Module 2: Cardiovascular Assessment - Nursing Skills Theory 3

Course Overview and Competencies

• Course Name: Nursing Skills Theory 3
• Course Code: NCSI 1191
• Development and Revision History:   - Developed: April 4, 2024, by Rhonda Power.   - Revised: April 25, 2026, by Katie Washburn.
• Focus: Module 2 - Cardiovascular Assessment.
• Competencies to be Achieved:   - Explain the principles, procedure, and rationales for a focused cardiovascular system assessment.   - Collect both subjective and objective data.   - Formulate and ask three to five health history questions.   - Ensure bilateral assessment of extremities.   - Distinguish between the use of the bell versus the diaphragm of the stethoscope.   - Assess blood pressure.   - Inspect for jugular distention.   - Palpate and auscultate carotid arteries for the presence of bruits.   - Inspect and palpate the precordium for abnormalities.   - Utilize landmarks for valve sounds using the APETM mnemonic.   - Palpate and auscultate the apical pulse (Point of Maximum Impulse - PMI).   - Auscultate for normal heart sounds ($S1$ and $S2$) and understand the causes of extra heart sounds ($S3$ and $S4$).   - Report unexpected findings and perform required interventions within the licensed scope of practice.   - Document all findings and interventions accurately.

Subjective and Objective Data Collection

• Subjective Data (Patient-Reported Symptoms):   - Chest Pain: Any discomfort or pressure in the chest.   - Dyspnea: Difficulty breathing or shortness of breath.   - Orthopnea: Difficulty breathing while lying flat.   - Cough: Type, frequency, and duration.   - Fatigue: Low energy levels or tiredness.   - Color Changes: Presence of cyanosis (bluish tint) or pallor (pale skin).   - Nocturia: Frequent urination at night.   - Cardiac History: Past personal and family history of cardiac disease.   - Personal Habits: Information regarding diet, smoking, and exercise routines.   - Medications: Current medications the patient is taking.

• Health History Questions (Examples):   - "Do you have a family history of heart disease? Diabetes? High blood pressure?"   - "Do you smoke? How many cigarettes a day would you have?"   - "Have you experienced any cardiac issues in the past? Heart failure? High blood pressure?"   - "Have you experienced any numbness, tingling in your extremities or swelling in your feet?"

• Objective Data (Clinical Observation):   - It is ideal to assess the heart immediately after the lungs while the chest is already exposed and the patient is in a favorable position.   - The heart, neck vessels, and periphery are assessed together because of their functional interdependence.   - Always compare extremities bilaterally to identify discrepancies.

The Precordium: Inspection and Palpation

• Definition: The precordium is the area of the chest that directly covers the heart, major vessels, and thorax.

• Inspection:   - General skin color, looking for scars, bruises, lumps, and symmetry.   - Visible pulsations at the apex of the heart.   - Visible thrust or lift of the chest wall.

• Palpation Procedures:   - Apical Impulse (PMI - Point of Maximum Impulse): Palpate at the midclavicular line in the $5^{th}$ Intercostal Space (ICS) using the fingertips.   - Pulsations and Thrills: Palpate at each auscultation landmark using the proximal portion of four fingers held together.     - Thrill: Described as a continuous vibration resembling the feeling of a purring cat’s throat. The most common cause of a thrill is aortic stenosis.   - Thrusts (Heave or Lift):     - Right Ventricular Hypertrophy: A thrust will lift the heel of the hand with each heartbeat at the left sternal border.     - Left Ventricular Hypertrophy: A thrust will lift the heel of the hand at the apex.

Heart Auscultation and Normal Sounds

• Auscultation Principles:   - Used to gather specific information by assessing the heart directly.   - Location adjustments for the stethoscope may be necessary as every person is unique.   - Diaphragm: Use first at each landmark to note rhythm, $S1$, and $S2$.   - Bell: Use to repeat the process, listening for extra heart sounds ($S3$, $S4$) and murmurs (blowing, swooshing sounds indicative of turbulent blood flow).
• Normal Heart Sounds ($S1$ and $S2$):   - Created by the movement of blood through valves and chambers.   - $S1$ (The First Sound): A low, dull "lub" sound.   - $S2$ (The Second Sound): A higher-pitched, short "dub" sound.

