Chapter 2. Patient Assessment

2.8 Head-to-Toe Assessment: Cardiovascular Assessment

Checklist 18 provides a guide for subjective and objective data collection in a cardiovascular assessment.

Checklist 18: Cardiovascular (CV) Assessment

Figure 2.11 Cardiovascular system
Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.

Objective Data

Consider the following observations.

Steps

 

Additional Information
Colour of Skin & Mucous Membranes Cyanosis (a bluish tinge) may suggest inadequate oxygenation and CV compromise
Temperature of Extremities Hot skin may suggest fever and should be followed up with full vital signs, report to the primary prescriber, and investigation of any suspected sources of infection.

Cold skin may suggest existing or new circulatory related issues.
Blood Pressure, Heart Rate, SpO2 Baseline vital signs are important in any assessment. Vital signs should be compared to the patient’s normal values. Patterns and trends outside of the normal range should be reported to the appropriate person.

See Chapter 2.4 Vital Signs
Capillary Refill

 Press on the nail beds of toes and/or fingers until there is blanching (whiteness). Release the pressure and count how many seconds until the patient’s full colour returns.

  • Brisk capillary refill: < (less than) 3 seconds
  • Delayed capillary refill: > (greater than) 3 seconds

Delayed cap refill may suggest cardiovascular or respiratory dysfunction and should be followed-up with a focused assessment.
Edema

Figure 2.12 Hand edema
Figure 2.13 Foot and ankle edema
 Edema can be the result of many things, including:

  • Inflammatory response from things like bee stings, sprains, or injury
  • Altered venous return
  • Diseases of the lymphatics
  • Fluid shifts
  • Side effects of some medications
  • Circulatory overload
  • Heart failure

It is important to ask the patient if is this normal for them.

Observe limbs simultaneously in order to compare. Unilateral edema of the leg may suggest deep vein thrombosis (DVT).

Edematous tissue has a high risk of skin breakdown. Implement strategies to maintain skin integrity.
Palpate Extremities to Quickly Assess Colour, Warmth, Movement, and Sensation (CWMS), Capillary Refill of Hands and Feet

 Colour and warmth provide information about perfusion.

Movement provides a brief overview about musculoskeletal function of extremities, which is affected by circulation.

Sensation: by asking if the client has numbness and/or tingling in extremities the nurse gets a brief overview of client baseline. Altered sensation may be the result of impaired neurological function or impaired perfusion.

Palpate pulses for symmetry in quality, rate, and rhythm. This provides information about perfusion.

Asymmetry in relation to assessment findings may indicate a number of things including cardiovascular conditions, history of injury, or post surgical complications.

Report concerns to the appropriate healthcare professional.

 
Auscultate: Apical Heart Rate for Rate and Rhythm

 Apical pulses are assessed using a stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults. For accuracy, an apical heart rate should be taken for a full minute. Identify S1 and S2 and follow up on any unusual findings.

See Chapter 2.3 Vital Signs
Clubbing of Nails

Figure 2.14 Clubbing of finger nails
 Clubbing of nails may suggest underlying cardio pulmonary disease

Subjective Data

Ask about chest discomfort, pain, or pressure. All of these may be indicative of a larger cardiovascular issue. Reports of these must be followed up with a more detailed assessment and notification to the appropriate healthcare provider.

A focused cardiovascular assessment may also include:
Rating of Edema Using an Objective Scale

Figure 2.15 Pitting edema
Rating of Edema
Grade Description Depth of Indent Time to Return to Normal
+1 Slight pitting, no visible change in the shape of the extremity; 0–1/4 inch
(< 6 mm)		 Rapidly
+2 No marked change in the shape of the

extremity

 1/4–1/2”
(6–12 mm)		 10–15 seconds
+3 Noticeably deep pitting, swollen extremity 1/2–1”
(1–2.5 cm)		 1–2 minutes
+4 Very swollen, distorted extremity > 1”
(>2.5 cm)		 2–5 minutes
Adapted from Brodovicz et al., 2009

Jugular Vein Distension (JVD)

Figure 2.16 Jugular vein distension (JVD)
 Jugular vein distension of more than 3 cm above the sternal angle while the patient is sitting at
45 degrees may indicate heart failure.
Rating of Peripheral Pulses Using an Objective Scale

Figure 2.17 Pulse Sites
 Pulse quality may be important to assess following surgery when the patient is at risk for arterial compromise (i.e., graft occlusion). A deterioration in pulse quality might suggest arterial occlusion.

 Peripheral Pulse Rating Scale
Rating Description
0 No pulse
+1 Faint but detectable
+2 Slightly diminished compared to normal
+3 Normal
+4 Bounding
Adapted from Hill & Smith, 1990
Auscultation of Heart Sounds Depending on the context, nurses may need to have the skill to be able to assess specific heart sounds.

Additional resources:
Potential cardiovascular related nursing diagnoses:

  • Activity intolerance related to diminished cardiac function.
  • Acute chest pain due to increased cardiac workload.
  • Ineffective cardiac or peripheral tissue perfusion secondary to heart failure.
  • Learning need in relation to risk factors associated with cardiovascular disease.
Data sources: Assessment Skill Checklist, 2014; BCCNP, 2018; Brodovicz et al., 2009; Hill & Smith, 1990; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Perry, Potter, & Ostendorf, 2018; Potter et al., 2019; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. A client has +4 edema to bilateral feet and ankles. Identify two strategies to assist in maintaining skin integrity.
  2. A client has just had a femoral popliteal bypass. Which peripheral pulses should be included in the assessment specific to determining arterial perfusion of the affected leg?

Attributions:

Figure 2.11 3D Human Heart and Circulatory System Illustration by Bryan Brandenburg is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.12 Edema of Right Hand Due to Allergic Reaction by CNX Openstax is used under a Creative Commons Attribution 4.0 International license.

Figure 2.13 Post Heart Transplant 21 October 2018 Harefield Hospital by Ryaninuk is used under a Creative Commons Attribution 4.0 International.

Figure 2.14 Clubbing Fingers by Desherinka is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 2.15 Pitting Edema by James Heilman is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.16 JVD by Ferencga is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.17 Pulse Sites by  CFCF  is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

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Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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