Assessment of

Cardiovascular
System

Evelin Malinti, MSN

 Health History
• Chief Complaint
• Present Illness
• Past Health history
• Family Health history
• Personal and Social history

2
 Chief Complaint
• Patient’ interpretation of what prompted
him to seek medical care.
• The nurse should record it in the patient’
own words
• The most common cardiovascular
complaints are: chest pain, shortness of
breath; peripheral edema, weight gain,
abdominal distension; palpitation; fatigue;
diizziness. 3
 Chest Pain
• Chest pain: or discomfort, a symptom of
cardiac disease, can result from ischemic
heart disease, pericarditis and aortic
dissection.
• Chest pain: can also be due to non-
cardiac causes; pleurisy, pulmonary
embolus, hiatal hernia and anxiety
musculoskeletal strain, GERD
 Chest Pain
• Palliative/Provocative
• Quality and Quantity: How does it feel? (heavy,
tight, burning/ deep or superficial). Pain scale
• Radiation: Exact Location and radiation
• Severity: Associated phenomena
• Time: sudden or gradual, comes and goes or
present at all time

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 Assessment: Subjective
• Paroxysmal Nocturnal Dyspnea – client
has been recumbent for several hours,
increase in venous return leads to
pulmonary congestion.
• Fatigue- resulting from decreased cardiac
output is usually worse in evening. Ask pt.
if they can perform same activities as a
year ago
 Assessment: Subjective
• Palpitations- fluttering or unpleasant
awareness of heartbeat. Non- cardiac-
causes- fatigue, caffeine, nicotine, alcohol
• Weight gain- a sudden increase in wt. of
2.2 pounds (1 kg) can be result of
accumulation of fluid (1L) in interstitial
spaces, known as edema.
• Syncope- transient loss of consciousness,
decrease in perfusion to brain.
 Past History

• Childhood diseases and

Immunizations
• Medical & Surgical History
• Medications
• Allergies

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 Family Health History
• Seek information on age,
health, and cause of
death of the pt’s
grandparents, parents,
and siblings.
• Tobacco & Smoking habits
• Familial hypercholesterolemia
• Hypertrophic cardiomyopathy 9
 Health History
Personal &Social History
• Biographic data
• Diet history: 24 hr. sample diet
Opportunity for teaching food selection
and preparation
• Socioeconomic status – ability to
purchase proper foods, medicines.
Employment and its effects on health?
• Cigarette smoking : # packs /day and
also # years smoked PACK YEARS
 Assessment: Subjective
• Physical Activity/Inactivity – 30 minutes
daily of moderate exercise recommended
on most days
• Obesity – associated with HTN,
hyperlipidemia, and diabetes and all
contribute to CV disease.
• Type A personality – not conclusive proof
 Physical Assessment
• Inspection
• Palpation
• Percussion
• Auscultation
Technique for Cardiovascular Exam
 Before beginning, if possible:
› Quiet environment
› Proper positioning (patient sitting for posterior
thorax exam, supine for anterior thorax exam)
› Expose skin for auscultation
› Patient comfort, warm hands and diaphragm of
stethoscope, be considerate of women (drape sheet
to cover chest)
 After that the nurse should apply the four techniques;
Inspection, Palpation, Percussion and Auscultation
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INSPECTION:
 Eyes

• The presence of
yellowish plaques on
the eyelids
(xanthelasma) could
indicate
hyperlipoproteinemia, a
risk factor for
hypertension as well as
arteriolosclerosis.
Chest

• Observe the chest for

overall torso contour.
• Do you see pectus
excavatum (caved-in
chest)?
• Do you see pectus
carinatum (pigeon
chest)?
 Skin
• Clubbing
The presence of clubbing
(broadening of the
extremities of the digits,
accompanied by nails
which are abnormally
curved and shiny)
indicates chronic poor
oxygen perfusion to the
distal tissues of the hand
and feet.
Cyanosis

• The presence of
cyanosis (bluish
colour) also
denotes chronic
poor oxygen
delivery to the
peripheral tissues
of the hands and
feet.
 Xanthomas

• The presence of
yellowish plaques
under the skin (non-
eruptive) excoriated
through the skin
(eruptive) could
indicate
hyperlipoproteinemia,
a risk factor for
hypertension as well
as arteriolosclerosis.
 Edema

