CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEMS ASSESSMENT

INTRODUCTION:
The cardiovascular system consists of the heart and the central blood vessels (primarily the pulmonary, coronary, and neck arteries and veins).
The peripheral vascular system includes those arteries and veins distal to the central vessels, extending all the way to the brain and to the
extremities.
TERMINOLOGIES IN CARDIAC ASSESSMENT:
Precordium: The area of the chest overlying the heart, is inspected and palpated for the presence of abnormal pulsations or lifts or heaves.
Lift and heave: These terms are often used interchangeably. It refers to a rising along the sternal border with each heartbeat. A lift occurs when
cardiac action is very forceful. It should be confirmed by palpation with the palm of the hand. Enlargement or overactivity of the left ventricle
produces a heave lateral to the apex, whereas enlargement of the right ventricle produces a heave at or near the sternum.
S1 sound: The first heart sound, S1, occurs when the atrioventricular (AV) valves close. These valves close when the ventricles have been
sufficiently filled. Although the AV valves do not close simultaneously, the closure occurs closely enough to be heard as one sound. S1 is a dull,
lowpitched sound described as “lub.” S1 occurs when Mitral, tricuspid valves close
S2 sound: The second heart sound, S2, occurs after the ventricles empty the blood into the aorta and pulmonary arteries, the semilunar valves
close producing the second heart sound described as “dub.” S2 has a higher pitch than S1 and is shorter in duration. These two sounds, S1 and
S2 (“lub-dub”), occur within 1 second or less, depending on the heart rate. S2 occurs when Aortic, pulmonic valves close.
Systole: It is the period in which the ventricles contract. It begins with S1 and ends at S2.
Diastole: It is the period in which the ventricles relax. It starts with S2 and ends at the subsequent S1.
Bruit: A blowing or swishing sound. It is created by turbulence of blood flow due either to a narrowed arterial lumen (a common development
in older people) or to a condition, such as anemia or hyperthyroidism, that elevates cardiac output. If a bruit is found, the carotid artery is then
palpated for a thrill.
Thrill: It frequently accompanies a bruit, is a vibrating sensation like the purring of a cat or water running through a hose. It, too, indicates
turbulent blood flow due to arterial obstruction.
METHODS USED IN THE ASSESSMENT OF THE HEART AND CENTRAL VESSELS:
 Assess the heart through inspection, palpation, and auscultation sequence.
 The heart is usually assessed during an initial physical assessment and periodic reassessments may be necessary for long-term or at-risk
clients or those with cardiac problems.
 Assess the central vessels through auscultation and palpation sequence.
Equipments
• Stethoscope
• Centimeter ruler
Preprocedure planning:
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are
going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Inquire if the client has any of the following: family history of incidence and age of heart disease, high cholesterol levels, high blood pressure,
stroke, obesity, congenital heart disease, arterial disease, hypertension, and rheumatic fever; client’s past history of rheumatic fever, heart
murmur, heart attack, varicosities, or heart failure; present symptoms indicative of heart disease (e.g., fatigue, dyspnea, orthopnea, edema,
cough, chest pain, palpitations, syncope, hypertension, wheezing, hemoptysis); presence of diseases that affect heart (e.g., obesity, diabetes, lung
disease, endocrine disorders); lifestyle habits that are risk factors for cardiac disease (e.g., smoking, alcohol intake, eating and exercise patterns,
areas and degree of stress perceived)
ASSESSING THE HEART AND CENTRAL VESSELS:
SR. STEPS OF PROCEDURE NORMAL FINDINGS ABNORMAL
NO. FINDINGS
1. ASSESSMENT OF THE HEART

INSPECTION AND PALPATION:

Inspect and palpate the precordium for the presence of

abnormal pulsations, lifts, or heaves. Locate the valve areas
of the heart:
• Locate the angle of Louis. It is felt as a prominence on the
sternum.

• Move your fingertips down each side of the angle until you
can feel the second intercostal spaces. The client’s right
second intercostal space is the aortic area, and the left second
intercostal space is the pulmonic area. From the pulmonic
area, move your fingertips down three left intercostal spaces
along the side of the sternum. The left fifth intercostal space
close to the sternum is the tricuspid or right ventricular area.

