Structure of the Heart

CONDUCTION SYSTEM OF THE HEART

Assessing the cardiovascular system includes performing several subjective and objective
assessments. At times, assessment findings are modified according to life span considerations.

Subjective Assessment

The subjective assessment of the cardiovascular and peripheral vascular system is vital for
uncovering signs of potential dysfunction. To complete the subjective cardiovascular assessment,
the nurse begins with a focused interview. The focused interview explores past medical and
family history, medications, cardiac risk factors, and reported symptoms. Symptoms related to
the cardiovascular system include chest pain, peripheral edema, unexplained sudden weight gain,
shortness of breath (dyspnea), irregular pulse rate or rhythm, dizziness, or poor peripheral
circulation. Any new or worsening symptoms should be documented and reported to the health
care provider.

Table 9.3a outlines questions used to assess symptoms related to the cardiovascular and
peripheral vascular systems. Table 9.3b outlines questions used to assess medical history,
medications, and risk factors related to the cardiovascular system. Information obtained from the
interview process is used to tailor future patient education by the nurse.

Interview Questions for Cardiovascular and Peripheral Vascular Systems

 Follow-Up
Symptom Question
Safety Note: If findings indicate current severe
symptoms suggestive of myocardial infarction or another
critical condition, suspend the remaining cardiovascular
assessment and obtain immediate assistance according
to agency policy or call 8888.

Chest Pain Onset – When did the pain start?

 Location – Where is the pain?

 Duration – When it occurs, how long does the pain
last? Is it constant or intermittent?
 Characteristics – Describe what the pain feels like
(e.g., sharp, dull, heavy, etc.).
Have you had any
 Aggravating/Alleviating Factors – What brings on
pain or pressure in
the pain? What relieves the pain?
your chest, neck, or
 Radiation – Does the pain radiate anywhere?
arm?
 Treatment – What have you used to treat the pain?
 Effects – What effect has the pain had on you?
 Severity – How severe is the pain from 0-10 when it
occurs?
 Associated Symptoms – Have you experienced
any nausea or sweating with the chest pain?

Shortness of
Do you ever feel short What level of activity elicits shortness of breath?
Breath
of breath with activity? How long does it take you to recover?
(Dyspnea)
Do you ever feel short
Have you ever woken up from sleeping feeling
of breath while suddenly short of breath
sleeping? (paroxysmal nocturnal dyspnea)?
Do you feel short of How many pillows do you need to sleep, or do you
breath when lying sleep in a chair (orthopnea)? Has this recently
flat? changed?

Edema Have you noticed Has this feeling of swelling or restriction gotten
swelling of your feet worse?
or ankles?
 Have you noticed Is there anything that makes the swelling better (e.g.,
your rings, shoes, or sitting with your feet elevated)?
clothing feel tight at
the end of the day? How much weight have you gained? Over what time
period have you gained this weight?
Have you noticed any
unexplained, sudden
weight gain?

Have you noticed any

new abdominal
fullness?

Palpitations Have you ever Are you currently experiencing palpitations?

noticed your heart
feels as if it is racing When did palpitations start?
or “fluttering” in your
Have you previously been treated for palpitations? If
chest?
so, what treatment did you receive?
Have you ever felt as
if your heart “skips” a
beat?

Dizziness Do you ever feel light- Can you describe what happened?
headed?
(Syncope) Did you have any warning signs?
Do you ever feel
dizzy? Did this occur with position change?

Have you ever

fainted?

Do your hands or feet What, if anything, brings on these symptoms?

ever feel cold or look
pale or bluish? How much activity is needed to cause this pain?
Poor Peripheral
Circulation Is there anything, such as rest, that makes the pain
Do you have pain in
your feet or lower legs better?
when exercising?
 Do you currently have Can you point to the area of pain with one finger?
Calf Pain any constant pain in
your lower legs?

Table 9.3b Interview Questions Exploring Cardiovascular Medical History, Medications, and
Cardiac Risk Factors

Topic Questions

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?
Medical
History
Have you had any procedures done to improve your heart function,
such as ablation or stent placement?

Have you ever had a heart attack or stroke?

Do you take any heart-related medications, herbs, or supplements to

Medications treat blood pressure, chest pain, high cholesterol, cardiac rhythm, fluid
retention, or the prevention of clots?

Have your parents or siblings been diagnosed with any heart

conditions?

 If yes, who has what conditions?

Do you smoke or vape?

Cardiac
Risk  If yes, how many do you smoke/vape daily?
Factors  For how many years have you smoked/vaped?

If you do not currently smoke, have you smoked in the past?

 If yes, what did you smoke?

 For how many years did you smoke?
 Are you physically active during the week?

 How many times per week do you exercise and for how many minutes?
 What type of exercise do you usually do?

