10 Helpful Tips for Performing a Nursing Assessment of the
Nurses routinely perform a complete head-to-toe assessment on their patient. However, sometimes it becomes necessary to focus on one system. Occasionally, patients may present with a symptom that does not appear to relate to the cardiovascular system. This symptom can still be a clue. Knowing those possible symptoms and how to assess those symptoms are important to know. This is where a nursing assessment of the cardiovascular system becomes useful.
For a patient admitted with possible symptoms of a cardiovascular problem, the cardiovascular nursing assessment is important. So, performing a good nursing assessment of the cardiovascular system is a helpful tool for the nurse to have in their arsenal.
It is important to have a good understanding of anatomy and physiology. Review your anatomy and physiology before you practice your assessment skills. During an assessment, the nurse will use the skills of inspection, auscultation, and palpation. Learning how to perform a nursing health assessment takes practice. A nursing assessment of the cardiovascular system can encompass a lot of steps. Therefore, this article contains 10 helpful tips for performing a nursing assessment of the cardiovascular system to get you started.
Tip #1: Know the Landmarks
The landmarks of the chest (thorax) include the ribs, clavicle, manubrium, Angle of Louis, the body of the sternum, and xiphoid process. There are twelve (12) pairs of ribs. There are seven (7) true ribs and five (5) false ribs. The manubrium provides a place for the first rib and clavicle to attach to the sternum. The Angle of Louis is the joint between the manubrium and the body of the sternum. The body of the sternum is just below the manubrium. And the xiphoid process is the lowest bone of the sternum. The nurse can easily palpate the manubrium, the body of the sternum, and xiphoid process in some people.
There are several terms to become familiar with related to the landmarks of the chest (thorax). First, is the term costal which refers to the ribs. Next, is the intercostal space. This is the area between the ribs. Some additional terms to know include the left sternal border (LSB), right sternal border (RSB), and the midclavicular line (MCL). The right and left sternal borders are the right and left edges of the sternum. The midclavicular line is an imaginary line drawn down the middle of the right or left rib cage. The midclavicular line is sometimes called the nipple line.
Use the technique of palpation to become familiar with the intercostal space. First, find the clavicle. The first rib is immediately below the clavicle. Therefore the first intercostal space is located below the first rib. There are five landmarks on the chest (thorax) that are helpful to know. These landmarks extend from the second intercostal space to the fifth intercostal space. It is helpful to practice palpating the first through the fifth or sixth ribs and intercostal spaces. Also, practice palpating the sternum and the sternal borders. The five landmarks include:
- The second intercostal space right sternal border (2nd ICS, RSB)
- The second intercostal space left sternal border (2nd ICS, LSB)
- The third intercostal space left sternal border (3rd ICS, LSB)
- The fourth intercostal space left sternal border (4th ICS, LSB)
- The fifth intercostal space midclavicular line (5th ICS, MCL)
Tip #2: Assess Vital Signs
A good set of vital signs are important for any patient but especially for a patient with cardiovascular symptoms or complications. Always take a full set of vital signs including blood pressure, heart rate (pulse, apical pulse), respiratory rate and temperature. It is usually a good idea to take a manual blood pressure when a patient is experiencing cardiac symptoms. Also, obtain a weight unless a baseline weight has already been taken.
Also, take an orthostatic blood pressure. An orthostatic blood pressure should include the heart rate and blood pressure in the standing, sitting and lying position. Be sure to be efficient with measuring and the charting of your findings especially if they are baseline measurements. If your measurements are not the baseline measurements, compare them to the baseline measurements.
Tip #3: Interview the Patient for Cardiac Symptoms
Your patient can be your greatest source of information to assist in the diagnosis of a problem. In a focused nursing assessment of the cardiovascular system, it is important to gather information about symptoms and behaviors that may affect the cardiovascular system directly or indirectly.
