Focused Cardiovascular Assessment Notes

Overview of the Cardiovascular System

  • Purpose: The heart's main job is to pump blood throughout the body, delivering oxygen, nutrients, and other substances to tissues, while removing waste products from cellular metabolism.

Structure of the Cardiovascular System

  • Anatomy: The heart sits in the thoracic cavity, between the lungs and above the diaphragm, in the mediastinum.
  • Circulatory System:
    • Arterial pathways distribute blood.
    • Venous pathways collect blood and return it to the heart. (Calleja et al., 2016, pp. 442-446)
  • Heart Chambers:
    • Right Atrium: Receives deoxygenated blood from the body via the Vena Cava.
    • Right Ventricle: Pumps deoxygenated blood to the lungs via the Pulmonary artery.
    • Left Atrium: Receives oxygenated blood from the lungs via the Pulmonary vein.
    • Left Ventricle: Pumps 4-5 liters of oxygenated blood to the body per minute via the aorta.

Cardiovascular Physiology

  • Right Side of the Heart:
    • Low oxygen (O2)
    • High carbon dioxide (CO2)
    • Low pressure
  • Left Side of the Heart:
    • High oxygen (O2)
    • Low carbon dioxide (CO2)
    • High pressure

Cardiovascular Pathophysiology

  • Conduction System:
    • SA Node: Pacemaker in the right atrium.
    • AV Node: Impulses travel via internodal tracts with a slight delay to allow filling of the ventricles.
    • Bundle of HIS: Located in the interventricular septum.
    • Purkinje Fibers: Transmit impulses to myocardial cells, causing the apex to contract first.

Circulatory System Pathophysiology

  • Blood Vessels: A closed system of tubes.
  • Blood Volume Distribution:
    • 64% in veins and venules
    • 13% in arterioles
    • 7% in capillaries
    • 9% in the pulmonary system
    • 7% in the heart

Potential Cardiovascular Health Problems

  • Color changes in lips, face, and nail beds
  • Peripheral skin color changes
  • Chest discomfort, pressure, squeezing, or pain
  • Palpitations
  • Sweating
  • Light-headedness
  • Syncope (fainting)
  • Shortness of breath
  • Oedema (swelling)
  • Pain and/or numbness/tingling in the extremities
  • Fatigue
  • Feeling of doom
  • Self-care restrictions due to tiredness, pain, or breathing difficulties

Preparing for a Physical Assessment

  • Introduce yourself and explain the procedure, including the estimated time.
  • Invite and address patient questions.
  • Explain any prolonged tasks.
  • Maintain patient privacy and comfort.
  • Ensure accessibility to the patient from both sides of the bed.
  • Adjust bed height as needed.
  • Warm all equipment.
  • If the patient is fatigued, postpone the assessment.
  • Use a systematic approach, such as head-to-toe.
  • Thank the patient upon completion.
  • Thoroughly document findings.

Nursing Assessment Considerations

  • Privacy
  • Quiet environment
  • Adequate lighting
  • Room temperature

Communication During Assessment

  • Introduce yourself
  • Explain the assessment process
  • Invite and address questions
  • Be mindful of non-verbal cues
  • Maintain privacy
  • Allow ample time
  • Thank the patient afterward
  • Document thoroughly

Patient Positioning for Assessment

  • Supine position
  • Semi-Fowler's position (45°)
  • High-Fowler's position (90°)

Cardiovascular Assessment Techniques

  • General observation (general survey)
  • Primary survey (ABCDE - Airway, Breathing, Circulation, Disability, Exposure)
  • Vital signs: Manual blood pressure, radial pulse
  • Inspection: Observing skin color, peripheral vessels, oedema
  • Palpation: Feeling for neurovascular changes (sensation, circulation, pain)
  • Auscultation: Listening to heart sounds and apical heart beat
  • Electrocardiogram (ECG)
  • Observe and record urine output and other fluid losses

General Survey Data

  • Objective Data:
    • Nurse observations during the physical exam.
    • Measurements.
    • Diagnostic tests (ultrasound/X-ray).
    • Specialist investigations.
  • Subjective Data:
    • Patient's past medical, health, family, and social history.
    • Current health problems.
    • Feelings and perceptions.

The Primary Survey

  • A rapid visual assessment to identify:
    • Abnormalities or issues.
    • Patient deterioration.
    • Modifications needed in the care plan.
  • Components:
    • A - Airway
    • B - Breathing
    • C - Circulation
    • D - Disability
    • E - Exposure

Circulation Assessment

  • Adequacy of circulation is assessed by:
    • Observing skin color for cyanosis or pallor.
    • Feeling for radial pulse (assessing rate, rhythm, strength).

