Assessment of Cardiovascular Function

Topic Outline
1. Anatomy and Physiology Overview of Cardiovascular System
2. Assessment of Cardiovascular System
3. Diagnostic Evaluation of Patients with Cardiovascular Disorders

Learning Objectives
After going through this topic, you will be able to:
 Explain cardiac physiology in relation to cardiac anatomy and the conduction system of the heart.
 Incorporate assessment of cardiac risk factors into the health history and physical assessment of the patient
with cardiovascular disease.
 Discriminate between normal and abnormal assessment findings identified by inspection, palpation, percussion,
and auscultation of the cardiovascular system.
 Recognize and evaluate the major manifestations of cardiovascular dysfunction by applying concepts from the
patient's health history and physical assessment findings.
 Discuss the clinical indications, patient preparation, and other related nursing implications for common tests and
procedures used to assess cardiovascular function and diagnose cardiovascular diseases.

Introduction
An understanding of the structure and function of the heart in health and disease is essential to develop
cardiovascular assessment skills. Key components of assessment include a health history, physical assessment,
and monitoring of a variety of laboratory and diagnostic test results. This assessment provides the data necessary
to identify nursing diagnoses, formulate an individualized plan of care, evaluate the response of the patient to the
care provided, and revise the plan as needed.

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Amazing Facts about the Heart
Did you know that:
1. The heart starts to beat in the uterus long before birth, usually by 21 to 28 days after conception.
2. The average heart is the size of a fist in an adult and weighs between 7 and 15 ounces.
3. Your heart will beat about 100,000 to 115,000 times each day and a half billion times over a 70-year lifetime.
4. Your heart pumps about 2,000 gallons of blood every day.
5. If you were to stretch out your blood vessel system, it would extend over 60,000 miles.

Preassessment
True/False: Write T if the statement is true and F if the statement is false.
1. The sinoatrial (SA) node, with an inherent firing rate of 60 to 100 impulses/min, is considered the primary pacemaker
of the heart.
2. Postural (orthostatic) hypotension is a sustained decrease of at least 10 mm Hg in systolic BP or 20 mm Hg in diastolic
BP within 3 minutes of moving from a lying or sitting to a standing position.
3. During diastole, the tricuspid and mitral valves are open, allowing the blood in the atria to flow freely into the relaxed
ventricles.
4. An elevated blood level of the amino acid homocysteine is believed to indicate a high risk for coronary artery disease.
5. The patient undergoing nuclear imaging techniques with stress testing should be instructed not to eat or drink anything
for at least 12 hours before the test.
Fill-in-the-Blank: Write your answer that best completes the statement.
1. During _________________ systole, contraction of the papillary muscles causes the chordae tendineae to become
taut, keeping the valve leaflets approximated and closed.
2. The apical impulse, formerly called the point of maximum impulse (PMI), is normally palpable at the intersection of
the midclavicular line of the left chest and at the _______________ intercostal space.
3. The S1 heart sound results from the closure of the __________ and tricuspid valves.
4. Turbulent blood flow caused by a narrowed or malfunctioning valve is called a ______________, which can be heard
during auscultation of the heart.
5. The mainstay of cholesterol lowering therapy is ___________________ changes.
Preassessment Key Answer: T/F: 1. True; 2. False; 3. True; 4. True; 5. False; Fill-in-the-Blank: 1. Ventricular; 2. Fifth; 3. Mitral; 4. Murmur; 5. lifestyle

CARDIOVASCULAR SYSTEM
The heart is a hollow muscular organ and lies on the mediastinum and rests on the diaphragm. It receives
and pumps blood through the blood vessels.

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  The heart is encased in the pericardium, a thin, membranous sac that has two layers: a visceral layer
in contact with the heart and an outer parietal layer. The space between the pericardial layers contains
20 to 30 ml of serous fluid (pericardial fluid), which protects the heart from trauma and friction.
 The heart wall, specialized muscle tissue, consist of three tissue layers:
a. Epicardium: a thin serous outer layer
b. Myocardium: the thick, muscular middle layer
c. Endocardium: the smooth inner layer that
comes in contact with blood. Lines the
chambers of the heart & covers the heart
valves. Its smoothness prevents abnormal
blood clotting because clotting would be
initiated by contact of blood by with a rough
surface.
 A membranous muscular septum divides the heart
into two distinct sides, each containing two chambers:
Atrium and a Ventricle
 The Right atrium, a low-pressure chamber, receives
systemic venous blood via the superior and inferior
vena cava, and coronary sinus.
 The Right ventricle: another low-pressure chamber,
receives blood from the right atrium through the
tricuspid valve during ventricular diastole, then ejects
deoxygenated blood via the pulmonic valve through the
pulmonary artery and into pulmonary circulation during
ventricular systole.
 The Left atrium: a low-pressure chamber, receives oxygenated blood returning to the heart from the
lungs via four pulmonary veins.
 The Left-ventricle: a high-pressure chamber receives blood from the left atrium through the mitral valve
during ventricular diastole and ejects oxygenated blood via the aortic valve through the aorta and into

