CMHS

SCHOOL OF NURSING AND MIDWIFERY

DEPARTEMENT OF ADULT HEALTH NURSING
CVS Assessment

1
 Objective
At the end of this lesson learners will be able
to:
 understand the importance of CVS assessment
discuss CVS assessment with ‗Look, listen and feel
approach‘ and the components of basic CV assessment
Explain cardiac anatomy/physiology and the conduction
system of the heart.
 Recognize abnormal cardiovascular assessment findings
associated with inspection, auscultation, percussion, and
palpation.

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 Introduction

• Cardiovascular disease is the leading killer for both

men and women among all racial and ethnic groups in
the U.S.

• According to the CDC studies among coronary heart

disease patients, 90% of patients have had prior
exposure to at least one heart disease risk factor that
contributed to their disease (CDC, 2014).
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  Anatomy and physiology of
Cardiovascular system
The cardiovascular system is sometimes called
the circulatory system. It consists of the heart,
which is a muscular pumping device, and a
closed system of vessels called arteries, veins,
and capillaries.

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Anatomy of the heart

• The heart is a four-chambered hollow muscular

organ normally about the size of a fist.
• It lies within the thorax in the mediastina space
that separates the right and left pleural cavities.
• The heart is composed of three layers: a thin inner
lining, the endocardium; a layer of muscle, the
myocardium; and an outer layer, the pericardium. .

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 • The heart is covered by a fibro serous sac called
the pericardium. This sac consists of two layers:
the inside (visceral) layer of the pericardium (part
of the epicedium) and the outer (parietal) layer.
• A small amount of pericardial fluid
(approximately 10 to 15 mL) lubricates the space
between the pericardial layers (pericardial space)
and prevents friction between the surfaces as the
heart contracts

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• The heart is divided vertically by the septum.
• The inter atrial septum creates a right and left
atrium, and the inter ventricular septum creates a
right and left ventricle.
• The thickness of the wall of each chamber is
different.
• The atrial myocardium is thinner than that of the
ventricles, and the left ventricular wall is two or
three times thicker than the right ventricular wall.
• The thickness of the left ventricle is necessary to
produce the force needed to pump the blood into
the systemic circulation.
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 Valves of the Heart
• The heart has two types of valves that keep the
blood flowing in the correct direction.
• The valves between the atria and ventricles are
called atrioventricular valves, while those at the
bases of the large vessels leaving the ventricles
are called semilunar valves.
• The right atrioventricular valve is the tricuspid
valve.
• The left atrioventricular valve is the bicuspid, or
mitral, valve.
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 • The valve between the right ventricle and
pulmonary trunk is the pulmonary semilunar
valve.
• The valve between the left ventricle and the aorta
is the aortic semilunar valve.
• When the ventricles contract, atrioventricular
valves close to prevent blood from flowing back
into the atria.
• When the ventricles relax, semilunar valves close
to prevent blood from flowing back into the
ventricles.

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 Pathway of blood through heart
Both atria contract at the same time and both
ventricle contract at the same time
Heart work as two pump R & L
Pathway of blood through heart include three
circulation:
1. Pulmonary circulation
2. Systemic circulation
3. Coronary circulation

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 Pulmonary circulation
The Pulmonary circulation is the portion of the
cardiovascular system which Transports oxygen
depleted blood away from the heart to the lungs
and returns oxygenated blood back to the heart.

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• Oxygen deprived blood from the vena cava
enters the R A of the heart and flows through
the tricuspid valve into the right ventricle,
from which it is pumped through the
pulmonary semilunar valve into the pulmonary
arteries which go to the lungs.
• Pulmonary veins return the oxygen-rich blood
to the heart, where it enters the left atrium
before flowing through the mitral valve into
the left ventricle.
• Then, oxygen-rich blood from the left ventricle
is pumped out via the aorta, and on to the rest
of the body.

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 Systemic circulation

• Systemic circulation is the portion of the

cardiovascular system which transports
oxygenated blood away from the heart, to the
rest of the body, and returns oxygen-depleted
blood back to the heart.
• Systemic circulation is much longer than
pulmonary circulation, transporting blood to
every part of the body.

