Dr.

Samia Youssef Sayed

1 Assistant Prof. Medical Surgical Nursing
 Introduction:
To differentiate between normal and
abnormal, The nurse must have appropriate
knowledge regarding the following:
 Structure &function of the heart
 Great vessels
 The electrical conduction system
 The cardiac cycle
 Heart sounds
 Cardiac output
 Neck vessels.
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 Nursing Assessment of the Cardiovascular System

I-Subjective Data: can help the nurse:

 To identify abnormal conditions that may affect the
patient's ability to perform activities of daily living
 Provides information on the patient's risk for
cardiovascular disease
 Identify area where health education is needed.

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 Nursing History:
History
Question Rational
Items
1. Do you Chest pain can be cardiac,
experience chest pulmonary, muscular or
pain? gastrointestinal in origin
2. Do you tire easily Fatigue may result from
Current or experience compromised cardiac output.
fatigue?
sympto
ms 3.Do you have Dyspnea may result from
dyspnea? congestive heart failure, pulmonary
disorders, coronary artery disease,
and myocardial infarction. It may
occur at rest, during sleep or with
exertion.
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History
Question Rational
Items
Do you Enhanced renal perfusion
experience during periods of rest may
nocturia? promote nocturia
Do you Palpitations due to increase
experience cardiac out put by increase the
Current palpitations? heart rate.
sympto Do you Dizziness indicate decreased
ms experience blood flow to the brain & put
dizziness? the patient at risk for falls.
experiencing Swelling in the lower
swelling in feet, extremities usually occurs as a
ankles, or legs? result of heart failure.
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History
Question Rational
Items
1. Have you been Congenital or acquired defects
diagnosed with a affect the heart's ability to
heart defect or a pump, decreasing the oxygen
murmur? supply to the tissues.
2. Have you ever Approximately 40% of people
Past had rheumatic with rheumatic fever develop
History fever? rheumatic carditis.

3. Have you ever Previous heart surgery may

had cardiac change the heart sounds
surgery?

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History
Question Rational
Items
1.history of A genetic predisposition
Family hypertension, MI, increases the patient chance for
History in your family? development of heart disease.

Do you smoke? Cigarette smoking greatly

How many backs increases the risk of heart
per day for how disease
Life
Style & many years?
Health What type of Stress has been identified as a
Practice stress do you possible risk factor for heart
have in your life? disease.
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History
Question Rational
Items
Do you exercise? A sedentary life style is a
What type of modifiable risk factor
exercise and how contributing to heart disease.
often?
Life How many Orthopnea is the inability to
Style & pillows do you breathe while supine result from
Health use to sleep at compromised heart function.
Practice night?
Have you ever Dyslipidemia is the greatest risk
had a lipid for developing CAD.
profile?

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II-Objective Data

Is collected through Physical Examination Techniques

Begin examination with the patient seated upright with

the chest un- draped

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 Inspection
Examination Abnormal Findings
Technique
Normal

Inspect The  Uniform Flushed skin may indicate rheumatic heart

Patient's color disease or presence of a fever or increased
Skin& Hair cardiac out put may make the skin warmer.

Grayish undertones seen in patients with

CAD or those in shock.
A ruddy color may indicate polycythemia
(increase number of red blood cells) or
Cushing syndrome

Absence of body hair on the arms or legs

may indicate diminished arterial blood flow
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 Examination Abnormal Findings
Normal
Technique
Inspect the • The eyes should be Protruding eyes are seen in
eyes and the uniform & not have hyperthyroidism. High cardiac
tissues a protrusion output, tachycardia & potential
surrounding for congestive heart failure
eyes • - Perorbital area Perorbital puffiness may result
should be relatively from fluid retention,
flat. No puffiness myxedema, or valvular
diseases
• Sclera should be
whitish
An arcus in a young person
• - The cornea may indicate
should be without hypercholesterolemia.
an arcus, which is a
ring like structure.
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 Examination Abnormal Findings
Normal
Technique
Inspect the Marfan's syndrome, a
eyes and the - The conjunctiva
tissues should be pinkish degenerative disease in the
surrounding in color connective tissue, which over
eyes
times may cause descending
aorta to dilate or dissect, leading
to death.
- the eye lid Xan-thelasma are yellowish
should be
smooth. cholesterol deposits on the
eyelids which indicate premature

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atherosclerosis.
Examination Abnormal Findings
Normal
Technique

Inspect the  Uniform of Blue-tinged lips may

Lips color without indicate cyanosis which
any underlying is a late sign of
tinges of inadequate tissue
blueness perfusion

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Examination Abnormal Findings
Normal
Technique

Inspect The  The patient Rhythmic head (up&

Head should be able down) with heart beat is

Position to hold the characteristics of sever

head steady aortic regurgitation

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 Examination Abnormal Findings
Normal
Technique

Inspect Legs  Skin color& hair Swelling or edema

For; distribution as may indicate heart

Skin Color mentioned failure or venous

,hair&Edema before. insufficiency

 Free from

edema
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Examination Abnormal Findings
Normal
Technique

Inspect the  The earlobes Bilateral earlobes creases are

Earlobes should be often associated with CAD

relatively

smooth

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Examination Abnormal Findings
Normal
Technique

Inspect the  Fingernails Clubbing may be associated with

Hands flat & pink, cyanosis or infective endocarditis,.

and The with white Thin red lines or splinter

Fingers base of each hemorrhage in the nail beds are

nail. also with infective endocarditis.

