As a nurse, you know that cardiovascular health is essential in providing healthcare to your patients. Knowing this, it is vital to understand the pathophysiology and signs and symptoms of any cardiopulmonary diseases or conditions the patient may have and how to assess their needs accurately.
With a thorough cardiovascular assessment, nurses can diagnose disorders quickly and develop treatment plans for successful outcomes. In this blog post, we’ll discuss why cardiac evaluation should be conducted on all patients, what test results you need to pay special attention to during your examinations, and tips for efficient downstream management of cardiopulmonary concerns.. Keep reading to learn more.
Table of Contents
What is the Cardiovascular System?
The cardiovascular system is the body’s system of organs and vessels that make up the cardiopulmonary system. It comprises the heart, blood vessels, and lungs. The heart pumps oxygen-rich blood to all body parts through a complex network of arteries and veins, helping cells receive the energy they need to function correctly. Before assessing a patient’s cardiovascular system, it is essential to understand the various functions of the cardiovascular system.
Functions of the Cardiovascular System
- The heart pumps oxygen-rich and nutrient-filled blood throughout the body.
- Blood carries waste products away from cells and tissues in the body.
- The lungs take in oxygen and expel carbon dioxide.
- Blood vessels distribute nutrients, hormones, and other substances to various organs in the body.
- Kidneys filter blood to remove toxins from the body.
How Does the Blood Circulatory System Work?
- The heart is a muscular organ that pumps oxygen-rich blood through the body.
- It contains four chambers – two upper atria and two lower ventricles – that fill with blood and contract to pump it out of the heart.
- Blood enters the heart from veins, passes through the right side, travels to the lungs to pick up oxygen, and then returns to the left.
- The left side of the heart pumps oxygen-rich blood out to the body through arteries.
- Blood is distributed throughout the body via smaller arteries called arterioles, which can dilate or constrict depending on the needs of individual organs.
- The nervous system regulates blood flow to ensure cells receive enough oxygen and nutrients.
- Veins return deoxygenated blood to the heart, which is pumped out again.
Why do Nurses Need to Assess the Cardiovascular System?
Cardiovascular assessment is essential for nurses, as it allows them to understand the patient’s current health status and determine any signs or symptoms that may indicate a cardiovascular disorder. By detecting potential problems early, nurses can help patients manage their conditions more effectively before they worsen. Furthermore, nursing assessments also allow practitioners to monitor progress, adjust medications if necessary, and refer patients to specialists as needed.
What is a Cardiovascular Assessment in Nursing?
When assessing the cardiovascular system, nurses should focus on three primary goals. First, they must identify any abnormalities or problems in the heart and vasculature that can indicate a cardiac disorder. Second, nurses must determine if there are any risk factors for developing cardiovascular diseases, such as smoking, high cholesterol levels, poor diet, or lack of exercise. Lastly, during the assessment, nurses must assess the patient’s lifestyle and medication history to determine any potential contributing factors that must be addressed.
What Tests are Conducted during a Cardiovascular Assessment?
To accurately assess the cardiovascular system, nurses can use a variety of physical exam techniques as well as diagnostic tests such as electrocardiograms (ECGs), echocardiograms (echo), and stress tests. Nurses may also order laboratory tests such as troponin, natriuretic peptide, and creatine kinase levels to measure cardiac biomarkers.
What are the Components of a Cardiovascular Assessment?
When conducting a cardiovascular assessment, nurses should focus on evaluating heart rate and rhythm; blood pressure; respiratory rate and effort; chest pain or palpitations; peripheral pulses including carotid, radial, and femoral arteries; abdomen for bruits and other signs of cardiovascular abnormalities; skin for pallor, cyanosis or rash; and any extremity edema.
In addition to these physical examination components, nurses should consider obtaining a 12-lead electrocardiogram (ECG) in all patients presenting with chest pain or palpitations. An ECG can provide valuable information about the patient’s heart rhythm and underlying arrhythmias. In some cases, further tests such as echocardiography or stress testing may be required to confirm a diagnosis.
Cardiac Assessment Nursing: Step By Step
Assessing the cardiovascular system includes performing several subjective and objective assessments. At times, assessment findings are modified according to lifespan considerations.
The subjective evaluation of the cardiovascular and peripheral vascular systems is critical in detecting any possible signs of dysfunction. To complete the assessment, a nurse usually begins with a focused interview that explores the previous medical history, family health, medications, cardiac risk factors and reported symptoms.
Some common signs associated with these systems include:
- chest pain
- peripheral edema
- sudden weight gain
- dyspnea (shortness of breath)
- an irregular pulse rate or rhythm
- dizziness and poor peripheral circulation.
