Assessment of the Heart

and Peripheral
Vasculature
PREPARED BY: MARY HAZEL S. FACUNDO
What is Cardiovascular Assessment?
The cardiovascular examination is a portion of the physical
examination that involves evaluation of the cardiovascular
system. The exact contents of the examination will vary
depending on the presenting complaint, but a complete
examination will involve the heart, lungs, belly and the blood
vessels.
 2 Major Compartments of
Cardiovascular
Assessment

Precordium
1. Assessment of the
Precordium
Periphery
2. Assessment of the
Periphery
Considerations
•Assessment of the cardiovascular system
requires the use of inspection, palpation,
percussion, and auscultation.
•During each of the procedures, the nurse is
gathering objective data related to the
function of the heart as determined by the
heart rate and the quality and the
characteristics of the heart sounds.
Considerations
•In addition, the nurse observes for signs of
appropriate cardiac function in relation to oxygen
perfusion by assessing skin color and temperature,
abnormal pulsations, and the characteristics of the
client’s respiratory effort.
•Knowledge of normal parameter and expected
findings is essential in determining the meaning of
the data during a physical health assessment.
1. Instruct the client.

•Explain that you will be looking at the

head, neck, and extremities to provide
clues to cardiac function.
•Explain that you will ask the client to
sit up and lie down as part of the
examination.
1. Instruct the client.

•Explain that you will be touching the neck

and chest, as well as tapping on the chest
and listening with the stethoscope.
•Tell the client that none of the
procedures should cause discomfort but
assure the client that you will stop any
time if discomfort occurs or the
examination is causing fatigue.
2. Position the client.

Begin the examination with the client

seated upright with the chest exposed.
3. Inspect the client’s face, lips, eyes, ears, and scalp.

These structures can provide valuable clues to the

client’s cardiovascular health.
 Begin with the facial skin.
N: Skin color should be uniform
 3. Inspect the client’s face, lips,
eyes, ears, and scalp.

A: Flushed skin may indicate RHD

or presence of a fever.
A: Grayish under stones are often
seen in clients with CAD or those
in shock.
A: A ruddy color may indicate
polycythemia, or Cushing’s
syndrome (Excessive secretion of
ACTH by the pituitary gland)
Examine the eyes and the tissue surrounding the eyes
(periorbital area).

N: Eyes should be uniform and not have a protruding

appearance.
The periorbital should be relatively flat. No puffiness.

A: Protruding eyes are seen in hyperthyroidism. The excess

in hormone secretion results in high cardiac output, a
tendency toward tachycardia, and potential for CHF.
Periorbital puffiness may result from fluid retention
(edema) or valvular disease.
The sclera should be whitish in color.
N: The cornea should be without an arcus, which is a ring-
like structure.
A: A blue color in the sclera is often associated with
Marfan’s syndrome, a degenerative disease of the
connective tissue, w/c overtime may cause the ascending
aorta to either dilate or dissect, leading to abrupt death.

An arcus in young person may indicate

hypercholesterolemia, however, may be normal in African
descent.
N: The conjunctiva should be
pinkish in color. The eyelid is
smooth.

A: Xanthelasma are yellow

cholesterol deposits seen on the
eyelids and are indicative of
premature atherosclerosis.
Inspect the lips. Inspect the buccal mucosa, gums, and tongue for
cyanosis.

N: Should be uniform in color w/o any underlying tinge of blueness.

A: Blue – tinged lips may indicate cyanosis, which is often a late sign
of inadequate tissue perfusion.
Assess the general appearance of the face.
N: It should be uniform and flat.
A: Clients w/ Down syndrome may exhibit a
large protruding tongue, low – set ears, and
an underdeveloped mandible.
Children w/ Down syndrome often have
congenital heart disease.
Wide – set eyes may be seen in a child w/
Noonan’s syndrome, w/c is accompanied by
pulmonic stenosis.
Examine the head. Look first for the ability of the client to hold
the head steady.

N: Rhythmic head bobbing should not be present.

