulders	Not applicable	Dissecting aortic aneurysm	Analgesics, surgery
Sudden, stabbing pain; may be accompanied by cyanosis, dyspnea, or cough with hemoptysis	Over lung area	Inspiration	Pulmonary embolus	Analgesics
Sudden and severe pain; sometimes accompanied by dyspnea, increased pulse rate, decreased breath sounds, or deviated trachea	Lateral thorax	Normal respiration	Pneumothorax	Analgesics, chest tube insertion
Dull, pressurelike, squeezing pain	Substernal, epigastric areas	Food, cold liquids, exercise	Esophageal spasm	Nitroglycerin, calcium channel blockers
Sharp, severe pain	Lower chest or upper abdomen	Eating a heavy meal, bending, lying down	Hiatal hernia	Antacids, walking, semi-Fowler’s position
Burning feeling after eating sometimes accompanied by hematemesis or tarry stools; sudden onset that generally subsides within 15 to 20 minutes	Epigastric	Lack of food or highly acidic foods	Peptic ulcer	Food, antacids
Gripping, sharp pain; possibly nausea and vomiting	Right epigastric or abdominal areas; possible radiation to shoulders	Eating fatty foods, lying down	Cholecystitis	Rest and analgesics, surgery
Continuous or intermittent sharp pain; possibly tender to touch; gradual or sudden onset	Anywhere in chest	Movement, palpation	Chest-wall syndrome	Time, analgesics, heat applications
Dull or stabbing pain usually accompanied by hyperventilation or breathlessness; sudden onset; lasting less than a minute or as long as several days	Anywhere in chest	Increased respiratory rate, stress or anxiety	Acute anxiety	Slowing of respiratory rate, stress relief

Key questions for assessing cardiac function

These questions and statements will help you to assess the patient more accurately:

Are you still in pain? Where’s it located? Point to where you feel it.
Describe what the pain feels like. (If the patient needs prompting, ask if he feels a burning, tightness, or squeezing sensation in his chest.)
Does the pain radiate to any other part of your body? Your arm? Neck? Back? Jaw?
When did the pain begin? What relieves it? What makes it feel worse?
Tell me about any other feelings you’re experiencing. (If the patient needs prompting, suggest nausea, dizziness, fatigue, or sweating.)
Tell me about any feelings of shortness of breath. Does a particular body position seem to bring this on? Which one? How long does any shortness of breath last? What relieves it?
Has sudden breathing trouble ever awakened you from sleep? Tell me more about this.
How many pillows do you sleep on at night?
Do you ever wake up coughing? How often? Have you ever coughed up blood?
Does your heart ever pound or skip a beat? If so, when does this happen?
Do you ever feel dizzy or faint? What seems to bring this on?
Tell me about any swelling in your ankles, feet, or hands. For example, do your rings or shoes feel tight? At what time of day?
Does anything relieve the swelling?
Have you noticed changes in color or sensation in your legs? If so, what are those changes?
If you have sores or ulcers, how quickly do they heal?
Do you stand or sit in one place for long periods at work?
Do you urinate more frequently at night?
Tell me how you feel while you’re doing your daily activities. Have you had to limit your activities or rest more often while doing them?

Family history

Information about the patient’s blood relatives may suggest a specific cardiac problem. Ask him if anyone in his family has ever had hypertension, MI, cardiomyopathy, diabetes mellitus, coronary artery disease (CAD), vascular disease, hyperlipidemia, or sudden death.

As you analyze a patient’s problems, remember that age, gender, and race are essential considerations in identifying the risk of cardiovascular disorders. For example, CAD most commonly affects white men between ages 40 and 60. Hypertension occurs most commonly in blacks.

Women are also vulnerable to heart disease, especially postmenopausal women and those with diabetes mellitus. Many elderly people have increased systolic blood pressure because of an increase in the rigidity of their blood vessel walls with age. Overall, elderly people have a higher incidence of cardiovascular disease than do younger people.

Psychosocial history

Obtain information about your patient’s occupation, educational background, living arrangements, daily activities, and family relationships.

Also, obtain information about:

stress levels and how he deals with them
current health habits, such as smoking, alcohol intake, caffeine intake, exercise, and dietary intake of fat and sodium
environmental or occupational considerations
activities of daily living.

During the history-taking session, note the appropriateness of the patient’s responses, his speech clarity, and his mood so that you can better identify changes later.

Performing a cardiovascular assessment

Cardiovascular disease affects people of all ages and can take many forms. A consistent, methodical approach to your assessment will help you identify abnormalities. The key to accurate assessment is regular practice, which helps improve technique and efficiency.

When assessing the cardiovascular system, you must first assess the factors that reflect cardiovascular function. These include general appearance, body weight, vital signs, and related body structures.

Preparing for the assessment

Wash your hands and gather the necessary equipment. Choose a private room. Adjust the thermostat if necessary; cool temperatures may alter the patient’s skin temperature and color, heart rate, and blood pressure. Make sure the room is quiet. If possible,
close the door and windows and turn off radios and noisy equipment.

Combine parts of the assessment, as needed, to conserve time and the patient’s energy. If the patient experiences cardiovascular difficulties, alter the order of your assessment as needed.