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systemic circulation during ventricular systole.
 Valves connect the chambers and outflow tracts; types include atrioventricular and semilunar valves.
 Atrioventricular (AV) valves, separating the atria from the ventricles, include:
a. The tricuspid valve between the right atrium and ventricle
b. The mitral valve between the left atrium and ventricle.
 Situated between each ventricle and its corresponding artery, Semilunar valves include:
a. The pulmonic valve between the right ventricle and pulmonary artery
b. The aortic valve between the left ventricle and aorta
 Papillary muscles: muscle bundles on the ventricular walls, and chordae tendineae, fibrous bands
extending from the papillary muscles to the valve cusp, keep the valves closed during systole, maintaining
unidirectional blood flow through the AV valves and preventing backflow of blood.
 The cardiac conduction system consists of specialized cardiac cells that either initiate or propagate
electrical impulses throughout the myocardium as a
precursor to cardiac muscle contraction.
 Located at the junction of the right atrium and the
superior vena cava, the sinoatrial (SA) node functions as
the pacemaker for the myocardium, initiating rhythmic
electrical impulses at an intrinsic rate of 60 to 100
impulses per minute.
 The AV node, located at the right atrial wall near the
tricuspid valve, receives impulses from the SA node and
relay them to the ventricles.
 These impulses travel through a bundle of specialized
muscle fibers on the myocardial septum – the bundle of
His – that divides into left and right branches.
a. The right bundle branch, which conducts
impulses down the right side of the septum
b. The left bundle branch, which conducts impulses
down the left side of the septum that fans out
into the left ventricular muscle.
 The right & left bundle branches terminate in the Purkinje
fibers, which propagate electrical impulses into the
endocardium and on to the myocardium of the ventricles
and bring about ventricular systole (contraction).
 The coronary arteries supply the heart with blood. The right coronary artery supplies blood to the right
heart wall. The left main coronary artery, which divides into two branches – the left anterior descending
coronary artery and the circumflex artery – supplies most of the blood to the left heart wall.

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 The right and left coronary arteries branches into smaller arteries and arterioles, then to capillaries. After
passing through capillaries in the myocardium, the coronary capillaries merge to coronary veins, which
empty blood into a large coronary sinus that returns the blood to the right atrium.

The Function of the Cardiovascular System

 The heart has electrophysiologic, mechanical, and neurologic properties that coordinate to produce
effective myocardial contraction and pumping of blood.
 Each complete heartbeat or cardiac cycle consists of two phases in response to electrical stimulation:
a. Systole, the contraction phase
b. Diastole: the relaxation phase
 Systole is triggered by depolarization of cardiac muscle cells, which involve a transient change in sodium
and potassium ion concentration inside and outside the cell.
 Immediately after depolarization is completed, the process reverses itself, resulting in repolarization and
a return to the resting state, or diastole.
 Heart sounds result from vibrations caused by valve closure and ventricular filling; they include:
a. The first heart sound (S1), associated with tricuspid and mitral valve closure.
b. The second heart sound (S2), associated with aortic and pulmonic valve closure
c. The physiologic third sound (S3), often normal in person under age 30 but pathologic on older
persons (known as ventricular gallop), occurring during the rapid ventricular fillings stage of
diastole.
d. The fourth heart sound (S4), or atrial gallop, is linked to resistance to the ventricular filling, as in
hypertrophy or injury of the ventricular wall.
 Cardiac output (CO) is defined as the volume of blood ejected by each ventricle in 1 minute; CO=SV
(stroke volume) X HR (heart rate)
 Several factors influence CO indirectly by affecting SV, including:
a. Preload, the end-diastolic filling volume of the ventricle; increase by increased returning volume
to the ventricle
b. Afterload, the resistance to left ventricular ejection; increased by increase systemic arterial
pressure.

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 Various neurologic factors regulate heart function, including:
a. Sympathetic nervous system stimulation, with the release of norepinephrine, which results in
arteriolar vasoconstriction, increase heart rate, and a positive inotropic effect.
b. Parasympathetic nervous system stimulation, with the release of acetylcholine, resulting in
decreased heart rate and slowed AV conduction, and causes slight decrease in ventricular
contractility.
c. Response to chemoreceptors located in carotid and aortic bodies to decrease in O 2 and increase
in CO2 leading to increase heart rate.
d. Response baroreceptors located in the aortic arch carotid sinus, vena cava, pulmonary arteries,
and atria to blood pressure changes; either decrease or increase heart rate, resulting in blood
pressure changes.

Self-Check!
Multiple Choice: Read each question carefully then select the letter that corresponds to your choice.
1. The nurse who is caring for a patient with pericarditis understands that there is inflammation involving the:
a. thin fibrous sac encasing the heart. c. heart’s muscle fibers.
b. inner lining of the heart and valves. d. exterior layer of the heart.
2. The coronary arteries arise from the:
a. aorta near the origin of the left ventricle.
b. pulmonary artery at the apex of the right ventricle.
c. pulmonary vein near the left atrium.
d. superior vena cava at the origin of the right atrium.
3. The pacemaker for the entire myocardium is the:
a. atrioventricular junction. c. Purkinje fibers.
b. bundle of His. d. sinoatrial node.
4. The intrinsic pacemaker rate of ventricular myocardial cells is:
a. more than 80 bpm. c. 40 to 60 bpm.
b. 60 to 80 bpm. d. fewer than 40 bpm.
5. Which of the following represents the correct sequence of structures in the cardiac conduction system?
a. AV node, SA node, bundle of His, Purkinje fibers
b. SA node, bundle of His, AV node, Purkinje fibers
c. SA node, AV node, Purkinje fibers, bundle of His
d. SA node, AV node, bundle of His, Purkinje fibers
d
Answer to Self-Check: 1. a; 2. a; 3. d; 4. d; 5.

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 Cardiovascular Assessment
A. Health History: allow us to obtain relevant information about the health status of the patient
1. Chief Complaint or Problem: the reason that prompted the patient to seek consultation
2. Family History: estimate the risk of cardiac disease of patients; ask if the patient’s family members were
diagnosed with coronary artery disease, HPN, hyperlipidemia, DM, or cardiovascular disease.
3. Risk Factors of Cardiovascular Disorders
Modifiable:
a. Hyperlipidemia: abnormally high level of blood lipids and lipoproteins. Lipoproteins carry
cholesterol in the blood. Low-density lipoproteins (LDLs) are the primary carriers of cholesterol.
High levels of LDL promote atherosclerosis because LDLs deposit cholesterol on artery walls.
b. Hypertension: an elevated blood pressure damages the arterial endothelium, creating a rough
surface that possibly triggers clot formation.
c. Cigarette Smoking: carbon monoxide in cigarette smoke damages vascular endothelium,
promoting cholesterol deposition. Nicotine stimulates catecholamine release and increases blood
pressure, heart rate, and myocardial oxygen demand. Nicotine also causes arterial
vasoconstriction, which reduces tissue perfusion. Nicotine also reduces HDL levels, increases
platelet aggregation, and increases the risk of thrombus formation.
d. Diabetes Mellitus: associated with several risk factors, including hyperlipidemia, a higher incidence
of hypertension, and obesity. In addition, diabetes affects the vascular endothelium, which
contributes to the development of atherosclerosis.
e. Obesity: have higher rates of hypertension, diabetes, and hyperlipidemia.
f. Physical Inactivity (sedentary life-style): regular exercise increases HDL and decreases
triglyceride levels.

