DETERMINE	TYPICAL QUESTION
Location, radiation	Where is it?
	Does it move or stay in one place?
Quality	What is it like?
Quantity	How severe is it? How frequent?
	How long does it last?
Chronology	When did it begin?
	How has it progressed?
	What are you doing when it occurs?
	What do you do to get rid of it?
Associated findings	Do you feel any other symptoms at the same time?
Treatment sought and effect	Have you seen a physician in the past for this same problem?
	What was the treatment?
Personal	What do you think this is from?
Perception	Why do you think it happened now?

• Little correlation may exist between the severity of chest discomfort and the gravity of its cause. This is a result of the subjective nature of pain and the unique presentation of ischemic disease in women, older patients, and individuals with diabetes.

• Subjective descriptors vary greatly among individuals. Not all patients use the word “pain”; some may describe their problem as “pressure,” heaviness,” discomfort,” or “indigestion.”

• A correlation is not always present between the location of chest discomfort and its source because of referred pain. For example, in patients with gastroesophageal reflux disease (GERD), esophageal spasm can cause visceral substernal chest pain that radiates to the left arm and jaw and may be described by patients as “heartburn.”²

• Other nonpainful symptoms that may signal cardiac dysfunction are dyspnea, palpitations, cough, fatigue, edema, ischemic leg pain, nocturia, syncope, and cyanosis.

In a meta-analysis of the evaluation of stable, intermittent chest pain, a patient’s description of chest pain was found to be the most important predictor of underlying coronary disease.³ In the evaluation of acute chest pain, the 12-lead electrocardiogram (ECG) was the most useful bedside predictor for a diagnosis of ST-elevation myocardial infarction (STEMI).³

Physical Examination

A comprehensive physical assessment is fundamental to arriving at an accurate diagnosis. The nurse who has developed the skills of inspection, palpation, and auscultation can be confident when assessing patients with cardiovascular disease. Percussion, however, is not employed when assessing the cardiovascular system.

Inspection

The nail beds are inspected for signs of discoloration or cyanosis.⁴ Clubbing in the nail bed is a sign associated with long-standing central cyanotic heart disease or pulmonary disease with hypoxemia.^4,5 “Clubbing” of the nail refers to a nail that has lost the normal angle between the finger and the nail root; the nail becomes wide and convex. The terminal phalanx of the finger also becomes bulbous and swollen.⁶ Clubbing is rare and is a sign of severe central cyanosis (Fig. 13-1). Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output (CO). Clubbing never occurs as a result of peripheral cyanosis.

Lower Extremities

Legs are inspected for signs of peripheral arterial or venous vascular disease. The visible signs of peripheral arterial vascular disease include pale, shiny legs with sparse hair growth. Recent guidelines indicate that many individuals, especially women, can have peripheral atherosclerosis without obvious signs or symptoms.⁷ Venous disease causes edema of the limb, with deep red rubor, brown discoloration, and, frequently, leg ulceration. A comparison of typical assessment findings in arterial and venous diseases is presented in Table 13-2.

TABLE 13-2

INSPECTION AND PALPATION OF EXTREMITIES: COMPARISON OF ARTERIAL AND VENOUS DISEASE

CHARACTERISTIC	ARTERIAL DISEASE	VENOUS DISEASE
Hair loss	Present	Absent
Skin texture	Thin, shiny, dry	Flaking, stasis, dermatitis, mottled
Ulceration	Located at pressure points; painful, pale, dry with little drainage; well-demarcated with eschar or dried; surrounded by fibrous tissue; granulation tissue scant and pale	Usually at the ankle; painless, pink, moist with large amount of drainage; irregular, dry, and scaly; surrounded by dermatitis; granulation tissue healthy
Skin color	Elevational pallor, dependent rubor	Brown patches, rubor, mottled cyanotic color when dependent
Nails	Thick, brittle	Normal
Varicose veins	Absent	Present
Temperature	Cool	Warm
Capillary refill	Greater than 3 seconds	Less than 3 seconds
Edema	None or mild, usually unilateral	Usually present foot to calf, unilateral or bilateral
Pulses	Weak or absent (0 to 1+)	Normal, strong, and symmetric

Modified from Krenzer ME. Peripheral vascular assessment: finding your way through arteries and veins. AACN Clin Issues. 1995;6(4):631.

