Assessment in Cardiovascular

Disorders
Varieties of assessments are
carried out in a client with CVD’s
in order to collect data for
arriving at a diagnosis some of
this data are subjective while
others are objective information
is elicited via the following:
1 History (hx) taking: History
taking may comprise the
following:
A) Health hx: The north
should be alerted for the
possibilities of underlying
cardiac or vascular diseases
(dz). If the client has the
following complaints, the
nurse should explore and
document them.
-Fatigue- no energy, needs
more resting than normally
necessary, normal activities
resulting in entirely fatigue is
considered as the easily
symptom of heart dz, also
seen in congenital cardiac dz ,
corpulmonale, mitral valve
stenosis, complicated by
pulmonary hypertension.
However rest improve fatigue
-fluid retention (oedema)-
weight gain, feeling of
bloatedness, tightening of
usual clothings, shoes no
longer fitting comfortably,
indentation left on the skin
from constricting garment.
 Oedema is defined as
accumulation of fluid in the
interstitial spaces. It may be
localized or generalized in
distribution. Peripheral
oedema is one important
indicator for CVD and is
located mainly in the feet,
ankles, leg and sacrum. Major
causes of oedema in CVDs are
-obstruction of blood into or
from the heart, fluid overload
resulting in circulatory
overload, abnormal retention
of water and electrolyte by the
kidney, elevated renal arterial
and venous pressure, increase
permeability of the capillaries,
a decrease in colloidal osmotic
pressure, abnormalities in the
formation and flows of lymph
and when the venous return to
the heart is interrupted.
Oedema often disappears on
elevation of the body part
affected. In contrast, pitting
oedema does not disappear
with elevation of the
extremities and may indicate
fluid overload or pathological
condition such as congestive
cardiac failure (CCF). Pitting
oedema is present if an
indentation on the skin after a
finger or thumb has been used
to apply gentle pressure,
remains for a while.
-Irregular heartbeat- sensation
of the heart in the throat or
skipped beat, racing heart etc.
-Dyspnea- shortness of breath
on exertion (moderate
exercise) which is often
relieved with rest. Orthopnea (
pt can comfortably breath only
when standing or sitting erect)
is indicative of advanced heart
dz. Paroxysmal nocturnal
dyspnea (awakening at nights
with several difficulties in
 breathing, at times, with
sweating, relieved by changing
position such as ,sitting or
standing) . It is due to
overworking of the left
ventricle, increased blood
pressure (BP), aortic stenosis
or aortic insufficiency.
- Coughing, nightmares,
abdominal distention, full
bladder, heavy evening meals or
frightening noise are
factors that place additional
strain on the heart and may
precipitate heart attack during
the night. Dyspnea and
wheezing respiration are related
to pulmonary congestion and
the heart dz. Lying flat in bed
can cause all this.
-Cheyne-stokes respiration (a
periodic breathing) caused by
dz affecting the respiratory
center, heart failure or brain
damage. It is characterized by
rhythmic waxing and waning of
the depth of respirations.
Respirations may be deep, then
shallow, cease completely for a
short period. Then pattern is
repeated over and over.
-Pain- chest pain could be
described as, sharp, dull,
crushing, squeezing, stabbing
(angina pectoris), burning etc.
Assess quality, nature,
characteristics, onset and
duration of pain; Precipitating
/predisposing event related or
associated factors.
Location -where the pain begins
and area it’s radiates.
Quality – how often and how
long pain is experienced, was it
enough to cause patient (pt) to
stop activity, any change in
intensity
NB: Substernal pain radiating
to the shoulder, neck and arm
in typical of angina pectoris.
-Tenderness in the calf or leg;
note- inability to bear weight,
swelling of the involved
extremity and inflamed, warm
skin over a vein.
Aching in the calves:
distended, discoloured,
turtous veins in the calves,
ache in the lower extremities
after standing for a short
period of time.
Presence of the following
habits/ conditions: alcoholism,
anaemia, asthma, bleeding
disorders, bronchitis, collagen
dz, diabetes mellitus (DM),
gout, hypertension,
intermittent claudication,
kidney dz, pneumonia,
rheumatic fever, scarlet fever,
streptococcal sore throat,
stroke, syncope,
thrombophlebitis, varicosities,
influenza.