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 Coronary circulation
• The coronary circulatory system provides a
blood supply to the heart.
• It provides oxygenated blood to the heart ,
through R & L coronary artery

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CONDUCTION SYSTEM
For the heart to beat regularly in a rhythmic
sequence, electrical impulses follow a set pattern
through the conduction system of the heart.
The conduction system consists of the sinoatrial
node, atrioventricular node, bundle of His, bundle
branches and Purkinje fibers.

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 MECHANICAL SYSTEM
• Depolarization triggers mechanical activity.
• Systole, contraction of the myocardium, results in
ejection of blood from the ventricles.
• Relaxation of the myocardium, diastole, allows for
filling of the ventricles.
• Cardiac output (CO) is the amount of blood pumped
by each ventricle in 1 minute.
• It is calculated by multiplying the amount of blood
ejected from the ventricle with each heartbeat—the
stroke volume (SV)—by the heart rate (HR) per minute
(CO = SV x HR 4 – 7 L/min)
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  Stroke volume: amount of blood ejected
with each heartbeat
 Cardiac output: amount of blood pumped
by ventricle in liters per minute
 Preload: degree of cardiac muscle fiber
tension at end of diastole (prior to
contraction)
 Afterload: resistance that ventricles must
overcome to eject the blood
 Contractility: ability of cardiac muscle to
shorten in response to electrical impulse

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 Examination of the cardiovascular
system
• History
• Manifestation of CVS
• Clinical examination of the heart
• Special method of examination

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 History
• The purpose of the cardiovascular health history
is to provide information about a patient‘s
cardiovascular symptoms and how they
developed.
• A complete cardiovascular history will provide
indications to potential or underlying
cardiovascular illnesses or disease states

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• History of Present Illness Ask the patient
what problem has brought him or her to the
health care facility or provider. Fully explore
all symptoms the patient is experiencing
• Past Health History Many illnesses affect the
cardiovascular system directly or indirectly.
e.g anemia, rheumatic fever, streptococcal
throat infections, congenital heart disease, stroke
etc.

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• Family History is an important factor used in
identifying a patient‘s risk for certain
cardiovascular diseases.
• Current Lifestyle and psychosocial status
 Nutrition,
 Smoking
 Alcohol
 Exercise
 drugs

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 Assessment: Subjective Data
 Typical concerns expressed by client with
cardiac disorder are chest pain, dyspnea
(difficulty in breathing), edema, fainting,
palpitations, extremity change, and fatigue.

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 Symptom analysis
1. Chest pain
 Location- sub sternal, pericardial, localized
 Radiation-to jaw, arm, neck
 Character- dull, aching, burning, crushing
 Intensity-mild, moderate and sever(0-10 scale)
 Onset-sudden or abrupt
 Duration-1-10,more than 15 or continuous
 Precipitating factor- exercise, eating, emotion
 Reliving factor- rest, walking, drugs
 Accompanying symptoms-
dyspinea,syncope,fatigue,restlesness
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2. palpitation
3. syncope
syncopal attacks (dizziness) are another
symptoms that may signal cardiovascular
problem.
4. Edema
may be seen with right sided heart failure.
Pitting edema is depression in the skin from
pressure.

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5. Fatigue is associated with cardiovascular
disease.
6. Extremity change may be provide clues
about underlining cardiovascular disease.
Symptoms such as parenthesis (numbness,
tingling), coolness, and intermittent
caudation(pain in calves during ambulation)may
be associated with vesicular disease, coronary
heart disease, or cerebral vascular disease.

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 Dyspnea
 May occur with cardiac disease such as left side
CHF.
 Types
1. Exertional (when client participates in activity
and becomes short of breath).
2. Orthopnea (difficulty breathing when lying
down).
3. Paroxysmal nocturnal dyspnea (person suddenly
awakes, is sweating, and is having difficulty
breathing).