Posture

Body posture can indicate the amount of effort it takes to breathe. For example, sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning forward may be the least painful position for the patient with pericarditis.

The jugular veins of the neck are inspected for a noninvasive estimate of intravascular volume and pressure. The internal jugular veins are observed for jugular vein distention (JVD) (Fig. 13-2; Box 13-2). JVD is caused by an elevation in central venous pressure (CVP). This occurs with fluid volume overload, right ventricular dysfunction, pericardial effusion, or any condition that elevates right atrial pressure.^9,10 The right internal jugular vein can be palpated for measurement of CVP in centimeters of water (Fig. 13-3; Box 13-3). Bedside ultrasound is also used to evaluate JVD and estimate CVP.¹¹

Box 13-2 Procedure for Assessing Jugular Vein Distention

1. Patient reclines at a 30- to 45-degree angle.

2. The examiner stands on the patient’s right side and turns the patient’s head slightly toward the left.

3. If the jugular vein is not visible, light finger pressure is applied across the sternocleidomastoid muscle just above and parallel to the clavicle. This pressure fills the external jugular vein by obstructing flow (see Fig. 13-2).

4. After the location of the vein has been identified, the pressure is released, and the presence of jugular vein distention (JVD) is assessed.

5. Because inhalation decreases venous pressure, JVD should be assessed at end-exhalation.

6. Any fullness in the vein extending more than 3 cm above the sternal angle is evidence of increased venous pressure. Generally, the higher the sitting angle of the patient when JVD is visualized, the higher is the central venous pressure.

7. Documentation: JVD is reported by including the angle of the head of the bed at the time JVD was evaluated (e.g., “Presence of JVD with the head of the bed elevated to 45 degrees”).

Box 13-3 Procedure for Assessing Central Venous Pressure

1. The patient reclines in the bed. The highest point of pulsation in the internal jugular vein is observed during exhalation.

2. The vertical distance between this pulsation (top of the fluid level) and the sternal angle is estimated or measured in centimeters.

3. This number is then added to 5 cm for an estimation of central venous pressure (CVP). The 5 cm is the approximate distance of the sternal angle above the level of the right atrium (see Fig. 13-3).

4. Documentation: The degree of elevation of the patient is included in the report (e.g., “CVP estimated at 13 cm, using internal jugular vein pulsation, with the head of the bed elevated 45 degrees”).

Abdominojugular Reflux

The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. This noninvasive test is used in conjunction with measurement of JVD. The procedure for assessing abdominojugular reflux is described in Box 13-4. A positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP equivalent) of 4 cm or more sustained for at least 15 seconds.¹²

Box 13-4 Procedure for Assessing Abdominojugular Reflux

1. Ask the patient to relax and breathe normally through an open mouth.

2. Measure the jugular vein distention (JVD) in the patient’s right internal jugular vein, following the procedure described in Box 13-2.

3. Apply firm pressure of approximately 20 to 35 mm Hg to the patient’s midabdomen for 15 to 30 seconds, and remeasure the JVD during the compression.

4. Measure the right JVD a third time after the compression is released.

5. Ask the patient not to tense or hold the breath during the test. (Doing so increases venous return to the heart and may produce a falsely positive result.)

6. A positive abdominojugular reflux is identified when abdominal compression causes a sustained JVD increase of 4 cm or more. This sign is indicative of right-sided heart failure.

7. A normal abdominojugular reflux is reported if there is no rise in JVD, a transient (<10 seconds) rise in JVD, or a rise in JVD less than or equal to 3 cm sustained throughout compression.

Thoracic Reference Points

The thoracic cage is divided with imaginary vertical lines (sternal, midclavicular, axillary, vertebral, and scapular), and the intercostal spaces are divided by imaginary horizontal lines to serve as reference points in locating or describing cardiac findings (Fig. 13-4). The ribs are numbered from 1 (the first rib below the clavicle) to 12. The intercostal space below each rib is given the same number as the rib that lies above it. The second rib is the easiest to locate because it is attached to the sternum at the angle of Louis. This angle (also called the sternal angle) is the bony ridge on the sternum that lies approximately 2 inches below the sternal notch (see Fig. 13-4A). After the second rib has been located, it can be used as a reference point to count off the other ribs and intercostal spaces.