-Syncope- temporary loss of
consciousness with or without
preceded dizziness, as a result
of decrease blood flow to the
brain. Causes include heart
block, cardiac arrhythmias,
aortic stenosis, idiopathic
hypertrophic sub aortic
stenosis, pulmonary
hypertension, mitral valve
occlusion caused by
malfunction or formation of
thrombus orthostatic
hypotension and cerebral
vascular dz. Types of syncope
include; cough syncope,
micturition syncope,
hypoglycemic syncope etc.

Hospitalization: specific illness

and treatment, any
cardiovascular symptoms, any
ECG or chest X-ray films, if
available, are collected as
forms of baseline data.
Medications- note past and
current use of drugs, over the
counter and prescribed drugs
inclusive, eg.
Antihypertensives,
anticoagulants, diuretics,
glycosides and nitrates. Drugs
adversely affecting the CNS
should be assessed, eg.
Tricyclic antidepressants,
phenothiazines,
antidysrhythmias,
hypotensives and oral
contraceptives (they cause
thrombophlebitis).
Doxorubicin or Adriamycin
(cause cardiomyopathy),
lithium (cause dysrhythmias),
corticosteroids (cause sodium
and fluid retention),
theophylline preparation,
recreational/abused drugs (all
cause tachycardia and
dysrhythmias).
- Allergies- find out whether
allergic and/or anaphylactic
reactions have ever been
experienced.
B. Obstetrical/gynaecological
hx: number of pregnancies (if a
woman), no. of children,
weight gain, any abnormal obs
hx, use of contraceptives,
sexually transmitted infections
(STIs), etc.
C. Family hx: confirmed illness
of blood relatives can highlight
hereditary and/or familial
tendencies towards some
CVDs, eg. Coronary artery dz,
peripheral vascular dzs,
hypertension, bleeding
disorders, DM, atherosclerosis
and stroke, vascular disorders
such as, intermittent
claudication, varicosities. Also
family hx of non cardiac
conditions such as, asthma,
renal dzs and obesity, should
be assessed.
D. Social and Personal hx:
background information such
as, age, sex, race- these are
related to CV health. Marital
status, family role, age and no.
of children, living environment,
significant others (contact
community), spiritual
orientation and stress coping
strategies. These may assist
the nurse to identify stressors,
strength and support system in
the client’s life.
2. Life style: There is a strong
correlation between the
component of a client’s life-
style and cardiovascular
health. There is need for
careful scrutiny of stressors,
exercise, diet, sleep pattern
and habits.
-Stressors:- ascertain areas
that cause stress or anxiety, eg.
marital relationship, family,
friends, work, finance,
housing, religious or/and
recreational activities.
Although some activities can
be enjoyable, they can
stressful at the time they are
rewarding.
Also investigate usual method
of coping with stress.
Behaviours, such as, explosive,
rapid speech and emotions
(hostility, outburst of anger
etc.) have been associated
with the risk of CVDs.
Frequency of these behaviours
should be noted.
-Exercise:- this is very
beneficial to CV health. The
nurse should enquire of the
type, duration frequency of
each type of exercise and if
there occurrence of any
unwanted effects.
Enquire if pt participates in any
individual or group sports;
frequency and duration.
-Diet:- determine the amount
of salt, saturated fats and
triglycerides in pt’s diet.
Examine a typical day’s diet for
adequacy in relation to client’s
life-style, attitude and plan
towards diet. Pt’s wt in relation
to height (BMI) should be
determined. Overweight or
underweight should be noted.
Food intake and exercise
pattern should be
complementary. The big eater
should be a disciplined
exerciser. Conversely, the
sedentary person should
adjust caloric intake
accordingly, to avoid over-
taxing the heart, by excessive
wt gain.
-Sleep and rest:- ascertain pt’s
sleep habit, number and size
of pillows, frequency of
urination, nocturnal dyspnea
and interrupted sleep patterns.
-Habits:- ascertain if pt
smokes, number of
sticks/packets per day,
duration of smoking, attitude
to smoking, any willingness to
quit.