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 Assessment: Objective Data
A head-to-toe assessment of a cardiac client
should include assessments of:
• Skin.
• Neck veins.
• Respirations.
• Heart sounds.
• Abdomen.
• Extremities

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 Physical Examination
 Inspection
 Palpation
 Percussion
 Auscultation

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1. Skin- color, turgor temperature, moisture and
scar

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 Abnormal skin color
Pallor
indicates Anemia may exacerbate angina &
heart failure
Cyanosis
Bluish discoloration of skin & mucous
membranes due to decreased arterial O2
saturation, and reduced CO.

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 2. Inspection of Nail
Note- color shape, thickness, symmetry and adherence
Normal nail color is same variation of pink
Thickness generally is 0.3 to 0.65mm but it may be
thicker in men.

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 SCHAMROTHS WINDOW TEST

The normal angle

between nail & nail bed
– 160.

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Clubbing of the fingers is associated with
decreased oxygen.
In clubbing, the distal tips of the fingers
become bulbous, the nails are thickened hard,
and curved at the tip, and the nail bed feels
boggy when squeezed.
Separation from the nail bed produces a white,
yellowish, or greenish color on the non
adherent portion of the nail.

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 Capillary refill time
 is quickly test to assess the adequacy of
circulation in an individual with poor cardiac
out put. An area of skin is pressed firmly by
(say) a fingertip until it becomes white; the
number of seconds for the area to turn pink
again indicates capillary refill time.
Normal capillary refill takes around 2 seconds.

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3. NECK- inspection
• Use inspection to look for any distention.
• 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.
• Using penlight to cast a shadow on the neck vessels
may help you visualize the pulsation.

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• Inspecting the carotid artery and jugular venous
system
• With the patient in a supine position, inspect the
carotid and jugular venous systems in the neck for
pulsations.
• To visualize external venous pulsations, look for
pulsations in the supraclavicular area.
• To visualize internal venous pulsations, look for
pulsations at the suprasternal notch.
• Carotid have visible pulsation, jugular have
undulated wave.

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• Carotid not affected by respirations, jugulars
are.
• Carotid not affected by position, jugulars
normally only visible when client is supine.
• Large bundling visible pulsation in neck of at
supra sternal notch: HTN, Aortic stenosis,.

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 Inspection of Jugular Vein

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Measuring jugular venous pressure
• Position patient with the head of bed at 30 to
45 degree angle.
• Place a ruler vertically, perpendicular to the
chest at the angle of Louis(sternal angle).
• Identify the highest level of the jugular vein
pulsation; if unable to see pulsations, use the
highest jugular vein distention.

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 Cont.……
• Place another ruler horizontally at the point of
the highest level of the venous pulsation.
• Measure the distance up from the chest wall.
• The normal JVP is less than 3 cm.
• A central venous pressure can be estimated by
adding 5cm to the JVP.

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 Assess for hepatojugular reflex
• Apply pressure to the liver for 30 seconds
• Observe for a rise in the JVP
• Normally return to the previous level but not
hold to the previous level it indicates elevated
JVP (>4cm).
• Preferable position is supine position.

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Elevated jugular vein pressure: right-sided
congestive heart failure, constrictive
pericarditis, tricuspid stenosis, or superior vena
cava obstruction.

Low jugular vein pressure: Hypovolemia.

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 5- chest inspection
 Inspect the chest with the patient in a high,
mid and low Fowler‘s position.
 Look for pulsations at the five landmarks.
 Inspect any scar.
 Shape-Before commenting about chest shape,
look for spine abnormality
 Normal shape of chest – bilaterally
symmetrical
 Common abnormalities of shape - Barrel
shaped chest, Funnel shaped chest, Pigeon
chest.

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 Barrel chest
• Increased AP diameter.
• Normal in infancy &
aging.
• Seen in COPD.

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 Funnel chest

• Depression in lower portion

of sternum.
• Compression of heart &
great vessels may produce
murmurs.

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 Pigeon chest
• Sternum is displaced
anteriorly.
• ↑ AP diameter.
• The costal cartilages adjacent
to protruding sternum are
depressed.

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 Palpation
Palpation allows assessment of the neck for
tenderness, abnormal temperature, excessive moisture,
pulsations, or masses.
light palpation, press the skin about 1/2 inch to 3/4
inch with the pads of your fingers.
deep palpation, use your finger pads and compress the
skin about 1½ inches to 2 inches.
 palpate the chest, Feel for pulsations over the five
landmarks.