What does a typical day look like in your diet?

 How many fruits and vegetables do you normally eat in a day?

 Do you monitor the amount of saturated fats you eat?
 How many times a week do you eat a meal prepared by a restaurant?
 Do you pay attention to salt in your diet? Do you add salt to your foods
before tasting it?
 Do you have caffeine during the day? If so, how much?

Do you drink alcoholic drinks?

 How many alcoholic drinks do you have on average per day? Per
week?
 Do you drink while at work?

Would you say you experience stress in your life?

 How would you rate the amount of stress in your life from 0-10?
 How do you cope with the stress in your life?

How many hours of sleep do you normally get each day?

 Do you have difficulty falling asleep?

 Do you have difficulty staying asleep?

Objective Assessment

The physical examination of the cardiovascular system involves the interpretation of vital signs,
inspection, palpation, and auscultation of heart sounds as the nurse evaluates for sufficient
perfusion and cardiac output.

Equipment needed for a cardiovascular assessment includes a stethoscope, penlight, centimeter

ruler or tape measure, and sphygmomanometer
 Evaluate Vital Signs and Level of Consciousness

Interpret the blood pressure and pulse readings to verify the patient is stable before proceeding
with the physical exam. Assess the level of consciousness; the patient should be alert and
cooperative.

As a general rule of thumb, findings of systolic blood pressure in

adults less than 100,or a pulse rate less than 60 or greater than 100,require immediate
follow-up.

Inspection
 Skin color to assess perfusion. Inspect the face, lips, and fingertips for cyanosis or pallor.
Cyanosis is a bluish discoloration of the skin, lips, and nail beds and indicates decreased
perfusion and oxygenation. Pallor is the loss of color, or paleness of the skin or mucous
membranes, as a result of reduced blood flow, oxygenation, or decreased number of red blood
cells. Patients with light skin tones should be pink in color. For those with darker skin tones,
assess for pallor on the palms, conjunctiva, or inner aspect of the lower lip.
 Jugular Vein Distension (JVD). Inspect the neck for JVD that occurs when the increased
pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the
right side of a person’s neck. JVD should not be present in the upright position or when the head
of bed is at 30-45 degrees.
 Precordium for abnormalities. Inspect the chest area over the heart (also called precordium)
for deformities, scars, or any abnormal pulsations the underlying cardiac chambers and great
vessels may produce.
 Extremities:
o Upper Extremities: Inspect the fingers, arms, and hands bilaterally noting Color, Warmth,
Movement, Sensation (CWMS). Alterations or bilateral inconsistency in CWMS may indicate
underlying conditions or injury. Assess capillary refill by compressing the nail bed until it
blanches and record the time taken for the color to return to the nail bed. Normal capillary refill
is less than 3 seconds.[11]
o Lower Extremities: Inspect the toes, feet, and legs bilaterally, noting CWMS, capillary refill,
and the presence of peripheral edema, superficial distended veins, and hair distribution.
Document the location and size of any skin ulcers.
 Edema: Note any presence of edema. Peripheral edema is swelling that can be caused by
infection, thrombosis, or venous insufficiency due to an accumulation of fluid in the tissues.
 Deep Vein Thrombosis (DVT): A deep vein thrombosis (DVT) is a blood clot that forms in a
vein deep in the body. DVT requires emergency notification of the health care provider and
immediate follow-up because of the risk of developing a life-threatening pulmonary embolism

 Inspect the lower extremities bilaterally. Assess for size, color, temperature, and for presence of
pain in the calves. Unilateral warmth, redness, tenderness, swelling in the calf, or sudden onset of
intense, sharp muscle pain that increases with dorsiflexion of the foot is an indication of a deep
vein thrombosis (DVT).
Auscultation

HEART SOUNDS

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. They will make a “lub-dub” sound.

The first heart sound (S1) identifies the onset of systole, when the atrioventricular (AV) valves
(mitral and tricuspid) close and the ventricles contract and eject the blood out of the heart.

The second heart sound (S2) identifies the end of systole and the onset of diastole when the
semilunar valves close, the AV valves open, and the ventricles fill with blood. 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.

EXTRA HEART SOUNDS

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 you notice any new or different
sounds, consult an advanced practitioner or notify the provider.

A mid systolic click, associated with mitral valve prolapse, may be heard with the diaphragm at
the apex or left lower sternal border.

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 health care 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.

A pleural friction rub is caused by inflammation of the pericardium and sounds like sandpaper
being rubbed together. It is best heard at the apex or left lower sternal border with the diaphragm
as the patient sits up, leans forward, and holds their breath.
CAROTID SOUNDS

The carotid artery may be auscultated for bruits. Bruits are a swishing sound due to turbulence
in the blood vessel and may be heard due to atherosclerotic changes.

