Assessment

Cardiac Assessment

Cardiovascular nursing assessment involves careful, systematic

evaluation of a pt medical, family, social, cultural, psychological,
and occupational history and examination of the heart & vascular
system

Cardiovascular assessment should be conducted in an organized

manner. It begins with an overall evaluation of the pt, assessing
the skin, nails, & extremities for general signs of circulatory
compromise. It proceeds to a more direct evaluation of
cardiovascular integrity, consisting of palpating the pulses,
evaluation the major arteries & veins, measuring the blood
pressure, and assessing the heart by palpation and auscultation.

Inspection

Inspection of Nails

Skin
- should be evaluated for color, turgor, temp, & moisture

Nails should be assessed for color, shape, thickness,

symmetry, & nail adherence

Color-normal pink to deep or

light brown
For darker skinner-more
difficult to determine so eval
the conjunctiva, tongue,
buccal mucosa, &palms.
Check for pallor which
means decreased
oxyhemoglobin concentration;
cyanosisbluish color, best observed at
the nailbeds, lips & inside the
mouth caused by increased
amt of deoxygenated
hemoglobin.

Turgor-reflects elasticity &

the water content of the skin
& subcutaneous tissues. It is
assessed by lifting a fold of
skin & observing how quickly
it returns to normal position
Temperature & Moisturethe skin should be warm &
dry, unless environmental
temperature are extreme. An
extremity that is cooler &
drier than other body surfaces
suggest arterial insufficiency

Inspection of Extremities
The upper & lower extremities should be evaluated for S/S
of acute & chronic changes due to arterial or venous
disorders
Chronic arterial
insufficiency can over time
lead changes such as uneven
hair distribution or hair loss &
atrophy of the skin, which
becomes smooth, shiny &
thin.
Severe ischemia of the
lower extremity results in
varying degrees of tissue loss,
including ulceration or
gangrene.

The presence of gangrene

indicates complete occlusion
of the arterial circulation to a
portion of the extremity that
has been going on for several
days. It is demonstrated when
the skin is black, dry, & hard.
Pre-gangrene signs can be
recognized by a deep cyanosis
or purple-black color that is
not affected by pressure or
changes in position

Peripheral Vascular
Disease can produce nail
depression, pitting,
longitudinal striations.
Koilonychia-spoon shaped
nail is associated with several
conditions, including
Raynauds disease

Clubbing of the fingers

accompanies longstanding
cyanosis & is associated with
decreased oxygen.
The distal tips of fingers
become bulbous. The nails are
thickened, hard, & curved at the
tip & the nail bed feels boggy
when squeezed.
Separation from the nail
bed produces a white,
yellowish, or greenish color on
the non adherent portion of the
nail.

Inspection of Extremities - continued

The upper & lower extremities should be evaluated for S/S of acute
& chronic changes due to arterial or venous disorders
Venous incompetence can
lead to a number of chronic
problems.
Varicose veins appear as
dilated, often tortuous veins
when the legs are in a
dependent position.

The Trendelenburg test is

used to evaluate venous
incompetence.
With the pt supine, lift
the leg above the level of the
hart until the veins empty and
then lower the leg quickly.
Venous incompetency is
distinguised by rapid filing of
the veins.

Inspection of Extremities - continued

Redness, thickening, &
tenderness along a superficial
vein suggest thrombophlebitis.
Deep vein thrombosis (DVT)
cannot be confirmed on
physical exam alone, but should
be suspected if swelling, pain,
& tenderness appear over a
vein.
Homans sign, which is used
to test for DVT, involves having
the pt quickly dorsiflex the foot
while the knee is slightly flexed.
Calf pain is a (+) sign & usually
indicated thrombosis.

The lower extremities should be

evaluated for edema. Edema is
a sign of >interstitial fluid.
Bilateral edema of the lower
extremities can be a sign of
heart failure or venous
insufficiency.
To check for edema, press the
bony prominence over the tibia
or middle malleolus for several
seconds & lift the finger. If the
depression does not fill almost
immediately, pitting edema is
present.