Non-modifiable:
a. Family history of coronary heart disease: first-degree relatives with cardiovascular disease are at
risk to develop cardiovascular disorders.
b. Increasing age: more than 45 years for men and more than 55 years for women due to

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degenerative changes in the heart and blood vessels as we grow older
c. Gender: men are affected at a younger age; women, after menopause (estrogen seems to provide
some protection)
d. Race: risk appears higher in African-Americans
4. Past Medical History: assess childhood and adult illnesses, hospitalizations, accidents, and injuries.
a. Past illness/hospitalizations: trauma to chest (possible myocardial contusion), sore throat
(possible endocarditis), rheumatic fever (valvular dysfunction), and thromboembolism (MI,
pulmonary embolism).
b. Allergies: note & describe any environmental, food, and drug allergies.
c. Medications: numerous drugs can affect the cardiovascular system like antihypertensive drugs,
vasodilators (nitroglycerin), cardiogenic drugs (digoxin), anticoagulants, bronchodilators,
contraceptives, and hormones.
5. History of Present Illness: an overview of the patient’s symptoms

Most Common Signs and Symptoms of Cardiovascular Disease

1. Chest Pain: caused by an increase in demand for coronary blood flow and oxygen delivery, which exceeds
available blood supply, due to coronary artery disease (CAD).
Assessment of Chest Pain:
a. Nature and Intensity: ask the patient to describe in their own words what the pain is like such as
dull, sharp, crushing, burning, heaviness, ache, pressure, etc.; pain scale of 1-10 for the intensity.
b. Onset and Duration: ask when did the pain start and how long did the pain episode last.
c. Location and Radiation: ask the patient to point to the area where it hurts most and if the pain
seems to travel (most commonly radiates to the left arm, jaw, and abdominal region).
d. Precipitating and Relieving Factors: ask the patient what activity was doing just before pain and
what relieves the pain.
e. Associated Signs and Symptoms: dyspnea (shortness of breath), palpitations, fatigue, dyspnea,
light-headedness, and right arm pain.
2. Dyspnea: characterized by difficulty of breathing or shortness of breath.
Types:
a. Exertional: breathlessness on moderate exertion that is relieved by rest.
b. Paroxysmal nocturnal: sudden dyspnea at night; awakens patient with a feeling of suffocation;
sitting up relieves breathlessness.
c. Orthopnea: shortness of breath when lying down. The patient must keep head elevated with more
than one pillow to minimize dyspnea.
Assessment Question of Dyspnea:
a. What precipitates or relieves dyspnea?
b. How many pillows does the patient sleep with at night?

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 c.
How far can the patient walk or how many flights of stairs can the patient climb before becoming
dyspneic?
3. Palpitations: characterized by rapid, forceful, or irregular heartbeat felt by the patient.
Nursing Assessment of Palpations:
a. Do you ever feel your heart pound, beat too fast, or skip a beat?
b. What brings you on this sensation and how long does it last?
c. What do you do to relieve these sensations?
4. Weakness and Fatigue: produce by low cardiac output.
Nursing Assessment of Weakness and Fatigue:
a. What activities can you perform without becoming tired?
b. What activities cause you to become tired, weak, or fatigued?
c. Is the fatigue relieved by rest?
5. Dizziness and Syncope: a transient loss of consciousness due to a fall in cardiac output with resulting
cerebral ischemia.
Nursing Assessment of Syncope:
a. Is the dizziness characterized as light-headedness, feeling faint, off-balance, vertigo, or spinning?
b. How many episodes of syncope/near syncope have you been experienced?
c. Did a hot room, hunger, sudden position change or pressure on your neck precipitate the episode?

B. Physical Assessment: conducted to confirm information obtained from the health history, to establish patient current
or base line condition.
1. General Appearance & Cognition: indicates the heart's ability to propel O2 to the brain.
a. Is the patient awake and alert or lethargic, stuporous, or comatose?
b. Does the patient appear to be in acute distress, for example, clenching the chest (Levine sign)?
c. Assess the patient for shortness of breath and distention of jugular veins.
2. Inspection of the Skin
a. Palpate for temperature and evidence of diaphoresis. Warm, dry skin indicates adequate CO; cool,
clammy skin indicates compensatory vasoconstriction because of low CO.
b. Observe for Cyanosis, Xanthelasma, Pallor, Ecchymosis, and Clubbing

