History Taking and Physical Examination
Barbara S. Levine
Assessment data, which are obtained from the patient’s history, physical examination, and diagnostic tests, are used to formulate clinical diagnoses, establish patient goals, plan care, and evaluate patient outcomes. A complete history and physical examination includes the same content areas, whether elicited by nurses or physicians. A complete history and physical examination is impractical in most clinical situations. Many hospitals and clinics are using an electronic health record that establishes which data are included. The electronic health record assures systematic assessment but may constrain the kinds of data that are obtained. With freeform records the inclusion of appropriate content areas is determined by the patient’s clinical condition and the purpose and context of the clinical encounter. Specific content areas may be investigated in greater detail by clinicians from different disciplines, and the data may be used in different ways. Nurses must be able to incorporate historical data into the nursing assessment so the interdependent nursing and medical responsibilities are completed in the correct priority sequence. Conversely, physicians need to be aware of the data elicited by nurses so the complete database is the foundation for the total plan of care.
The provision of culturally appropriate care requires understanding of and sensitivity to differences in health beliefs and practices that reflect cultures or subcultures. The challenge is to be sensitive to cultural influences that may affect the clinical encounter without stereotyping the patient based on limited knowledge of the culture of origin. Three overarching concepts that are influenced by culture and affect the clinical encounter are perception of illness or explanatory model, patterns of kinship and decision making, and comfort with touch.1
This chapter focuses on history taking and physical examination of the patient with heart disease. Emphasis is placed on those sections of the health history and physical examination that are affected by heart disease. General assessment techniques, with their rationale, are described. Competence in obtaining a history and in performing a physical examination cannot be achieved simply by reading the material presented. It is vitally important to become actively involved in clinical assessment, ideally with a qualified preceptor. Many hours of practice are required before the beginning student becomes skilled in assessment techniques.
CARDIOVASCULAR HISTORYCardiac patients who are acutely ill require a different initial history than do cardiac patients with stable or chronic conditions. A patient experiencing a myocardial infarction requires immediate, and possibly life-saving, medical and nursing interventions (e.g., relief of chest discomfort and treatment of arrhythmia) rather than an extensive interview. For this patient, asking a few, well-chosen questions regarding chest discomfort using the patient’s descriptors are important. In addition, associated symptoms (such as shortness of breath or palpitations), drug allergies and reactions, current medications, history of cardiac and other major illnesses, and smoking history should be determined while assessing vital signs (heart rate and rhythm and blood pressure) and starting an intravenous line. As the patient’s condition stabilizes, a more extensive history should be obtained. Cardiac patients who are not acutely ill benefit from a more detailed history and physical examination.
A comprehensive history includes the following areas:
Identifying information
Chief complaint or presenting problem
History of the present illness
Past history
Review of systems
Family history
Personal and social history
Perceived health status
Functional patterns
The responsibility for obtaining particular portions of the health history varies with practice model and setting. In traditional, hospital-based practice models, the first six areas of the history are usually obtained by a physician, some data related to personal and social history are obtained by a physician and some by a nurse, and data related to perceived health status and functional patterns are obtained by a nurse. In collaborative practice models, all data may be obtained by an advanced-practice nurse, or responsibility for all areas of data collection may be shared by the physician, advancedpractice nurse, nurse, and other members of the health care team. The cardiac nurse uses the data to make informed clinical judgments, to monitor change over time, to identify patient and family learning needs, and to coordinate care across settings.
Health History
The health history is the patient’s story of his or her diseases, symptoms, illness experiences, and responses to actual and potential health problems. Because concepts of health and healing are rooted in culture, it is essential to elicit information about the
person’s beliefs about the causes, symptoms, and treatment of illness. Empathy, openness, and interest communicated by the clinician will enable patients to share their perspectives and beliefs.
person’s beliefs about the causes, symptoms, and treatment of illness. Empathy, openness, and interest communicated by the clinician will enable patients to share their perspectives and beliefs.
Table 10-1 ▪ DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The history-taking process may be the first phase in establishing a therapeutic relationship. The history is a precise, concise, chronologic description of the patient’s current health status. The patient is the primary source of historical data; however, questioning of family members or close friends may provide essential information about symptoms and the impact of heart disease on family members. For example, the bed partner is more likely than the patient to provide a history of periodic respiration or sleep apnea. Review of records from previous encounters is a valuable secondary source of historical data.
The primary symptoms of heart disease include chest discomfort, dyspnea, syncope, palpitations, edema, cough, hemoptysis, and excess fatigue. Heart disease develops slowly, and the patient may have a long period of asymptomatic disease and may present initially with acute collapse. To describe the health history, a sample symptom, chest discomfort, is used throughout this chapter. A systematic approach is useful in differentiating chest discomfort due to serious, life-threatening conditions from those conditions that are less serious or would be treated in a different manner.2 Table 10-1 summarizes conditions associated with chest discomfort.
Identifying Information
The patient’s name, the name by which he or she prefers to be called, his or her age and birth date, and date and time of the interview are all recorded under identification of the patient. Country of origin, religious or cultural group, education, and socioeconomic level constitute optional information that may be included. It is assumed that all data in the history are obtained from the patient; when this is not the case, secondary data sources (e.g., family member, clinical records) should be identified. The use of an interpreter should also be recorded.
Chief Complaint or Presenting Problem
The chief complaint or presenting problem is the reason the person has sought health care and represents his or her priority for treatment. It should be recorded within quotation marks exactly as stated. The chief complaint also should indicate duration, such as “chest discomfort for 2 hours.”
An asymptomatic patient may present because of a community screening activity (e.g., “high blood cholesterol discovered on finger-stick last month”) or because of a positive diagnostic result (e.g., “positive calcium score on electron beam CT last week”).
