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Course: Medical Surgical Nursing

Topic: Health History and Physical Examination-II

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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Objective Assessment

Objective assessment involves the physical examination of the cardiovascular system.

Interpretation of vital signs
Inspection
Palpation
Auscultation of heart sounds as the nurse evaluates for sufficient perfusion and cardiac output.

Equipment needed: Stethoscope, penlight, centimeter ruler or tape measure, and sphygmomanometer.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Evaluate Vital Signs and Level of Consciousness

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

Assess the level of consciousness: Alert (Oriented to person, place and time) and cooperative.

Ernstmeyer & Christman, 2021

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Objective Assessment

Inspection:

Skin color to assess perfusion

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

Jugular Vein Distension (JVD)

Bulge in jugular vein

Precordium for abnormalities

Inspect the chest area over the heart for deformities, scars, or any abnormal pulsations the underlying cardiac chambers and great vessels may produce

Ernstmeyer & Christman, 2021

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Objective Assessment

Inspection:

Extremities:

Upper Extremities:

Inspect the fingers, arms, and hands bilaterally, noting Color, Warmth, Movement, Sensation (CWMS).
Capillary refill time

Lower Extremities:

Inspect the toes, feet, and legs bilaterally, noting CWMS, capillary refill, peripheral edema, superficial distended veins, hair distribution, and the location and size of any skin ulcers.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Inspection:

Edema:

Note any presence of edema
Peripheral edema is swelling that can be caused by infection, thrombosis, or venous insufficiency due to an accumulation of fluid in the tissues

Ernstmeyer & Christman, 2021

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Objective Assessment

Inspection:

Deep Vein Thrombosis (DVT):

Inspect the lower extremities bilaterally.
Assess for size, color, temperature, and for the presence of pain in the calves.
Unilateral warmth, redness, tenderness, swelling in the calf, or sudden onset of intense, sharp muscle pain.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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

The nurse is assessing a client following abdominal surgery. The client complains of pain in the back of his calf that hurts when he touches it.

What is the nurse’s priority action at this time?

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Objective Assessment: Auscultation

Heart Sounds:

Performed over five specific areas “APE To Man”
A = The aortic area: 2nd intercostal space to the right of the sternum.
P = The pulmonary area: 2nd intercostal space to the left of the sternum.
E = Erb’s point: directly below the aortic area and located at the third intercostal space to the left of the sternum.
T =The tricuspid area: 4th intercostal space to the left of the sternum.
Man: The mitral area: 5th intercostal space at the midclavicular line.

Ernstmeyer & Christman, 2021

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Auscultation

Location of valves

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Auscultation

Begins at the aortic area
Use the diaphragm of the stethoscope to listen to S1 and S2 sounds (lub-dub)

When assessing the mitral area for female, ask them to lift up their breast tissue.
Count apical pulse for a full one minute
Normal range for an adult: 60-100, regular.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Please click the speaker icon above to hear the S1 and S2 sounds.

Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1).�� Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and tricuspid area (fourth intercostal space).�� When assessing the mitral area for female patients, it is often helpful to ask them to lift up their breast tissue so the stethoscope can be placed directly on the chest wall. Repeat this process with the bell of the stethoscope.�� The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within the normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.��The first heart sound (S1) identifies the onset of systole, when the atrioventricular (AV) valves (mitral and tricuspid) close and the ventricles contract and eject the blood out of the heart. The second heart sound (S2) identifies the end of systole and the onset of diastole when the semilunar valves close, the AV valves open, and the ventricles fill with blood. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.�

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How to Auscultate Heart Sound Effectively?

Repositioning

Ask the client to lean forward if able, or position them to lie on their left side.

Instruct them to briefly hold their breath (10 seconds or as tolerated) if lung sounds impede adequate heart auscultation.
Minimize environmental noise: lower the television volume, shut the door/windows.
Explain the procedure and instruct the client not to speak while listening to their heart.

Ernstmeyer & Christman, 2021

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Auscultation of Extra Heart Sound

Include clicks, murmurs, S3 and S4 sounds, and pleural friction rubs. Difficult for a novice to distinguish; needs lot of experience and practice.
A midsystolic click: heard with the diaphragm at the apex or left lower sternal border, may be followed by murmur.
A murmur is a blowing or whooshing sound heard with diaphragm of stethoscope.
Listen to murmur here.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Extra heart sounds include clicks, murmurs, S3 and S4 sounds, and pleural friction rubs. These extra sounds can be difficult for a novice to distinguish, so if you notice any new or different sounds, consult an advanced practitioner or notify the provider.�� A midsystolic click, associated with mitral valve prolapse, may be heard with the diaphragm at the apex or left lower sternal border. A click may be followed by a murmur.�� A murmur is a blowing or whooshing sound that signifies turbulent blood flow, often caused by a valvular defect. New murmurs not previously recorded should be immediately communicated to the health care provider. In the aortic area, listen for possible murmurs of aortic stenosis and aortic regurgitation with the diaphragm of the stethoscope. In the pulmonic area, listen for potential murmurs of pulmonic stenosis and pulmonary and aortic regurgitation. In the tricuspid area, at the fourth and fifth intercostal spaces along the left sternal border, listen for the potential murmurs of tricuspid regurgitation, tricuspid stenosis, or ventricular septal defect.