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 Cyanosis: bluish discoloration of the skin and mucous membrane.
 Central- low oxygen saturation of arterial blood (noted on the tongue, buccal mucosa,
and lips).
 Peripheral- reduce blood flow through extremities (noted on distal aspects of
extremities, tip of the nose, and earlobes).
 Xanthelasma: yellowish, slightly raised plaques in the skin; associated with
hypercholesterolemia and CAD.
 Pallor: a decrease in the color of the skin caused by a lack of oxyhemoglobin (most apparent
on the face, conjunctiva, oral mucosa, and nail beds).
 Ecchymosis: a purplish-blue color; associated with blood outside of blood vessels.
 Clubbing: swollen nail base and loss of normal angle. It is associated with chronic pulmonary
or cardiovascular disease.
3. Vital Signs
a. Monitor blood pressure
 Determine Pulse Pressure (systolic pressure minus the diastolic pressure) to evaluate cardiac
output (30 to 40 mm Hg, normal; less than 30 mm Hg, decreased CO).
 Note the presence of pulsus alternans: loud sound alternates with soft sound with each
auscultatory beat (the hallmark of left-sided heart failure).
 Note presence of pulsus paradoxus: abnormal fall in blood pressure more than 10 mmHg
during inspiration (the cardinal sign of cardiac tamponade).
b. Assess for postural/orthostatic hypotension: a significant drop in blood pressure after an upright
posture is assumed. It is usually accompanied by dizziness, lightheadedness/syncope. It occurs
when a patient’s blood pressure drops 15 to 20 mmHg or more when rising from a supine to
sitting or standing position.
c. Determine heart rate
 Time for 1 full minute to determine the apical pulse rate and the regularity of the heartbeat.
 Compare apical and radial pulse rate.
d. Determine arterial pulses: rate, rhythm, and pulse quality.
0: pulse not palpable or absent
+1: weak, thready pulse; difficult to palpate; obliterated with pressure
+2: diminished pulse; cannot be obliterated
+3: easy to palpate, full pulse; cannot be obliterated
+4: strong, bounding pulse; may be abnormal
4. Edema: an abnormal accumulation of serous fluid in the soft tissues. Increase hydrostatic pressure in the
venous system causes shifting of plasma leading to the accumulation of fluids in the interstitial
compartment.
 Location of edema is influenced by gravity – fluid collects bilaterally in the lower parts of the body:
sacral area, ankle and feet, and pits with pressure.
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 Describe the degree of edema in terms of depth of pitting:
1+ = 2 mm/less (mild)
2+ = 2-4 mm (moderate)
3+ = 4-6 mm (severe)
4+ = 6-8 mm (severe)
5. Assess jugular venous pressure and observe for venous distention. Neck vein/jugular distention indicates
venous congestion.
 Obvious distention of the veins with the patient’s head elevated 45 to 90 degrees indicated an
abnormal increase in the volume of the venous system.
6. Heart Inspection and Auscultation
a. Inspection:
 Inspect the precordium for any bulging, heaving, or thrusting. Look for the apical pulse
approximately in the 5th intercostal space at the midclavicular line.
b. Palpation:
 Use the ball of the hand to detect vibrations or “thrills”.
 Aortic area: 2nd intercostal space to the right of the sternum
 Pulmonic area: 2nd intercostal space to the left of the sternum
 Erb’s point: 3rd intercostal space to the left of the sternum
 Right ventricular or tricuspid area: 4 th intercostal space to the left of the
sternum.
 Left ventricular or apical area: the point of maximal impulse (PMI); 5th
intercostal space midclavicular line.
c. Chest Percussion: outline the border of the heart
 Normally, only the left borders of the heart can be detected by percussion. It extends from the
sternum to the midclavicular line in the 3 rd to 5th intercostal spaces. The right border lies under
the right margin of the sternum and is not detectable.
d. Cardiac Auscultation:
 Systematically auscultate the heart for normal

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and abnormal heart sound, murmur, and friction
rub, covering four main areas: aortic area,
pulmonary area, mitral area, and the tricuspid
area.
 Listen for rate and regularity
 Murmurs: are audible vibrations of the heart and
great vessels that are produced by turbulent
blood flow
 Pericardial friction rub: it is an extra heat sound
originating from the pericardial sac. This may be
a sign of inflammation, infection, or infiltration.
It is described as a short, high-pitched, scratchy
or grating sound.
7. Inspection of the extremities: observe for skin and vascular changes like:
a. Decrease capillary time. Capillary refill is the basis for estimating the rate of peripheral blood flow.
Normal capillary refill time: 1-2 seconds
b. Vascular changes from decrease arterial circulation include a decrease in quality of loss of pulse,
discomfort and pain, paresthesia, numbness, decrease in temperature, pallor, and loss of movement.
c. Hematoma: a localized collection of clotted blood.
d. Peripheral edema: fluid accumulation on the dependent area of the body.
e. Clubbing of the fingers and toes (implies chronic hemoglobin desaturation, as in congenital heart
disease).
f. Lower extremity ulcers (observed in patients with arterial or venous insufficiency).
8. Perform a Respiratory Assessment.
 Note rate, depth, and respiratory pattern
 Findings pointing to cardiovascular problems may include tachypnea; cough; rales, crackles, or
wheezing; hemoptysis; Chyne-Stokes respiration.
9. Perform Abdominal Assessment noting particularly liver enlargement and ascites; bladder distention; and
bruits just above the umbilicus which may reflect abdominal aortic obstruction or aneurysm.

Diagnostic Evaluation
Laboratory Test: to assist in making the diagnosis, to screen for risk factors associated with coronary artery
disease.
1. Complete Blood Count (CBC)
 Elevated RBCs suggest inadequate tissue oxygenation.
 Elevated WBCs may indicate infectious heart disease.

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2. Blood Lipid Profile. Lipids are measured to evaluate the risk of CAD and to monitor the effectiveness of anti-
cholesterol medications.
a. Serum Cholesterol (LDH and HDL): is a lipid required for hormone synthesis and cell membrane
formation.
The client should be NPO from 10 to 12 hours
Normal Range: 150 to 200 mg/dl
LDLs : less than 160mg/dl
HDLs : 35-70 mg/dl (male)
: 35-85 mg/dl (female)
b. Serum Triglycerides: composed of free fatty acids and glycerol
Normal range: 100 to 200 mg/dl
3. Cardiac Enzymes: released from injured cells when the cell membrane rupture.
a. Creatinine kinase (CK-MB): it is the most cardiac-specific enzyme.
Normal Range:
Male: 55-170 units/L
Female: 30 – 135 units/L
Range with myocardial Infarction
Onset: 2 to 6 hours
Peak: 6 to 8 hours
Return to normal: 2 to 3 days
b. Troponin: most specific laboratory tests to detect MI. Troponin T and I are proteins found only on the
cardiac muscle.
Onset: 2 to 4 hours.
Peak: 6 to 10 hours
Remains elevated for 1 to 3 weeks
4. Homocysteine: an amino acid that promote thrombus formation
Interpretation: Optimal: < 12 mcmol/L
Borderline: 12 – 15 mcmol/L
High risk: > 15 mcmol/L