Documenting and reporting any new or worsening symptoms to the relevant healthcare provider is essential.
The Blow Table outlines questions to assess symptoms related to the cardiovascular and peripheral vascular systems. This Table summarizes questions to determine medical history, medications, and risk factors associated with the cardiovascular system. Information obtained from the interview process is used to tailor future patient education by the nurse.
Table- A Interview Questions for Cardiovascular and Peripheral Vascular Systems
|Have you had any pain or pressure in your chest, neck, or arm?
|Safety Note: If findings indicate 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 911.
|Do you have swelling in your legs, feet, or ankles?
|Measure the circumference of affected areas.
|Sudden Weight Gain
|Have you had significant weight gain within the last few months?
|Weigh the patient and compare to previous weight.
|Have you been having difficulty breathing recently?
|Note activity level when symptoms occur.
|Do you feel like your heart is skipping beats, racing, or fluttering?
|Palpate peripheral pulses for rate and rhythm.
|Poor Peripheral Circulation
|Do you feel like your hands and feet are cold or numb?
|Note the color of the skin. Measure the temperature of affected areas.
|Do you ever feel like your heart is skipping beats, racing, or fluttering?
|Palpate peripheral pulses for rate and rhythm.
|Do you have any pain or discomfort in your calves?
|Measure the circumference of the affected area.
|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?
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?
|Are you taking medications, including prescription or over-the-counter drugs, to treat your heart condition?
|Do you smoke cigarettes? Are you overweight/obese? Do you consume alcohol in excess? Do you have a family history of heart disease?
The physical assessment of the cardiovascular system includes:
- Evaluate Vital Signs
- Life Span Considerations
- Lung Examination
- Abdominal and Extremity Examination
Equipment needed for a cardiovascular assessment includes:
- a stethoscope
- centimeter ruler or tape measure
1. Evaluate Vital Signs
Interpret the blood pressure and pulse readings to confirm that the patient is stable before moving forward with the physical exam. Assess their level of consciousness; they should be aware and willing to participate in the process. Evaluate these readings to ensure the patient is healthy and balanced before continuing with the physical examination.
Vital signs include
- Blood pressure
- Heart rate and rhythm
- Respiratory rate
The average blood pressure is 120/80 mmHg. Low or high readings are considered indications of possible CVS dysfunction. Measuring blood pressure is an essential aspect of any medical examination.
- Normal blood pressure: 120/80 or lower
- Prehypertension: Systolic between 120-139, diastolic between 80-89
- Hypertension: systolic over 140, diastolic over 90
Measuring blood pressure in both arms and legs is crucial for suspected congenital cardiac or peripheral vascular disorders. The cuff used for this measurement should encircle 80% of the limb’s circumference, and its width should be 40% of the circumference.
When auscultating for blood pressure, the first sound heard is systolic pressure, while the disappearance of sound indicates diastolic pressure. The Pressure differential between the arms is standard Up to 15 mm Hg, but more significant differences may suggest vascular abnormalities. Additionally, leg pressure is typically 20 mm Hg higher than arm pressure.
While automated devices have simplified blood pressure measurements, we must remember that it is essential to ensure the accuracy of these measurements for proper diagnosis and treatment.
- Sit in a chair (not on the examination table) for > 5 minutes, feet on the floor, back supported.
- Ensure the measured limb is at heart level and no clothing covers the cuff placement area.
- Before the measurement, abstain from exercising, consuming caffeine, or smoking for at least 30 minutes.
Heart rate and rhythm
The heart rate and rhythm should be assessed to determine if any abnormalities exist. An average resting heart rate is 60-100 beats per minute. The rhythm should be regular, with no extra beats or pauses. The pace and rhythm can vary depending on the patient’s age, activity level, and overall health.
Respirations should be assessed to ensure proper oxygenation of the blood. The regular respiratory rate for adults is between 12-20 breaths per minute when resting, with an inhale/exhale ratio of 1:2. Respiration can affect heart rate, so it is essential to confirm that the patient’s respiration is within normal range before assessing the heart rate.
Body temperature should be measured to detect any fever or other abnormal readings. The average body temperature is 36°C (98°F). A temperature > 38.3°C (101°F) may indicate an infection or other underlying condition. It is important to note that body temperature can vary depending on measurement location and activity level.
- Skin color to assess perfusion. Inspect the face, lips, and fingertips for signs of cyanosis or pallor. Cyanosis is a bluish discoloration of the skin which indicates an insufficient amount of blood perfusion and oxygenation. Pallor (paleness) may be observed in the skin or mucous membranes due to reduced blood flow, oxygenation, or fewer red blood cells. People with lighter skin tones should appear pink, while those with a darker complexion may show pallor on the palms, conjunctiva, or inner part of the lower lip.
