Cardiovascular System Assessment

In this article we will learn how to gather the patient's health history concerning the heart and peripheral vascular systems, conduct a physical examination of the heart and peripheral vascular system using appropriate techniques, and record the results of the cardiac and peripheral vascular assessment.

I. Overview of the Cardiovascular System 

The cardiovascular system assessment involves examining the peripheral vascular system by evaluating color, temperature, swelling, capillary refill, and peripheral pulses. It also includes examining the heart through inspection, palpation, and auscultation of specific heart landmarks.

II. Step-by-Step Assessment

• Wash hands thoroughly.
• Assess room for necessary contact precautions.
• Introduce yourself to the patient.
• Verify patient identity using two identifiers (e.g., name and date of birth).
• Explain the assessment procedure to the patient.
• Prepare all required equipment before beginning the examination.
• Conduct the assessment in an orderly and methodical manner.
• Employ effective listening and questioning techniques.
• Attend closely to any cues provided by the patient.
• Respect patient privacy and maintain dignity throughout.
• Adhere to principles of cleanliness (asepsis) and safety.
• Record vital signs.

Steps	Additional Information
1.Conduct a targeted interview regarding cardiovascular and peripheral vascular conditions.	Inquire about symptoms such as chest discomfort, irregular heartbeat (palpitations), difficulty breathing (dyspnea), cough, swelling, fatigue, known cardiac risk factors, leg discomfort, changes in skin condition, limb swelling, past medical history, and diabetes history.
2. Inspect: Face, lips, and ears for cyanosis, pallor Chest for scars, deformities, and visible pulsations Both arms/hands, noting color, temperature, moisture, movement, sensation (CTMMS), edema, nail beds, nail shape, and capillary refill Both legs, noting CTMMS, hair distribution, edema, nail beds, and capillary refill, numbness/tingling Calf size/pain for signs of deep venous thrombosis (DVT)	Cyanosis indicates reduced blood flow and oxygen levels. To assess capillary refill, press on the fingernails or finger pads until they blanch; release and note how quickly the original color returns. Normal capillary refill is within 2 seconds. Evaluate capillary refill on both lower legs. Assess capillary refill bilateral lower legs Changes and discrepancies in color, warmth, movement, and sensation (CWMS) may suggest underlying conditions or injury. When assessing capillary refill, also examine the angle of the nail base. Normally, the angle of the nail base is about 160 degrees. Clubbing of the fingers occurs when this angle increases beyond 160 degrees, often associated with chronic oxygen deprivation (hypoxemia). Clubbing fingers The sudden onset of severe, sharp muscle pain worsened by dorsiflexion of the foot suggests deep vein thrombosis (DVT), along with increased warmth, redness, tenderness, and swelling in the calf. Assess calf for CWMS Note: Immediate referral is necessary for deep vein thrombosis (DVT) due to the potential risk of developing a pulmonary embolism.
3. Auscultate: Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral Auscultate apical pulse for one minute. Note the rate and rhythm.   Source: Heart sounds - wikidoc	Instruct the patient to breathe normally. Use the diaphragm side of the stethoscope to auscultate the five landmark areas: Aortic – 2nd ICS on the right sternal border. Pulmonic – 2nd left ICS ERB’s Point – 3rd left ICS Tricuspid– 4th left ICS (for children 4th or 5th left ICS) Mitral Area – 5th left ICS medial to the MCL Auscultate for rate, rhythm, and pitch (the quality of the sound). Auscultate apical pulse at the fifth intercostal space and midclavicular line. Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.
4. Palpate: Inspect and palpate of the heart Bilateral radial, brachial, dorsalis pedis, and posterior tibialis pulses. Skin turgor edema (Tip from CNC on palpating pulses- Pulses are felt best when the artery is pressed against a bone, example radial pulse felt best when pressed against the radial bone, dorsalis pedis artery felt best when you palpate at the roundest curve of the dorsum of the foot, carotid pulse felt best at the angle of the jaw but palpate for only 5 to 10 seconds)	The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. Inspect and palpate for: Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow. The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded).  Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place. To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema. Source: Pitting Edema Assessment: Physical Exam (ebmconsult.com)    No clinical edema = 0 2-4 mm indentation = 2+ edema 4-6 mm indentation = 3+ edema 6-8 mm indentation = 4+ edema
5. Report and record assessment findings and associated health issues following organizational protocols.	Accurate and timely documentation and reporting promote patient safety.