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5. Serum Electrolytes: affect cardiac contractility, specifically Na, K, Ca
Normal Range:
Na+ : 135 to 145 mEq/L Ca ++ : 4.5 to 5.5 mEq/L (8.6-10.2 mg/dl)
K+ : 3.5 to 5 mEq/L Mg ++ : 1.3 to 2.3 mEq/L

Diagnostic Test
1. Electrocardiography (ECG): a visual representation of the electrical activity of the heart. It is still the standard
for the evaluation of myocardial ischemia. It is a useful tool in the diagnosis of conditions that may cause
aberrations in the electrical activity of the heart such as MI and other types of CAD such as angina, cardiac
dysrhythmias, cardiac enlargement, electrolyte disturbances (calcium, potassium, magnesium, & phosphorous)
 Obtain by placing leads (electrodes) on various body parts and recording the electrical impulses as a
tracing on a strip of paper or on the screen of an oscilloscope
 Waves, complexes, and intervals:
o P wave: indicates atrial depolarization produced by atrial depolarization;
indicates SA node function
o P-R interval (N= 0.12 - 0.20 secs.): indicates the time for an impulse to
travel from the SA node down through the AV node.
o QRS complex (N= 0.08-0.12 secs.): indicates ventricular depolarization
o ST-segment: represents the end of ventricular depolarization and the start
of ventricular repolarization.
o T wave: represents ventricular repolarization
 ECG Electrode Placement:
o Right arm (white) Right leg (green)
o Left arm (black) Left leg (red)
o V1 (red) : 4th intercostal space, right sternal border
o V2 (yellow) : 4th intercostal space, left sternal border
o V3 (green) : diagonally between V2 & V4
o V4 (blue) : 5th intercostal space, left midclavicular line
o V5 (orange) : same level as V4, anterior axillary line
o V6 (violet) : same level as V4 & V5 midaxillary line
 Nursing Interventions: provide privacy and ask the patient to
undress, exposing the chest, wrists, and ankles. Assist with draping
as appropriate. Remove large jewelry or metal from the upper body
to avoid interference. Instruct the patient to lie still, avoiding
movement, coughing, or talking, while ECG is recording to avoid
artifact.

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2. Stress Testing or Exercise Testing: ECG is monitored during exercise on a treadmill
or a bicycle-like device.
 Purpose: to identify ischemic heart disease, to evaluate patients with chest pain,
to assess results of therapy, and to aid in developing a physical fitness program
during cardiac rehabilitation.
 The patient is exercised by increasing walking speed and the incline of the
treadmill or by increasing the load against the pedal of a stationary bicycle.
 Nursing Intervention: Obtain informed consent. Avoid smoking & taking
nitroglycerin, eating, and drinking 4 hours before the test; adequate sleep the
night before the test and avoid stimulants (tea, coffee, energy drinks, etc).

3. Echocardiography (Ultrasound Cardiography): uses ultrasound to assess cardiac structure and mobility. It is
the most commonly used noninvasive cardiac imaging tool.
 The patient is placed in a supine position, and the transducer is placed on the chest. The transducer is
applied with ultrasonic gel to maintain airless contact between the skin and transducer.
 It is painless and takes approximately 30-60 minutes to complete.
 Position the patient on the left side, if tolerated, to bring the heart closer to the chest wall. Assist the
patient to clean the chest of transducer gel after the test.
 Clinical usefulness: demonstration of valvular and other structural deformities, detection of pericardial
effusion, and diagnosis of cardiac tumors and cardiomegaly.

4. Transesophageal Echocardiography (TEE): allows ultrasonic imaging of the cardiac structures and great vessels
via the esophagus. Yields a higher quality picture of the heart than does regular echocardiography. In TEE, an
ultrasound transmitter located at the end of a catheter is passed through the esophagus to the stomach, where
flexion of the tip permits imaging of the heart through the stomach wall and the diaphragm, thus allowing clearer
and more accurate diagnostic evaluation.
Nursing Interventions Before TEE
 NPO for 4 to 6 hours before the study to prevent aspiration
 Administer sedatives as ordered to relieve anxiety

NCM 112
 Keep suction and resuscitation equipment available
 Cardiac monitoring is done during the entire procedure to
assess for dysrhythmias.
 Topical spray anesthetic is administered before the probe is
inserted to depress the gag reflex which facilitates the
insertion of the probe (transducer) into the esophagus.
 Place the patient in a chin-to-chest position to facilitate the
passage of the endoscope.
Nursing Interventions After TEE
 NPO until gag reflex returns to prevent aspiration usually 2
hours after the procedure.
 Place in lateral (side-lying) position to promote drainage of
secretions from mouth.
 Encourage cough
 Throat lozenges or rinse may be used to relieve throat soreness.

5. Roentgenologic studies:
a. Chest X-ray: show the heart size, contour, and position; and demonstrate physiologic alteration in
the pulmonary circulation.

b. Fluoroscopy: provides visual observation of the heart on the luminescent x-ray screen. Shows heart
and vascular pulsations while the heart is in motion. Useful in the assessment of cardiac contours.

c. Coronary Angiography: Invasive imaging procedure that involves

the introduction of a contrast medium into the vascular system
through the insertion of a catheter to outline the heart and blood
vessels for their patency of blood flow versus blockage. Accompanied
by cineangiograms, which record the passage of contrast media
through the vascular tree.
Useful for providing information regarding coronary anatomy,
structural abnormalities, or abnormal heart valve function.