A patient may have more than one chief complaint. Some complaints are closely related and may be listed together, such as “chest discomfort and weakness for 2 hours.” If complaints are unrelated, they should be listed separately in the order of importance to the patient. In general, “the greater the number of symptoms, the less the significance of each.”3
There are four important points to remember when evaluating chest discomfort.4
For a patient who has a history of or who is at risk for development of coronary heart disease, always assume that the chest discomfort is secondary to ischemia until proven otherwise. This practice is important because unrelieved myocardial ischemia is immediately life threatening and can extend infarct size, resulting in serious complications such as lethal arrhythmia or cardiogenic shock. Chest discomfort related to other conditions, such as pulmonary emboli, usually is not as immediately life threatening.
There may be little correlation between the severity of the chest discomfort and the gravity of its cause. That is, pain is a subjective experience and depends, in part, on a lifetime of learned reactions to it. A stoic person may not admit to having much discomfort and yet may be having a large myocardial infarction. Another person may express extreme pain and yet may be experiencing stable angina rather than an acute myocardial infarction. Stress can increase pain. Taking into account the patient’s usual response to pain (often obtained from a family member) may help the nurse interpret the patient’s pain response better. In addition, older adults or people with diabetes may have altered sensory perception and little or no discomfort in the presence of severe disease.5 When present, positive objective signs, such as ST segment shifts on the electrocardiogram, are clear indicators of the significance of the
subjective symptom. It is important to realize that the absence of electrocardiographic criteria for ischemia or infarction does not eliminate the clinical significance of the chest discomfort.
There is a poor correlation between the location of chest discomfort and its source because of the concept of “referred pain,” which is pain originating in one location but being interpreted by the patient as occurring in another location. Commonly, cardiac discomfort is perceived as being in the arm, jaw, neck, or epigastric area rather than in the chest.
The patient may have more than one clinical problem occurring simultaneously, particularly if he or she has delayed seeking medical assistance.
History of the Present Illness
For the symptomatic patient, obtaining the history of the present illness starts with a more detailed discussion of the chief complaint. Begin with an open-ended question, such as “Tell me more about your chest discomfort.” There is a wide range in patients’ abilities to express thoughts accurately, chronologically, and succinctly. Some patients need guidance more than others. Listen to the patient. It is best to let patients tell their stories in a comfortable manner. However, patients who appear to be rambling need to be redirected by clarifying or leading questions. The information that must be obtained when describing any symptom is the time and manner of onset, frequency and duration, location, quality, quantity, setting, associated symptoms, alleviating or aggravating factors, pertinent negative responses, impact of the symptom on usual or desired activities, and the meaning attributed to the symptom by the patient.
The time of onset should be recorded, when possible, with both the date and time (e.g., “9 PM on December 22nd”). When the patient presents with chest discomfort, it is essential to know how long the discomfort has been present and if it has been present continuously since onset. The manner of onset is the way in which the symptom began. For example, discomfort may begin suddenly and reach maximum intensity immediately, or there may be a growing awareness of the discomfort over time. Frequency and duration should be stated specifically rather than generally (e.g., “once a week,” “once a day,” or “more than three times a day”). Likewise, patients should be assisted to express the duration of the discomfort, as in “2 minutes,” “15 minutes,” or “1 hour.” For patients with a history of angina, it is also important to determine if there has been any change in frequency or duration of chest discomfort, which suggests worsening of the underlying disease.
Ask the patient to describe the exact location of the symptom by pointing to it. Cardiac pain is diffuse, and the patient often rubs a hand over the sternum and precordium. Chest pain that can be precisely located with a fingertip is usually related to chest wall abnormalities.6 If the pain radiates, the patient should trace its path with a fingertip. The quality of a symptom refers to its unique characteristics, such as color, appearance, and texture. Chest discomfort is so subjective that its quality is particularly difficult to describe. Thus, whenever possible, it is important to use the patient’s own words (in quotation marks). Angina means tightening, and the discomfort associated with angina may be described as “pressing,” “squeezing,” “tightening,” “strangling,” or “constricting.”6 The patient’s response to the symptom also should be recorded (e.g., “It makes me stop what I’m doing and sit down,” or “I can continue my activities without stopping”).
Quantity refers to the size, extent, or amount of the symptom. The quantity of the chest discomfort is described in terms of its severity. Again, quantity is extremely subjective and might be rated best on a 10-point scale, ranging from “barely noticeable” (1) to “the worst pain ever” (10). The severity of pain should be recorded as a fraction (e.g., 2/10 or 10/10).
Ask patients to describe the setting and if they were alone or with someone when the symptom occurred. If the symptom has occurred before, ascertain if the setting, circumstances, or the presence of another person is consistent during symptom onset. This information may be useful later in counseling or helping a patient gain insight into the development of his or her symptoms. Chest discomfort that is reliably associated with activity (e.g., walking up hill) is a specific indicator of cardiac ischemia.
The patient should be asked to describe any associated symptoms that always accompany the chief complaint. For example, palpitations and dizziness might always precede the chest discomfort. If the patient mentions associated symptoms, these should be described in the same manner as the chief complaint (i.e., quality, quantity, onset, duration). It is important to note whether these associated symptoms occur consistently with the chief complaint or occur independently at other times.
Alleviating factors, such as resting, changing position, or taking medication, should be noted. Change in the time it takes for alleviating factors to be effective should be identified. For example, if, in the past, the chest discomfort resolved with 5 minutes of rest and now requires 10 minutes, worsening or a new pathologic process is suggested. Aggravating factors, such as eating, exercising, or being in a cold climate, also must be recorded. These factors can provide helpful diagnostic information. To complete the present illness history, it is also important to record any pertinent negative responses to the interviewer’s questions, such as “The chest discomfort is not made worse by strenuous exercise.” The patient should be specifically asked about palpitations, dizziness, syncope, dyspnea, orthopnea, and paroxysmal nocturnal dyspnea, if these symptoms have not already been described.
Impact of the symptom on usual or desired activities should be explored. Some people with recurrent chest discomfort reduce their activity over time to try and prevent chest discomfort. It is essential that clinicians understand how the symptom or disease has affected the patient’s activity and perceived quality of life.