The subjective data or the interview of your patient is just as important as the objective data or the physical examination. Some of the more common cardiac symptoms include chest pain, angina, and palpitations or irregular heartbeat. However, there are other symptoms that affect different parts of the body that may have a cardiovascular origin.
It is important for the nurse to be aware of all symptoms related to the cardiovascular system. Ask the patients questions related to the cardiac system and any other symptoms that they may have.
Gather a Heath History Related to the Cardiovascular System
To begin, the obvious questions would relate to a history of cardiovascular disease. This includes things like congenital problems, stroke, previous cardiac incidents (myocardial infarction, etc), hypertension, and peripheral vascular disease to name a few. The cardiac history can give a wealth of information about the problems the patient is having. Also, ask about any cardiac procedures the patient has had.
Next, ask about medications. For instance, a patient with a cardiac history may be on an anticoagulant, antihypertensive, antihyperlipidemic agent or a diuretic. Be sure and get a list of prescription medication your patient is taking. And don’t forget the herbal medications or supplements.
Finally, ask the patient about their lifestyle. Health patterns are important when assessing a patient with cardiovascular symptoms. Here are a few points to assess. These questions are not all-inclusive. Your textbook will have a more inclusive list of questions.
- Assess the patient’s diet or nutritional status. What do they eat? Do they know how much sodium they intake? How much water do they drink in a day? Have they had an unplanned weight change recently?
- Assess the patient’s health practices. Ask them if they exercise regularly? Do they fatigue easily? Are they able to perform activities of daily living? Do they use tobacco? If so, ask them what type, how much, and how long?
- Assess the patient’s elimination practices. Do they take medication for excess fluid? Ask about bowel elimination?
- Ask the patients about themselves and significant others. What is their job? Ask the patient about role responsibilities? What are their family responsibilities? Ask the patient if they are still able to perform their responsibilities at work and home? Ask the patient about stress, coping, values and beliefs.
Remember, when interviewing patients, practice good communication skills. Don’t approach the patient with a laundry list of questions. You will get a more thorough assessment by being conversational.
Activity and Precipitating Factors.
If a patient is suffering from cardiovascular symptoms, it is important to ask the patient what they were doing when the symptom began. Was the patient exerting themselves? Was the patient doing something strenuous that they do not routinely do?
It’s important to find out if the patient is normally active or sedentary. Also, ask the patient if they exercise or have they begun a new exercise program? If they exercise, ask them how long and what type of exercise they perform? Finally, ask the patient if their exercise tolerance has gotten better or has it declined?
Tip #4: Assess Pain and Other Symptoms
Assess Chest Pain
Chest pain can come in many different forms. Also, chest pain can be described as pressure or tightness. Likewise, the patient can complain of indigestion, burning, or numbness. Cardiovascular pain is usually located mid to left sternum but can radiate to the jaw, shoulder, neck, or arm. And, some people especially women have atypical chest pain that may not radiate or take on the characteristics of familiar symptoms. The cardiac symptoms could be as elusive as back pain in some women.
With symptoms like chest pain, it is important to know the location of the chest pain. Have the patient point to the pain. Ask the patient if the pain radiates, if so where? Then, ask the patient if they have had any additional episodes of chest discomfort prior to this episode?
Further, always use a pain scale to assess the severity of the pain. And, ask the patient to describe the quality of the pain.
- Ask the patient if there are any other symptoms that are associated with the pain?
- What was the patient doing when the pain started?
- Ask the patient to describe the quality of the pain?
- Is the pain sharp, dull, burning or feels like pressure?
- Does the pain come and go throughout the day, when they eat or occasionally?
- Ask the patient if anything relieves the pain?
Palpitation is another symptom. A palpitation is an irregular heartbeat that feels like a sensation in the throat or chest. It may feel as if the heart has skipped a beat or speeds up for a second. Ask the patient if they have experienced these symptoms. It is ok to assist the patients in describing symptoms or to give them cues. They did not take a health assessment class. Ask the usual questions.
