Upon completion of this chapter, the nurse will:
1. Outline the areas to include when assessing the cardiovascular system
2. Identify appropriate questions to assess the cardiovascular system
3. Analyze approaches to gather more information about the cardiovascular system
THE CARDIOVASCULAR SYSTEM
The cardiovascular system includes the heart, blood vessels, lymphatic system, and components of the blood. Before focusing on the assessment of this system, a brief review of each component might be helpful.
As a review, the heart:
Is a “double pump”
Is composed of three layers of thick muscle
Has four chambers: two atria and two ventricles
Has an independent conduction system that stimulates contraction
Has four valves that create heart sounds
Is nourished through the coronary arteries
Plays an active role in blood pressure regulation
Is affected by electrolyte and fluid balance
The arteries carry oxygenated blood to all body organs and tissues. This structure is composed of three layers of tissue—tunica intima, media, and adventitia—which play a role in blood pressure regulation. The pumping action of the heart in addition to blood viscosity and vessel wall integrity influence arterial circulation. The integrity of the peripheral arterial system is evaluated when assessing peripheral pulses in the arm/hand, neck, groin, knee, ankle, and foot.
The veins carry deoxygenated blood. These vessels are thicker and rely on muscular contraction, pressure changes with breathing, and one-way valves to ensure blood return back to the heart.
This system plays a role in infection control and total body immunity. It consists of a network of vessels that drain into two major lymphatic ducts located on each side of the body. Lymph nodes are located throughout the body and collect fluid and other debris.
The blood is made up of red and white blood cells and plasma. The blood has many purposes, to include:
Transporting oxygen to body tissues
Removing carbon dioxide and other body wastes
Transporting electrolytes and fluids to maintain balance
Hemoglobin measures the oxygen-carrying capacity of the red blood cells. Hematocrit is the percentage of red blood cells within the entire circulation.
Because the cardiovascular system has several different parts, it makes sense to focus on one section at a time. As a telephonic nurse you will be limited in your ability to:
Visualize skin color
Perform capillary filling time
Palpate peripheral pulses
Auscultate heart sounds
Visualize the skin for bruising
Palpate lower extremities for peripheral edema
Palpate lymph nodes
Measure blood pressure
However, when conducting a telephonic assessment of this system you will use careful questioning to gather important information. Keep in mind that the cardiovascular and respiratory systems are intimately related. Because of this, some of the assessment questions may be appropriate for either body system. As with all major body system assessments, determine first if the patient is experiencing any particular cardiovascular problem. If so, focus on that area first. If not, complete a general assessment of this system.
QUESTIONS TO ASSESS THE CARDIOVASCULAR SYSTEM
How would you rate your energy level? Good, fair, poor?
Have you ever been told that you have a heart problem?
Have you ever had an electrocardiogram (EKG)?
Have you ever been told that you have an irregular heart rhythm?
Do you ever feel like your heart skips a beat or “changes gears”?
Do you ever feel like your heart is beating fast?
Do you ever feel like there is a bird fluttering in your chest?
Have you ever passed out (lost consciousness) without any known reason?
Have you ever had an infection that affected your heart?
Have you ever had surgery on your heart as an adult or as a child?
Have you ever experienced chest pain?
If so, described the pain.
Describe the color of the skin under your fingernails. Would you say that it is: pink, red, white, pale?
Listen to the client talk and if a cough is present. If coughing, note if it sounds dry or moist. If it sounds moist ask:
How long have you had a cough?
Do you produce any phlegm?
Does the phlegm appear pink in color?
Have you ever been told that you have a problem with any of your arteries? If so, which ones?
When was the last time that you had your blood pressure measured?
If so, do you remember what the numbers were?
Do you ever wake up with a headache?
Do you ever experience blurred vision?
Do you ever have nosebleeds?
If so, when was the last nosebleed?
How long did it last?
What did you do to make it stop?
Have you been prescribed or are taking medication for high blood pressure?
What is the name of your medication?
How often do you take it?
How long have you been taking it?
Have you had any problems or side effects from taking this medication?