Throughout the interview, the nurse observes the patient carefully and may begin to understand the meaning the illness has for the patient. The personal meaning of the illness can amplify or reduce the symptom experience and course of action. When interviewing members of a culture not one’s own, ask “Can you tell me what caused your illness?” and about the use of home remedies, foods, or traditional healers.7
The results of diagnostic or laboratory testing specifically related to heart disease are included in the history of present illness. Prior cardiac events (e.g., coronary artery bypass surgery or myocardial infarction) are included also.
Cardiovascular risk factors and current activity may be added in a separate paragraph to the conventional content of the history of present illness. Risk factors for coronary heart disease are discussed in Chapter 32.
Sample questions that may be used in assessing the patient with acute or recurrent chest discomfort are listed below. Similar questions may be generated to assess patients with other symptoms. However, it is important to phrase the questions according to the appropriateness of the situation and logically to pursue areas where further clarification is necessary.
When exactly do you get the discomfort? Are you having discomfort now?
What were you doing when the chest discomfort occurred?
Exactly how often does the chest discomfort occur?
How many minutes does it usually last?
Can you point to the exact location where it starts?
Does the discomfort move anywhere else?
If so, can you trace its path with your fingertip?
What words would you use to describe how the discomfort feels?
What do you do when you have the chest discomfort?
Quantify your discomfort on a 1-to-10 scale.
Where were you when the discomfort occurred?
If the chest discomfort has occurred before, have you always been in the same place?
Were you alone at the time or with someone?
Did you notice any other symptoms that occurred at the same time?
If yes, does this other symptom ever occur by itself?
What can you do to make the chest discomfort better?
What can you do to make it worse?
Are you taking any medication, botanical medications, supplements, foods or home remedies to improve your chest discomfort?
If yes, what is the medication, botanical medication, supplement, food, or home remedy?
Does any medication you are taking affect your chest discomfort?
If yes, what is the medication?
What time of day do you prefer to take your medication?
Are you doing anything else to improve your chest discomfort, for example yoga or meditation?
What activities have you given up because of your chest discomfort?
What do you think this chest discomfort means?
Do you know anyone else who has had this kind of discomfort?
Past History
The past history includes past illnesses and interventions not directly related to the present illness. For a patient with chest discomfort, the history of a previous myocardial infarction, coronary artery bypass surgery, or cholecystectomy belongs in the history of present illness, whereas a remote appendectomy does not. Major elements of the past history include childhood and adult illnesses, accidents and injuries, current health status, current medications, allergies, and health maintenance. Always ask about major illnesses such as chronic obstructive airway disease, diabetes mellitus, bleeding disorders, and acquired immuno deficiency syndrome (AIDS).
Allergic reactions (e.g., to drugs, food, environmental agents, or animals) also should be noted. Always ask if the patient has an allergy to penicillin or to commonly used emergency drugs, such as lidocaine hydrochloride and morphine sulfate. Allergy to shellfish suggests iodine sensitivity and is important because agents used in cardiac diagnostic tests may contain iodine. Both the allergen and the reaction should always be noted, because some patients confuse an allergic reaction with a drug’s side effect.
Medication history includes all prescription and over-the-counter drugs, including botanical medicines, supplements, and home remedies. Over-the-counter preparations, botanical medications, and supplements that increase heart rate or afterload may precipitate or worsen symptoms. If the patient has brought medications with him or her, these should be reviewed by the nurse and then sent home or to the appropriate area for safekeeping.
Family History
The major purpose of the family history is to assess risk factors affecting the patient’s current or future health. Notations regarding the age and health status of each first-degree family member are made: living and well, deceased, and the possible or confirmed diagnosis now or at death. Family occurrences of diabetes, kidney disease, tuberculosis, cancer, arthritis, asthma, allergies, mental illness, alcoholism, and drug addiction are included. A family history of coronary heart disease, myocardial infarction, or sudden death would be included in the history of present illness for a patient presenting with chest discomfort.
Personal and Social History
The personal and social history includes important and relevant information about the patient as a person. A person’s response to illness is determined in part by his or her cultural background, socioeconomic standing, education, and beliefs about the illness. Major elements include health habits, home situation, and supports and resources. Occupational history may be included here or in the past history. Health habits include alcohol, drug, or tobacco use; nutrition; sleep; and physical activity. Use of alcohol and the amount per time period (day, week, year) should be recorded. The use of recreational drugs, especially cocaine and its derivative “crack,” should also be assessed. The cigarette smoking history should be recorded as the number of pack-years (packs per day multiplied by the number of years) the patient has smoked. For ex-smokers, approximate quit date should be recorded. Other tobacco use, such as pipe or cigar smoking or chewing tobacco, should be recorded. Special diets, such as low-sodium, low-fat, low-carbohydrate, or high-protein diets, should be identified, and the patient’s usual eating pattern should be described. The usual number of hours the patient sleeps and circumstances that impair or facilitate sleep should be assessed.
Current Living Circumstances.
These circumstances include marital status, number of children, occupation, financial resources, and hobbies.
Perceived Health and Coping Challenges.
The patient’s perception of his or her current health status as either good or bad is helpful in assessing how he or she views its effect on daily living. For example, a 42-year-old man with an old anterior myocardial infarction is seen in the clinic. His chief complaint is extreme fatigue that prevents him from working a full day at the office. Initial investigation focuses on ruling out any new process affecting the adequacy of cardiac output, such as a left ventricular aneurysm. Nonpathophysiologic causes for fatigue must be considered also, such as fear of overstressing his heart and sudden death, changes in the work situation, family difficulties, or depression.
Being aware of patients’ goals in terms of health and lifestyle is important in determining whether their expectations are realistic. “What do you see yourself doing 3 months from now?” is a good way to ask the patient to define the goal. Another approach is ascertaining what changes the patient would be willing to make in life if the goal could not be achieved.