- How long have they had this symptom?
- When does it happen?
- Does it happen more when they are active or inactive, etc?
Assess Symptoms Affecting Other Parts of the Body
When assessing a patient it is important to think outside the box. It’s better to have too much information instead of not enough. If a patient has vague cardiac symptoms, move away from cardiac symptoms and assess for those symptoms that may alert you to a cardiac problem.
Some additional problems a patient may have include edema, cyanosis, hypotension and respiratory symptoms.
Edema is when fluid accumulates in the tissue. This can be related to increased filling pressures in the heart during the cardiac cycle. Hence, a patient can experience edema of the extremities or the eyes. Both are a symptom of possible cardiac dysfunction. Also, inspect the extremities for stasis ulcers. A stasis ulcer can be due to venous congestion or circulatory problems.
Then, inspect the skin observing the color. Discolorations such as cyanosis can be due to decreased oxygenation causing decreased tissue perfusion. The decrease in oxygenation can be due to decreased cardiac output. Consequently, cyanosis can be visible on the lips as well as the periphery.
In addition, a patient may experience hypotension. This can be due to decreased fluid volumes or cardiovascular medications such as antihypertensives and diuretics. With hypotension, a patient may experience lightheadedness and syncope.
Respiratory symptoms can be a sign of cardiovascular problems. Therefore, assess for signs of fatigue or dyspnea. Also, check the nails for clubbing. Clubbing is related to decreased oxygenation or a decreased blood supply to the cells over an extended period of time.
Tip #5: Assess the Vessels of the Neck
The neck vessels include the jugular veins and the carotid arteries. The jugular veins drain blood from the face, head, and neck and empty into the superior vena cava. The jugular veins are an assessment tool to measure central venous pressure (CVP) or right atrial pressure. Monitoring right atrial pressure gives an idea of fluid balance in the body.
Inspect the Jugular Veins
Inspect for the internal jugular veins and the external jugular veins. The internal and external jugular veins are usually not visible in most patients. Use inspection to look for any distention. The patient should be elevated to about a 45-degree angle. The jugular veins are usually flattened and disappear at this angle. This is a normal finding. The veins will become distended with an increased in central venous pressure.
Palpate the Carotid Arteries
Use palpation to assess the carotid artery. The carotid artery is located on each side of the neck lateral to the trachea. The patient should be at a 45-degree angle. Use the fingertips to palpate the carotid artery. Remember to apply gentle pressure. Applying too much pressure may occlude the pulsation. You should be able to palpate a pulse on each side. Palpate only one carotid artery at a time. An absence pulse may indicate an obstruction.
Next, assess the carotid artery for a thrill or bruit.
Tip #6: Feel the Thrill – Auscultate the Bruit
Some students may be familiar with a thrill and a bruit as it relates to dialysis patients that have a graft or AV shunt. This is a great patient to practice feeling a thrill and auscultating a bruit.
When performing a nursing assessment on the cardiovascular system, you will use palpation and auscultation to assess the carotid arteries for a thrill and a bruit. The thrill is a vibration against your fingers. It can feel like a buzzing or humming under the skin. Use the same method as palpating the carotid arteries. If you feel a thrill, listen for a bruit.
As a result of hearing a thrill, you should listen for a bruit. Use a stethoscope to auscultate a bruit. A bruit sounds like rushing fluid in a rhythm. It can sometimes sound like a fetal heart tone. Turbulent blood flow causes a bruit. Normally, a patient should not have a carotid thrill or bruit.
To auscultate a bruit, have the patient hold their breath and listen with the bell of the stethoscope midpoint of the carotid artery.