- Jugular Vein Distension (JVD). Inspect the neck for Jugular Vein Distention (JVD), which is visible as a bulge on the right side when the pressure in the superior vena cava increases. This should not be present when standing or when the head of the bed is positioned at an angle between 30-45 degrees.
- Precordium for abnormalities. Look for any visible pulsations that may indicate an underlying cardiac problem. A heave or thrill is a palpable outward movement of the precordium when the ventricle contracts and is usually indicative of a structural heart defect. A thrill may be felt over the base, apex of the heart, or in a region between them.
- Upper Extremities: Inspect the arms for signs of peripheral vascular disease, such as pallor, cyanosis, edema, or temperature difference between limbs. Examine the presence of bruits along the course of vessels which may indicate an arterial occlusion.
- Lower Extremities: Observe the lower extremities for any signs of peripheral vascular disease (e.g., pallor, edema, ulcers), as well as any evidence of pedal pulses and their symmetry.
- Edema: Edema can be assessed by gently pressing a finger against the skin and noting whether an indentation remains after releasing pressure. Mild edema is not visible but can be detected by light palpation. Moderate edema creates a shallow dimple in the skin, while severe edema is more easily seen, forming a deep indentation.
- Deep Vein Thrombosis (DVT): Deep vein thrombosis can be identified by inspecting the affected leg for tenderness, swelling, redness, warmth, and an area of induration. If there is a palpable cord along the course of veins, this could indicate venous thrombosis.
Auscultate the heart sounds with a stethoscope. Listen for any murmurs, which could indicate an underlying structural defect or valvular issue. A normal heart will make two distinct ‘lub-dub’ sounds as the atria and ventricles contract and relax.
Auscultation begins at the aortic area on the sternum’s upper right side. Using the stethoscope’s diaphragm, carefully listen for both S1 and S2 sounds, which produce a “lub-dub” sound. While assessing this area, it is essential to note that S2 (the “dub”) will be louder than S1 (the “lub”).
Follow this same process when listening over the pulmonic area, Erb’s point, and tricuspid area. When examining female patients, you may ask them to lift their breast tissue so that the stethoscope can be placed directly on the chest wall.
The apical pulse should be counted over 60 seconds, with a heart rate between 60 and 100 to be considered normal. Evaluation of this pulse is essential before administering many cardiac medications.
The first heart sound (S1) marks the beginning of systole, which is when the atrioventricular (AV) valves (mitral and tricuspid) close and the ventricles contract to pump blood out of the heart. The second heart sound (S2) signifies the end of systole and the start of diastole, when the semilunar valves shut, allowing AV valves to open and fill ventricles with blood. S1 directly corresponds with a palpable pulse.
When listening to one’s heartbeat, it is essential to determine both S1 (“lub”) and S2 (“dub”), along with noting rate and rhythm while being aware of abnormal heart sounds.
Extra Heart Sounds
Listen for any extra heart sounds, such as S3 or S4, indicating a pathology. S3 (third sound) is caused by turbulence in the ventricles during diastole due to rapid filling of the ventricles and is usually heard when the pressure in the left ventricle reaches its peak. An S4 (fourth sound) occurs near the end of diastole and is caused by forceful atrial contraction against closed AV valves. This sound is indicative of decreased ventricular compliance.
Listen for any carotid sounds which occur when the carotid artery or its branches narrow due to plaque formation. The patient should recline back with their neck slightly extended while you listen for these sounds using the diaphragm of your stethoscope on both sides of the neck, checking for any changes in intensity or pitch between them.
Inspect and palpate pulses on both upper and lower extremities, assessing rate, rhythm, and strength. A normal pulse should be regular and symmetrical between sides (rate between 60-100 bpm).
The pulse quality is evaluated on a scale from 0 to 3, with 0 representing an absent pulse, 1 indicating decreased pulses, 2 denoting normal range, and 3 signifying increased (or “bounding”) pulses. If palpation is not possible, additional assessment is required. First off, establish if it is a new or existing condition. If accessible, utilize a Doppler ultrasound to check for the presence or absence of the pulse. Several organizations make use of Doppler ultrasound to document non-palpable pulses. If no pulse can be located, this could indicate an emergency, necessitating instant follow-up and informing the provider.
Check the capillary refill time (CRT) by pressing your finger over a nail bed until it becomes white. Release pressure and count the number of seconds for the color to return. An ordinary CRT is two seconds or less, with a more extended response indicating decreased circulation.