Assessing the patient’s and family’s expectations of health care has implications for teaching. For example, is the patient with unstable angina pectoris who has been admitted after “cardiac catheterization” able to explain what the test was and why it resulted in admission? Communication among the health care team members is essential before planning any teaching.
Resources and Support System.
It is important to consider the patient’s strengths and support system when planning care across the continuum: environmental resources, such as the proximity to the hospital; personal—social support, such as a spouse to provide home care; and economic support, such as adequate insurance, are all examples. Needed resources that are not readily available also must be considered. Knowledge of the patient’s health benefits and financial status assists the health care team in designing an affordable therapeutic regimen (e.g., the avoidance of expensive combination or sustained-release medications when other drugs and dosage forms that are as effective and less costly are available).
Review of Systems
To ensure that all important areas have been considered, a systematic review of all body systems is conducted. Lists of major symptoms associated with each body system are included in health assessment textbooks.8 Some clinicians prefer to conduct the review of systems simultaneously with the physical examination. For the patient with chest discomfort, the review of the cardiac, pulmonary, and gastrointestinal systems is logically included in the history of present illness.
Functional Patterns
Clinical information related to function is collected in the following areas9:
Health perception-health management
Nutrition-metabolism
Elimination
Activity-exercise
Cognitive-perceptual
Sleep-rest
Self-perception-self-concept
Roles and relationships
Sexuality
Coping-stress
Values-beliefs
Information collected within these functional patterns does not duplicate information collected within other areas of the health history. The sequence of data gathered in the functional assessment is determined by the patient’s clinical condition and the purpose of the encounter. Relevant data obtained earlier in the history should not be repeated.
For the acutely ill cardiac patient who is admitted to the hospital, areas that affect the hospital experience are assessed first. As the patient is able, all functional patterns are assessed. To facilitate the gathering of subjective information for the functional assessment, examples of questions, using the sample symptom of chest discomfort, are listed below. Functional assessment is an ongoing process that evaluates the effect of intervention on patient outcome.
Health Perception-Health Management.
Collect the following information:
What concerns do you have about your health or hospitalization?
What things are important to you while you are hospitalized? How can we make this experience as easy as possible for you?
What do you think caused this illness (symptom)?
Compared with others your age, how would you rate your general health?
What things do you believe are important to maintain your health?
Nutrition-Metabolism.
Collect the following information:
What do you like to eat (including cultural or ethnic favorites)?
How are your foods prepared (canned or commercially prepared foods versus fresh foods)?
Do you usually eat in a restaurant, fast-food outlet, or at home?
Who shops for groceries?
Who prepares the meals?
Are you on a special diet?
Elimination.
Collect the following information:
Is the amount that you urinate normal for you?
Do you ever get up at night to use the bathroom? If so, how many times?
If there was a change in elimination pattern, when did you notice it?
Do you sometimes lose urine or find that you cannot quite make it to the bathroom?
Do you take a diuretic? If so, when do you take it?
What is your usual frequency of bowel movements? When was your last movement?
Are there things you do to maintain that pattern?
Activity-Exercise.
Collect the following information:
Have you noticed a change in your usual or desired activity level?
Do you have sufficient energy for your desired activities?
What is the most strenuous activity you perform on a regular basis? How often and how long? What stops you?
What leisure or recreational activities do you enjoy? Are you currently able to participate in these activities? What prevents your participation?
Are you satisfied with your current level of activity?
Cognitive-Perceptual.
Collect the following information:
Do you have any difficulty with seeing or hearing? Glasses or hearing aid?
Do you think as fast as you used to? As clearly?
In general, what is the easiest way for you to learn new material? Any learning difficulties?
Do you understand why you are in the hospital?
What does your diagnosis mean to you?
What is your understanding of the treatment plan?
Do you understand the risk factors for heart disease and how to modify them?
Do you understand how long you will be in the hospital and when you can return to your usual activities of daily living?
Sleep-Rest.
Collect the following information:
How many hours do you usually sleep? What hours?
Do you have difficulty falling asleep or staying asleep? Has this been a change for you or have you always had this difficulty?
Do you follow a specific bedtime routine or ritual?
Do you snore loudly?
Do you feel rested when you wake up in the morning?10
Are you tired and excessively sleepy during daytime hours?10
Self-Perception-Self-Concept.
Collect the following information:
Roles and Relationships.
Collect the following information:
Do you live alone? With whom do you live?
Do you have a close friend or confidant?
How do you and those close to you feel about your illness?
Do you often feel lonely? Do you feel part of the neighborhood in which you live?
Sexuality.
Collect the following information:
Have you experienced any changes in your sexuality? Problems in sexual relationships?
For women: are you still menstruating? Are you taking hormone replacements? Do you have menopausal symptoms (such as hot flashes and sleep disturbances)?
Coping-Stress.
Collect the following information:
Do you feel tense or anxious much of the time? What helps? Do you use medicines for anxiety?
When you feel stressed, who is most helpful to you?
When you have big problems in your life, how do you handle them? Does that usually work for you?
Values-Beliefs.
Collect the following information:
Are you generally satisfied with your life?
Is religion important to you?
Do you hold religious or other beliefs that you wish to observe here?
Functional and Therapeutic Classification
After the history is completed, it may be possible to categorize the patient according to the New York Heart Association’s Functional and Therapeutic Classification (Table 10-2).11 This classification may be helpful in assessing symptom severity and monitoring effects of treatment over time. The patient’s functional classification may improve as recovery from an acute event, such as myocardial infarction, occurs or as intervention is optimized. Conversely, it may decline with worsening or additional disease.