Is the color of your lower legs the same color as the rest of your skin?
Do you have any swelling around your feet or ankles?
Do you have any numbness or tingling of your feet or hands?
Do you ever have pain in your calves (the back of your lower legs) when you walk? If so:
How would you describe the pain? (The pain of arterial insufficiency is often described as sharp or stabbing.)
Does exercise or walking make it better or worse? (Walking will make arterial insufficiency worse.)
How long does it last?
What do you do to make it stop?
Does elevating your legs make the pain better or worse?
Have you noticed if the amount of hair on your lower legs has changed?
Does the skin of your lower legs appear shiny?
Do you smoke cigarettes or use any tobacco products?
If so, for how long? (pack years)
How much do you smoke or use tobacco products?
Is the skin over the front of your lower legs darker in color than the rest of the skin on your legs?
Do you have any wounds or sores on your legs or ankles? If so:
How long have you had these sores?
What have you been using to treat the sores?
Do you ever experience swelling of your legs and ankles?
If so, does elevating your legs make the swelling go down?
Do your legs swell if you sit or stand in one position too long?
How would you rate your activity level?
Active (participate in sports or other activity daily)
Moderate (participate in sports or other activity a few times a week)
Sedentary (limited to household chores)
Do you ever experience pain in your lower legs?
Describe the pain. (The pain of venous insufficiency is often described as a feeling of fullness or aching.)
Does walking make the pain better or worse?
How long does the pain last?
What do you do to make the pain stop or improve?
Have you ever been diagnosed with varicose veins? If so:
What treatment have you received, if any?
What do you do to reduce the discomfort from the varicose veins?
Do you have any swellings?
On your neck?
Around your upper chest/armpits?
One arm or hand?
Have you ever been told or diagnosed with a problem with your lymph system or drainage?
Have you had any surgeries that interrupt lymph drainage such as surgery for breast cancer?
Do you ever get “swollen glands” with an infection or chest cold?
Have you ever had to be hospitalized for the infection and the swollen glands?
Have you ever been diagnosed or treated for cancer that affects the lymph or glands?
Have you ever been told or diagnosed with a problem with your blood? If so, please describe the problem.
Have you ever been diagnosed with anemia caused by low iron?
Have you ever been diagnosed with anemia caused by something else?
Do you take or have been prescribed medication to treat anemia? If so:
What is the name of the medication?
How long have you been taking it?
How many times a day do you take it?
Is it a pill or do you have to get injections?
Do you ever get short of breath when you do routine activities? (This question might be inappropriate if the client smokes. If the client does not smoke, shortness of breath can be an indication of a low hemoglobin level.)
Do you take or have been prescribed any medication that makes your blood thinner? If so:
What is the name of the medication?
How long have you been taking the medication?
How many times a day do you take it?
Do you ever get any bruises on your skin that just occur without any injury?
Where are these bruises located?
How long do they last?
Do they routinely reappear?
Do your gums bleed easily when brushing your teeth?
How long has this been going on?
Have you discussed this with your doctor, dentist, health care provider?
When you get a minor cut or scrape of the skin, how long does it take for the area to stop bleeding?
Do you have to apply pressure to the area to make it stop bleeding?
Have you ever been told or diagnosed with a health problem that affects your blood’s ability to clot such as hemophilia? If so:
Do you know the type of hemophilia?
Have you had to be hospitalized for treatment of the hemophilia?
Do you take medication for the hemophilia?
Do you recall the last time that you had an infection? If so:
What type of infection was it?
Were you prescribed antibiotics for the infection?
Has the infection reappeared since the last treatment?
How often do you experience a fever? If frequently:
Is there a particular time of day when the fever occurs?
What do you do to treat the fever?
Do you experience extreme sweating when the fever breaks?
Do you take or have been prescribed a medication called a steroid? If so:
Why were you prescribed this medication?
Are you still taking this medication?
Can you recall the last time you had to take this medication?
How long did you take it?