Exam of Arterial Pulses

Pulse amplitude ratings:
4+ full volume, bounding,
hyperkinetic
3+ full volume
2+ normal
1+ diminished, barely palpable
0+ Absent

Note: In palpating carotid

arteries,
NEVER
PALPATE BOTH
SIDES
SIMULTANEOUSLY
to avoid a reduction in
cerebral blood flow or vagal
bradycardia
Excessive pressure could
result in slowing of the heart
rate & hypotension

Exam of Jugular Veins - continued

This position [30-45 degrees]achieves maximum excursion of the
internal vein which pulsates in response to the changes in right atrial
pressure. A 45 degree angle will cause the venous pulsation to rise
1-3cm above the level of the manubrium. The upper limit of normal
for jugular venous pressure is 3cm H20 above the sternal angle.
Clinically, this represents a JVP of 8 cm (since the sternal angle is
equal to 5cm above the right atrium.
Abnormal: (1) >inJVP greater than 4cm [8cm] are most often the
result of >Blood Volume. Ex are RV failure such as tricsuspic valve
regurgtation, Rt sided heart failure & pulmonary hypertension.
(2) Flat Jugular Vein - when pt lying down may suggest
vascular volume depletion
(3) Unilateral distension-may indicate vessel obstruction on
that side

Exam of Arterial Pulses

Careful examination of the
arterial pulses provides
valuable information about
the cardiovascular system,
including the
(1) overall function of the
ventricles, the
(2)quality of the arterial blood
vessles, and the
(3) condition of the aortic
valve.

The arterial pulses include:

Carotid
Radial
Brachial
Femoral
Popliteal
Dorsalis pedis
Posterial tibial

Exam of Jugular Veins

Assessment of jugular veins provides information regarding the
volume & pressure in the right side of the heart.
The external jugular vein is visible above the clavicle. Because
palpation obliterates the jugular pulse, veins are assessed by visual
inspection. Not usually visible when pt sitting upright; assessment
should be done with the pt reclining 30-45degree angle.
Use sternal angel as reference point. Using centimeter ruler,
measure the vertical distance between sternal angle & the point of
highest venous pulsation.
Normal value <3-4cm with HOB elevated 30-45 degrees
>4 indicates (a) increased RA or RV pressure as in RV failure
(b) Triscupid regurgitation or pericordial tamponade

Cardiac Auscultation
Carotic artery: Have pt hold breath, you listen for bruits or murmurs
. Using fingertips gently palpate carotid arteries one side at a time,
comparing rate, rhythm. Ausultate for btuits (blowing sound)..
Bruit: indicative of turbulence-blood flowing under pressure Ask pt
to hold breath so as not to confuse trachial breath sounds. A bruit
generally indicates that carotid artey has narrowed (atherosclerosis) or
radiation from sources from an aortic valve murmur. Bruit usually
caused by atherosclerotic narrowing in arteries, increased force of
movement of blood (ex: Hypermetabolic states like hyperthyroidism)

Cardiac Auscultation - continued

Murmurs - Heart Sounds
Heart murmurs are a series of prolonged sounds heard during
either systole or diastole.
They are produced by vibrations that are created by disruption in
the blood flow as it passes through the heart or great vessels.
They can arise from structural changes or defects in the valves, the
heart itself, or the great vessels.
Murmurs are classified by timing (systolic or diastolic),
pitch (high, medium, low), intensity, sound pattern, quality,
location, radiation, & effects of respiration(see next slide)
Pericardial friction rub produces grating, machine like sounds
heard throughout systole & diastole. Caused by roughened visceral
& parietal surfaces of an inflamed pericardial sac rubbing together.
Indicates infection such as pericarditis, inflammation, infiltration.

Describe Murmur-continued

7. Intensity- degree of
loudness.
Grade I-VI with I being
very faint and increasing in
sound to VI very loud

1. Timing when it occurs

2. Quality- blowing, harsh,

during cardiac cycle, systolic

or diastolic, early, mid, or late
Hypertropic
Cardiomyopathy crescendo-descrecendo

3. Pitch
- high or low
4. Location
- where it is

S1

S2

Pansystolic-heard throughout
systole
S1
S2
Decrescendo-aortic &
pulmonary insufficiency
S1

S2

rumbling, musical

heard loudest (aortic,

pulmonic, mitral, triscupid, &
what ICS)

5. Radiation
- murmurs
transmitted in direction of
blood flow therefore can
radiate to axilla, neck, back &
other locations on the chest
6. Configuration -next slide
7. Intensity- see next slide

