Cardiovascular assessment

What do you inspect in inspection?

• Colour of skin, lips, nail beds

• Diaphoresis (Sweating)

• WOB

• External jugular vein

• Oedema

What does diaphoresis indicate?

May be due to stress related to pain and reduced cardiac output

What does cyanosis and clubbing nails indicate?

Prolonged hypoxia

What does external jugular distention and oedema indicate?

Congested heart failure and fluid overload

How should you position the patient and why

Semi fowlers to assess jugular venous pressure

Name the valves

• Aortic valve

• Pulmonary valve

• Mitral valve

• Tricuspid valve

Where is the Aortic valve located

2nd ICS, right sternal border

Where is the Pulmonary valve located?

2nd ICS, left sternal border

Where is the Tricuspid valve?

4th-5th ICS, left lower sternal border

Where is the Mitral valve located?

5th ICS, left of midclavicular line

What do you palpate?

• Carotid artery - if weak, heart isnt pumping hard enough

• Apical pulse - sit pt forward to get better palpation

• Diaphoresis

• Peripheral pulse

What is S1?

Closing of mitral and tricuspid valves

What is S2?

Closing of aortic and pulmonary valves

Where is S2 best heard?

2nd ICS, left sternal border

Where is S1 best heard?

5th ICS, left of midclavicular line

Should S1 or S2 be louder?

S1

What are the anatomical landmarks?

• Sternal notch

• Angle of louis (2nd ICS)

• Clavicle

• 5th ICS

What does the apical pulse tell us?

The true heart rate because it reflects ventricular contractions and detects irregular rhythms

Nursing diagnoses’ for cardiovascular assessment

• Acute pain

• Impaired tissue perfusion

• Decreased cardiac output

• Excess fluid volume

• Risk of activity intolerance

Rationale for “When did the pain start?”

• Gives onset and duration

• Determines urgency

Rationale for “What were you doing when the pain started?”

Determines if symptoms are related to exertion or activity

Rationale for “Have you experienced any SOB”

Assessing for reduced cardiac output or pulmonary congestion

Rationale “Have you noticed any swelling in your ankles, legs or feet?”

Assessing for fluid retention

Rationale for “Do you have any history of cardiac conditions”

To identify existing cardiovascular conditions that may affect the pts current health

Rationale for “Do you smoke or drink?”

Increases risk of cardiovascular disease