Nursing Care Consideration for Coronary Angiography

 Check for allergies, particularly to iodine (shellfish).
 Make sure there is a signed consent
 NPO before the examination to minimize the danger of pulmonary aspiration should emesis occur.
 Record vital signs every 15 minutes after the angiogram until vital signs are stable.
 Check for bleeding at the puncture site and check distal extremity for normal color and intact pulses
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  The patient may complain of mild headache and or discomfort in the groin or other site depending on the
route by which the contrast medium is administered.
 Encourage patient to increase fluid intake to enhance excretion of the contrast media.

6. Cardiac Catheterization: is a diagnostic procedure in which a catheter is introduced into the heart and blood
vessels.
 Purpose: measure oxygen level and pressure in the various heart chambers; determine cardiac output
and pulmonary blood flow; assess heart structures and coronary artery visualization.
 Right- Heart Catheterization: is done by insertion of a radiopaque catheter into a large vein (brachial or
femoral vein) into the right atrium, right ventricle, and pulmonary vasculature under direct visualization
with a fluoroscope.
 Left-Heart Catheterization: is done by passing a catheter into the aorta via the brachial or femoral artery.

Nursing Interventions before the procedure:

 NPO 8 hours before the procedure to prevent nausea and vomiting
 Assess for allergy to iodine or seafood. The radiopaque contrast medium
used is iodinated.
 Administer sedatives as ordered to allay anxiety.
 Mark distal pulses for easy reference after catheterization.
 Do cardiac monitoring to assess for dysrhythmia.
 May experience warm or flushing sensation as the contrast medium is
injected
 A fluttering sensation is felt as the catheter enter the chambers of the
heart

After the procedure:

 Bed rests until vital signs are stable if the catheter is inserted in the upper
extremity and bed rest for 6 to 8 hours if inserted in the lower extremity to avoid bleeding.
 Monitor vital signs especially peripheral pulses (dorsalis pedis, posterior tibial pulse in the lower

NCM 112
extremities, and radial pulse in upper extremities). Diminished/absent pulse indicates circulatory
impairment.
 Monitor ECG and note for dysrhythmia
 Apply pressure dressing and a small sandbag or ice over the puncture site to prevent bleeding.
 Immobilize affected extremity in extension to promote circulation.
 Monitor extremities for color, temperature, and complaints of pain, numbness, or tingling sensation.
Impaired circulation in the affected extremity is manifested by pallor, cyanosis, cold skin, diminished
pulse/pulselessness, and numbness or tingling sensation.

7. Magnetic Resonance Imaging: is a non-invasive, painless technique that is used to examine both the physiologic
and anatomic properties of the heart. MRI uses a powerful magnetic field and computer-generated pictures to
image the heart and great vessels.
Nursing Interventions:
a. Secure consent (required for MRI with contrast media)
b. Inform that the procedure may last 45 to 60 minutes
c. Assess for claustrophobia
d. Remove all metal items like watches, eyeglasses, and jewelry
e. Instruct the patient to remain still during the procedure
f. Inform the client that the MRI unit makes an intermittent knocking to
thumping sound from the magnetic coils.
g. Caution: a client with a pacemaker, metal plates, prosthetic joints, or
other metallic implants.

8. Hemodynamic Monitoring: the assessment of the patient’s circulatory status.

a. Central Venous Pressure: monitors the pressure within the right atrium; monitors blood volume,
adequacy of venous return to the heart, pump function of the right side of the heart.
 The 0 level of the manometer should be placed at the right, mid-axillary, 4th intercostal space.
 Place the client in a supine position
 Practice asepsis to prevent infection
 Normal reading: Right atrium: 2-6 mmHg
b. Pulmonary Artery Pressure (PAP) and Pulmonary Capillary Wedge Pressure (PCWP)
 Swan-Ganz catheter is inserted via the antecubital vein into the right side of the heart and is floated into
the pulmonary artery. It reflects pressure in the left heart. Left-sided congestive heart failure may lead
to pulmonary edema. Elevated PAP and PCWP reading indicate Left-side congestive heart failure.
 Swan-Ganz catheter is a flow-directed, balloon-tipped, 4-lumen catheter.
 The catheter allows continuous monitoring of: right and left ventricular function; pulmonary arterial
pressure; cardiac output; and arterial-venous oxygen difference.

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 Normal Range: PAP: 4-12 mmHg; PCWP: 4-12 mmHg

Nursing Interventions
 Inflate the balloon for PCWP readings; deflate between readings
 Observe catheter insertion site
 Assess extremities for color, temperature, capillary refilling, and sensation to observe for signs and symptoms
of circulatory impairment in the extremity involved.

Cardiopulmonary Resuscitation: it is done to re-establish the client’s airway, breathing, and circulation.
Downward vertical pressure is used when performing cardiac compressions.

For adults and children: use both hands in cardiac compression (heel of one hand with the hand of the other on
top) and compress the lower half of the sternum 1½ (between the nipples) to at least 2 inches deep. The carotid
artery is used for monitoring the pulse. The brachial artery is used in infants for monitoring the pulse.
Compression rate: at least 100 compressions per minute
Compression ventilation ratio: 30:2 for 1 or 2 rescuers; 30:2 for 1 rescuer & 15:2 for 2 rescuers for children.

Steps
1. Assess the responsiveness or level of consciousness
a. Shake the victim’s shoulder and shout
b. Look at the chest and torso for movement and listen for the escape of air and feel the for
movement of air against the face to check for normal breathing
c. Call for help if no response
2. Circulation - check the pulse. If no pulse is noted, provide compression and ventilation at a 30:2 ratio.
3. Airway - use the head-tilt, chin-lift maneuver to open the airway.
4. Breathing - provide two rescue breaths if no respiration is noted. Use a barrier device if available and
pinch the patient’s nose closed

NCM 112
Activity
Written Assignment: Prepare a diagram that illustrates the relationship between the anatomic structures and
the physiologic function of the cardiovascular system.
Group Assignments: As a group, review the proper techniques to perform a comprehensive cardiovascular
assessment.