Cardiac Auscultation
Murmur: similar to bruit but radiates from the aortic valve

6. Configuration - note
shape of sound.
Does it begin soft &
become louder = crescendo
or the opposite which is
loud & becomes
soft = crescendodecrescendo
or
remain
constant = plateau

Describe Murmur

Pericardial Friction Rubproduced by inflammation of

pericardial sac.
(1) Parietal visceral
layers of pericardium rub
against each other during
cardiac motion
(2) heard heard with
diaphragm at apex Lf Sternal
border
(3) Scratch, grating,
rasping, squeaky

Location of the Heart

6 Anatomical Landmarks of Heart - each area corresponds to a

specific vavular outflow tract
Aortic area = Right 2nd intercostal space (component of S2)
Pulmonic are = Left 2nd intercostal space (component of S2)
Erbs Point = left 3rd ICS (S1 S2)
PMI/Apical Impulse = 5th ICS mid clavicular line (MCL)
Tricuspid or Right Ventricular = Left sternal border (5th ICS)
Epigastric = just below tip of sternum - aorta
Mitral = at apex of Left Lower Sternal boarder (5th ICS)

Cardiac Auscultation - Continued

Normal heart sounds
AV valve closure generates the lubb sound (S1)
Closing of the aortic & pulmonic valves is the dubb sound (S2)
Use a systemic approach beginning with the diaphragm of the
stethoscope at the apex, moving to the lower sternal border, &
then ascending along the left sternal border to to the right and left
base.
Diaphragm of stethoscope detects high pitched sounds
Bell of stethoscope detects low pitched sounds/murmurs

Heart Sounds
Normal (Lub-dub, Lub-dub)
S1 Lub (Closure of AV Valves at start of
systole)
S2 Dub (Closure of pulmonic and aortic
valves upon end diastole)
3rd Heart Sound Middle 3rd of diastole
4th Heart Sound Atrial

Cardiac Auscultation - Continued

Consider points as you examine each auscultatory site:
(1) Overall rate & rhythm of heart
(2) Intensity, pitch, duration,& timing in cardiac cycle
(a) Intensity or loudness is the degree to which a heart sound can be heard.
Varies widely
(b) Pitch is the frequency of the heart sound. Heart sounds are usually low
intensity, however, extra sounds, such as diastolic murmur of mitral stenosis
& S3 are of lower frequencies. The diastolic murmur of aortic regurgitation
or a normal S2 are high frequency sounds
Duration refers to how long the heart sound lasts. Heart sounds are brief,
lasting much less than 1 second
(d) Timing describes the heart sounds as they occur during the cardiac
cycle. Ex-Systole begins with S1 & extends to S2. Diastole which is a
longer interval, begins with S2 & extends to the next S1

(3) Extra sounds: systolic clicks or ejection sounds, diastolic

opening snaps, gallops, & murmurs

Cardiac Output

Stroke Volume (amount ejected in 1 hb)

Pre-load (at the end of diastole)
After-Load (PVR) (pumps against)
Peripheral Vascular Resistance

S1 - Normal Heart Sounds

S1 is the 1st heart sound produced by closure of the triscupid &
mitral valves & marks the beginning of systole.[venticular
contraction] Systole=S1__S2
Best heard at the apex & 5th ICS at left sternal border.
Corresponds with upswing of carotid pulse.
S1 more intense in high output states & with mitral valve
stenosis.
A decreased intensity occurs in systemic or pulmonary HTN &
valve fibrosis or calcification
Obesity, emphysema, & excess pericardial fluid can obscure S1
A varying intensity of S1 suggests severe dysrhythmia or
complete heart block
S1>S2 at apex

S2 - Normal Heart Sounds

S2 The second heart sound, is produced by closure of the
pulmonic & aortic valves[semi-lunar valves] & marks the
beginning of diastole[ventricular filling] dup shorter & higher
pitched than S1
Higher in pitch & shorter duration than S1
Diastole = S2___S1
Aortic valve closure is at the 2nd right ICS & pulmonic valve
closure is best heard at the 2nd left ICS.
Instruct pt to breathe normally while you listen for 2 distinct
components of S2 (Physiologic splitting of S2 due to delayed
closure of pulmonic valve). Instruct pt to exhale & hold breath,
then inhale & hold breath. Normally, S2 tends to merge on
expiration, becoming a single sound.
A decreased intensity of S2 occurs in severe arterial hypotension
& in immobile, thickened, calcified, or stenostic valves.
Overlying tissue, fat, or fluid also mutes S2
S2>S1 at base

Abnormal Heart Sounds -Gallops

Gallops- diastolic filling sounds occur during the
2 phases of ventricular filling.
Sudden changes of inflow volume causes
vibrations of the valves producing
low pitched sounds either early [S3]
or late [S4] in diastole.