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 Neck Vessels
Examination
Normal
Technique
Inspect the  Jugular veins are not visible in upright position.
Jugular Veins
 The external jugular vein is located over the
sternocleidomastoid
 The internal jugular vein is located behind this
muscle medial to the external jugular lateral to the
carotid artery

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 Jugular Veins

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 Neck Vessels

Examination Abnormal Findings

Technique
Inspect the Distension of the neck veins indicates
neck for elevation of central venous pressure
distension of commonly seen with:
the jugular • congestive heart failure
veins • fluid overload
• pressure on the superior vena cava.

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 Chest
Examination Abnormal Findings
Normal
Technique
Inspect the  Should be even, Pulmonary edema is
Patient's Chest regular, and often a sever complication
1. Observe the unlabored, with of cardiovascular disease.
Respiratory Pattern. no retractions.

2. Observe the veins  Should be evenly Dilated, distended veins

on the chest. distributed and on the chest indicate an
relatively flat. obstructive process, as
seen with obstruction of
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 Chest
Examination Normal Abnormal Findings

Inspect the Observe the patient in heaves or lifts, (forceful rising

precordium upright position then of the landmarks) other than

for pulsation at a 30- degree angle. apical pulsation.

Stand on the patient's This result from valvular
right side & Look for regurgitation, or pulmonary
apical impulse. artery dilatation.
Confirm that the point If left ventricular hypertrophy is
of maximum impulse present , the PMI is displaced
(PMI) is located at the laterally from the 5th ICS
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 Palpation
Examination Abnormal Findings
Normal
Technique
Palpate the  Pulses equally Pulse inequality: arterial
carotid arteries strong; a 2+ with constriction or occlusion in
Note; elasticity no variation in one carotid.
of the artery & strength from beat Weak pulses :hypovolemia,
any thrill to beat shock or decreased COP.
 Arteries are elastic A bounding, firm pulse
& no thrills. hypervolemia or decreased
COP.
Loss of elasticity
arteriosclerosis.
Thrill indicate narrowing of
the artery.

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 Palpation
Examination Abnormal Findings
Normal
Technique
The apical impulse is The apical pulse may be
Palpate the palpated in the impossible to palpate in
Apical Impulses mitral area over the patients with pulmonary
MCL, 5th ICS as a soft emphysema.
vibration , If the apical impulse larger
than 1 to 2 cm, displaced,
suspect cardiac
enlargement.

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 Palpation

Examination Abnormal Findings

Normal
Technique
Palpate For  No pulsations or A thrill which feels
Abnormal vibrations similar to a purring cat ,
Pulsation use palpated in the or a pulsation is usually
palmar surface to areas of the apex, associated with a grade
palpate the apex, left sternal IV or higher murmur
left sternal border, border, or base.
& base

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 Percussion
Examination Abnormal Findings
Normal
Technique
Percuss the  Dullness An enlarged heart emits
patient's chest to percussion in the a dull sound on
determine the left 5th ICS in the percussion over a larger
cardiac border MCL in the size area than a heart of
of 1-2 cm. normal size

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 Auscultation

Examination Abnormal Findings

Normal
Technique
Auscultate the  No A bruit, a blowing or
Carotid Arteries blowing or swishing sound
Using bell & ask the swishing or caused by turbulent
patient to hold breath other blood flow through a
sounds are narrowed vessels
heard

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 Auscultation

Examination Abnormal Findings

Normal
Technique

Auscultation  Rate: 60 to 100 Bradycardia(less than 60

Auscultate Heart beat per minute beats /min) or

Rate & Rhythm with regular tachycardia (more than

rhythm. 100 beats/min) may result

in decreased cardiac out

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put
 Auscultation

Examination Abnormal Findings

Normal
Technique
Auscultate  The radial and A pulse deficit (difference
radial and apical pulse between the apical
apical pulse should be &peripheral/radial pulses) may
identical. indicate atrial fibrillation,
premature ventricular
contractions

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 Auscultation for heart sounds
Identify anatomical landmarks :

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 Auscultation

Auscultate to identify S1 or
"lub" (systole) & S2 or "dub"
(diastole)
 S1 is loudest at the apex of
the heart.
 S2 immediately follows after
S1 & is loudest at the base of
the heart

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 Auscultation

 Auscultate For Extra Heart Sounds

 Normally no sounds are heard
 S3 & S4 and murmurs (originated from
stenotic valves are best heard with the bell )
 Murmur: Is a swishing or blowing sound. It
indicate that that there may be a hole in one
of the heart's walls, or narrowing in one of the
heart's vessels.
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 Auscultation

 Friction rub: is a sandpaper-like sound. It

occurs when inflamed pericardial surfaces rub
together. may also be heard during the systolic
pause.
 Thrill: vibration felt by touch over an artery
Caused by an abnormal flow of blood

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 Bibliotheca Alexandrina

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