A: Head bobbing up and down in synchrony w/ the heartbeat is

characteristic of severe aortic regurgitation. This bobbing is
created by the pulsatile waves of regurgitated blood, w/c
reverberate upward toward the head
Assess the structure of the scalp and
the proportion of the skull to the face.
A: A protruding skull is seen in Paget’s
disease (rare bone disease).
Paget’s disease is also characterized
by a high cardiac output w/c may lead
to heart failure.
Examine the client’s earlobes.
N: Should be relatively smooth/o
presence of creases unless an
injury has been sustained.

A: Bilateral earlobe creases,

especially in young adult, are
often associated w/ CAD
4. Inspect the jugular veins.

Examination of the jugular veins can provide essential information

about the client’s central venous pressure and the heart’s pumping
efficiency.
With the client sitting upright, adjust the lamp to cast shadows on
the client’s neck. Tangential lighting is effective in visualizing the
jugular vessels.
Ensure that the client’s head is slightly turned away from the side
you are examining. Look for the external and internal jugular veins.
Note that the jugular veins are
normally visible when the client
sits upright.
The external jugular vein is
located over the
sternocleidomastoid muscle.
The internal jugular vein, w/c is
the best indicator of CVP, is
located behind this muscle,
medial to the external jugular
and lateral to the carotid artery.
Video on
how to https://www.youtube.com/watch?v=MZKSkVSbH8k
measure
JVP
5. Inspect the carotid arteries.

The carotid arteries are located lateral to the client’s trachea in a

groove that is medial to the sternocleidomastoid muscle.

With the client still lying at a 45 – degrees angle, inspect the carotid
arteries for pulsations.
N: Pulsations should be visible bilaterally.
A: Bounding pulses are not normal findings and may indicate fever.
The absence of pulsation may indicate an obstruction either
internal or external to the artery.
6. Inspect the client’s hands and fingers.
Confirm that the client’s fingertips are rounded and
even.
N: The fingertips should be relatively pink, w/ white
crescents at the base of each nail.
A: Fingertips that are clubbed bilaterally are
characteristic of Congenital Heard Disease .
Clubbing may be assoc. with long – term tobacco
smoking.
Thin red lines or splinter hemorrhages in the nail beds
are associated w/ infective endocarditis.
Fingertips and nails may be stained yellow when the
client is a smoker.
 Inspection and Palpation of the Arms
Inspect for:
◦ Capillary refill is an index of peripheral perfusion and cardiac output.
◦ Depress and blench the nail beds; release and note the time for color return.
◦ Normally 1 to 2 seconds.
Palpate both radial pulses:
◦ Symmetricity (equal force), rhythm, rate, elasticity.
◦ Grade the force (amplitude) on a fore-point grade:
◦ 0 – absent
◦ 1+, weak
◦ 2+, normal
◦ 3+, increased
◦ 4+, bounding
For ulnar pulse palpate along the medial site of the inner forearm.
Not palpable in healthy person.
Palpate the brachial pulses.
Palpate the epitrochlear lymph node
Modified Allen test: Normal 2 to 5 seconds
Assess for
Marfan’s
syndrome.
 7. Inspect the client’s chest.
Observe respiratory pattern.
N: Even, regular, unlabored, and with no retractions
A: Respiratory distress may be precipitated by various disorders. Ex. Pulmonary
edema is a severe complication of cardiovascular disease.

Observe the veins on the chest.

N: Evenly distributed and flat.
A: Dilated, distended veins indicate an obstructive process, as seen with
obstruction of the superior vena cava
Assessment of the Precordium
Inspection, palpation, and auscultation should be
performed in a systematic manner, using cardiac landmarks.
Percussion has limited usefulness because X-rays and other
diagnostic tests provide a more accurate information.
Cardiac landmarks are essential for accurate identification
of anatomical cardiac features that allows more robust and
accurate functional and structural analysis of the heart.
Cardiac Landmarks
Are the locations where the
heart sounds are heard best,
not where the valves are
located.
Assessment of the heart
should proceed from the
base of the heart to the apex
or from the apex of the heart
to the base.
General Approach to Heart Assessment

Explain Ensure Expose Place Stand

Explain to Ensure that Expose the Place the Stand to the
the patient the room is patient’s patient in patient’s
what you are warm, quiet, chest only as supine or right side.
going to do. and well lit. much as is sitting Light should
needed for position. come from
the the opposite
assessment. side where
you are
standing so
shadows can
be
accentuated.
Equipment

What do you see?