S3 [Ventricular gallop] - Normal Heart Sounds

S3 [Ventricular gallop] - Normal Heart Sounds

continued

Vibration of the ventricular walls during a rapid passive filling

in early diastole produces the 3rd heart sound (also referred to as
ventricular gallop)

Occurs after closure of semilunar valves.. Occurs in early

diastole during passive rapid ventricular filling of ventricles. Best
heard with the stethoscope bell at the apex or left lower sternal
border the pt is in left lateral position. S3 immediately follows S2
Lub-dup-a [low pitched sound]

S3 is low pitched, heard as Ken - Tuc - Key

S3 is commonly heard in children & young adults & is considered

normal (physiologic S3).
In adults >30, S3 gallop signal left sided heart failure, lf vent
dysfunction.

An accentuated S3 sound can result from conditions that cause

more rapid filling, including exercise & elevation of the legs, or
any factors that increase the heart rate.
Nursing Alert: Auscultate lungs for crackes with a new S3

S4 [Atrial Gallop]- Normal Heart Sounds

S4 (atrial gallop) is normally a soft, low pitched sound caused by
vibration of the valves, supporting structure & ventricular
walls during the 2nd phase of rapid ventricular filling in late
diastole.
Best heard with the bell at the apex with pt left lateral position
Immediately preceeds S1 da - lub-da
S4 found most commonly in disorders in which there is increased
stiffness of ventricles as in ventricular hypertrophy, MI, fibrosis,
mitral stenosis, cardiomyopathy, cor pulmonale (COPD)

S4 [Atrial Gallop]- Normal Heart Sounds

continued
S4-Atrial Gallop-Occurs in late diastole during atrial contraction
& active filling of ventricles [ventricles resistant to filling when
almost full] Heard late diastole just before S2. Auscultated at
apex or Sternal boarder [sounds like Ten-Nes-See)
S4 gallop is caused by loss of ventricular wall compliance from
HTN or CAD or from increased stroke volume in high cardiac
output states.

Not heard in absence of atrial contract as in A-Fib

Splits

S1
S4

MT

Systole

S2
A P

Diastole
S3

S4

S1 Systole S2
MT

AP

Distinguish between split S2

and an S3
Split occurs at base
S3 does not vary as pt
breathes & Split varies with
inspiration & expiration
S3 is low pitched and the
split has a constant pitch

Split S1 - common physiologic

split (M1 T1)
Normal
Hear Mitral valve M1 close
before triscupid valve T1
Head loudest at apex
Split S2 (A2 P2)
Normal physiological splitting
of delayed inspiration due to
pulmonary valve (P2) closing
after aortic valve (A2)

Cardiac Assessment - History

History-Risk Factors of Heart Disease

Blood relative with cardiac
disease before age 55
Male
post menopausal female
African American women of
any age
African American, Puerto
Rican, Cuban & Mexican men
are at higher risk of HRN &
Heart Disease
Mature American over age
35=twice risk
African American male=2x risk
of stroke

>age 60 = 3x risk
Hyperlipidema (>lipid count)
Diabetes
Obesity
Sedentary lifestyle
Stress
High fat diet
Left ventricular hypertrophy
Use of oral contraceptives
Gout

Inquire about the chief complaint to establish

priorities for nursing intervention & to evaluate pt
understanding of condition
What are the common presenting c/o pt cardiac disorder?

Chest Pain
Dyspnea
Fatigue
Palpitation
Syncope(transient LOC/faint)
Wt gain-edema

Past Medical History

History

Cyanosis
Pallor
Edema
Peripheral vascular disease
Clubbing of fingernails
Arrhythmias
Nocturia

Past Medical
History

Do you ever have chest pressure, heaviness, or pain?

Do you ever feel fatigued? Tired?
Swelling in ankles, feet or hands? How long?
Experience confusion?
Noticed a Bluish tinge to skin, lips, mucous membranes?
Experience palpitations?
Experience shortness of breath?
Felt dizzy or or have fainted?
Any of above adversely affected your life?