Alcohol; determine use, type,
amount, frequency and
attitude to its use.
The use of habit-forming drugs
and recreational drugs are also
sorted.
3. Clinical manifestations that
may offer cues to CVDs -
Cardiovascular problems may
affect other body systems,
especially the pulmonary, renal
and neurological systems. The
following could be a guide, eg.
wheezy respiration, productive
cough, shortness of breath,
fatigue, dark concentrated
(conc) urine, leg oedema,
memory loss, etc.
Also ask pt if he/she has had
the ff CV symptoms in the
past; chest pain, palpitation,
claudication, fainting, leg
cramps, hypertension,
rheumatic fever, varicose vein,
etc.
Physical assessment:
Physical assessment in
cardiovascular conditions is
carried out using the ff 4 steps;
inspection, palpation,
percussion and auscultation.
1. Inspection- inspect pt from
head to toe, noting the ff:
-Symmetry of posture and
thorax, colour of the skin for
palor or discoloration and
other gross deformities of the
skin. Apart from the symmetry
of the thorax, also check for
point of maximum intensity
(PMI). This is the place where
the apical pulse can be
palpated as strongest; often in
th
the 5 intercostal space in the
thorax, just medial to the left
mid-clavicular line. It is also
the place where the apex beat
is assessed. Colour of the
thorax is also evaluated.
-Bone structure and bony
surfaces are inspected for any
deformity.
-The neck, face and eyes; for
any abnormal contours.
Inspect the eye for Arcus
Senile; a light gray ring
surrounding the iris,
commonly found in older pts.
When found in younger pts ,
might indicate a type of lipid
metabolism disorder which
can lead to coronary artery
disease (CAD). Check for
xanthelasma, a yellowish
plaque on the skin surrounding
the eye, a sign of
hypercholesterolaemia (due to
atherosclerosis) which can
cause CAD.
-Breathing pattern, presence
of cyanosis; central and
peripheral cyanosis (central
cyanosis causes blue
discoloration of lips, mouth
and conjunctiva, while
peripheral cyanosis causes
blue discoloration of
ear lobes, nail beds and lips.
2. Palpation- abnormalities
detected during inspection
are further evaluated via
palpation.
-The skin; for tempt,
texture, moisture, lumps,
bumps etc.
-Pulses in the neck and
extremities provide some
information on arterial
blood flow. (Body tempt is
simultaneously determined
during the palpation of the
pulses).
Peripheral pulses are
evaluated on the basis of
their presence or absence,
rate, rhythm, amplitude,
quality and equality.
Each pulse (except carotid
pulse, which is central pulse)
should be palpated on the
left and right
simultaneously, to evaluate
the contralateral symmetry.
A special scale used for
pulse documentation, based
on rating the scale from 0 t0
+4 as follows:
0 ----------------- absent
+(+1) -------------palpable,
but diminished
++(+2) ----------- normal or
average
+++(+3) --------- full and risky
++++(+4) -------- full and
bounding, often visible.
Abnormalities of Pulse:
Several abnormalities may
be detected during
palpation of pulse. They are
as follows:
i) Hypokinetic pulse - weak
pulse of small volume
and pulse pressure due
to low cardiac output (
CO).
ii) Hyperkinetic pulse - a
high amplitude pulse
with a rapid rise, large
volume and wide pulse
pressure, bounding
pulse.
iii) Pulsus alternans - an
arterial waveform,
showing alternating
strong and weak pulses.
It indicates left
ventricular systolic
 impairment. (It has poor
prognosis).
iv) Pulsus paradoxus – an
exaggerated fall in pt’s
blood pressure during
inspiration (by greater
than 10mmHg). This is
due to reduced left
ventricular stroke
volume.
v) Tachycardia – an
abnormally rapid heart
rate, mainly due to
 valvular heart dz,
atherosclerosis etc.
Pulse rate < 100 b/m.
vi) Bradycardia – an
irregular and slow heart
rate, lower than 60 b/m.