• The presence of edema (tissue

swelling) can be caused by several
factors, although most commonly is
associated with decreased cardiac
function leading to decreased capillary
flow.
• 1+- Mild pitting, slight indentation.
• 2+- Moderate pitting- indentation subsides
rapidly.
• 3+- Deep pitting, indentation remains short
time, leg looks swollen.
• 4+- Very deep pitting, very swollen.
•
 Palpation

• Use the palm of your hand to feel the

chest wall for the "Point of Maximal
Impulse" (PMI), which is usually
found at the apex of the heart. This
apical pulse is generally located in
the 5th intercostal space, about 7-9
cm (the width of your palm) to the left
of the midline.
• Palpate the peripheral arteries. These include
the brachial, radial, femoral, popliteal, dorsalis
pedis, and posterior tibial. Note the contour and
amplitude of each pulsation. These should feel
similar bilaterally.
• 0= nonpalpable
• 1+ = easily obliterated
• 2+ = weak, but cannot be obliterated
• 3+ = easy to palpate; full; cannot be obliterated.
• 4+ = strong, bounding; may be abnormal
Palpate Skin & Capillary refill
test
 Chest percussion:
• Normally only the left border of heart
can be detected by percussion. It
extends from the sternum to mid
clavicular line in the third to fifth inter
costal space. The right border lies
under the right margin of the sternum
and is not detectable. Enlargement of
the heart too either the left or right
usually can be noted.
Auscultation:
S1
• S1, the “lub” of the “lub-dub,” is
produced by the closure of tricuspid and
mitral valves. Loudest in apical area
• S1 is accentuated in exercise, anemia,
hyperthyroidism, and mitral stenosis.
• S1 is diminished in first degree heart
block.
• S1 split is most audible in tricuspid area
(T-lub-dub)
 S2
• S2, the “dub” of the “lub-dub,” is
produced by the closure of aortic &
pulmonic valves.
• Normal physiological splitting of S2 is
best heard at pulmonic area. It occurs
on inspiration(“lub-T-dub, lub-dub”).
• Splitting of S2 can indicate pulmonic
stenosis, atrial septal defect, right
ventricular failure, and left bundle
branch block
S3
• S3 is also known as a ventricular
gallop (“lub-DUB-ta”). S3 is heard in
early diastole. It is normal in
pregnancy, children, adults less than
thirty years old, during exercise,
anxiety, or anemia.
• It is heard best at the apex in the left
lateral decubitus position, using the
bell. Pathologic S3 occurs in people
over the age of 40, usually due to
myocardial failure.
left lateral decubitus position
 S4

• S4 is also known as an atrial

gallop (“ta-lub-DUB”). It is typically
heard in late diastole before S1. It
results when ventricular resistance
to atrial filling is increased from
either decreased ventricular
compliance or increased
ventricular volume