Will help identify risk factors

Pt is asked questions about
(1) Childhood & Infectious
diseases
May cause structural
damage to heart such as
(a)Rheumatic Fever
(b)Severe Strep Infection
(2) Major Illnesses &
Hospitalizations
Presence of co-morbidities
such as DM, COPD, Kidney
disease, anemia, HTN, stroke,
gout, thrombophlebitis,
bleeding disorders

Specific drugs to ask pt

about:

Provides abundant info about risk factors for dev of CV Disease, Age,
Gender, Race, Family Hx, Stress, Diet, Exercise, Habits

Chief Complaint: should document in pt own words.

Ask the following questions:

(3) Medications
Numerous meds can affect
overall CV system
Need to eval prescription as well
as OTC meds
When asking pt use simple
descriptions such as Water pill,
Heart pill BP med

Psychosocial History

AntiHTN
Diruetics
Vasocilators (nitro)
Cardiotonic drugs (Digoxin)
Anticoagulants
Bronchodilators-dysrhythmias
(increase HR)
Contraceptives
Cocaine toxicity-symptomatic
Cite example of cocaine
induced effect such as - >HR,
>contractility, peripheral
vasoconstriction, blood glucose
levels.

History
Medication History
OTC
Herbal/natural remedies
List of prescription meds

Smoking & Alcohol-exact amount, duration

Diet history/Nutrition-cholesterol levels, caffeine, cultural
beliefs
Stress Exercise Occupation-past, present, job related stress
Geographical Location-where one lives is significantly R/T
death caused by cardiac events
Environment-safety issues at home, mode of transportation,
access to public transportation, noise, pollution or violence in
neighborhood, access to family & friends, grocery store,
pharmacy, health facility, etc.

Every time you inhale smoke,

arteries
all over your body constrict especially
in the brain and heart

Physical Assessment - continued

3. Blood Pressure - measure BP from both arms if possible to R/O
certain disorders.
Ex-vascular obstruction, dissecting aortic aneurysm & errors in
measurement
Record which arm was used, the pt position & time of reading
Postural BP-taken when hypovolemia or decreased vascular tone is
suspected.
BP is taken with pt in supine position, sitting, & standing.
A drop of more than 10-15 mgHg systolic &
more than 10mg Hg diastolic
indicates postural hypotension.
Is usually accompanied by 10-20 increase in pulse rate.

Physical Assessment
Obtain objective data (measurable) via inspection, palpation,
auscultation
1. General Appearance-much can be learned through simple
observation
Quiet or restless
Posture-can pt tolerate flat bed or only upright position
Facial expression - signs of pain or resp distress
Signs of pallor/cyanosis
Can pt answer questions without dyspnea, assess for color, shape
Capillary filling
2. Level of Consciousness - this reflects ade1uacy of cerebral
perfusion/oxygenation
1&2 provide an initial composite picture of patient & indicates level
of comfort & distress

Physical Assessment - continued

4. Pulse-assess for pulse
deficit if pulse is irregular by
taking apical & radical pulse
simultaneously & noting
differences in rate.
5. Respiration - note rate,
thythm, depth, & quality.
Auscultate lungs for presence
of crackles, rhonchi, & other
abnormal sound variations
(CHF, pulmonary edema)

**For Postural BP, pt in supine, sitting, & standing. If pt cannot

stand legs must be dangling to detect postural changes in BP

Physical Assessment - continued

6(a) Neck Veins-estimate
central venous pressure
(CVP).
Distention of neck veins
reflects pressures & volume
Venous tone, Bld volume
Atrial pressure.
Distended neck
vein=cir. Overload, Rt sided
heart failure.
Changes within
the right atrium.

7. Assess Lungs-common rep

findings R/T cardiovascular
disease
(a) Tachypnea-rapid resp, may
accmpany myocardial ischemia
pain or as a compensatory
mechanism in CHF &
Pulmonary edema
(b) Crackles-frequent signs of
LV failure. Fluid shifts to intra
alveolar spaces due to backward
pressure of LV failure. Best
heard at lung bases during
inspirations.