Tachycardia and
bradycardia are forms of
arrhythmias (irregular or
abnormal heart rhythm)
3. Percussion: The borders of
the right and left sides of
the heart can be estimated
by percussion. The use of
percussion for detecting
cardiac enlargement, has
generally been replaced by
chest X-ray, which is of more
accuracy. Pt is placed in
recumbent position while
the stands to the right and
percusses along the curve of
th th
the rib in 4 and 5
intercostal space, starting at
the mid axillary line. The
percussion noted over the
 heart is dull in comparison
with the resonance over the
lungs and is recorded in
relation to the mid clavicular
line. Cardiac dullness is a
characteristic of cardiac
hypertrophy.
4. Auscultation: The heart
sounds can be perceived
using a stethoscope placed
on the chest wall. The first
heart sound (S1) is caused
by the closure of the
tricuspid and mitral valves
(the atrio-ventricular valves
AV,). AV has a soft “lubb”
sound. It is long and of low
pitch than the second heart
sound (S2), which is due to
closure of aortic and
pulmonic (semilunar) valves.
It has a sharp “dubb” sound.
Both S1 and S2 are referred
to as the “lub-dub” sound of
the heart.
The nurse should listen to
the auscultatory areas in
sequence with both the
diaphragm and bell of
stethoscope. Both sounds
are best heard with the
‘diaphragm’ bc they are of
high pitch. Extra heart
sounds (S3 and S4), if
present are best heard with
the ‘bell’ bc they of low
pitch.
Listen at the epical area with
the diaphragm while
simultaneously palpating
the radial pulse. If there is a
fewer radial than the apical
pulse, it is called a pulse
deficit. This is monitored.
The heart rhythm is
monitored and heart
murmurs, which are due to
cardiac abnormalities, are
also noted.

Laboratory Investigations:
Lab tests are indicated for
many reasons, such as;
I) To assist in diagnosis of
CVDs
II) To identify abnormalities
of the blood that affect
the prognosis CVDs
III) To assess the degree of
inflammation
IV) To determine baseline
values before
performing therapeutic
interventions.
V) To screen for risk factors
associated with
 atherosclerotic coronary
dz
VI) To assess the effects of
medications, eg.
diuretics on serum
potassium levels
VII) To screen generally for
any abnormalities
Some of the blood tests
that could be carried out
include:
1. Cardiac enzyme analysis-
these are non specific in
 relation to a particular
organ damage has
occurred but there are
certain isoenzymes that
are released from
myocardial cell damage
due to sustained hypoxia
resulting from infarction.
Some of these enzymes
are; creatine kinase, lactic
dehydrogenase,
myoglobin and troponin.
2. Blood chemistry, such as;
. Lipid profile –
cholesterone, triglycerides
and lipo proteins are
measured to evaluate risk
for developing
atherosclerotic dz, eg for
a family hx of premature
heart dz
. Cholesterone level – this
may be affected by age,
gender, diet, exercise
pattern and stress (normal
cholesterone level – less
than 200mg).
. Serum electrolyte levels
– blood levels of Na+, K+
and C+ are vital to cellular
depolarization and
repolarization. Serum
calcium and magnesium
ions are also evaluated.
3. Blood urea Nitrogen
level – high level of this
may indicate reduced
renal perfusion, due to
reduced CO or
intravascular fluid volume
deficit (from diuretic
therapy).
4. Serum glucose level-
many pts with cardiac
disorders also have
diabetes mellitus (DM).
Other conditions where
serum glucose level may
also be elevated include:
a) In stressful situations,
eg. in flight-or-fight
 process of stress, when
metabolism of
endogenous
epinephrine results in
conversion of liver
glycogen to glucose.
b) Following immediate
carbohydrate (CHO)
consumption.
5.Coagulation studies – this
is also done to monitor the
levels of coagulation
factors in pts receiving
therapeutic
anticoagulants, eg.
warfarin.

Complex Diagnostic
Investigations in CVS
A number of complex
diagnostic procedures add
to the information and lab
investigations for a pt with
CVS conditions. They may
be invasive or non-
invasive.
Invasive procedures use
open or minor surgery to
investigate or treat cardiac
abnormalities.
In non-invasive procedures
there is no body
puncturing, it may be only
withdrawing of blood by
needle insertion, injection
of dye (contrast medium)
etc. Most important and
common types are:
1. Chest X-ray- done to
evaluate the size of the
heart, heart valves and
other cardiac
conditions.