Table 10-2 ▪ FUNCTIONAL AND THERAPEUTIC CLASSIFICATION OF PATIENTS WITH DISEASES OF THE HEART | ||||||||||||||||||||||||||||
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PHYSICAL ASSESSMENTAssessment of physical findings confirms or expands data obtained in the health history. Baseline information is obtained at the initial encounter, and frequency of subsequent assessments is based on the clinical encounter. Change in the data over time documents progression of, or recovery from, acute disease; new disease; the effectiveness of current interventions; and the patient’s current functional status. The type, degree, and rate of change assist the nurse in identifying or predicting immediate or long-term problems, formulating nursing diagnoses, planning care, and establishing individual patient outcome criteria.
In the acutely ill cardiac patient, segments of the physical examination are performed every 2 to 4 hours or more frequently if indicated. Although some data may be available from monitoring devices, physical examination assists in evaluating the accuracy of those data. As the acutely ill patient improves, assessments are routinely done once per shift or more frequently if indicated. If a rapid change in patient condition occurs, the initial assessment is problem focused and the complete assessment is done at a later time. Because nurses spend 24 hours per day with the hospitalized patient, they are in the best position to identify any changes that occur. It is to the patient’s benefit for changes to be detected early, before serious complications develop. Any changes observed in the examination should be documented in the patient’s record and reported to the physician. To collect, correlate, and interpret the data accurately, a thorough understanding of the cardiac cycle
(Chapter 1) is essential. A cardiac physical assessment should include an evaluation of:
(Chapter 1) is essential. A cardiac physical assessment should include an evaluation of:
The heart as a pump—reduced pulse pressure, cardiac enlargement, and presence of murmurs and gallop rhythms
Filling volumes and pressures—the degree of jugular venous pressure and the presence or absence of crackles, peripheral edema, and postural changes in blood pressure
Cardiac output—heart rate, blood pressure, pulse pressure, systemic vascular resistance, urine output, and central nervous system manifestations
Compensatory mechanisms—increased filling volumes, peripheral vasoconstriction, and elevated heart rate
The order and techniques of examination proceed logically. The precise order may vary with the setting and the condition of the patient. With practice, the focused cardiovascular examination can be done in approximately 10 minutes:
General appearance
Head
Arterial pulse
Jugular venous pressure
Blood pressure
Peripheral vasculature
Heart
Lungs
Abdomen
General Appearance
Observe the general appearance of the patient while the history is being obtained.6 The patient’s appearance and responses provide cues to the cardiovascular status. Note general build, skin color, presence of shortness of breath, and distention of neck veins. Assess the patient’s level of distress. If he or she is in pain, the patient’s response to it may assist in the differential diagnosis. For example, moving about is a characteristic response to the pain of myocardial infarction, whereas sitting quietly is more characteristic of angina, and leaning forward is more characteristic of pericarditis.12 Some abnormalities of the arterial pulses may be observed unobtrusively. For example, patients with severe aortic insufficiency may have bounding pulses that cause the head to bob. Note appropriateness of weight; malnutrition and cachexia are associated with chronic, severe heart failure.6 Skeletal manifestations of Marfan’s syndrome, tall stature, and arachnodactyly, may be observed. Level of consciousness should be described. Appropriateness of thought content, reflecting the adequacy of cerebral perfusion, is particularly important to evaluate. Family members who are most familiar with the patient can be of help in alerting the examiner to subtle behavior changes. The nurse also should be aware of the patient’s anxiety level, not only to attempt to put the patient more at ease, but to realize its effects on the cardiovascular system.
Height, Weight, and Waist Circumference
Height and weight are best measured using a standing platform scale with a height attachment. Weak, immobile, or critically ill patients may require a bed or chair scale for weighing, and it may be necessary to rely on the patient’s self-reported height. Weight is an indicator of nutritional and fluid status; excessive weight indicates increased cardiovascular risk.
Body mass index (BMI) describes relative weight for height. BMI is calculated as weight in kilograms (kg) divided by the square of the height in meters (m2). In adults, obesity is defined as a BMI of 30 kg/m2 or more; overweight is a BMI of 25 kg/m2 or more.13
Larger BMI and abdominal fat distribution are associated with increased cardiovascular risk.14 In overweight people, waist circumference of 102 cm (40 inches) in men or 88 cm (35 inches) in women indicates increased risk of cardiovascular disease, Type II diabetes mellitus, and metabolic syndrome (Chapter 39).
Head
The examination of the head includes assessment of facial characteristics, color, temperature, and eyes. Advanced practice nurses may examine the fundi and retinal vasculature.
Facial Characteristics
Examination of the facial characteristics may aid in the recognition of disorders affecting the cardiovascular system.6 Coronary heart disease is suggested by the presence of an earlobe crease in a person younger than 45 years of age. Rheumatic heart disease with severe mitral stenosis is associated with a malar flush, cyanotic lips, and slight jaundice from hepatic congestion. With severe aortic regurgitation, head bobbing with each heartbeat (de Musset’s sign) may be present. Infective endocarditis is associated with a “café au lait” complexion. Constrictive pericarditis and tricuspid valve disease tend to cause facial edema. Pheochromocytoma is associated with episodic facial flushing, as well as severe hypertension and tachyarrhythmia.
Systemic conditions may affect or reflect cardiovascular function or treatment.6 Systemic lupus erythematosus may present with a butterfly rash on the face and may suggest inflammatory heart disease. Myxedema is characterized by dry, sparse hair; loss of lateral eyebrows; a dull, expressionless face; and periorbital puffiness. Because a myocardial effect of hypothyroidism is reduced cardiac output, heart failure may develop in these patients. Cushing’s syndrome is characterized by moon facies, hirsutism, acne, and centripetal obesity with thin extremities. High blood pressure frequently occurs with Cushing’s syndrome.
Color
Cyanosis is the bluish discoloration seen through the skin and mucous membranes when the concentration of reduced hemoglobin exceeds 5 g/100 mL of blood. Peripheral cyanosis implies reduced blood flow to the periphery. Because more time is available for the tissues to extract oxygen from the hemoglobin molecule, the arteriovenous oxygen difference widens. Cyanosis of the nose, lips, and earlobes is considered peripheral. Peripheral cyanosis may occur physiologically with the vasoconstriction associated with anxiety or a cold environment, or pathologically in conditions that reduce blood flow to the periphery, such as cardiogenic shock.
