An assessment of the cardiovascular system begins with questions about the patient’s family health history. Any history of heart disease in the patient’s family is important in understanding the patient’s health risks. Family history would include congenital heart disease,
angina,
myocardial infarction, elevated cholesterol levels (
dyslipidemia), high blood pressure, and strokes. Other diseases associated with heart problems include a family history of diabetes,
hypertension, and thyroid disease.
The patient’s health history should include questions about the presenting problem plus nonspecific symptoms. Ask the patient about what brought him to seek a healthcare provider and use follow-up questions to determine the timing of the symptom(s), alleviating factors, and how they affect the patient’s functioning. Nonspecific symptoms might include fatigue, cough (refer to Chapter 2), dizziness, palpitations, or problems with sleep including snoring and sleep apnea. Some common signs and symptoms of patients with cardiovascular disorders include the following:
To begin an examination of the cardiovascular system, have the patient disrobe. The examining room should be warm, well-lit,
and quiet. Start by assessing the skin and mucus membranes: color, lesions, ulcers, pigmentation changes, temperature, and hair distribution on the extremities. Patients with venous insufficiency may have brownish pigmentation or ulcers on the lower extremities. Those with arterial insufficiency may present with reddened, cool, or swollen extremities that are hairless. Check the nail beds for
clubbing, a symptom of central
cyanosis.
Pulses
Assess the adequacy of arterial
perfusion by palpating the peripheral pulses (see
Figure 6-1). The pulses that are palpable include the temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Using the pads of the index and middle fingers, gently palpate over the pulse and grade it on a scale of 0 to 4 (see the section on grading pulses). Too much pressure can obliterate the pulse during assessment. Assessing and grading the pulses allows the nurse to evaluate
perfusion by documenting the patient’s baseline status, monitoring changes in circulation, and comparing the corresponding pulses on the opposite side of the body. Compare findings with the medical record and document the present findings.
Sometimes the pulses are difficult to palpate, especially when there is arterial insufficiency of the lower extremities. A
Doppler ultrasound (DUS) may be used to listen for the presence of a pulse. The DUS apparatus has a special
stethoscope with a transducer and an audio unit. The transducer is applied to the skin, and ultrasound waves detect the movement of red blood cells in the blood vessels. The pressure wave of increased blood flow after the heart contracts is detectable by the transducer as a pulse. A water-soluble gel is used on the skin to enhance the transmission of the sounds. The pulse sites may be marked with a waterproof marker so that they are easier to locate during subsequent assessments.
With arterial insufficiency, the pulses may be weak or absent in the extremities.
Capillary filling may be slow (return to
normal color greater
than 1 second after tissue compression), and the affected extremity starts to blanch when elevated above the heart for 1 to 2 minutes. When patients have venous insufficiency of the extremities, the pulses are present but may be difficult to palpate due to peripheral edema.
Pulse Rate
Using the patient’s radial pulse on the wrist, count the pulsation for a full minute to get a sense of the heart rate and regularity. Use the finger pads of the middle fingers pressed lightly over the pulse. If the pulse is regular, count the pulsation for 30 seconds and multiply by 2 to get the 1-minute pulse rate. If the pulse is irregular, count the pulsation for a full minute.
The most accurate method for obtaining the heart rate, especially when the pulse is irregular, is by listening to the
apical pulse with a
stethoscope for a full minute (see Cardiac Assessment section later in this chapter.) An irregular heart rate can represent premature beats that might not be palpable peripherally at the radial pulse because left ventricular filling was incomplete prior to
systole. When a pulse is irregular, note the type of irregularity: regularly irregular (e.g., beat, beat, pause, beat, beat, pause), irregular with respiration (e.g., an increasing rate with
inspiration and decreasing rate with
expiration), or totally irregular. Alternately, take a radial and
apical pulse rate and note any discrepancies as they may vary with cardiac output.
Blood Pressure
The blood pressure is an important determinant of cardiovascular functioning. As the heart relaxes and contracts, it sends a pressure wave of blood through the circulatory system. The pressure wave produces the impulse detected as an arterial pulse and the
Korotkoff sounds that are heard when auscultating a blood pressure with a
stethoscope. Normally, the blood pressure is finely controlled by neural and hormonal influences that maintain adequate tissue
perfusion. Measuring the blood pressure can assess the adequacy of the circulation and the regulatory mechanisms.
Blood pressure can be measured either directly or indirectly. Direct measurement requires the insertion of a catheter into an artery (see
Figure 6-2). Indirect blood pressure readings are done with a blood pressure cuff and
auscultation of
Korotkoff sounds or Doppler reading of the pressure wave. Using a
sphygmomanometer (a blood pressure cuff attached to a manometer) and a
stethoscope, the blood pressure is usually taken on the upper arm. A mercury
sphygmomanometer aneroid instrument may be used to take a blood pressure (see
Table 6-1).
The blood pressure measurement should be taken on both arms. When
hypertension is suspected, the blood pressure should be repeated on three separate occasions. The patient should refrain from smoking cigarettes or drinking caffeine for 30 minutes before the blood pressure measurements. In patients with symptoms of dizziness and syncope, the blood pressure should be taken in the reclined, sitting, and standing positions to assess for
orthostatic hypotension. Changing from the reclined to the standing position does not normally change the
systolic pressure and may only slightly increase the
diastolic pressure. But a decrease in the systolic blood pressure of more than 20 mmHg when changing from the sitting to standing positions may indicate
orthostatic hypotension. Dehydration,
hypovolemia, and certain antihypertensive medications are common causes of
postural hypotension.
Blood pressure ranges for
normal and high blood pressure have been labeled by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure in the United States. Values for
normal and ab
normal blood pressures are seen in
Table 6-2.
Examination of the Chest
The examination of the chest allows assessment of the structure and functioning of the cardiovascular system as well as the respiratory system. To review, the landmarks for both cardiac and respiratory assessments are established by the anatomy of the
thorax: the
midsternal line, the
midclavicular line, the sternal notch, the midscapular line, the midaxillary line, and the
intercostal spaces between the ribs (see
Figure 6-3). Several key landmarks are used in cardiac assessment as they approximate the location of cardiac structures within the bony
thorax (see
Figure 6-4). These cardiac landmarks are used during
palpation of the chest wall and
auscultation of the heart.
Inspection
Start examining the patient by looking at the anterior chest while the patient is sitting. Take care to drape female patients as much as possible while allowing for adequate visualization of the
thorax. Notice any pulsation, retractions, or movements of the chest wall. Inspect the large vessels of the neck: the carotid arteries and jugular veins. Note their location and how high up the neck the pulsations are visible. The jugular veins may also be used to estimate the venous pressure and the pressure in the
right atrium of the heart. A noninvasive method of estimating venous pressure is to observe the jugular vein in the neck.
Assess the jugular venous distention using the following steps:
Position the patient in a supine position with the head of the bed at a 30° angle and turn the patient’s head slightly away from the side being inspected.
Use oblique lighting and observe the neck for the pulsation of the jugular vein on either side of the neck. It is usually above the sternal notch or just posterior to the sternocleidomastoid muscle.
Find the highest point up the neck where the jugular venous pulsation is visible.
Measure from the sternal angle (the connection of the second ribs to the
sternum and
manubrium) to this level using a vertical ruler and a horizontal reference point to the highest point of jugular venous pulsation (see
Figure 6-5).
Only gold members can continue reading.
Log In or
Register to continue
Related