ALGORITHM FOR ASSESSING THE CARDIOVASCULAR SYSTEM
As you can see, the assessment of the cardiovascular system can be lengthy. You might want to change your approach when assessing this system to focus on specific problematic areas. Suggestions to streamline the assessment are as follows:
Assess the pain for:
Radiation to the arm or jaw area
Associated with nausea/vomiting
Assess how long it has been going on
Suspect an acute myocardial infarction if this is a new episode and direct to seek immediate medical attention
Suspect angina if this has happened before
Assess if client has medication to treat the chest pain
Suggest the client follow the directions to treat the chest pain
Assess if the client has a history of an irregular heartbeat
Assess if the client ever feels like the heart is skipping beats
Assess if prescribed medication to treat the irregular heartbeat
Suspect a ventricular dysrhythmia (premature ventricular contractions)
Assess if the client is experiencing palpitations or fluttering. If so, determine:
Time the discomfort has been occurring
Any associated factors such as:
Occurs after ingesting something containing caffeine (coffee) or chocolate
Occurs during or after smoking
Suspect an atrial dysrhythmia (premature atrial contractions, atrial fibrillation, atrial flutter)
Encourage to seek medical attention
Assess if the client has a history of foot/ankle/lower leg swelling
Assess if the client has a cough. Determine if the cough “sounds” productive. If so, ask:
How long has the cough been occurring?
Is there any phlegm produced?
The color of the phlegm?
Assess if the client has noticed the veins in the neck being more prominent than usual
Assess if the client has ever been told or diagnosed with “heart failure”
Assess if the client takes or is prescribed medications for the “heart failure.” If so,
What is the name of the medication?
How long has the medication been prescribed?
How many times a day is the medication taken?
Assess if the client is experiencing any new symptoms of the “heart failure”
Encourage the client to discuss the new symptoms with the doctor or health care provider
Problems with circulation
Assess if there is a change in the color of the skin over the lower extremities
Assess if the feet and legs feel cold or warm to touch
Assess if the feet/legs feel numb
Assess if the skin appears shiny or if there is a change in the amount of body hair over the lower extremities
Assess if there is any swelling of the feet/ankles/lower legs
Assess if there are any wounds on the legs
Assess if the client is experiencing any pain with activity and inactivity
Suspect arterial insufficiency if the skin is red in color and experiences pain with walking or other activity.
Suspect venous insufficiency if the skin is dark brown and experiencing a feeling of heaviness or fullness of the legs when sitting or standing in the same position
Encourage discussing the issues with circulation with the doctor or health care provider
Assess the location of the swollen gland (the neck, under the arm, in the groin)
Assess how long the gland has been swollen
Assess if the swollen gland is painful to touch
Assess if the swollen gland can move or is fixed or feels like it is sticking to one area
Assess if the swollen gland feels like rubber or harder like a marble
Suspect an acute infection if the swollen gland is movable and rubbery
Suspect another disease process if the swollen gland is hard and immovable
Encourage discussing the swollen gland with the doctor or health care provider
New onset of morning headache, blurred vision, and nosebleed
Assess where the headache is located?
Around the back of the neck
Throughout the forehead
Assess if the headache gets better as the day progresses?
Assess what has been done for the headache:
Taking over-the-counter medication
Laying down with a cool compress
Assess when the blurred vision first started
Assess if the client participates in any activities that could cause eyestrain: needlepoint, reading small print, extensive computer work, etc.
Assess if there are any other eye changes noticed: tearing, crusting, redness, drainage
Assess what the client was doing when the nosebleed started
Assess how long the bleed lasted
Assess what was done, if anything, to help stop the bleeding
Suspect an elevation in blood pressure
Encourage to see the doctor or health care provider for the new symptoms and to have blood pressure measured as soon as possible
New onset of fatigue
Assess how long the fatigue has been occurring
Assess when the fatigue was first noticed
Assess what is being done about the fatigue
Assess if the fatigue is associated with anything else such as:
New onset of productive cough
New onset of foot/ankle/lower extremity swelling
Change in amount of urine output
Change in appetite
Shortness of breath or difficulty “catching the breath”
New onset of numbness or tingling of the feet/hands
Inability to complete activities of daily living without having to stop and rest
Suspect exacerbation or new onset of heart failure if fatigue is associated with productive cough, lower extremity edema, change in urine output, change in appetite, shortness of breath, irritability
Suspect acute elevation of blood pressure if fatigue is associated with blurred vision and headache
Suspect anemia for the fatigue is associated with shortness of breath, activity intolerance, or numbness/tingling of the hands/feet
Encourage to talk with the doctor or health care provider about the symptoms
Assess where the bruises are located
Assess for the estimated size of the bruises
Assess if the bruises are “clustered” around a joint such as the knee or ankle or scattered over a large area such as over both arms, both legs, the abdomen, the lower back, etc.