Summary
Changes in cardiac rate, rhythm, or output may limit almost all human functions, including self-care,
mobility, and the ability to maintain tissue perfusion, fluid volume status, respirations, and comfort. Cardiac
changes may also affect self-concept, sexuality, and role performance. To provide effective care for these patients,
you need a clear understanding of cardiovascular anatomy and physiology, assessment techniques, diagnostic
tests, and treatments as well as cardiovascular disorders. Therefore, such knowledge, skills, and attitudes allow
us, nurses better promote recovery, improve client compliance, and ensure adequate home care. And finally,
enable the patients to achieve quality life.

Readings and References

Lippincott Manual of Nursing Practice 11th Edition. Nettina et al., 2019
Textbook of Medical-Surgical Nursing-13th Edition. Brunner & Suddarth, 2014
Medical-Surgical Nursing 8th Edition. Joyce Black, 2014
Mosby’s Comprehensive Review of Nursing 20 th Edition. Nugent et al., 2014
Assessment & Management of Clinical Problems 9 th Edition. Lewis et al., 2014
Medical-Surgical Nursing 2nd Edition. Udan, 2009
Anatomy and Physiology. Tortora. 2008.

Interactive Link
https://tinyurl.com/y2o3eab8 (Anatomy & Physiology of the Cardiovascular System)
https://tinyurl.com/y3nsjo96 (Assessing heart sound)
https://tinyurl.com/y5avglys (Blood flow through the heart)
https://tinyurl.com/y6l5rymm (Preload & afterload)
https://tinyurl.com/y3t73ney (Cardiac catheterization)

Case Study 1 (Angina Pectoris)

Patient Profile:
L.P., a 63-year-old man, is brought to the emergency department by ambulance at 6 AM after calling
911.

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10
Subjective Data:
Complaints of chest pain, shortness of breath (SOB), palpitations, and dizziness.
Immediate Management:
The paramedics have started an IV and oxygen at 2 L/min via nasal cannula. They also administered four
ASA and a nitroglycerin tablet, and they obtained a 12-lead ECG. L.P. is pain-free on arrival but still
complains of palpitations and dizziness.

Discussion Questions:
Using a separate sheet of paper, answer the following questions:
1. What are the possible causes of L.P.’s chest pain, SOB, palpitations, and dizziness?
2. What would be your major focus when assessing L.P.?
3. What questions would you ask L.P.?
4. What should be included in the physical assessment? What would you be looking for?
5. What diagnostic studies would you expect to be ordered?

Case Study 2
Mr. Anderson is a 45-year-old executive with a major oil firm. Lately, he has experienced frequent episodes of
chest pressure that are relieved with rest. He has requested a complete physical examination. The nurse
conducts an initial cardiac assessment.
1. The nurse immediately inspects the patient’s skin. She observes a bluish tinge around the patient’s lips.
She knows that this is an indication of:
a. central cyanosis. c. peripheral cyanosis.
b. pallor. d. xanthelasma.
2. The nurse takes a baseline blood pressure measurement after the patient has rested for 10 minutes in a
supine position. The reading that reflects a reduced pulse pressure is:
a. 140/90 mm Hg. c. 140/110 mm Hg.
b. 140/100 mm Hg. d. 140/120 mm Hg.

NCM 112
3. Five minutes after the initial blood pressure measurement is taken, the nurse assesses additional readings
with the patient in a sitting and then in a standing position. The reading indicative of an abnormal postural
response would be:
a. lying, 140/110; sitting, 130/110; standing, 135/106 mm Hg.
b. lying, 140/110; sitting, 135/112; standing, 130/115 mm Hg.
c. lying, 140/110; sitting, 135/100; standing, 120/90 mm Hg.
d. lying, 140/110; sitting, 130/108; standing, 125/108 mm Hg.
4. The nurse returns Mr. Anderson to the supine position and measures for jugular vein distention. The finding
that would initially indicate an abnormal increase in the volume of the venous system would be obvious
distention of the veins with the patient at what angle?
a. 15 degrees c. 35 degrees
b. 25 degrees d. 45 degrees
5. The nurse auscultates the apex of the heart by placing a stethoscope over:
a. Erb’s point. c. the pulmonic area.
b. the fifth intercostal space. d. the tricuspid area.
Key Answer: 1. c; 2. d; 3. c; 4. d; 5. b

Review Questions
1. A client with chronic heart failure is examined in the outpatient department to investigate the recent onset of
peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart
sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse
documents the severity of pitting edema as +1. What is the best description of this type of edema?
a. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg
contours
b. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal
foot and leg contours
c. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
d. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and
leg swelling
2. The nurse is teaching a client about maintaining a healthy heart. The nurse should include which
recommendation?
a. Smoke in moderation.
b. Exorbitant use alcohol
c. Consume a diet high in saturated fats and low in cholesterol.
d. Exercise three to four times per week

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11
3. The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
a. establish unresponsiveness. c. open the airway.
b. call for help d. assess the client for a carotid pulse.
4. A client is admitted to the coronary care unit with a second-degree atrioventricular heart block. The nurse
closely monitors the heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the
nurse knows that the QRS complex represents:
a. atrial repolarization. c. atrial depolarization.
b. ventricular repolarization d. ventricular depolarization.
5. An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by:
a. cerebral bleeding c. myocardial necrosis
b. I.M. injection d. skeletal muscle damage due to a recent fall.
6. A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes the
highest priority at this time?
a. Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired
electrical conduction
b. Anxiety-related to an actual threat to health status, invasive procedures, and pain
c. Ineffective family coping related to knowledge deficit and a temporary change in family dynamics
d. Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time
7. During a routine health examination, a 48-year-old patient is found to have a total cholesterol level of 224
mg/dL and an LDL level of 140 mg/dL. What does the nurse teach the patient based on the Therapeutic
Lifestyle Changes diet (select all that apply)?
a. Use fat-free milk d. Eliminate the intake of simple sugars
b. Abstain from alcohol use e. Avoid egg yolks and foods prepared with whole eggs
c. Reduce red meat in the diet
8. When palpating the patient’s popliteal pulse, the nurse feels a vibration at the site. How should the nurse
record this finding?
a. Thready, weak pulse c. Bounding pulse volume
b. Bruit at the artery site d. Thrill of the popliteal artery