* Search for: Summation Gallop, Opening Snap, Ejection Click,

 Pericardial Friction Rub
• A pericardial friction rub is usually
heard best and is sometimes palpable
over the tricuspid and xyphoid areas. It
occurs when inflamed pericardial
surfaces rub together
 Murmurs
• A murmur is an abnormal heart
sound caused by turbulent blood
flow. The sound may indicate that
blood is flowing through a
damaged or overworked heart
valve, that there may be a hole in
one of the heart's walls, or that
there is a narrowing in one of the
heart's vessels
• Some heart murmurs are a harmless
type called innocent heart murmurs
which are common in children and
usually do not require treatment
• Auscultation:
• Carotid arteries in older adults;
Use bell of stethoscope
Blood Pressure
BP Classification for Adult
Jugular Vein
Distension
Obvious distention of the veins
with the patient’s head elevated
45 to 90 degrees indicates an
abnormal increase in the volume
of the venous system.
This occurs with right
ventricular failure, pulmonary
hypertension, and pulmonary
stenosis; less commonly with
obstruction of blood flow in
the superior vena cava; and
rarely with acute massive
pulmonary
embolism.
 Allen Test
• Allen test- occlude radial & ulnar arteries,
pt. opens and closed fist, hand should
blanch. Then let go of ulnar artery quickly
while you are occluding radial artery; if
hand turns pink, ulnar is intact.
 Doppler Assessment
• Position client supine
• Externally rotate leg
• Apply conducting gel
• Place transducer over
pulse site
• 45 degree angle with
light pressure
• Listen for whooshing
sound
 DIAGNOSTIC TEST
• Laboratory Test
• Chest X-Ray & Fluoroscopy
• Electrocardiography
• Cardiac Stress Testing
• Echocardiography
• Radionuclide Imaging
• Cardiac Catheterization
• Electro physiologic Testing
• Hemodynamic Monitoring
 Diagnostic Cont’
• Laboratory Test
a.Cardiac Biomarker analysis
- CK, CK-MB, proteins (myoglobin,
troponin T, troponin I)
- Released from necrotic myocardial cells
to interstitial lymphatic system
Systemic circulation
 Lab cont’
b. Blood chemistry, Hematologic, & Coagulation
study
- Lipid profile (Cholesterol, lipoprotein, trygliceride)
- Ions (Sodium, Potassium, Calsium, Magnesium)
- BUN & Creatinine
- Glucose & Glycohemoglobin (HbA1c)
- Thromboplastin & prothrombin
- Complete Blood Counts (CBC)
c. Brain (type-B) Natriuretic Peptide
- Neurohormone that helps regulate BP & fluid
volume
- BNP > 100 pg/mL suggestive HF
d. C-Reactive Protein (CRP)
- A protein produced by the liver in response to
systemic inflammation. Inflammation is thought
to play a role in the development and
progression of atherosclerosis
• Homocysteine
- Homocysteine, an amino acid, is linked to
the development of atherosclerosis
because it can damage the endothelial
lining of arteries and promote thrombus
formation.
- ↑ Homocysteine, ↑ risk for CAD, stroke,
peripheral vascular diseases
 Chest X-Ray & Fluoroscopy
• A chest x-ray is obtained to determine the size,
contour, and position of the heart. It reveals cardiac
and pericardial calcifications and demonstrates
physiologic alterations in the pulmonary circulation.
• Fluoroscopy is an x-ray imaging technique that allows
visualization of the heart on a screen. It shows cardiac
and vascular pulsations and unusual cardiac contours.
 Electrocardiography
• The ECG is a graphic representation of
the electrical currents of the heart. The
ECG is obtained by placing disposable
electrodes in standard positions on the
skin of the chest wall and extremities
 Electrode placement
• V1 4th Intercostal space to the right of the sternum
• V2 4th Intercostal space to the left of the sternum
• V3 Midway between V2 and V4
• V4 5th Intercostal space at the midclavicular line
• V5 Anterior axillary line at the same level as V4
• V6 Midaxillary line at the same level as V4 and V5
• RL Anywhere above the ankle and below the torso
• RA Anywhere between the shoulder and the elbow
• LL Anywhere above the ankle and below the torso
• LA Anywhere between the shoulder and the elbow
• Normal EKG tracings
consist of waveform
components that indicate
electrical events during
one heart beat. These
waveforms are labeled P,
Q, R, S, T and U. The
following descriptions are
with respect to Lead II.
 ECG Interpretation
• ECG interpretation should be performed
using a standard procedure. For this
course, we are using an eight step
procedure:
- Rhythm - QRS Interval
- Rate - T Wave
- P Wave - QT Interval
- PR Interval - ST Segment
Rhythm
 Heart Rate

• Our first method is simple. Count the

number of QRS complexes over a 6
second interval. Multiply by 10 to
determine heart rate. This method works
well for both regular and irregular rhythms.
• The second method uses
small boxes. Count the
number of large boxes
for a typical R-R interval.
Divide this number into
300 to determine heart
rate.
• Or small boxes, divided
into 1500
Continuous Electrocardiographic
Monitoring
• Hardwire Cardiac Monitoring
• Ambulatory Electrocardiography
• Transtelephonic Monitoring
• Wireless Mobile Cardiac
Monitoring Systems
 Cardiac Stress Testing
• Exercise Stress Testing (Treadmil)
• Pharmacologic Stress Testing

Nursing Intervention:
- Instruct pt not to eat or drink for at least 4
hours
- Wear suitable clothes & shoes for exercise
- Inform pt about the procedure
 Assignment
• Buat ringkasan tentang prosedur berikut
dengan Nursing Implicationnya
1. Echocardiography
2. Radionuclide Imaging
3. Cardiac Catheterization
4. Electrophysiology Testing
5. Hemodinamic Monitoring
6. Angiography