6. Head & Neck - Pay attention

to lips, ear lobes, & buccal
mucosa[tongue]. Bluish tinge or
duskiness indicative of central
cyanosis-which can imply
serious heart or lung disease.
Hgb is not able to fully saturate
with 02. Peripheral cyanosis
usually accompanies central
cyanosis.
6(a) Neck Veins-estimate
central venous pressure (CVP).
Distention of neck veins reflects
pressures & volume

Physical Assessment - continued

7. Assess Lungs-continued
Cough-dry hacking
Wet cough-if on ACE
inhibitors
Frank Hemoptysis
- associated with pulmonary
embolism
(d)Wheezing-may be caused
by beta blocker on COPD pt

(e) Sputum Blood tinged sputum

Pink frothy sputum Sign
of acute pulmonary edema.
Together with crackles denotes
very serious LV failure
(f) Cheyne-Stokes respirationcharacterized by abnormal
periods of deep breathing
alternating with periods of
apnea.
Common finding in heart
failure or brain damage.

Cardiac: Inspect/Palpate
Inspect the undressed pt from the side & at an angle. Have adequate
light. Palpate the chest & anatomical landmarks using ball of the hand
& the posterior side of the proximal finger joints placed lightly on the
chest surface in each area.
Carotid Artery: Do not palpate together-you may cut off blood
supply to the brain or cause vagal bradycardia
Normal findings: Smooth contour 2+ strength symmetrical
Decreased pulse with decreased stroke volume secondary narrowing
of artery
Increased pulse with hyperkinesis
Change in regularity of pulse as pt breathes in- sinus dysrhythmia
change in regularity of rate as pt exhales - asymmetry

Cardiac: Inspect/Palpate
Precordium (1) apex (2) Lf sternal border (3) base to
determine presence of normal & abnormal pulsations
Myocardial hypertrophy or right ventricular hypertrophy may also
cause displacement of PMI
Palpate for thrills-abnormal vibration produced by turbulent blood
flow from narrowing, obstruction, or irregularity of blood flow.
Palpate at apex, left sternal boarder, base.
Felt rather than heard- resembles purring of a cat & associated
with significant heart murmurs
Heaves-forceful pulsations that bound against the hand
Observe & Inspect chest for size, shape, symmetry of movement &
any apparent pulsations

Chest Pain
(1)What are some of the disorders
that can cause chest pain?
Chest pain commonly occuring in cardiac disorders, such as
mycardial ischemia, myocardial infarction or MI, pericarditis. Can
be present in pulmonary diseases such as pleursy, pneumonia,
pulmonary embolism and may be associated with anxiety.

(2) Basic pathophysiology of chest pain due to cardiac

disorders Often a result of myocardial ischemia.
Example-lack of blood supply to myocardial tissues

Cardiac: Inspect/Palpate
Precordium (1) apex (2) Lf sternal border (3) base- to
determine presence of normal & abnormal pulsations
1. Point of maximum impulse or apical impulse-this is normally at
or medial to the midclavicular line in the 5th interspace where mitral
valve closure sound is usually heard. Refers to tapping of the chest by
the apex of the heart as it moves & contracts.
Here you can often see the apical impulse, the brief early systolic
pulsation of the left ventricle a it moves anteriorly during contraction
& touches the chest wall.
The apical impulse may not be visible in the supine pt, often is
most easily felt in the left lateral position. Ask pt to roll partly onto the
left side [to move heart closer to chest wall] & look again. Then feel
for the impulse. Tapping sensation 1-2cm & confined to one
intercostal space.

Cardiac: Inspect/Palpate - continued

2. Carotid pulse: Ask pt to turn his head away from side chosen for
palpation. Place tips of two fingers held together lightly over
pulsation. Auscultate heart at the same time, determine if carotid pulse
is regular and synchronous to the first heart sound (S1)
Compare apical & radial pulse if rhythm of heart is irregular.
Other Considerations:
[LV Dilation]- Left Ventricular Dilation-displaced down & to the left;
occupies more than one intercostal space
Left Ventricle of Systole Hypertrophy-elevated forced duration
NonPalpable-pulmonary emphysema, obesity, increased muscularity,
large breasts. Ask pt to assume left lateral position to move heart
closer to chest.