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 Use palpation to assess the carotid
pulse volume and character.
 apex beat
 parasternal heave
 any palpable pulsations in
precordial region
 thrills

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  General rule
• Fingertips – To feel pulsations,
• Base of fingers – Thrills,
• Base of hand – Heaves.

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 Assessment of pulse
Note-
• Rate, Rhythm, Volume, Amplitude ,Contour,
thrills and symmetry.
• Counted for 1 full min by palpating the artery.
 Normal pulse rate – 60-100/min.
 Sinus bradycardia - <60/min.
 Sinus tachycardia - >100/min
 Normal sinus rhythm - Regular

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 Causes
 Sinus Bradycardia
Physiological
 Athlets, children, Sleep.
Pathological
 Severe hypoxia, Hypothermia, Myxedema, Raised ,
& digoxin

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 Sinus Tachycardia
Physiological
 Infants, Emotions, & Exercise.
Pathological
Tachyarrhythmia, High output states,
Hypervolemia, Hypotension, Atropine, &
thyroxin

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 femoral pulse compared with radial
pulse

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 Palpating edema
• To determine the presence of pitting edema, the nurse
presses firmly with his or her thumb over the bony
surface.
• The severity of edema is described on a 5 point scale,
from 1to4 none to (very marked).
 None(0)
 Mild pitting(1+) -slight indentation on perceptible
swelling of the leg.
 Moderate pitting(2+) –indentation subsides rapidly
 Deep pitting(3+)-remains for a short time ,leg looks
swollen
 Very deep pitting (4+)-remains for along time,leg is
very swollen.

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 Percussion
 Percussion of the cardiac area provide ―Dull sound‖
because it‘s gas free organ

Abnormalities Of Percussion
 Increase of area of cardiac dullness
1. Cardiac hypertrophy or dilatation
2. Hydro or haemopericardium.
3. Pericarditis especially in late stage
4. Neoplasm
 Decrease of area of cardiac dullness
1. Pneumothorax
2. Hydrothorax
3. Pulmonary emphysema
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 Auscultation
chest piece of the stethoscope should pressed
firmly against the chest wall on the left side in
the 2-6th intercostal space beneath and above
the point of elbow joint.
Normal Heart Sounds:-Lubb dupp sound
• LUBB sound (Systolic sound ) Originated
from contraction of the ventricles and closure
of atrioventricular valve
• DUPP sound(Diastolic sound )Originated
from the closure of semilunar valves (aortic
and pulmonary)

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Diaphragm –midi and high frequency sound.
Bell –low frequency sound.
Normally hear closure of valves sounds for left
side of heart louder than right side of heart.

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 Characteristics of heart sounds
Heart sounds are described by :
1.Frequency (pitch) as high pitched or low pitched.
2.Intensity (loudness) - soft or loud.
3.Duration- very short for heart sounds: silent
periods are longer.
4.Timing -systole or diastole.

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 • S1 –closure of mitral and tricuspid valve.
• S2- closure of aortic and pulmonic valve.
• Low pitched sound S3, S4,mitral stenosis.
• Right second intercostal space-aortic valve.
• Left second ICS- pulmonic valve.
• Left lower sternal border- tricuspid valve.
• Apex-over apical impulse- mitral valve.
• Bruit sound on the carotid artery due to
turbulent blood flow.

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S3(called ventricular gallop) may be heard in
the tricuspid and mitral area during the early to
mid diastole following the S2 sound.
S3 is heard well when the client is in left
lateral recumbent position.
S4 (atrial diastolic gallop) may be heard in the
mitral and tricuspid valve area during the late
phase of diastole before S1 of the next cardiac
cycle.
S4 is heard well when the client is in supine
position.

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 Causes of S3
Physiological S3 Pathological S3
• Children • High output states
• Young adults • CHD – ASD, VSD,
• Athlets PDA
• Pregnancy • MR, TR, AR
• IHD
• Syst HTN
• Pulm HTN

Causes of S4
• Whenever atria has to contract forcefully.
• LVH
• Systolic HTN
• CAD
•
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 Auscultating the pericardium
Auscultate the apex

Note-rate, rhythm, extra sounds, or murmurs.