 Chest pain

Common or Palpitations
Concerning
Symptoms
(Health History) Shortness of Breath: Dyspnea, Orthopnea,
or Paroxysmal Nocturnal Dyspnea (PND)

Swelling or Edema
Inspect the entire chest for bulges and masses.
N: Intercostal spaces and clavicles should be even.
A: Bulges may indicate aneurysms. Masses may indicate obstructions or
presence of tumors.

Inspect entire chest for pulsations. Observe the client 1st in an upright position
and then at a 30 – degree angle. w/c is low to mid – Fowler’s position.
Observe for pulsations over the five key landmarks.
A: If entire precordium pulsates or shakes w/ every heartbeat, extreme valvular
regurgitation or shunting may be present.
 INSPECTION
Landmark Examination Normal finding Abnormal Pathophysiology
Aortic Place index finger on No visible pulsation Pulsation A pulsation may
the 2nd rib to the ICS indicate an aortic root
(to the right of the aneurysm.
sternum)

Pulmonic Lightly place index No visible pulsation Pulsation or bulge Pulmonary stenosis
finger on the 2nd ICS impedes blood flow
to the left of sternum from right ventricle to
the lungs, causing a
bulge.
Erb’s Lightly place index No visible pulsation Pulsation or systolic Left Vent. Aneurysm
finger on the 3rd ICS, bulge
left sternal border Retraction in the Erb’s Pericardial disease
Point
 INSPECTION
Landmark Examination Normal Finding Abnormal Pathophysiology
Tricuspid Lightly place index No visible pulsation Visible systolic Right ventricular
finger at the 5th ICS, pulsation enlargement
left of the sternal secondary to an inc.
border stroke volume
Mitral Lightly place index Apical impulse is Hypokinetic pulsation Conditions that place
finger on the 5th ICS generally seen in more fluid bet. Left
midclavicular line about half of adult ventricle and chest
population. (PMI – such as pericardial
point of maximal effusion.
impulse)
Hyperkinetic High-output states
such as mitral
regurgitation,
thyrotoxicosis, severe
anemia, & left-to-right
shunt
8. Inspect the client’s abdomen.

 Have the client lie flat, if possible.

Look for pulsations in the abdominal area
over the areas where major arteries are
located.
N: Pulsations may be visible in lean clients;
normally seen in the epigastric area.

A: Abnormal pulsations usually indicate

aortic aneurysm
9. Inspect client’s legs and skeletal structure.

Help the client in sitting position and inspect the legs for color and
hair distribution.
Ask the client to stand and observe skeletal structure for
deformities.

A: Patches of lighter color is often a sign of circulatory compromise

that has occurred overtime.
Scoliosis is associated w/ mitral valve prolapse
Palpation
Palpate cardiac landmarks for:
1. Pulsations using the finger pads
2. Thrills (vibrations) using the
palmar surface of the hand at the
base of the fingers (ball of the hand)
3. Heaves (lifts) using ball of the
hand
 Palpation
Landmark Examination Normal Findings Abnormal Pathophysiology
Aortic Palpate area for No pulsation, thrills, Thrill Aortic
pulsation, thrills, and and heaves stenosis/regurgitation
heaves create turbulent blood
flow in the left
ventricle
Pulmonic Palpate area for No pulsation, thrills, Thrill Pulmonary stenosis/
pulsation, thrills, and and heaves regurgitation create
heaves turbulent blood flow in
the right ventricle
Erb’s Palpate area for No pulsation, thrills, Pulsations Due to left vent.
pulsation, thrills, and and heaves aneurysm and
heaves enlarged right ventricle

Palpate area for No pulsation, thrills, Thrill Tricuspid

pulsation, thrills, and and heaves stenosis/regurgitation
heaves create turbulent flow
in the right atrium
 Palpation
Landmark Examination Normal Findings Abnormal Pathophysiology