Abnormal Heart Sounds ($S3$ and $S4$)

• General Significance: These sounds indicate that the heart is too full, too weak, or too stiff.

• $S3$ Sound ("lub-dub-ee"):   - May indicate dilated, weak, or "floppy" ventricles.   - Potential Causes:     - Systolic Heart Failure: Ventricle cannot contract properly.     - Volume Overload: Excessive blood return or leaky valves.     - Normal Physiological Finding: Common in children, athletes, and pregnant women.

• $S4$ Sound ("dee-lub-dub"):   - Occurs just before $S1$.   - Indicates blood being pushed into a noncompliant or "stiff" ventricle.   - Potential Causes:     - Chronic Hypertension: Leads to thickened heart muscle.     - Diastolic Heart Failure: Ventricle cannot fill properly.     - Active Myocardial Ischemia: Muscle stiffness during a heart attack.     - Aortic Stenosis: Narrowing of the valve leads to high pressure.

Auscultation Landmarks (The APETM Mnemonic)

1. Aortic Valve: Located at the Right $2^{nd}$ Intercostal Space.
2. Pulmonic Valve: Located at the Left $2^{nd}$ Intercostal Space.
3. Erb's Point: Located at the Left $3^{rd}$ Intercostal Space (where $S1$ and $S2$ are heard well).
4. Tricuspid Valve: Located at the Left $4^{th}$ Intercostal Space along the lower left sternal border.
5. Mitral Valve: Located at the Left $5^{th}$ Intercostal Space, medial to the midclavicular line.

• Apical Pulse: Auscultate at the mitral location for a duration of $1\,\text{minute}$.

Neck Vessel Assessment

• Vessels of Interest: Carotid arteries and Jugular veins.

• Positioning: Patient should be supine with the head elevated to approximately $30^{\circ}$.

• Inspection:   - Neck skin color, lumps, and scars.   - Carotid Arteries: Inspect for visible pulsations on either side.   - Jugular Veins: Remove the pillow. Have the patient look to one side. Inspect for distention (bulging on the side of the neck). Repeat on both sides.   - Clinical Significance: Distended jugular veins (JVD) are abnormal and can indicate right-sided heart failure or fluid overload.

• Palpation of Carotids:   - Palpate gently for a thrill.   - Precaution: Assess only one artery at a time to prevent impairing blood flow to the brain.   - Landmark Precaution: Palpate only the lower half of the artery. Avoid the upper half (carotid sinus), as pressure here can trigger a decrease in heart rate, a decrease in blood pressure, or syncope.   - Finding: Pulse should be smooth and identical on both sides.

• Auscultation of Carotids:   - Listen for a Bruit: A blowing, swishing sound caused by turbulent blood flow in a narrowed artery. Note: If the artery is healthy, no sound will be heard.   - Procedure:     - Keep neck in a neutral position.     - Ask the patient to hold their breath while listening.     - Use the bell lightly without compression.     - Listen at three levels: Jaw level, midway, and the base of the neck.

Critical Thinking and Professional Responsibility

• Assessment Sequence:   - Routine Head-to-Toe: Start with Vitals (BP and Pulse), then proceed to the Precordium, Neck Vessels, and Peripheral Circulation. The specific order of the latter three is categorized as flexible, provided the pattern is organized.   - Change in Condition: Order matters significantly. For example, if a patient reports chest pain, the nurse must collect data about the pain, obtain vitals, and listen to the heart immediately, rather than starting with extremities.
• Required Actions for LPNs:   - It is the responsibility of the Licensed Practical Nurse to report unexpected findings.   - Perform required interventions within the scope of practice.   - Document findings and interventions in the medical record.