Palpation

Palpation is used to evaluate peripheral pulses, capillary refill, and for the presence of
edema. When palpating these areas, also pay attention to the temperature and moisture of the
skin.

PULSES

Compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial,
brachial, posterior tibialis, and dorsalis pedis pulses.

The quality of the pulse is graded on a scale of 0 to 3, with 0 being absent pulses, 1 being
decreased pulses, 2 is within normal range, and 3 being increased (also referred to as
“bounding”).

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.
Figure 9.9 Assessing Tibial Pedal Pulses
CAPILLARY REFILL

The capillary refill test is performed on the nail beds to monitor perfusion, the amount of blood
flow to tissue. 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. Once the tissue
has blanched, 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 2 to 3
seconds after the pressure is removed.

EDEMA

Edema occurs when one can visualize visible swelling 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 non
pitting. 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 nonpitting edema. If indentation occurs, it is referred
to as pitting edema.
Grading of Edema

Life Span Considerations

The cardiovascular assessment and expected findings should be modified according to common
variations across the life span.

INFANTS AND CHILDREN

A murmur may be heard in a newborn in the first few days of life until the ductus
arteriosus closes.

When assessing the cardiovascular system in children, it is important to assess the apical pulse.
Parameters for expected findings vary according to age group. After a child reaches adolescence,
a radial pulse may be assessed. Table 9.3c outlines the expected apical pulse rate by age.

Table 9.3c Expected Apical Pulse by Age

 Age Group Heart Rate

Preterm 120-180

Newborn (0 to 1 month) 100-160

Infant (1 to 12 months) 80-140

Toddler (1 to 3 years) 80-130

Preschool (3 to 5 years) 80-110

School Age (6 to 12 years) 70-100

Adolescents (13 to 18 years) 60-90

Listen to pediatric heart tones:

OLDER ADULTS

In adults over age 65, irregular heart rhythms and extra sounds are more likely. An “irregularly
irregular” rhythm suggests atrial fibrillation, and further investigation is required if this is a
new finding.
Expected Versus Unexpected Findings

After completing a cardiovascular assessment, it is important for the nurse to use critical thinking
to determine if any findings require follow-up. Depending on the urgency of the findings, follow-
up can range from calling the health care provider to calling the rapid response team. Critical
conditions are those that should be reported immediately and may require notification of a rapid
response team. Expected Versus Unexpected Findings on Cardiac Assessment

Unexpected Findings (Document

Assessment Expected Findings and notify the provider if this is a
new finding*)

Scars not previously documented

Apical impulse may or that could indicate prior cardiac
Inspection
may not be visible surgeries

Chest anatomy malformations

Apical pulse felt to the left of the

Apical pulse felt over
midclavicular fifth intercostal space
Palpation midclavicular fifth
intercostal space

New irregular heart rhythm

S1 and S2 heart sounds
Auscultation
in a regular rhythm Extra heart sounds such as a
murmur, S3, or S4

Symptomatic tachycardia at rest

(HR>100 bpm)

Symptomatic bradycardia (HR<60

*CRITICAL bpm)
CONDITIONS to
report immediately New systolic blood pressure (<100
mmHg)

Orthostatic blood pressure changes

()
 New irregular heart rhythm

New extra heart sounds such as a

murmur, S3, or S4

New abnormal cardiac rhythm

changes

Reported chest pain, calf pain, or

worsening shortness of breath

Expected Versus Unexpected Peripheral Vascular Assessment Findings

Unexpected Findings (Document or

Assessment Expected Findings
notify provider if new finding*)

Skin color uniform and Cyanosis or pallor, indicating

appropriate for race decreased perfusion
bilaterally
Decreased or unequal hair
distribution
Equal hair distribution
on upper and lower Presence of jugular vein distention
extremities (JVD) in an upright position or when
Inspection
head of bed is 30-45 degrees
Absence of jugular
vein distention (JVD) New or worsening edema

Absence of edema Rapid and unexplained weight gain

Sensation and Impaired movement or sensation of

movement of fingers fingers and toes
and toes intact

Skin cool, excessively warm, or

Skin warm and dry
diaphoretic
Palpation
Pulses present and
Absent, weak/thready, or bounding
equal bilaterally
pulses
 Absence of edema New irregular pulse

Capillary refill less New or worsening edema

than 2 seconds
Capillary refill greater than 2
seconds

Unilateral warmth, redness,

tenderness, or edema, indicating
possible deep vein thrombosis (DVT)

Auscultation Carotid pulse Carotid bruit

Cyanosis

Absent pulse (and not heard using

Doppler device)
*CRITICAL
CONDITIONS to Capillary refill time greater than 3
report immediately seconds

Unilateral redness, warmth, and

edema, indicating a possible deep
vein thrombosis (DVT)