Mitral Palpate for pulsations, Apical impulse is Thrill Mitral

thrills, heaves. If a palpable in approx. half stenosis/regurgitation
pulsation is not of the adult pop’n & may produce a thrill
palpable turn patient impulse may be from turbulent blood
to the left side to exaggerated in young flow in the left atrium.
facilitate palpation. patients . A thrill is not
found in the normal A visible heave, or Left vent. hypertrophy
adult. A heave is sustained apex beat produces a laterally
absent in the healthy displaced apical
adult. impulse because of the
increased size of the
left vent. In the thorax
and the subsequent
shifting of the heart.
 Palpation
Landmark Examination Normal Findings Abnormal Pathophysiology
Mitral Palpate for Apical impulse is Hypokinetic Conditions that
pulsations, thrills, palpable in approx. pulsations usually place more fluid
heaves. If a half of the adult <1 to 2 cm in bet. Left vent. &
pulsation is not pop’n & impulse diameter & of chest wall such as
palpable turn may be small amplitude pericardial
patient to the left exaggerated in effusion,
side to facilitate young patients . A tamponade;
palpation. thrill is not found obesity; low-
in the normal output states such
adult. A heave is Hyperkinetic as shock.
absent in the pulsations usually
healthy adult. > 1 to 2 cm in High – output
diameter & of states such mitral
increased regurgitation,
amplitude thyrotoxicosis, ,
severe anemia, &
left-to-right shunts
Palpate the carotid pulse

N: Bilaterally equal in intensity and

pattern. Should be strong, not bounding

A: Diminished or absent pulse may be

found is clients w/ carotid disease or
dissecting ascending aneurysm.

A: Absence of both pulses indicate

asystole.
Percussion
 Percuss the chest to determine
the cardiac border.
Help the client to a reclining
position at the lowest angle the
client can tolerate.

N: Resonance because of the lung

tissue
A: Dullness if w/an enlarged
heart.
 Explain Explain what you are going to do.

Expose the patient’s chest only as much as is needed for the

Expose assessment. Never auscultate through any type of clothing.

Position patient in supine or sitting. Left lateral position may be used for
Position auscultation of the mitral & tricuspid areas. Upright leaning – forward position
may be used for aortic auscultation.

Auscultation: Stand Stand to patient’s right side.

General Approaches Use Use correct headpiece of stethoscope.

Warm the headpiece in your hands prior to touching it to

Warm the patient.

Listen to all 4 valvular cardiac landmarks @ least twice. On 1st,

Listen identify S1 and S2, and then listen for possible S3 and S4. On 2nd
listen to murmurs and friction rubs.

Listen Listen for a few cardiac cycles (@ least 15 sec.) in each area.
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Aortic Place diaphragm S2 is caused by The components Aortic

of stethoscope the closure of of S2 are hypertension
on the landmark the semilunar A2(aortic) an P2
and listen for S2 valves. (pulmonic). A
S2 corresponds greatly
to the “dub” intensified or
sound in the diminished A2 is
phonetic “lub- considered
dub”. abnormal.
S2 heralds the It is created by
onset of diastole; An ejection click. the opening of
is louder than S1. damaged valve
such as in aortic
stenosis
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Pulmonic Place diaphragm S2 is also heard S2 that is Delayed closure

of stethoscope in the pulmonic abnormally wide, of the pulmonic
on the landmark area; is louder the aortic valve valve may be due
and listen for S2 than S1. closes early and to a delay in the
There is normal the pulmonic electrical
physiological valve closes late. stimulation of
splitting of S2 There is a split the right
during on both ventricle.
inspiration. inspiration and
expiration , but a
wider split on
inspiration.
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Pulmonic Fixed splitting, a Right ventricular

wide splitting failure that
that does not results in a
change with prolonged
inspiration or ventricular
expiration. The systole or a large
pulmonic valve septal defect can
consistently lead to a fixed
closes and the splitting.
right side of the
heart is already
ejecting a large
volume.
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Pulmonic A pulmonic Caused by the

ejection click opening of a
always indicates diseased
an abnormality pulmonic valve.
Is heard loudest
on expiration.
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Tricuspid Place the S1 is softer than A split that is Usually due to

diaphragm of the the S1 in the abnormally wide electrical
stethoscope on mitral area during malfunctions.
the chest wall at because the inspiration and is
the tricuspid pressure in the still heard on
landmark to left side of the expiration.
listen to S1 heart is greater
than in the right.
 Auscultation
Landmark Examination Normal Findings Abnormal Pathophysiology