Central cyanosis, as observed in the buccal mucosa, implies serious heart or lung disease and is accompanied by peripheral cyanosis. In severe heart disease, a right-to-left shunt exists in which blood passes through the lungs without being fully oxygenated, as happens in severe heart failure with interstitial pulmonary edema. In severe lung disease, changes produced by chronic obstructive airway disease or fibrosis impede oxygenation. Pallor can denote anemia (with concomitant decreased oxygen-carrying capacity) or an increased systemic vascular resistance. Jaundice can be associated with hepatic engorgement from right ventricular failure.
Temperature
Temperature reflects the balance of heat production and dissipation in the body. Normal oral temperature is considered to be
37°C (98.6°F). However, there is a diurnal pattern of temperature fluctuation, with temperatures as low as 35.8°C (96.4°F) orally in the early morning to as high as 37.3°C (99.1°F) orally in the late afternoon or evening. Oral temperatures average 0.5°C (1.0°F) lower than rectal temperatures, but this difference is quite variable.8 Normal body temperature may be less than 37°C in older adults because of reduced heat production (lower metabolic activity, less muscle mass and activity) and conservation (less insulation).15
37°C (98.6°F). However, there is a diurnal pattern of temperature fluctuation, with temperatures as low as 35.8°C (96.4°F) orally in the early morning to as high as 37.3°C (99.1°F) orally in the late afternoon or evening. Oral temperatures average 0.5°C (1.0°F) lower than rectal temperatures, but this difference is quite variable.8 Normal body temperature may be less than 37°C in older adults because of reduced heat production (lower metabolic activity, less muscle mass and activity) and conservation (less insulation).15
In hospitalized patients, body temperature usually is measured on admission and then every 4 hours or more often if indicated. After cardiac surgery, temperature is measured every 15 to 30 minutes until rewarming is complete, and every 1 to 4 hours until normothermia is achieved. Measure the temperature orally unless the patient is unconscious or unable to close his or her mouth. Body temperatures also may be measured rectally, by means of a pulmonary artery catheter equipped with a thermistor, by means of a thermistorequipped urinary bladder catheter, or with a device that measures temperature in the insulated auditory meatus close to the tympanic membrane. Pulmonary artery, urinary bladder, tympanic, and rectal temperatures are all considered to be core temperatures; however, they actually measure somewhat different things, and simultaneous measurements may not agree, especially during hypothermia. Pulmonary artery temperature measures the mean blood temperature that results from core thermogenesis and peripheral heat loss or gain. Because urine is a filtrate of blood, urinary bladder temperature also reflects mean blood temperature, but may be falsely low in the setting of low-output renal failure. During hypothermia after cardiac surgery, rectal temperatures reflect peripheral, rather than core, temperatures.16
Eyes
The eyes are examined for vision and appearance. A funduscopic examination may be performed.
Vision.
Vision is assessed to determine if defects exist that may affect activities of daily living. The examination is as simple as having the patient read a name tag or identify an object.
Appearance.
Corneal arcus, a thin, grayish-white circle around the iris, may occur normally with aging (Fig. 10-1A). When seen in white people younger than age 40 years, corneal arcus suggests hyperlipidemia. Xanthelasmas are slightly raised, yellowish plaques of cholesterol in the skin that appear along the nasal side of one or both eyelids (Fig. 10-1B). They are associated with hyperlipidemia but also may occur normally. Ophthalmitis and petechial and subconjunctival hemorrhages of the upper and lower eyelids are seen with bacterial endocarditis.
Fundi.
Examination of the ocular fundi provides the only opportunity for direct visualization of blood vessels. Vascular changes from high blood pressure and diabetes mellitus can be detected in the arteries and small veins of the retina. In general health care, funduscopic examination is conducted without pharmacologic dilation of the pupils. Physiologic dilation may be maximized by darkening the room and asking the patient to gaze off in the distance. Photographs printed in books are taken through a maximally dilated pupil with a special camera. The view through the ophthalmoscope is only a small portion of the retina. It is necessary to direct the ophthalmoscope in varying directions, following blood vessels and observing the retinal structures and background.
The funduscopic examination technique is as follows:8
Darken the room.
Turn on the ophthalmoscope light; select the large round beam of white light.
Adjust the lens disc to 0 diopter. Keep your index finger on the lens disc throughout the examination.
Use your right hand and right eye to examine the patient’s right eye; use your left hand and left eye to examine the patient’s left eye.
Place your opposite thumb over the patient’s eyebrow to gain proprioceptive guidance as you move closer to the patient.
Ask the patient to look straight ahead and to fix his or her gaze on a distant point.
Brace the ophthalmoscope firmly against your face, with your eye directly behind the sight hole.
Position yourself 15 inches away from the patient and 15 degrees lateral to his or her line of vision. Shine the light beam on the patient’s pupil and note the red reflex. Absence of a red reflex suggests a lens opacity, such as a cataract.
With both of your eyes open and keeping the light beam focused on the red reflex, move horizontally at a 15-degree angle slowly toward the patient. When you are approximately 1.5 to 2 inches (3 to 5 cm) from the patient, the optic disc or blood vessels should come into view (Fig. 10-2). Rotate lenses with your index finger until fundic structures are as clearly visible as possible.
To overcome corneal reflection (light reflected back into the examiner’s eye), direct the light beam toward the edge of the pupil rather than through its center.
Examine the optic disc, a yellowish-orange to creamy pink oval or round structure. If you do not see the disc, follow a blood vessel centrally (by noting the angles of vessel branching and the progressive enlargement of vessel size toward the disc) until it is visible. Assess disc border clarity (nasal margin may be normally somewhat blurred) and color.