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Auscultation of Extra Heart Sound

S3 sound

Often heard when the client lies on their left side and listens over the apex with the bell of the stethoscope.
Also called a ventricular gallop, occurs with fluid overload or heart failure when the ventricles are filling.
Occurs after the S2 and sounds like “lub-dub-dah,” or a sound similar to a horse galloping.

Ernstmeyer & Christman, 2021

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Auscultation of Extra Heart Sound

S4 sound

Also called atrial gallop
Occurs immediately before the S1
Sounds like “ta-lub-dub”

Can occur with decreased ventricular compliance or coronary artery disease.

Ernstmeyer & Christman, 2021

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Auscultation of Extra Heart Sound

Pleural friction rub:

Caused by inflammation of the pericardium.
Sounds like sandpaper being rubbed together.
Best heard at the apex or left lower sternal border with the diaphragm as the patient sits up, leans forward, and holds their breath.

Ernstmeyer & Christman, 2021

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Objective Assessment

Carotid Sounds

Auscultate carotid artery for bruits.
Bruits are a swishing sound due to turbulence in the blood vessel and may be heard due to atherosclerotic changes.

Palpation

Palpation is used to evaluate peripheral pulses, capillary refill, and the presence of edema.
Pay attention to the temperature and moisture of the skin.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Pulse

Compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses.
Bilateral comparison for all pulses (except the carotid) is important for determining subtle variations in pulse strength.
Carotid pulses should be palpated on one side at a time to avoid decreasing perfusion of the brain.

Ernstmeyer & Christman, 2021

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Objective Assessment

Pulse

The posterior tibial artery (behind the medial malleolus)

Palpated by scooping the patient’s heel in the hand and wrapping the fingers around.

The dorsalis pedis artery(lateral to the extensor tendon of the big toe)

Identified by asking the client to flex their toe.
Gently place the tips of the second, third, and fourth fingers adjacent to the tendon and try to feel the pulse.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Pulse

Quality of the pulse is graded on a scale of 0 to 3

0: Absent pulses
1: Decreased pulses
2: Within normal range
3: Being increased

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Pulse

If unable to palpate a pulse, additional assessment is needed.
First, determine if this is a new or chronic finding.
Second, if available, use a doppler ultrasound.
If the pulse is not found, could be a sign of an emergent condition requiring immediate follow-up.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Capillary Refill

The capillary refill test is performed on the nail beds to monitor perfusion, the amount of blood flow to tissue.
Pressure is applied to a fingernail or toenail until it pales (blanching), indicating that the blood has been forced from the tissue under the nail.
Once the pressure is released, a pink color should return within 2 to 3 seconds after the pressure is removed.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Assessment

Edema

Visualize visible swelling caused by a buildup of fluid within the tissues.
Inspect if the edema is pitting or non-pitting.
Press on the skin over bony structure (tibia) to assess for indentation.
If no indentation occurs, it is non-pitting edema.
If indentation occurs, it is pitting edema.

Ernstmeyer & Christman, 2021

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Grading of Edema

Edema rated at 1+ indicates a barely detectable depression with an immediate rebound.
4+ indicates a deep depression with a time-lapse of over 20 seconds required to rebound.
Monitor for sudden changes in weight, which is considered a probable sign of fluid volume overload.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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

A home care nurse is assessing a client with congestive heart failure who has recently been discharged from the hospital.

The client has 3+ pedal edema today. At the previous visit, it was 2+.

How should the nurse proceed?