Assessing vital signs

Assessing vital signs includes measuring temperature, blood pressure, pulse rate, and respiratory rate.

Measuring temperature

Temperature is measured and documented in degrees Fahrenheit (° F) or degrees Celsius (° C). Choose the method of obtaining the patient’s temperature (oral, tympanic, rectal, or axillary) based on the patient’s age and condition. Normal body temperature ranges from 96.8° F to 99.5° F (36° C to 37.5° C).

Abnormal findings

An elevated temperature may indicate:

cardiovascular inflammation or infection
heightened cardiac workload (which may appear as tachycardia)
MI or acute pericarditis (mild to moderate fever usually occurs 2 to 5 days after an MI when the healing infarct passes through the inflammatory stage)
infections, such as infective endocarditis, which cause fever spikes (high fever).

In patients with lower than normal body temperatures, findings include poor perfusion and certain metabolic disorders.

Measuring blood pressure

First palpate and then auscultate the blood pressure in an arm or a leg. Wait 3 to 5 minutes between measurements. Normal blood pressure readings are less than 120/80 mm Hg in a resting adult and 78/46 to 114/78 mm Hg in a young child.

Emotional stress caused by physical examination may elevate blood pressure. If the patient’s blood pressure is high, allow him to relax for several minutes and then measure again to rule out stress.

When assessing a patient’s blood pressure for the first time, take measurements in both arms. If blood pressure is elevated in both arms, measure the pressure in the thigh. To do so, wrap a large cuff around the patient’s upper leg at least 1″ (2.5 cm)
above the knee. Place the stethoscope over the popliteal artery, located on the posterior surface slightly above the knee joint. Listen for sounds when the bladder of the cuff is deflated.

Abnormal findings

A difference of 10 mm Hg or more between the patient’s arms may indicate thoracic outlet syndrome or other forms of arterial obstruction. High blood pressure in the patient’s arms with normal or low pressure in the legs suggests aortic coarctation.

Determining pulse pressure

To calculate the patient’s pulse pressure, subtract the diastolic pressure from the systolic pressure. This reflects arterial pressure during the resting phase of the cardiac cycle and normally ranges from 30 to 50 mm Hg.

Abnormal findings

Rising pulse pressure is seen with:

increased stroke volume, which occurs with exercise, anxiety, and bradycardia
declined peripheral vascular resistance or aortic distention, which occurs with anemia, hyperthyroidism, fever, hypertension, aortic coarctation, and aging.

Diminishing pulse pressure occurs with:

mitral or aortic stenosis, which occurs with mechanical obstruction
constricted peripheral vessels, which occurs with shock
declined stroke volume, which occurs with heart failure, hypovolemia, cardiac tamponade, or tachycardia.

Checking radial pulse

If you suspect cardiac disease, palpate for 1 full minute to detect arrhythmias. Normally, an adult’s pulse ranges from 60 to 100 beats/minute. Its rhythm should feel regular, except for a subtle slowing on expiration, caused by changes in intrathoracic pressure and vagal response. Note whether the pulse feels weak, normal, or bounding.

Abnormal findings

A weak pulse may indicate increased peripheral vascular resistance or decreased stroke volume. A bounding pulse can indicate increased stroke volume, as with aortic insufficiency, or stiffness of arterial walls.

Evaluating respirations

Observe for eupnea—a regular, unlabored, and bilaterally equal breathing pattern.

Abnormal findings

In patients with irregular breathing, altered patterns may indicate:

low cardiac output with tachypnea
dyspnea, a possible indicator of heart failure (not evident at rest; however, pausing occurs after only a few words to take breaths)
Cheyne-Stokes respirations, which may accompany severe heart failure (seen especially with coma)
shallow breathing, which may occur with acute pericarditis as an attempt to reduce the pain associated with deep respirations.

Assessing appearance

Begin by observing the patient’s general appearance, particularly noting weight and muscle composition. Is he well-developed, well-nourished, alert, and energetic? Document any departures from normal. Does the patient appear older than his chronological age or seem unusually tired or slow-moving? Does the patient appear comfortable or does he seem to be anxious or in distress?

Measuring height and body weight

Accurately measure and record the patient’s height and weight. These measurements will help determine risk factors, calculate hemodynamic indexes (such as cardiac index), guide treatment plans, determine medication dosages, assist with nutritional counseling, and detect fluid overload.

Next, assess for cachexia—weakness and muscle wasting. Observe the amount of muscle bulk in the upper arms, thighs, and chest wall. For a more precise measurement, calculate the percentage of body fat. For men, this measurement should be 12%; for women, it should be 18%.

Abnormal findings

Loss of the body’s energy stores slows healing and impairs immune function. A patient with chronic cardiac disease may develop cachexia, losing body fat and muscle mass. However, be aware that edema may mask these effects.

Assessing the skin

Inspect the skin color and note any cyanosis. Because normal skin color can vary widely
among patients, ask him if his current skin tone is normal. Examine the underside of the tongue, buccal mucosa, and conjunctiva for signs of central cyanosis. Inspect the lips, tip of the nose, earlobes, and nail beds for signs of peripheral cyanosis.