Jugular Venous Pressure
Evaluate jugular venous pressure (JVP) by looking for visible pulsations in the neck veins, most notably at the jaw and sternal notch angle. The JVP should be lower when standing or when the head of the bed is positioned at an angle between 30-45 degrees. Increased JVP can indicate right ventricular failure and other cardiac disorders, such as tricuspid regurgitation when lying flat.
Auscultation of the lungs should also be performed, noting any abnormal sounds or rales that could suggest chronic conditions such as asthma or congestive heart failure.
Edema occurs when one can see swelling in a particular area due to the pooling of fluids. To detect edema, gently press a finger against the skin and note whether an indentation remains after releasing pressure. Mild edema is not visible but can be detected by light palpation. Moderate edema creates a shallow dimple in the skin, while severe edema is more easily seen, forming a deep indentation.
The presence or absence of pitting edema can provide critical information about underlying medical issues such as congestive heart failure or kidney disease. It should be noted during one’s physical examination.
Note –The depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original post are graded on a scale from 1 to 4.
- Grade-1: 0-2mm indentation rebounds immediately
- Grade-2: 2-4mm indentation rebounds in less than 15 seconds
- Grade-3: 4-6mm indentation rebounds in less than 30 seconds
- Grade-4: 6+ mm indentation rebounds in more than 20 seconds.
Heaves or Thrills
A thrill is a palpable vibration that can be felt when placing the hands on either side of the sternum, suggesting an increased blood flow to the heart. It can indicate pathologies, such as ventricular hypertrophy or valvular disease. A heave is a pulsation that can be felt in areas of high pressure, such as around the liver, indicating right-sided heart failure.
5. Life Span Considerations:
The cardiovascular assessment and expected findings should be modified according to common variations across the lifespan.
Infants And Children
When assessing a child’s cardiovascular system, paying attention to their apical pulse rate is essential. This rate varies depending on age group, and the Table below outlines the expected rate for each age bracket. In newborns, a murmur may be heard in the first few days of life until the closure of the ductus arteriosus. After adolescence, it is possible to assess a radial pulse as well.
|Newborn (0 to 1 month)
|Infant (1 to 12 months)
|Toddler (1 to 3 years)
|Preschool (3 to 5 years)
|School Age (6 to 12 years)
|Adolescents (13 to 18 years)
In adults over 65, irregular heart rhythms or extra sounds are more likely. If a new finding is an “irregularly irregular” rhythm, it may indicate atrial fibrillation, and further investigation is necessary. To learn more about this condition, please see the hyperlink below.
6. Lung Examination
The lungs should also be examined as part of the cardiovascular assessment. This can include percussion, palpation, and auscultation.
Percussion: To assess the lungs for abnormalities, tap on the chest wall with your fingertips in a rhythmic pattern. Listen for dull, flat, or resonant tones and note any changes that may indicate consolidation of an area.
Palpation: Place the palms of your hands lightly over the chest wall to feel for any vibration that might be present. This tactile fremitus can provide insight into underlying inflammation or fluid accumulation.
Auscultation: Use your stethoscope to listen and identify sounds while the patient takes deep breaths. Breath sounds should be precise, symmetrical, and equal bilaterally without adventitious (abnormal) breath sounds such as crackles or wheezing, which could suggest lung pathology.
7. Abdominal and Extremity Examination:
The abdomen and extremities should also be examined for signs of edema or tenderness. Palpate the abdomen to identify areas of tenderness or masses that may indicate underlying pathology, such as an abdominal aortic aneurysm or other vascular issues.
Assess the peripheral pulses, noting any irregularities or decreased perfusion with a Doppler ultrasound if necessary. Inspect the skin on both upper and lower limbs for color changes, lesions, swelling, or other abnormalities that could signal vascular issues.
Following these various assessments is a subjective summary with comments regarding the findings and possible implications. This can help inform further investigation and treatment decisions by providing pertinent information about cardiovascular health. A well-rounded cardiovascular assessment should include all the above components to understand the patient’s health clearly.
Any healthcare provider needs to comprehensively understand the cardiovascular system to diagnose and treat various conditions accurately. A thorough physical examination can provide valuable insight into an individual’s cardiovascular health and can help lead to successful treatment plans. By paying attention to vital assessments such as capillary refill time, jugular venous pressure, edema, heaves or thrills, life span considerations, lung examination, and abdominal and extremity exam, healthcare professionals are better able to understand their patient’s condition and proceed with appropriate medical interventions.
Therefore, healthcare providers must perform an accurate cardiovascular assessment to provide the best care possible. By using the abovementioned techniques, professionals can gain insight into their patient’s condition and deliver quality medical care.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.