Chest Pain
(3) Why is it important to assess chest pain thoroughly?
Highly variable in nature due to different causes,
therefore, needs to be evaluated thoroughly & correctly through
following (4)descriptive data:

(a) Characteristics -How a pt describes chest pain

May be described as strange feeling, indigestion, dull, heavy
pressure, burning, crushing, constricting, vice-like, aching,
stabbing, or tightness
(b) Location-Areas of the body to which chest pain may radiate
Usually substernal or precordia, may radiate to neck, jaw,
teeth, one or both shoulders, arms, elbows, back. Sometimes no
precordial pain, only radiated pain.
Duration-note time when pain begins & ends

Chest Pain
(5) Differentiate
between MI chest pain
& Anginal pain

(6) Severity/Quantityquantify the pain on

scale of -1 10

Generally, MI chest
pain last longer than 1/2
hours or till intervention is
instituted.
Anginal pain typically
lasts less than 20-30
minutes & relieved by rest

Chest Pain
Precipitating or Aggravating Factors
Name some factors that
may precipitate or
aggravate Chest Pain.

Emotional excitement
Temperature extremes
Exertion
Deep sleep
Position changes
Deep breathing
Straining during BM
Eating (heavy meals)

Chest Pain
Alleviating Factors
(1) State some interventions that may help relieve
Anginal Pain. Find out why these interventions will not
work for MI Chest Pain.
Anginal Pain
- may be relieved by rest, sublingual SL
nitroglycerin, 02, or change in position. Pain not relieved with
these interventions & last 20 min or longer highly suggest MI.

(2) Define Dyspnea. Why does it occur in cardiac

conditions?
Dyspnea-shortness of breath (SOB, labored breathing)
develops when left ventricle fails & lungs become congested

Chest Pain - Alleviating Factors

(3) Types of Dyspnea/ Characterize Dyspnea
What Nsg Interventions would be appropriate for a pt
with Orthopnea?
Find out pathophysiological explanation of
orthopnea
Types (3b) Orthopnea- occurs with pt
resting flat in bed & relieved when pt assumes upright position.
Ask pt what they do to facilitate breathing, such
as sit up, dangle feet at bedside, position when sleeping
Record degree of head elevation required to ease
breathing
(1 or 2 pillow orthopnea)
Pathophysiology- usually sign of more serious compromise of
CardioVascular
system

What other symptoms will

you assess for in a pt who
is c/o Chest Pain?
Associated Symptoms

SOB
Nausea
Vertigo
Diaphoresis
Palpitations
anxiousness

Chest Pain
Alleviating Factors
(3) What are the types of Dyspnea?
Characterize each type.
What are some questions to ask your pt who has
dyspnea?
Types (3a) Exertional- Dyspnea on exertion
Most common form of cardiac related dyspnea
Occurs during mile to moderate exercise or activity,
disappears
with rest
Can greatly limit activity tolerance if severe
Ask pt to describe degree of activity that precipitates
onset of
dyspnea

Chest Pain - Alleviating Factors

(3) Types of Dyspnea/ Characterize Dyspnea
What Nsg Interventions would be appropriate for a pt
with Paroxysmal Nocturnal Dyspnea
Types (3c) Paroxysmal Noctural
Dyspnea

Dyspnea cardiac asthma, severe, terrifying

attacks of SOB during the night waking the pt up from sleep.
May be relieved by sitting up or getting OOB.
May be accompanied by diaphoresis, coughing,
wheezing.
Associated with severe Left Ventricular Failure
caused by redistribution of fluid. (Advanced LVF- Orthopnea,
cyanosis, clubbing, cardiac arrhythmia leading to hypotension &
weak pulse)May be associated with decrease respiration drive.
Assess lungs for crackles & heart for gallops or S3 or
S4
continued see
t lid

Chest Pain - Alleviating Factors

Types (3c) Paroxysmal Noctural Dyspnea

Why is a pt with Paroxysmal Noctural Dyspnea be
encouraged to sit up or get OOB.
Rationale: Paroxysmal Noctural Dyspnea occurs when the pt has
been recumbent for several hours.
When pt is in lateral recumbent position, blood from the
splanchnic beds & lower extremities is redistrubuted to the venous
system, thereby increasing venous return.
This increase in blood volume returning to the heart elevates
pulmonary venous & pulmonary arterial pressures.
A diseased heart is unable to compensate for the increased
intravascular volume & is ineffective in pumping the additional
fluid into the circulatory system.
Therefore, pulmonary congestion results.
Pt awake abruptly, often with a feeling of suffocation & panic.

