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Course: Medical Surgical Nursing

Topic: Health History and Physical Examination

The Nurses International Community

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Module Goals

Learners will be able to

Describe the assessment of chest pain.
Explain the proper techniques to perform a comprehensive Cardiovascular (CV) assessment.
Discuss the common assessment findings associated with CV disorders.

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Cardiovascular Assessment

Provides valuable information about the function of a client’s cardiovascular system.
Identifying both normal and abnormal assessment provide quality, safe care to the patient.
Includes performing several subjective and objective assessments.

Note: At times, assessment findings are modified according to lifespan considerations

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Subjective Assessment

Vital for identifying signs of potential dysfunction.
Begins with a focused interview; explores:

Past medical and family history
Medications
Cardiac risk factors and
Reported symptoms

Information obtained from the interview process is used to tailor future patient education by the nurse.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Subjective Assessment

Symptoms related to the cardiovascular system include:

Chest pain
Peripheral edema
Unexplained sudden weight gain
Shortness of breath (dyspnea)
Irregular pulse rate or rhythm
Dizziness or poor peripheral circulation (common finding in heart failure)

Any new or worsening symptoms are documented and reported to the healthcare provider.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which signs and symptoms are related to the cardiovascular system? (Select all that apply).

Chest pain
Peripheral edema
Unexplained sudden weight gain
Dyspnea
Irregular pulse rate or rhythm
Dizziness or poor peripheral circulation

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems

Chest Pain:

Question: “Have you had any pain or pressure in your chest, back, neck, or arm?”

Onset: When did the pain start?
Location: Where is the pain?
Duration: When it occurs, how long does the pain last? Is it constant or intermittent?
Characteristics: Describe what the pain feels like (e.g., sharp, dull, heavy, etc.)

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Chest Pain:

Question: “Have you had any pain or pressure in your chest, neck, or arm?”

Aggravating/Alleviating Factors: What brings on/relieves the pain?
*Radiation: Does the pain radiate anywhere?
Treatment: What have you used to treat the pain?
Effects: What effect has the pain had on you?
Severity: How severe is the pain from 0-10 when it occurs?
Associated Symptoms: Have you experienced any nausea or sweating with the chest pain?

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Shortness of Breath

Questions:

“Do you ever feel short of breath with activity?”
“Do you ever feel short of breath while sleeping?”
“Do you feel short of breath when lying flat?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Shortness of Breath

If yes, Follow up Questions:

“How long does it take you to recover?”
“Have you ever woken up from sleeping feeling suddenly short of breath?”(paroxysmal nocturnal dyspnea)?
How many pillows do you need to sleep, or do you sleep in a chair (orthopnea)? Has this recently changed?

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular (CV) and

Peripheral Vascular (PVD)Systems (continued)

Edema:

Questions:

“Have you noticed swelling of your feet or ankles?”
“Have you noticed your rings, shoes, or clothing feel tight at the end of the day?”
“Have you noticed any unexplained, sudden weight gain?”
“Have you noticed any new abdominal fullness?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Palpitation:

Questions:

“Have you ever noticed your heart feels as if it is racing or ‘fluttering’ in your chest?”
“Have you ever felt as if your heart ‘skips’ a beat?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Edema:

If yes, Follow up Questions:

“Has this feeling of swelling or restriction gotten worse?”
“Is there anything that makes the swelling better (e.g., sitting with your feet elevated)?”
“How much weight have you gained? Over what time period have you gained this weight?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Palpitation:

If yes, Follow Up Questions:

“Are you currently experiencing palpitations?”
“When did palpitations start?”
“Have you previously been treated for palpitations? If so, what treatment did you receive?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Dizziness:

Questions:

“Do you ever feel light-headed?”
“Do you ever feel dizzy?”
“Have you ever fainted?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Dizziness:

If Yes, Follow Up Questions:

“Can you describe what happened?”
“Did you have any warning signs?”
“Did this occur with position change?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Peripheral Circulation:

Questions:

“Do your hands or feet ever feel cold or look pale or bluish?”
“Do you have pain in your feet or lower legs when exercising?”

Follow Up Questions:

“What, if anything, brings on these symptoms?”
“How much activity is needed to cause this pain?”
“Is there anything, such as rest, that makes the pain better?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions for Cardiovascular and

Peripheral Vascular Systems (continued)

Calf Pain

Questions:

“Do you currently have any constant pain in your lower legs?”

Follow Up Questions:

“Can you point to the area of pain with one finger?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

What are examples of questions the nurse would ask when assessing the client with shortness of breath?

“Do you ever feel short of breath with activity?”
“Do you ever feel short of breath while sleeping?”
“Have you noticed any unexplained, sudden weight gain?”
“Do you feel short of breath when lying flat?”