NCM 112
9. Which finding is associated with a blue tinge around the lips and conjunctiva?
a. Finger clubbing c. Peripheral cyanosis
b. Central cyanosis d. Delayed capillary filling time
10. Priority Decision: The nurse caring for a patient immediately following a transesophageal echocardiogram
(TEE) should consider which action the highest priority?
a. Monitor the ECG c. Assess vital signs (BP, HR, RR, temperature)
b. Monitor pulse oximetry d. Maintain NPO status until gag reflex has returned
11. When caring for a patient after cardiac catheterization with coronary angiography, which finding would be of
most concern to the nurse?
a. Swelling at the catheter insertion site
b. Development of raised wheals on the patient’s trunk
c. Absence of pulses distal to the catheter insertion site
d. Patient pain at the insertion site as 4 on a scale of 0 to 10
12. A female patient has a total cholesterol level of 232 mg/dL and a high-density lipoprotein (HDL) of 65 mg/dL).
A male patient has a total cholesterol level of 200 mg/dL and an HDL of 32 mg/dL. Based on these findings,
which patient has the highest cardiac risk?
a. The man, because his HDL is lower
b. The woman, because her HDL is higher
c. The woman, because her cholesterol is higher
d. The man, because his cholesterol-to-HDL ratio is higher

13. Number in sequence the path of the action potential along with the conduction system of the heart.
_______ a. Atrioventricular (AV) node _______ e. Ventricular cells
_______ b. Purkinje fibers _______ f. Sinoatrial (SA) node
_______ c. Internodal pathways _______ g. Right and left atrial cells
_______ d. Bundle of His _______ h. Right and left bundle branches

Key Answer and Rationale:

1. a. Pitting edema is documented as a +1 when depression is barely detectable on the release of thumb pressure and when
the foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot
contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as
+3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
2. d. Exercise three to four times per week; benefits of exercise include reduction in body weight and blood pressure, reduction
in bad (LDL and total) cholesterol and increase in good (HDL) cholesterol. Alcohol intake should be avoided. Smoking, a
diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client
should be encouraged to quit smoking and consume a diet low in cholesterol and saturated fat.
3. a. The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client
for breathing while opening the airway, deliver two breaths, and check for a carotid pulse

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12
4. d. The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same
time as ventricular depolarization and can't be distinguished on the ECG. The T wave represents ventricular repolarization.
The P wave represents atrial depolarization.
5. c. An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including
brain injury, such as cerebral bleeding; skeletal muscle damage, which can be caused by I.M. injections or falls; muscular
or neuromuscular disease; vigorous exercise; trauma; or surgery.
6. a. For a client recovering from CABG surgery, decreased cardiac output is the most important nursing diagnosis because
the myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased
cardiac output. Other possible causes of decreased cardiac output in this client include fluid volume deficit and impaired
electrical conduction. The other options may be relevant but take lower priority at this time because maintaining cardiac
output is essential to sustaining the client's life.
7. a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize a reduction in saturated fat and cholesterol intake.
Red meats, whole milk products, and eggs as well as butter, stick margarine, lard, and solid shortening should be reduced
or eliminated from diets. If triglyceride levels are high, alcohol and simple sugars should be reduced.
8. d. A palpable vibration of a blood vessel is called a thrill and usually indicates turbulent blood flow through the vessel. A
weak, thready pulse has little pressure and is difficult to palpate. A bruit is an abnormal buzzing or humming sound that
may be auscultated over diseased blood vessels and a bounding pulse is an extra full, hard pulse that may occur with
atherosclerosis or hypervolemia.
9. b. Central cyanosis is evident with a blue tinge in the lips, conjunctiva, or tongue. Finger clubbing results from endocarditis,
congenital defects, or prolonged O2 deficiency. Peripheral cyanosis is evident with blue-tinged extremities or in the nose
and ears. Decreased capillary refill may be seen in reduced arterial capillary perfusion or anemia.
10. d. All actions will be done but in order to perform a transesophageal echocardiogram (TEE), the throat must be numbed.
Until sensation returns, as evidenced by the gag reflex, the patient is at risk of aspiration so this action has the highest
priority (priority related to airway—ABCs).
11. c. The absence of pulses distal to the catheter insertion site indicates that clotting is occluding blood flow to the extremity
and is an emergency that requires immediate medical attention. Some swelling and pain at the site are expected but the
site is also monitored for bleeding and a pressure dressing and perhaps a sandbag or clamp may be applied. Hives may
occur as a result of iodine sensitivity and will require treatment but the priority is the lack of pulses.
12. d. A risk assessment for coronary artery disease (CAD) is determined by comparing the total cholesterol to high-density
lipoprotein (HDL) and a ratio can be calculated by dividing the total cholesterol level by the HDL level. The ratio provides
more information than either value alone and an increased ratio indicates an increased risk. The female patient has a ratio
of 3.56, which is an average risk, compared with the male patient’s ratio of 6.56, which is an increased risk.

NCM 112
13. a. 4; b. 7; c. 3; d. 5; e. 8; f. 1; g. 2; h. 6

Memory Tip

Pain: assessment—"PQRST"
P= Provocation: What caused it? What makes it better or worse?
Q= Quality/Quantity: What does it feel like?
R= Region/Radiation: Where is the pain located? Does the pain radiate?
S= Severity Scale: How severe is the pain on a scale of 0 to 10?
T= Timing: When/at what time did the pain start? How long did it last?

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13
 NCM 112

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
14