Identify the retinal arteries and veins using the differential criteria of color, size, and light reflex (or reflection; Fig. 10-3A). Arteries and veins appear to originate from the physiologic cup, a small, white depression in the optic disc. Arteries are light red, are two thirds to four fifths the diameter of veins, and have a bright light reflex. Veins are dark red, are larger than arteries, and have an inconspicuous or absent light reflex. Follow the vessels peripherally in all directions, noting the character of the arteriovenous crossings. To examine the extreme periphery, instruct the patient to look up, down, temporally, and nasally.
Assess the retina for any lesions, noting size, shape, color, and distribution. Optic disc edema (swollen optic disc with blurred margins) is present in patients with increased intracranial pressure, retinal venous outflow obstruction, inflammation, or ischemia (Fig. 10-4).8 Beading (abnormal constriction) of a retinal vein is common in diabetic retinopathy. With high blood pressure, thickening of the walls and narrowing of the lumen of retinal arteries develop. These changes are observed as focal narrowing, a narrowed column of blood, and a narrowed light reflex (Fig. 10-3B). If opacity is such that no blood column is visible, the artery appears as a silver wire artery (Fig. 10-3C). With increased filling and tortuosity, arteries closest to the optic disc manifest an increased light reflex and are known as copper wire arteries (Fig. 10-3D). Arteriovenous crossings also are affected by thickening of the artery walls, demonstrated by tapering of the vein on either side of the artery (Fig. 10-3E), arteriovenous nicking (abrupt cessation of the vein on either side of the artery; Fig. 10-3F), or banking of the vein (venous twisting distal to the artery, forming a dark, wide knuckle; Fig. 10-3G).8,17
 ▪ Figure 10-1 Eye changes suggestive of hyperlipoproteinemia. (A) Corneal arcus. (B) Xanthelasmas. |
 ▪ Figure 10-2 Funduscopic examination of retinal structures. |
 ▪ Figure 10-3 Vascular changes associated with high blood pressure. (A) Normal. (B) Spasm and thickening of arteriolar walls. (C) Silver wire arterioles. (D) Copper wire arterioles. (E) Venous tapering. (F) Arteriovenous nicking. (G) Venous banking. |
 ▪ Figure 10-4 Papilledema. The optic disc is swollen, its margins are blurred, and the physiologic cup is not visible. |
Red spots in the retina may be due to hemorrhage or microaneurysms, which can be associated with hypertension, diabetes, or a number of other conditions.8,17 Roth’s spots, hemorrhages with white centers, occur with subacute bacterial endocarditis and leukemia.8,17 Cotton wool patches are white or gray and have large irregular shapes and fuzzy borders (Fig. 10-5A). They occur with hypertension and are seen frequently in patients with AIDS. Hard exudates are small, creamy white or yellow lesions with well-defined borders (Fig. 10-5B). They occur frequently in clusters and are indicative of diabetes, hypertension, and other conditions.8 Abnormalities of the fundi are difficult to see, require much practice, and may require eye drops to dilate the pupil.
Arterial Pulse
Information about pulse rate, rhythm, amplitude and contour, and obstruction to blood flow is obtained from palpation of the arterial pulse. Pulses should be evaluated at baseline, before and after vascular procedures that might impair blood flow, and with the onset of any symptom associated with reduced peripheral flow or ischemia. On initial examination, both carotid, both radial, both femoral, both tibial, and both dorsal pulses should be assessed.
Pulse Rate and Rhythm
Pulse rate and rhythm commonly are assessed in the radial artery. However, in certain clinical situations, such as shock (with very low-amplitude or absent peripheral pulses) or during cardiac arrest (when information about central blood flow is essential), pulses should be assessed in the more centrally located carotid artery.
Pulse Rate.
The pulse rate at rest usually is between 60 and 100 (average of approximately 70) pulsations per minute. A lower resting heart rate is common in athletes. Conditions or activities such as exercise, fever, and stress increase the pulse rate. Hypothermia, certain drugs, and heart blocks, for example, decrease the pulse rate. Each pulse wave is indicative of a cardiac contraction. However, each cardiac contraction does not necessarily result in a peripheral pulse. In patients with heart disease, pulse rate may be slower than heart rate because not all cardiac contractions perfuse the periphery. Extremely fast heart rates, such as atrial fibrillation with a rapid ventricular response or premature supraventricular or ventricular contractions, have shortened diastolic filling times, resulting in reduced stroke volume and, therefore, diminished or absent pulses. For this reason, pulse rate should not be recorded from the heart rate display on the cardiac monitor or counted from an electrocardiographic strip.
 ▪ Figure 10-5 Light-colored spots in the retina. (A) Cotton wool patches. (B) Hard exudates. |
Using the pads of the index and middle fingers, compress the artery until maximum pulsation is detected. Count the rate. If regular, count for 15 seconds and multiply by 4; if irregular, count for a full minute, noting the variations in rhythm and amplitude.
In all cardiac patients and in any patient with an irregular heart rate, simultaneously auscultate the apical rate and palpate the peripheral rate (apical-radial rate); record both rates. It is important that the apical-radial rates be counted during the same minute. If the apical-radial difference is very large, if the rate is very fast, or if the examiner is not yet skilled, it may be helpful to have two people count for the same minute.
Pulse Rhythm.