Tip #7: Inspect and Palpate the Chest (Thorax)
Inspect the Chest
Inspect the chest for pulsations. Look for pulsations at the five landmarks. Inspect the chest with the patient in a high, mid and low Fowler’s position. First, observe the second intercostal space at the right sternal border. Next, move to the second intercostal space at the left sternal border. Then, inspect the third and fourth intercostal space at the left sternal border. Finally, move to the fifth intercostal space at the midclavicular line where the apex of the heart is located. This is the point of maximal impulse. Covered below is the assessment of the apical pulse and point of maximal impulse.
Inspect the chest for rises or lifts at those landmarks or anywhere else. These pulsations are called heave or lifts. You can visualize or palpate a heave or a lift.
Palpate the Chest
Next, palpate the chest. Feel for pulsations over the five landmarks. Place the patient in a high, mid or low Fowlers position to palpate the chest wall. Use the fingerpads or the palm of the hand to palpate the chest wall. You are feeling for pulsations, lifts or heaves.
First, feel over the second intercostal space at the right sternal border. Next, move to the second intercostal space at the left sternal border. Then, palpate the third and fourth intercostal space at the left sternal border. There should be no pulsations present at these landmarks.
Finally, move to the fifth intercostal space at the midclavicular line where the apex of the heart is located. When you palpate at this location you should feel a slight tapping sensation. This tapping sensation coincides with the heartbeat. This is the apical pulse. The apical pulse should be the only pulsation felt on the chest wall.
Tip #8: Assess the Point of Maximal impulse – Apical Pulse
Although apex means peak, the apex of the heart is at the bottom. The base is the top. The apical pulse is located at the fifth intercostal space midclavicular line. This is also called the point of maximal impulse (PMI). Also, the mitral valve can be auscultated at this location.
Note the location and characteristics of the apical pulse. An enlarged heart and pregnancy can displace the apical pulse. During a cardiovascular assessment, it would be a good idea to count the heart rate by auscultating the apical pulse with your stethoscope and compare to peripheral pulse.
Tip #9: Auscultate the Chest
Use the stethoscope to auscultate the chest for the apical pulse. Note the rate, rhythm, and any extra heart sounds. The rate will be normal (60-100), fast (tachycardia >100), or slow (bradycardia <60). The rhythm will be regular or irregular.
Next, auscultate over the five landmarks of the chest.
- First, auscultate the aortic valve. This is located at the second intercostal space right sternal border.
- Second, auscultate the pulmonary valve. It is located at the second intercostal space left sternal border.
- Third, auscultate Erb’s point. Erb’s point is located at the third intercostal space left sternal border.
- Fourth, auscultate the tricuspid valve. This is located at the fourth intercostal space at the left sternal border.
- Fifth, auscultation of the mitral valve. The mitral valve is located at the fifth intercostal space midclavicular line. This is the same placement as the apical pulse and the point of maximal impulse.
Next, auscultate the heart sounds. You are listening for S1 and S2 heart sounds. The closure of the heart valves produces the S1 and S2 heart sounds. Use the diaphragm of the stethoscope to hear these sounds the best. If you think your patient may have an extra heart sound (S3 or S4), use the bell of the stethoscope. Also, note any abnormal heart sounds.
Tip #10: Assess S1 and S2 Heart Sounds
S1 Heart Sound
The first heart sound is the S1 heart sound. This sound is heard best over the apex of the heart. The closure of the tricuspid and bicuspid (mitral) valve produces the S1 sound. The fourth intercostal space left sternal border is the location of the tricuspid valve sound. The fifth intercostal space left sternal border is the location of the bicuspid (mitral) valve sound. Therefore, this heart sound is heard the loudest over the fourth and fifth intercostal spaces or the apex of the heart.
The heart sound S1 is composed of the sounds M1 and T1. Consequently, the M1 sound is the closure of the bicuspid (mitral) valve. And, the T1 sound is the closure of the tricuspid valve. The mitral valve closes slightly before the tricuspid valve. Although there is a slight separation, both the M1 and T1 are heard as one sound (S1).