Chest Pain - Alleviating Factors

(4) Fatigue
Easy fatigued on mild exertion
Caused by decrease cardiac output
Heart not able to meet bodys metabolic demands

(5) Palpitations-sensations of rapid heartbeats, skipping,

irregularity, thumping or pounding.
Cardiac Causes:
Precipitated by changes in cardiac rate, thythm, increased force
of myocardial contractions
Non-Cardiac causes:
Nervousness, heavy meals, lack of sleep, large intake of coffee,
alcohol, tobacco

Chest Pain - Alleviating Factors

Chest Pain - Alleviating Factors

(7) Syncope- fainting, momentary loss of consciousness due to

decrease cerebral blood flow
Orthostatic Hypotension
Cardiac dysrhythmias (ventricular dysrhythmias)
Valvular disorders (aortic stenosis)
Pathophysiology explanation for syncope-Most common cause
is < perfusion to the brain. Any condition that suddenly < the cardiac
output, resulting in decreased cerebral blood flow.
Syncope in the aging pt-may result from hypersensitivity of the
carotid sinus bodies, located in the neck arteries. Pressure applied to
the carotid arteries (ex during turning the head,shrugging the
shoulders, shaving, buttoning a shirt) stimulates a vagal response. A
decrease in BP & HR usually results, but an exaggerated response
may produce syncope. Syncope in older pt may also result from
orthostatic (postural) hypotension due to an age affected baroreceptor
response

(8) Weight Gain - due to accumulation of fluid (interstitial)

An increase in body weight of 2-3 pounds or more within 24

hours results from fluid rather than body mass changes.
Body weight sensitive indicators of water & Na retention.
A patient asks why they need to check their weight everyday. What
would be an appropriate response?

How to Grade Pitting Edema

Scale
1+(trace)
2+ (mild)
3+(mod)

Duration

5-10 minutes

Precipating
Events

Usually from exertion

Relief
Measures

Response
Rapid
10-15 seconds
1-2 minutes

4+(severe) 1/2-1
2-5 minutes
When assessing for edema by pressing the body prominence over the
tibia with a finger then releasing the depression lifts up within 60 sec.
The nurse should document this pitting edema as ____+

Assessment of Chest Pain - Angina

Characteristics Substernal or retrosternal spreading across chest.
May radiate to inside of arm, neck, jaws

Degree
slight
0-1/4
1/4-1/2

Assessment of Chest Pain -MI

Characteristics Substernal or precordial. May spread
throughout chest. Painful, diability of shoulders
& hands may occur
Duration

>15minutes

Precipating
Events

Occurs spontanous but may follow

unstable angina

MSO4

Rest, nitro, 02
Relief
Measures
coronary

Successful reperfusion of blocked

arteries

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Assessment of Chest Pain -Pericarditis

Characteristics

Sharp, severe, stabbing substernal pain to the left

of sternum. May be felt in epigastrium, referred
pain to neck, arms, & back.

Duration

Intermittent

Precipating
Events

Sudden onset. Increased with inspiration,

swallowing, coughing, rotation of trunk

Relief
Measures

Assessment of Chest Pain -Pulmonary Pain

Characteristics

Arises from lower portion of pleura, referred to

costal margins on abdomen

Duration

30+minutes

Precipating
Events

Often spontaneous.
Occurs or increases with inspiration

Sitting upright
Meds-analgesic, anti-inflammatory

Relief
Measures

Assessment of Chest Pain -Esophageal pain

Assessment of Chest Pain -Anxiety

(Hiatal Hernia, Reflux Esophagitis or Spasm)

Characteristics Substernal. May project around chest to shoulders
Duration

5-60 minutes

Precipating
Events

Recumbent, cold liquids, exercise.

May be spontaneous.

Relief
Measures

Food, antacid. Nitro relieving spasms

Characteristics

Spain over left chest. Variable - does not radiate.

May c/o numbness, tingling of hands & mouth

Duration

2-3 minutes

Precipating
Events

Relief
Measures

Stress, emotional tachypnea

Assessment of Chest Pain -Cholecystitis

Characteristics

Epigastric.
May be substernal radiating to shoulders & back

Duration
Precipating
Events

Relief
Measures

30-60 minutes after eating

Rest
Treat underlying cause
Bronchodilators

Removal of stimulus. Relaxation

Assessment of Chest Pain -Pulmonary Embolism

Characteristics

Sharp, stabbing. Increase severity with deep

breath. May have difficulty breathing.

Duration

Sudden onset, short duration.

Precipating
Events

Relief
Measures

MSO4

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