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When a home care nurse assesses a client with congestive heart failure who has recently been discharged from the hospital and notices an increase in pedal edema from 2+ to 3+, the nurse should proceed as follows:

Assess Vital Signs: Take the client's blood pressure, heart rate, respiratory rate, and oxygen saturation levels to assess their overall hemodynamic stability.
Conduct a Focused Assessment: Perform a thorough assessment of the client's cardiovascular system, including auscultation of heart and lung sounds, checking for any signs of increased fluid retention or congestion, and assessing for any other symptoms, such as shortness of breath or increased fatigue.
Review Medication Regimen: Evaluate the client's medication adherence and review their prescribed diuretic regimen. Ensure that the client is taking the medication as prescribed and that the dosage is appropriate.
Evaluate Fluid and Sodium Intake: Discuss the client's recent dietary habits and fluid intake. Emphasize the importance of adhering to a low-sodium diet and monitoring fluid intake to help manage fluid retention.
Assess for Compliance with Treatment Plan: Review the client's understanding of their treatment plan, including medication management, dietary restrictions, and fluid restrictions. Address any barriers or challenges they may be facing in following the plan.
Educate the Client: Provide education on the importance of monitoring and managing fluid retention. Explain the signs and symptoms of worsening heart failure and the need to report any changes promptly. Reinforce the importance of adhering to medication and lifestyle modifications.
Consult the Healthcare Provider: If the client's condition has worsened or if there are concerns about their fluid status, promptly communicate the findings to the healthcare provider. They may need to adjust the medication regimen, order additional diagnostic tests, or provide further guidance.
Coordinate Follow-up: Schedule a follow-up visit or communicate with the healthcare provider to ensure ongoing monitoring and management of the client's congestive heart failure. This may involve coordinating additional home care visits, laboratory tests, or specialist consultations as needed.

Remember to document the assessment findings, interventions provided, and any communication with the healthcare provider. Prompt and thorough assessment, education, and collaboration with the healthcare team are essential to manage the client's worsening pedal edema and prevent further complications associated with congestive heart failure.

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Objective Assessment

Heaves or Thrills

A heave or lift:

Palpable lifting sensation under the sternum and anterior chest wall to the left of the sternum.
suggests severe right ventricular hypertrophy.

A thrill is a vibration felt on the skin of the precordium or over an area of turbulence, such as an arteriovenous fistula or graft.

Ernstmeyer & Christman, 2021

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Lifespan Considerations

INFANTS AND CHILDREN

A murmur may be heard in a newborn in the first few days of life until the ductus arteriosus closes.
When assessing the cardiovascular system in children, it is important to assess the apical pulse.
Parameters for expected findings vary according to age group.

Ernstmeyer & Christman, 2021

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Expected Apical Pulse by Age

Ernstmeyer & Christman, 2021

Age Group	Heart Rate
Preterm	120-180
Newborn (0 to 1 month)	100-160
Infant (1 to 12 months)	80-140
Toddler (1 to 3 years)	80-130
Preschool (3 to 5 years)	80-110
School Age (6 to 12 years)	70-100
Adolescents (13 to 18 years)	60-90

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Lifespan Consideration

Older Adults

In adults over age 65, irregular heart rhythms and extra sounds are more likely.
An “irregularly irregular” rhythm suggests atrial fibrillation and further investigation is required if this is a new finding.

Ernstmeyer & Christman, 2021

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

Discuss the significance of the nurse finding a thrill upon cardiac assessment.

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When a nurse detects a thrill during an assessment, it is important to promptly communicate this finding to the healthcare provider. The nurse should document the location, intensity, and timing of the thrill and assist in obtaining further diagnostic tests or consultations as indicated. The healthcare provider will evaluate the significance of the thrill, determine its underlying cause, and initiate appropriate management strategies based on the client's specific condition.

Feeling a thrill on a client's chest during an assessment can be significant for a nurse, as it may indicate an underlying cardiovascular condition. A thrill is a vibration or palpable sensation that can be felt upon palpation, and it is often associated with turbulent blood flow caused by structural abnormalities within the heart or blood vessels. Here are some potential implications for the nurse:

Heart Murmur: A thrill may be indicative of a heart murmur, which is an abnormal sound caused by turbulent blood flow through the heart valves. The presence of a thrill suggests that the murmur is significant and may require further evaluation and management.
Valve Disorders: Certain heart valve disorders, such as stenosis (narrowing) or regurgitation (leakage), can produce turbulent blood flow and cause a palpable thrill. Detecting a thrill can provide important information about the severity and location of the valve abnormality.
Ventricular Septal Defect (VSD): A VSD is a congenital heart defect characterized by an abnormal opening between the heart's ventricles. The turbulent blood flow through the defect can generate a palpable thrill. Identifying a thrill can help confirm the presence of a VSD and guide appropriate interventions.
Aneurysm or Fistula: In some cases, a thrill can be associated with an aneurysm (abnormal bulging of a blood vessel) or a fistula (an abnormal connection between blood vessels). These conditions can lead to turbulent blood flow and the presence of a thrill.
Cardiac Surgical Interventions: After certain cardiac surgical procedures, such as the implantation of a prosthetic valve or the repair of a septal defect, the nurse may expect to feel a palpable thrill due to the presence of the surgical materials or changes in blood flow patterns.

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