Assess if the client recalls bumping into anything (furniture, car door) that could have caused the bruising
Assess if the bruises are painful
Assess if experiencing any new onset of bleeding gums, nosebleed, or coughing of blood
Suspect an alteration in platelets/clotting with a new unexplained onset of bruising
Encourage to discuss the bruising with the doctor or health care provider
Assess when the fevers were first noticed
Assess if the fevers occur during any particular time of day
Assess if the fevers are associated with any other symptoms or body changes
Assess what the client has been doing to treat the fevers
Assess if the fevers are occurring more or less frequently
Encourage to discuss the new onset of fevers with the doctor or health care provider
New onset of swollen feet, ankles, or legs
Assess the area that is edematous
Assess if the client can see an indentation when the swollen area is pressed with a finger
Assess when client measured body weight
Assess if the weight has increased since the last measurement
Assess if there has been a change in amount of urine voided
Assess if the client has increased the amount of salt ingested
Assess if the client has noticed tightness or swelling of the fingers/hands and/or under/around the eyes
Suspect acute fluid volume overload (which can be due to heart failure, renal failure, hypertension)
Encourage to discuss the new onset of swelling with the doctor or health care provider
See Chapter 14 for additional information about cardiovascular system disorders.
TIPS FOR ASSESSING THE CARDIOVASCULAR SYSTEM
Clients may not understand the term dysrhythmia or arrhythmia. Asking about having an irregular heartbeat may provide more information for you.
Clients may not consider swelling of the feet or ankles as being unusual. Ask if the client notices that the shoes feel tight at the end of the day. You could also ask if the client’s rings are fitting tighter on the fingers. Some clients may be dismayed about a new onset of “gaining weight in the belly.” This could be ascites or sacral edema. Carefully assess how long this has been going on, if there has been an associated weight gain, and if the doctor or health care provider has been contacted about it.
Clients may react negatively to the term “heart failure.” Consider asking if the client has ever been told that they have extra “fluid in their heart or lungs” or have to take a “water pill” to get rid of extra body water.
Stay calm when discussing symptoms that the client may be experiencing. The client may already be anxious about a symptom and could be seeking reassurance from you during the call. Do not make any rote comments such as “I’m sure that is nothing” or “don’t worry about it.” Encourage the client to see the doctor or health care provider for additional evaluation.
Be aware of the client’s energy level while on the call. If the client is short of breath you will need to keep the call short and schedule follow-up calls more frequently.
Focus on the symptom and if the client has any other health problems that could be causing the symptom. Shortness of breath can be caused by a lung problem, heart problem, or anemia. Avoid assuming that the symptom is an extension of another problem but rather ascertain if it is new.
Be aware of your organization’s approach to emergency situations. Do not automatically direct clients to call an ambulance for emergency assistance unless it is truly an emergency and you fear that the client could lose consciousness while on the telephone. Not all clients have an ambulance benefit with their health plans and calling for emergency services that were not truly necessary could cause the client financial hardship. Always ask if the client’s doctor or health care provider is aware of the symptom before directing the client to seek immediate medical attention.
Do not automatically assume that bruising is caused by a bleeding disorder. Some medications have bruising as an adverse effect. Review the client’s current medications first and determine if any could be causing the bruising.
Remember that not all clients will willingly discuss health problems. You may find the client answering questions briskly, ending the call abruptly, or changing the topic. Should this occur, ask if the client is experiencing any new problems and wants to talk about them now.