2. Cardiac fluoroscopy –
contrast dye is
introduced into an
artery, with a catheter,
into the bloodstream, to
analyze blood
movement within the
vessels, then X-ray films
are taken. Nurse’s
responsibilities are the
same for the above two.
They are:
-Ask pt of frequency of
recent X-rays.
-Enquire of possible
pregnancy (if a woman).
-Provide lead- shield for
areas not to be viewed.
-Instruct pt to remove
any jewelries or metals
that may obstruct the
heart or lungs.
3. Electrocardiogram
(ECG)- this is a graphic
representation of the
electrical activities
produced within the
heart.
Nurse’s responsibility
includes; obtain a
consent form, educate
pt on the process of the
procedure and assure
him/her of its safety,
painlessness and
confortability.
4. Ambulatory ECG
monitoring – this
involves using Holler
monitor to obtain
continuous graphic
representation of a pt’s
ECG during daily
activities.
Nurse’s responsibilities –
prepare pt by explaining
the importance of
keeping accurate daily
activities and symptoms’
not to take a bath or
shower during
monitoring, and observe
the skin for irritation
which may develop from
the electrodes.
5.Sonic studies – these
include
Echocardiogram(EoCG)
which uses ultrasound
to assess and display
cardiac structure and
action of the heart as it
beats. They are of
different types, they
are-
. Stress EoCG –
evaluates how the heart
works under stress.
. Dobutamine EoCG –
the use of drug,
eg.dobutamine, to
induce stress instead of
exercise.
. 2 dimentional(2D)
EoCG ( 2 views of the
heart).
. 3 dimentional(3D)
EoCG ( 3 views of the
heart).
. Doppler EoCG- this
assesses the flow of
blood via the heart.
. Trans-oesophagus
EoCG- views the heart
via the oesophagus.
Nurse’s responsibilities:
Assess pt before
procedure, eg. enquire
hx of dysphagia or
radiation therapy as
they increase the risk of
complications during
procedure. Reassure pt
if he experiences
discomfort. Place pt on
nil per oral (NPO) for a
period of time before
the procedure. Monitor
intravenous (iv) line,
which is set for
administration of
dobutamine and
sedative. Monitor Bp
and ECG throughout the
study.
Pt must be alert enough
to follow instructions
 and report symptoms,
especially, of chest pain.
After procedure pt
continues fasting for
another 4 hours and
monitoring continues
for about 30 to 60
minutes.
6.Cardiac
catheterization; an
invasive diagnostic
procedure where
radiopaque arterial and
venous catheters are
introduced into selected
blood vessels of the right
and left sides of the
heart. Flouroscopy is used
to guide the
advancement of the
catheters through the
skin to the blood vessels
or via cut-down
procedure, if pt has poor
vascular assess. Right or
 left heart catheterization
may be performed.
The procedure may be
performed on an out
patient basis and requires
8 hours or less bed rest
for recovery.
During the procedure, pt
is usually placed on iv line.
Nurse’s responsibility-
monitor Bp and ECG
continuously.
Keep resuscitation
equipment in readiness,
as catheters inserted into
the ventricles can cause
fatal dysrythymias.
Provide additional cardiac
life support (ACLS)
measures for advance
resuscitation.
Assess pt for previous
allergies to contrast
agents or shellfish ( this
contains iodine) before
 procedure (contrast
agents are radiopaques
used to visualize the
coronary arteries, some
contain iodine).
7.Angiography – this is a
medical imaging technique
used to visualize the heart
chambers and blood
vessels, usually performed
with cardiac
catheterization. It is also
known as arteriography.
Angiography makes use of
cineangiograms (i.e
cinema) – a series of
rapidly changing films or
movies on an intensified
fluoroscopic screen that
records the passage of the
contrast agent via the
vascular sites. The
recorded information
allows for comparison of
information over time.
Common sites for selective
 angiography are: the aorta
(aortography), the
coronary arteries (coronary
arteriography) and the
right/ left sides of the
heart.

Assignment: Find out and

state in your note books,
other investigations carried
in CV conditions (not less
than five).