Pulse rhythm is normally regular. Physiologic variation can occur with respiration. During inspiration, blood flow to the right heart is increased, right ventricular output is enhanced, and pulmonary venous capacitance is increased. Consequently, blood flow to the left heart is reduced, causing a drop in left ventricular stroke volume. Cardiac output is maintained by a compensatory increase in heart rate (mediated by the baroreceptors). During expiration, the large amount of blood residing in the
pulmonary vascular bed during inspiration reaches the left heart. Left ventricular contractility is enhanced by means of the Frank-Starling mechanism, increasing left ventricular stroke volume. Because an increased heart rate is no longer needed to maintain cardiac output, the heart rate returns to baseline. This physiologically irregular rhythm is termed sinus arrhythmia. It is common in people younger than 40 years of age. Other irregular rhythms are not normal. The irregularity should be described as regularly irregular (e.g., every other pulse wave is early) or irregularly irregular (e.g., atrial fibrillation). Occasional, early pulsations that are perceived as transient skips or breaks in an otherwise regular rhythm are common and are not necessarily abnormal.
pulmonary vascular bed during inspiration reaches the left heart. Left ventricular contractility is enhanced by means of the Frank-Starling mechanism, increasing left ventricular stroke volume. Because an increased heart rate is no longer needed to maintain cardiac output, the heart rate returns to baseline. This physiologically irregular rhythm is termed sinus arrhythmia. It is common in people younger than 40 years of age. Other irregular rhythms are not normal. The irregularity should be described as regularly irregular (e.g., every other pulse wave is early) or irregularly irregular (e.g., atrial fibrillation). Occasional, early pulsations that are perceived as transient skips or breaks in an otherwise regular rhythm are common and are not necessarily abnormal.
Pulse Amplitude and Contour
Pulses are described in a variety of ways. The simplest classification is absent, present, and bounding. A 0-to-4 scale is often used, and pulses are graded as follows: absent (0), diminished (1+), normal (2+), moderately increased (3+), and markedly increased (4+).18 This scale is fairly subjective, and, although an individual tends to be internally consistent over time, different people may grade the same pulse differently. There are also other scales in which the numbers are defined differently.
The amplitude of an arterial pulse is a function of the pulse pressure, which is related to stroke volume, elasticity of the arterial tree, and velocity of left ventricular ejection. Increased stroke volume, as occurs with exercise or excitement, results in increased amplitude and a bounding arterial pulse.
Small, weak pulses (Fig. 10-6B) have a diminished pulse pressure, which is indicative of a reduced stroke volume and ejection fraction and of increased systemic vascular resistance.
Large, bounding pulses result from an increased pulse pressure (Fig. 10-6C). Increased pulse pressure is caused by increased stroke volume and ejection velocity and by diminished peripheral vasoconstriction. Corrigan’s pulse is a bounding pulse visible in the carotid artery. It occurs with aortic regurgitation.
The amplitude of a pulse contributes to its contour, but contour refers to the rate of rise and the shape of the arterial pulse. Because of the distortion that occurs when the pulse wave is transmitted peripherally, pulse contour is best assessed in the carotid arteries. The normal pulse contour has a rapid and smooth upstroke. The dicrotic notch is not palpable (Fig. 10-6A), although the dicrotic wave (Fig. 10-6I) may be palpable in heart failure and in febrile states.18 Usually it is palpable only in the peripheral arteries.
Pulsus bisferiens (Fig. 10-6D) is characterized by a rapid upstroke and double systolic peak. This pulse may be present in idiopathic hypertrophic subaortic stenosis, aortic stenosis with regurgitation, and pure aortic insufficiency.
Pulsus alternans (Fig. 10-6E) is a regular rhythm in which strong pulse waves alternate with weak ones. It is an ominous sign when it occurs at normal heart rates and suggests serious heart disease. The difference in amplitude may be slight and difficult to palpate. The presence of pulsus alternans can be confirmed with a sphygmomanometer. The cuff is inflated above systolic pressure and slowly released until the first heart sound is audible. Cuff pressure is held at this point, and the pulse is palpated to determine if every pulse is audible.
Bigeminal pulses (Fig. 10-6F), which should not be confused with pulsus alternans, are caused by a bigeminal, premature ectopic rhythm. Note that every other pulse wave is not only diminished but is early.
 ▪ Figure 10-6 Normal and abnormal pulses. (A) Normal. (B) Small and weak. (C) Large and bounding. (D) Bisferiens. (E) Pulsus alternans. (F) Bigeminal. (G) Pulsus paradoxus. (H) Parvus et tardus. (I) Dicrotic. |
Pulsus paradoxus (Fig. 10-6G) is the reduction in strength of the arterial pulse that can be felt during abnormal inspiratory decline of left ventricular filling. However, it is more apparent and can be quantified if sphygmomanometry is used. (Refer to the discussion of the determination of paradoxical blood pressure below.)
Pulsus parvus et tardus (Fig. 10-6H) is found in severe aortic stenosis. It resembles the double systolic beat in pulsus bisferiens, but its upstroke is more gradual and the pulse pressure is smaller. Usually it is palpable only in the carotid artery.
Carotid Pulse.
The carotid artery is best for assessing pulse-wave amplitude and contour. Observe the neck for pulsations. Carotid pulsations are visible bilaterally just medial to the sternocleidomastoid muscle. Place your fingertips along the medial border of the sternocleidomastoid muscle in the lower half of the neck. Press posteriorly to feel the artery. Palpate well below the upper border of the thyroid cartilage to avoid compressing the carotid sinus, which might result in a reflex drop in heart rate or blood pressure. Compare one side with the other, but do not palpate both sides simultaneously because brain blood flow might be interrupted. Using the side with the strongest pulsations, assess the amplitude and contour of the pulse wave and determine whether it occurs in early systole or has a delayed upstroke.
Peripheral Circulation.
In the legs, assess femoral, popliteal, dorsalis pedis, and posterior tibial pulses (Fig. 10-7). The popliteal pulse is not directly palpable; only the transmitted pulsations can be detected. Pedal pulses should be assessed in a dependent position before determining that they are absent.18 In the arms, assess brachial, radial, and ulnar pulses. When assessing peripheral circulation, always compare one side with the other. An Allen test should be performed before radial arterial cannulation to evaluate radial and ulnar arterial patency. Simultaneously compress the radial and ulnar arteries and ask the patient to make a fist. The hand blanches. Ask the patient to open his or her fist. Release the pressure from the ulnar artery while maintaining pressure on the radial artery. The hand color returns to normal if the ulnar artery is patent. Repeat the process releasing pressure from the radial artery. If dual circulation to the hand is not present, do not attempt radial arterial puncture or cannulation.
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