In a dark-skinned patient, inspect the oral mucous membranes, such as the lips and gingivae, which normally appear pink and moist but would appear ashen if cyanotic. Because the color range for normal mucous membranes is narrower than that for the skin, it provides a more accurate assessment. When evaluating the patient’s skin color, also observe for flushing, pallor, and rubor.

Next, assess the patient’s perfusion by evaluating the arterial flow adequacy. With the patient lying down, elevate one leg 12″ (30.5 cm) above heart level for 60 seconds. Next, tell him to sit up and dangle both legs. Compare the color of both legs. The leg that was elevated should show mild pallor compared with the other leg. Color should return to the pale leg in about 10 seconds, and the veins should refill in about 15 seconds.

Touch the patient’s skin. It should feel warm and dry. Then evaluate skin turgor by grasping and raising the skin between two fingers and then letting it go. Normally, the skin immediately returns to its original position.

Observe the skin for signs of edema. Inspect the patient’s arms and legs for symmetrical swelling. Because edema usually affects lower or dependent areas of the body first, be especially alert when assessing the arms, hands, legs, feet, and ankles of an ambulatory patient or the buttocks and sacrum of a bedridden patient. Determine the type of edema (pitting or nonpitting), its location, its extent, and its symmetry (unilateral or symmetrical). If the patient has pitting edema, assess the degree of pitting.

Finally, note the location, size, number, and appearance of any lesions.

Abnormal findings

Two types of cyanosis that may occur include:

central cyanosis, suggesting reduced oxygen intake or transport from the lungs to the bloodstream, which may occur with heart failure
peripheral cyanosis, suggesting constriction of peripheral arterioles, a natural response to cold or anxiety, hypovolemia, cardiogenic shock, or a vasoconstrictive disease.

Flushing can result from medications, excess heat, anxiety, or fear. Pallor can result from anemia
or increased peripheral vascular resistance caused by atherosclerosis. Dependent rubor may be a sign of chronic arterial insufficiency. Suspect arterial insufficiency if the patient’s foot shows marked pallor, delayed color return that ends with a mottled appearance, delayed venous filling, or marked redness.

Cool and clammy skin results from vasoconstriction, which occurs when cardiac output is low such as during shock. Warm, moist skin results from vasodilation, which occurs when cardiac output is high—for example during exercise.

Taut and shiny skin that can’t be grasped may result from ascites or the marked edema that accompanies heart failure. Skin that doesn’t immediately return to the original position exhibits tenting, a sign of decreased skin turgor, which may result from dehydration, especially if the patient takes diuretics. Tenting may also result from age, malnutrition, or an adverse reaction to corticosteroid treatment.

Edema can result from heart failure or venous insufficiency caused by varicosities or thrombophlebitis. Chronic right-sided heart failure may even cause ascites, which leads to generalized edema and abdominal distention. Venous compression may result in localized edema along the path of the compressed vessel.

Dry, open lesions on the patient’s lower extremities accompanied by pallor, cool skin, and lack of hair growth signify arterial insufficiency, possibly caused by arterial peripheral vascular disease. Wet, open lesions with red or purplish edges that appear on the patient’s legs may result from the venous stasis associated with venous peripheral vascular disease.

Assessing the arms and legs

Inspect the hair on the patient’s arms and legs. Hair should be distributed symmetrically and should grow thicker on the anterior surface of the arms and legs. Also note whether the length of the arms and legs is proportionate to the length of the trunk.

Abnormal findings

Hair that isn’t thicker on the anterior of the surface of the patient’s arms and legs may indicate diminished arterial blood flow to these extremities. A patient with long, thin arms and legs may have Marfan syndrome, a congenital disorder that causes cardiovascular problems, such as aortic dissection, aortic valve incompetence, and cardiomyopathy.

Assessing the fingernails

Fingernails normally appear pinkish with no markings. To estimate the rate of peripheral blood flow, assess the capillary refill in the patient’s fingernails (or toenails) by applying pressure to the nail for 5 seconds, then assessing the time it takes for color to return. In a patient with a good arterial supply, color should return in less than 3 seconds.

Assess the angle between the nail and the cuticle. Also evaluate the size of the patient’s fingertips and palpate the nail bases. Nail bases should feel firm.

Evaluate the shape of the patient’s nails. They should appear smooth and rounded. Finally, check for splinter hemorrhages—small, thin, red or brown lines that run from the base to the tip of the nail.

Abnormal findings

A bluish color in the nail beds indicates peripheral cyanosis. Delayed capillary refill suggests reduced circulation, a sign of low cardiac output that could lead to arterial insufficiency. An angle between the nail and the cuticle of 180 degrees or greater indicates finger clubbing, a sign of chronic tissue hypoxia. Enlarged fingertips and spongy nail bases also indicate early clubbing. A concave depression in the middle of a thin nail indicates koilonychia (spoon nail), a sign of iron deficiency anemia or Raynaud’s disease, whereas thick, ridged nails can result from arterial insufficiency. Splinter hemorrhages may develop in patients with bacterial endocarditis.

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