S2 Heart Sound
The second heart sound is the S2 heart sound. This heart sound is heard the loudest over the base of the heart. This sound is the closure of the pulmonary and aortic valve. Remember, the second intercostal space right sternal border is the location of the aortic valve sound. And, the second intercostal space left sternal border is the location of the pulmonary valve sound. Therefore, the S2 heart sound is the loudest over the second intercostal space at the left and right sternal borders or the base of the heart.
The combined A2 and P2 heart sounds produce the S2 heart sound The A2 sound is the closure of the aortic valve. The P2 is the closure of the pulmonary valve. The aortic valve closes slightly before the pulmonary valve. Even with the slight separation, both the A2 and P2 are heard as one sound (S2).
Correspondingly, the S1 and S2 heart sounds can be heard with equal intensity at the third intercostal space left sternal border. This location is Erb’s Point.
S3 Heart Sound
Depending on the diagnosis of your patient you may hear an additional heart sounds. One such heart sound is S3 heart sound. The placement of the S3 heart sound is after the S2 heart sound. It is sometimes hard to distinguish between an S3 heart sound and a split S2 heart sound. The split S2 heart sound is when the A2 and P2 sounds are separated enough to make a distention between the two.
An S3 heart sound can be normal or abnormal. You may hear an S3 heart sound in patients with heart failure, volume overload, and other conditions. When it is abnormal, a ventricular gallop is another name for the S3 heart sound.
The S3 heart sounds happen during ventricular filling in early diastole. Blood hitting the ventricle causes the S3 sound when it is overly compliant. Compliance refers to distensibility or expansion.
However, it is not easy to determine an S3 heart sound. It is better to assess the patient in a quiet room. The nurse should use the bell of the stethoscope. The apex of the heart is the best place to hear this sound. It is helpful to place the patient on their left side. The S3 heart sound is low and deep. Correcting the underlying condition causes the S3 heart sound to go away.
S4 Heart Sound
Another additional heart sound is the S4 heart sound. The placement of the S4 heart sound is immediately before the S1 heart sound. An S4 heart sound is usually abnormal. You may hear an S4 heart sound in patients with cardiovascular disease, high blood pressure, and other conditions. An atrial gallop is another name for an S4 heart sound.
The S4 heart sound happens during ventricular filling in late diastole. A patient with increased ventricular resistance will usually have an S4 heart sound.
In order to assess a patient with an S4 heart sound, place the patient in a quiet room. Use the bell of the stethoscope to auscultate. The S4 heart sound is even harder to auscultate than the S3 heart sound. Placing a patient on the left side helps auscultate the S4 heart sound better. The sound of the S4 is soft and low. The apex of the heart is the best location to hear the S4 heart sound.
A way to remember the placement of the normal and additional hearts sounds is:
S4 – S1 – S2 – S3
I am not really sure whether S3 lives in Kentucky or Tennessee or whether S4 does. I guess it depends on the part of the country you live.
There is additional heart sounds besides S3 and S4. While performing a nursing assessment for the cardiovascular system you may hear murmurs, clicks, or a split heart sounds. As assessment skills progress and with practice you will be able to distinguish more heart sounds. As a nursing student, hearing any other sound besides S1 and S2 is fabulous. Remember to trust what YOU hear. If you are not sure what you are hearing, find someone else to listen with you.
Overall, as with any nursing health assessment, learn and practice a pattern of assessment. Have a starting point and do it the same way every time. Remember that a focused assessment of any system can be done with a regular head-to-toe assessment. Perform a focused nursing assessment of the cardiovascular system any time there is a suspected cardiovascular problem.
In conclusion, this is just a few tips to improve your assessment skills of the cardiovascular system. With practice and knowledge, you will get better and better.
American Heart Association. (2018) Heart Attack Symptoms in Women. http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Heart-Attack-Symptoms-in-Women_UCM_436448_Article.jsp#.WuNSG6Qvz3g.
Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins.
Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc.
Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc.
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