Mitral Place the S1 is loudest in An abnormally Occurs in mitral

diaphragm of the the mitral area. loud S1 stenosis, short
stethoscope over It heralds the PR interval
the mitral area to onset of systole. syndrome, or in
identify S1.
high-output
If unable to
states such as
distinguish S1
from S2, palpate tachycardia,
the carotid artery hyperthyroidism,
w/hand closest to and exercise.
the head while A soft S1 Occur as a result
auscultating. S1 is of Rheumatic
heard with each fever where
carotid pulse beat. mitral valve has
limited motion.
Other heart Sounds
Pericardial Friction Rub
Usually occur in the setting of pericarditis.
They are caused by friction between the
inflamed pericardial surfaces.
Auscultation
- use diaphragm of the stethoscope over the
left lower sternal edge or apex during end
expiration
- position patient sitting up and leaning forward
or knee – chest position since it allows the best
detection of the rub
Auscultate the carotid arteries

N: You may hear heart

tones.

A: Turbulent sound like

murmurs - Bruit
Compare the apical and carotid pulse

N: Simultaneously palpated. Synchronous.

A: An apical pulse greater than the carotid

rate indicates a pulse deficit.

Atrial fibrillation and atrial flutter can cause

pulse deficit .
Inspection and palpation
of the legs
Inspect for:
◦ Color of skin and nailbeds
◦ Temperature, texture and turgor of skin
◦ Any lesions, edema
◦ Capillary refill
◦ Hair distribution
◦ Size (swelling or atrophy)
Palpate the inguinal lymph nodes
Palpate these peripheral arteries
in both legs:
◦ femoral
◦ popliteal
◦ dorsalis pedis
◦ posterior tibial
Grade the force on a fore-point
grade
Check for pretibial edema
Is pitting edema is present, grade it:
◦ 1+ Mild pitting, slide indentation, no perceptible swelling on the
leg
◦ 2+ Moderate pitting, indentation subsides rapidly
◦ 3+ Deep pitting, indentation remains for a short time, leg looks
swollen
◦ 4+ Very deep pitting, indentation lasts a long time, leg is very
swollen
Assess venous system. Note any
visible, dilated, and tortuous veins
Perform Manual compression test
Perform Trendelenburg test
 Elicit Homan’s Test
Other abnormalities
 Palpation and Auscultation of Arterial
Pulses
 Is best facilitated with the patient in supine position with the head of bed
elevated at 30 to 45 degrees.
 With the dominant hand, palpate the pulses with the pads and middle fingers.
 Evaluate in terms of:
- Rate
- Rhythm
- Amplitude
- Symmetry
If peripheral pulse
cannot be palpated,
an amplification
device can be used to
detect the presence,
rate, rhythm at that
location.
A: Asymmetric pulses are abnormal
P: Variations in the symmetry of pulses can occur because of
anatomic differences in the depths and locations of the arteries.

A: Auscultation of bruits at the temporal, carotid, and femoral areas

is abnormal.
P: Bruits in theses areas can be caused by an obstruction related to
atherosclerotic plaque formation, jugular vein-carotid artery fistula,
or high-output states such as anemia or thyrotoxicosis.
Video on Cardiovascular Examination

https://www.youtube.com/watch?v=XU_xeUMJ3Zc
References:
D'Amico, D and Barbarito, C. 2016 Health and Physical
Assessment in Nursing (3rd Ed.). Pearson.

Estes, M.E. 2010 Health Assessment and Physical Examination (4th

Ed.). Delmar