Contact info: info@nursesinternational.org

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Objective Assessment

The physical examination of the cardiovascular system involves the interpretation of:

vital signs
inspection
palpation
auscultation of heart sounds

Equipment includes:

penlight
centimeter ruler or tape measure
sphygmomanometer

Wisconsin Medical College System, 2021

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Objective Assessment (continued)

Interpret the blood pressure and pulse readings to verify the patient is stable before proceeding with the physical exam.

Assess the level of consciousness; the patient should be alert and cooperative.

As a general rule of thumb, findings of systolic blood pressure in adults less than 100 or a pulse rate less than 60 or greater than 100 require immediate follow-up.

Wisconsin Medical College System, 2021

Contact info: info@nursesinternational.org

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Objective Assessment - Inspection

Skin color to assess perfusion:

Inspect the face, lips, and fingertips for cyanosis or pallor.

Visually assess jugular vein distension (JVD):

JVD should not be present in the upright position or when the head of the bed is at 30-45 degrees.

Assess the precordium for:

deformities
scars
abnormal pulsations

Wisconsin Medical College System, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors

Medical History:

“Have you ever been diagnosed with any heart or circulation conditions, such as high blood pressure, coronary artery disease, peripheral vascular disease, high cholesterol, heart failure, or valve problems?”
“Have you had any procedures done to improve your heart function, such as ablation or stent placement?”
“Have you ever had a heart attack or stroke?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Medications:

“ Do you take any heart-related medications, herbs, or supplements to treat blood pressure, chest pain, high cholesterol, cardiac rhythm, fluid retention, or the prevention of clots?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Cardiac Risk Factors:

“ Have your parents or siblings been diagnosed with any heart conditions?”

“If yes, who has what conditions?”

“Do you smoke or vape?”

“If yes, how many do you smoke/vape daily?”
“For how many years have you smoked/vaped?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Cardiac Risk Factors:

“If you do not currently smoke, have you smoked in the past?”

If yes, “What did you smoke?”
“For how many years did you smoke?”

“Are you physically active during the week?”

“How many times per week do you exercise, and for how many minutes?”
“What type of exercise do you usually do?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Cardiac Risk Factors:

“What does a typical day look like in your diet?”

“How many fruits and vegetables do you normally eat in a day?”
“Do you monitor the amount of saturated fats you eat?”
“How many times a week do you eat a meal prepared by a restaurant?”
“Do you pay attention to salt in your diet? Do you add salt to your foods before tasting it?”
“Do you have caffeine during the day? If so, how much?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Cardiac Risk Factors:

“Do you drink alcoholic beverages?”

“How many alcoholic drinks do you have on average per day? Per week?”
“Do you drink while at work?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors (continued)

Cardiac Risk Factors:

“Would you say you experience stress in your life?”

“How would you rate the amount of stress in your life from 0-10?”
“How do you cope with the stress in your life?”

“How many hours of sleep do you normally get each day?”

“Do you have difficulty falling asleep?”
“Do you have difficulty staying asleep?”

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

Explain why the jugular vein is not palpated for distention in a cardiac assessment.

Contact info: info@nursesinternational.org

The jugular vein is not typically palpated during a routine assessment for several reasons:

Position and Depth: The jugular vein is located deep within the neck, beneath layers of tissue and muscles. Palpating it directly is challenging due to its depth, especially for individuals with minimal subcutaneous fat.
Fragility: The jugular vein is a delicate structure, and excessive pressure or manipulation can cause discomfort, pain, or potentially damage the vein.
Alternative Assessment Techniques: While the jugular vein may not be palpated, it can be assessed through other means. The jugular venous pulse can be observed visually, and its pulsations can be palpated indirectly by assessing the jugular venous pressure (JVP). Healthcare professionals typically use visualization and measurement of the JVP to assess fluid status and cardiac function.
Clinical Context: The palpation of the jugular vein is more commonly performed by healthcare professionals with specific training or in specific clinical contexts, such as during specialized examinations or procedures. It is not a routine part of general physical assessments.

It's important to note that palpation of the jugular vein should be performed by experienced healthcare professionals who are trained in its assessment to avoid any potential complications or misinterpretation of findings.

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Red Flags

Cyanosis
Absent pulse, Capillary refill time greater than 3 seconds
Deep vein thrombosis (DVT)
Symptomatic tachycardia and bradycardia
New systolic blood pressure (<100 mmHg)
Orthostatic blood pressure changes
New irregular heart rhythm
New extra heart sounds such as a murmur, S3, or S4
New abnormal cardiac rhythm changes
Reported chest pain, calf pain, or worsening shortness of breath

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be okay in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Agency for Healthcare Research and Quality (AHRQ). (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Skills. Chippewa Valley Technical College. https://wtcs.pressbooks.pub/nursingskills/

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