Physical Assessment Techniques (IPPA)

  • Inspection (I)
  • Palpation (P)
  • Percussion (P)
  • Auscultation (A)

Focused Cardiovascular Assessment

  • Review baseline data.
  • Hand hygiene; ensure comfort and privacy; explain procedure and address concerns.
  • Position patient supine at 45 degrees.
  • General observation: skin color, temperature, mental status.
  • Inspect and palpate upper limbs: color, warmth, movement, sensation.
  • Check peripheral and central capillary refill time.
  • Palpate radial pulse: rate, rhythm, strength.
  • Measure manual blood pressure.
  • Observe neck veins (at 45-degree angle).
  • Auscultate apical heart sounds: rate and rhythm; identify normal sounds; listen for changes (added sounds or murmurs).
  • Inspect and palpate lower limbs: color, warmth, movement, sensation; palpate pedal pulses; check for pitting oedema (ankles).
  • Inspect and palpate calves: redness, warmth, tenderness.
  • Observe urine output and other losses.
  • Observe ECG for abnormal changes

Inspection – Physical Appearance

  • First assessment technique.
  • Skin: Color (cyanosis, flushed, pale, jaundice)
  • Diaphoresis, Flushed, Pallor, Rash
  • Accessory muscle use, nasal flaring, tachypnea, shortness of breath
  • Chest: Shape and symmetry
  • Neck: Tracheal shifts, Jugular vein distension
  • Extremities: Clubbing, edema, skin tears
  • Discomfort, Pain and anxiety
  • Work of breathing
  • Size of patient: Malnourished, obese; Lethargic, alert, disoriented

Palpation

  • WARM HANDS and SHORT NAILS.
  • Communication.
  • LIGHT PALPATION: Superficial, delicate, gentle; Use finger pads; Depress 1cm below surface.
  • Information Gained: Skin texture, moisture, masses, fluid, tenderness, muscle guarding.
  • ASSESS for PAIN: Palpate tender areas last.

Inspection and Palpation: Peripheral Limbs

  • Inspect and palpate for color, warmth, movement, and sensation.
  • Assess radial and pedal pulses for rate, rhythm, and strength.
  • Palpate for pitting oedema.
  • Inspect and palpate calves for redness, warmth, and tenderness.
  • Check peripheral capillary refill time.

Auscultation: Assessing Heart Sounds

  • Heart Sounds:
    • 1st heart sound (S1 - lub): Closure of mitral and tricuspid valves.
    • 2nd heart sound (S2 - dub): Closure of aortic and pulmonary valves.

Assessing Apical Heart Beat

(Refer to diagrams for location)

Assessing the Cardiac Conduction System (ECG)

  • Normal Sinus Rhythm:
    • Must have a P wave.
    • P wave should be rounded and consistent in shape.
    • Every P wave should be followed by a QRS complex.
    • P-R interval should be 3-5 small squares and constant.
    • Rhythm should be regular.

ECG Lead Placement

(Refer to diagrams for placement details)

Sinus Rhythm: PQRST

  • 3 Stages:
    • Atrial depolarization
    • Ventricular depolarization
    • Atrial and ventricular repolarization

Sinus Rhythms

  • P wave: Contraction of atria
  • QRS complex: Contraction of ventricles; Repolarization of atria (hidden)
  • T wave: Repolarization of ventricles

Legal Considerations During Assessment

  • Establish a trusting and caring relationship.
  • Inform the patient of what to expect, where to expect it, and how it will feel.
  • Address patient concerns before proceeding.
  • Document the examination accurately.

The Clinical Reasoning Cycle

  1. Gather Subjective and Objective Data
  2. Compare data against normal parameters
  3. Identify Health Problems
  4. Establish goals: realistic and person-centered
  5. Take Action
  6. Evaluate & Reflect on outcomes

Cardiovascular Health Problems and Goals

  • Symptoms:
    • Color changes in lips, face, and nail bed
    • Chest discomfort/palpitations or pain
    • Sweating
    • Light-headedness and syncope
    • Shortness of breath
    • Oedema
    • Pain and/or numbness/tingling in the extremities
    • Fatigue
    • Feeling of doom
    • Self-care restrictions
  • Goals:
    • Patient feels comfortable and pain-free
    • Patient's skin is dry
    • Patient feels stable when walking & denies light-headedness
    • Reduced peripheral oedema
    • Patient feels positive about their health
    • Patient is able to care for themselves independently

Some Cardiovascular Diseases

  • Heart failure: returning blood not pumped fast enough
  • Myocardial dysfunction:
    • Cardiomyopathy
    • Myocarditis
  • Circulatory failure:
    • Hypovolemia (shock, haemorrhage, dehydration)
    • Valvular dysfunction
    • Congenital defects
  • Congestive heart failure: failing heart leads to fluid congestion
    • In lungs – pulmonary oedema
    • In body – oedema