Note S1,S2,extra sounds or murmur.

Listen at each site with both the bell and the

diaphragm.

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 Murmurs and stenosis
A valve that does not close efficiently, results
in the back flow of blood (i.e., insufficiency or
regurgitation).
A valve that dose not open wide enough may
cause turbulent back flow secondary to
obstruction or narrowing (i.e., stenosis).

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MURMUR
• Series of auditory vibrations of variable intensity,
quality & frequency
• d/to turbulence caused by increased blood flow or
• d/to blood flow through a irregular / constricted
orifice.
• Described in the following way :-
 Pitch (High/Low pitched)
 Timing & character
 systolic / diastolic
 Area where it is best heard
 Intensity (Grading)
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 Abnormal findings
 Irregular rhythm- Arrhythmia
 Accentuated S1 – high-output states, mitral or tricuspid
stenosis.
 Diminished S1- first degree heart block, CHF, CAD.
 Variable S1 –Atrial fibrillation.
 S3,low pitched, early diastolic sound- CHF.
 S4, low pitched, late diastolic sound –CAD,HTN,MI.
 Auscultate the lung –coarse crackle sound indicates
pulmonary edema secondary to left ventricular failure.

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 Auscultation with Diaphragm Aortic area

•Auscultation with bell. Mitral area

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 Blood pressure
 rested for 15 minuets before recording.
 in a quiet room.
 not have consumed coffee/tea for the
preceding 1 hr.
 not have smoked 15 minuets before recording.
 not be on adrenergic stimulants.
 Normal BP: SBP – 100-140mmHg.
DBP - 60-90mmHg.

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 Blood Pressure Classification in
Adults
Category Systolic Diastolic
Normal <120 <80
Pre- 120-139 80-89
Hypertension
Stage I 140-159 90-99
Hypertension
Stage II > 160 > 100
Hypertension
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Special Methods Of
Examination Of The
Heart

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 Homan‘s sign
• Indicator of deep vein thrombosis (DVT).
• To test, nurse dorsiflexes the client‘s foot. If
there is pain in the calf or the leg or behind the
knee, the Homan‘s sign is positive and may
indicate the presence of a venous clot.

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 Disorders of the heart

Tachycardia Bradycardia Heart block

Other disorders

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 Bradycardia: Defined as:
• Sinus bradycardia is a heart rate of 60
beats/minute or less.
• Causes include myocardial infarction,
electrolyte imbalances, vagal stimulation, heart
block, drug toxicity, intracranial tumors, sleep,
and vomiting.

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 Tachycardia
• A sinus rhythm with a heart beat ranging from
100 to 150 beats/minute.
• Causes are exercise, emotional stress, fever,
medications, pain, anemia, thyrotoxicosis,
pericarditis, heart failure, excessive caffeine
intake, and tobacco use.

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 Hart block
Detected by E.C.G
Heart block means that defect or delaying or
inhibition or interruption in the conduction of
contractile impulse from pacemaker to the
ventricle
Types of heart block:
1. Sinoatrial heart block.
2. Atrioventincular heart block.
3. Branch bundle heart block.
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 Dysrhythmia: Defined as
• An irregularity in the rate, rhythm, or
conduction of the electrical system of the
heart.
• Symptoms include fainting, seizures, fatigue,
decreased energy level, exertional dyspnea,
chest pain, and palpitations.

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 Atrial Dysrhythmias
• Premature Atrial Contractions.
• Atrial Tachycardia.
• Paroxysmal Supraventricular Tachycardia.
• Atrial Flutter.
• Atrial Fibrillation

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 Ventricular Dysrhythmias
• Premature Ventricle Contractions.
• Ventricular Tachycardia.
• Ventricular Fibrillation.
• Ventricular Asytole

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 Inflammatory Disorders
• Inflammatory or infectious conditions of the
heart include:
– Rheumatic Heart Disease.
– Endocarditis.
– Myocarditis.
– Pericarditis.

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