• From the tricuspid area, move your fingertips laterally 5 to

7 cm (2 to 3 in.) to the left midclavicular line. This is the
apical or mitral area, or point of maximal impulse (PMI). If
you have difficulty locating the PMI, have the client roll onto Pulsations
the left side to move the apex closer to the chest wall. No pulsations

• Inspect and palpate the aortic and pulmonic areas, Pulsations Diffuse lift or
observing them at an angle and to the side, to note the heave, indicating enlarged or
presence or absence of pulsations. Observing these areas at No pulsations overactive right ventricle.
an angle increases the likelihood of seeing pulsations. No lift or heave
PMI displaced laterally or
• Inspect and palpate the tricuspid area for pulsations and heaves or Pulsations visible in 50% of adults and lower indicates enlarged heart
lifts. palpable in most PMI in fifth LICS at or Diameter over 2 cm (0.8 in.)
medial to MCL indicates enlarged heart or
• Inspect and palpate the apical area for pulsation, noting its Diameter of 1 to 2 cm (0.4 to 0.8 in.) aneurysm
specific location (it may be displaced laterally or lower) and No lift or heave Diffuse lift or heave lateral to
diameter. If displaced laterally, record the distance between the apex indicates enlargement or
apex and the MCL in centimeters. overactivity of left ventricle.

Bounding abdominal
Aortic pulsations pulsations (e.g., aortic
aneurysm)
• Inspect and palpate the epigastric area at the base of the sternum
for abdominal aortic pulsations.

AUSCULTAION:

Auscultate the heart in all four anatomic sites: aortic, pulmonic, S1: usually heard at all sites Usually Increased or decreased
tricuspid, and apical (mitral). Auscultation need not be limited to louder at apical area S2: usually heard at intensity Varying intensity
these areas; however, the nurse may need to move the stethoscope all sites Usually louder at base of heart with different beats Increased
to find the most audible sounds for each client. Systole: silent interval; slightly shorter intensity at aortic area
duration than diastole at normal heart rate Increased intensity at
(60 to 90 beats/min) pulmonic area Sharp-
sounding ejection clicks
• Eliminate all sources of room noise. Rationale: Heart sounds are Diastole: silent interval; slightly longer
of low intensity, and other noise hinders the nurse’s ability to hear duration than systole at normal heart rate
them.
S3 in children and young adults S4 in
many older adults S3 in older adults S4 may be
• Keep the client in a supine position with head elevated 15° to a sign of hypertension.
45°.
 • Use both the diaphragm and the bell to listen to all areas.

• In every area of auscultation, distinguish both S1 and S2 sounds.

• When auscultating, concentrate on one particular sound at a time

in each area: the first heart sound, followed by systole, then the
second heart sound, then diastole. Systole and diastole are
normally silent intervals.

• Later, reexamine the heart while the client is in the upright sitting
position. Rationale: Certain sounds are more audible in certain
positions.
2. ASSESSMENT OF CAROTID ARTERIES

PALPATION: Symmetric pulse volumes Asymmetric volumes

Palpate the carotid artery, using extreme caution. (possible stenosis or
thrombosis)
Full pulsations, thrusting quality Quality Decreased pulsations (may
• Palpate only one carotid artery at a time. Rationale: This ensures remains same when client breathes, turns indicate impaired left cardiac
adequate blood flow through the other artery to the brain. head, and changes from sitting to supine output)
position Increased pulsations

Elastic arterial wall Thickening, hard, rigid,

• Avoid exerting too much pressure or massaging the area. beaded, inelastic walls
Rationale: Pressure can occlude the artery, and carotid sinus (indicate arteriosclerosis)
massage can precipitate bradycardia. The carotid sinus is a small
dilation at the beginning of the internal carotid artery just above
the bifurcation of the common carotid artery, in the upper third of
the neck.

• Ask the client to turn the head slightly toward the side being
examined. This makes the carotid artery more accessible.
AUSCULTATION:
Auscultate the carotid artery Presence of bruit in one or
• Turn the client’s head slightly away from the side being No sound heard on auscultation both arteries (suggests
 examined. Rationale: This facilitates placement of the stethoscope occlusive artery disease)

• Auscultate the carotid artery on one side and then the other.

• Listen for the presence of a bruit. If you hear a bruit, gently

palpate the artery to determine the presence of a thrill.
3. ASSESSMENT OF JUGULAR VEINS

INSPECTION:

Inspect the jugular veins for distention while the client is placed in Veins not visible (indicating right side of Veins visibly distended
the semiFowler’s position (15° to 45° angle), with the head heart is functioning normally) (indicating advanced
supported on a small pillow. cardiopulmonary disease)

If jugular distention is present, assess the jugular venous pressure

(JVP).

• Locate the highest visible point of distention of the internal Bilateral measurements
jugular vein. Although either the internal or the external jugular above 3 to 4 cm (1.2 to 1.6
vein can be used, the internal jugular vein is more reliable. in.) are considered elevated
Rationale: The external jugular vein is more easily affected by (may indicate right-sided
obstruction or kinking at the base of the neck. heart failure) Unilateral
distention (may be caused by
local obstruction)

• Measure the vertical height of this point in centimeters from the

sternal angle, the point at which the clavicles meet. Repeat the
preceding steps on the other side.

Document findings in the client record using printed or

electronic forms or checklists supplemented by narrative notes
when appropriate.