Physical Assessment of the

Adult Cardiac Patient

Dr Ian Jones
RN, PhD, NFESC
 Emergency Assessment

• Airway
• Breathing
• Circulation
• Disability
• Exposure

ILCOR (2005)
 Clinical Observations
see the lecture on observations for more detail

• Temperature
• Pulse
• Respiration
• Blood pressure
• Oxygen saturations
• ECG
• Pain
• Weight
• Blood (Troponin, U&Es, FBC, Glucose, LFTs)

Jones (2006)
 Eyes
• Sclera (yellow) signs of jaundice
• Cornea (white line around) arcus senilis is common in older patients but can be a
sign of hyperlipidaemia in younger patients (see above)

• Eyelids (Oedema)

• Upper eye lid (White or yellow deposits) xantholasma is a sign of

hyperlipidaemia (see below)

• Lower eyelid (Pale) signs of anaemia

Albarran & Tagney (2007)

 Skin
• Colour - Pale (peripheral shutdown)
- Blue (Cyanosis due to hypoxia)
- Yellow (Jaundice often due to liver or gall bladder disease)
- Rash

• Texture - Dry (can be a sign of dehydration)

- Thick (can be a sign of acromegaly)
- Thin (steroid use, hypothyroid, renal)

• Elasticity - Signs of dehydration

• Ulceration - Peripheral Vascular disease, Pressure ulcer, previous

surgery
 Mouth
• Tongue - Colour (blue is a sign of central cyanosis)
- Dry (sign of dehydration)
- Teeth (poor dentistry linked with infective
endocarditis)

• Breath - Alcohol
- Sweet smelling (sign of keto-acidosis)

• Gums - signs of bleeding

- Swollen
 Hands
Temperature - cold hands (low cardiac output)
- unduly warm (high cardiac output eg thyrotoxicosis)

• Colour - Blue (peripheral cyanosis)

• Stains - Nicotine
• Nails - Capillary refill (>2 secs = poor perfusion)
- Clubbing (congenital disease see left)
- Leukonychia (white nails can be a sign of Liver cirrhosis)
- Concave nails (can occur in anaemia)
- Splinter haemorhage (Endocarditis, see above)

Albarran & Tagney (2007)

 Pulses
• Rate- Check for full minute if pulse is irregular
• Rhythm- Check regularity of pulse. If pulse is irregular then establish if it is
completely irregular (AF) or whether there is some regularity with some irregular
beats (e.g. ectopics or 2 degree AV block)
• Volume- Small volume can indicate low cardiac output
large volume can indicate high output states such as thyrotoxicosis
• Equality- Should be equal in both sides and in all sites (e.g. radial & femoral)
and should not collapse.
• Blood Pressure – Both arms (if there is a difference of >20mmhg in the SBP
of the right arm compared with the left consider Disection of the aorta)
Pulse pressure should be no less than 25% and no more than 50% of the systolic BP
• Musset’s sign- Head bobbing during systole. Can be a sign of back pressure
Cox (2004)
 Jugular Venous Pressure
• Sit the patient at 45 degree and ask them to turn their head away from you
• Shine a pen torch across the neck
• Observe for pulsations in the neck between the angle of the jaw and
clavicle.
• A measurement is then taken of the height of the JVP.
• This measurement should be between 1 -9 cm
• Raised JVP is associated with acute heart failure which carries an increased
mortality risk

Albarran & Tagney (2007)

 Respiration
• Look - -Tracheal position
http://www.elu.sgul.ac.uk/cso/video.php?skill=tracheal_deviation

- Chest movement
http://www.elu.sgul.ac.uk/cso/video.php?skill=chest_expansion

- Rate, rhythm, depth

- Sputum
- Colour
- Chest shape

• Listen - Wet or dry obstruction

- wheeze (bronchospasm)
- Stridor (anaphylaxis)
- Bubbling (oedema)
 Assessing the Precordium
• Observe- Abnormal pulsation of the chest, abnormality of the chest
wall, scars

• Palpation- Feel for the position of the apex. This is usually 5th
Intercostal space mid clavicle, although may be 6th
intercostal space in older adults. (see video at end of
presentation)

• Heave- More rigorous apex beat

• Thrill- A vibration caused by vigorous blood flow. It

characterises a murmur
Cox (2004)
 Auscultation
• Cardiac auscultation is a skill that takes several years to
develop competence. Therefore I have only provided an intro

• The heart is auscultated in one of four areas. These areas relate to the position of the
heart valves (diagram).

• In the normal heart it is said that you can hear two sounds (lub & dub). The first
relates to the closure of the mitral and tricuspid valves (beginning of ventricular
systole) and the second relates to the closure of the pulmonic and aortic valves (end
of ventricular systole)

• However it is clear that each sounds relates to the closure of two valves so there may
be a splitting of the sounds if the valves close separately.

• There may also be sounds present during systole (after the lub) or diastole (after the
dub) These additional sounds are often related to abnormalities in the valves. There
are also third heart sounds heard which are related to heart failure

• Take a look at the link below for more information on heart sounds
• http://www.med.ucla.edu/wilkes/credits.htm
• http://www.blaufuss.org/
 Cardiac Assessment

• Watch the following video to observe a

patient examination in real time.

http://www.elu.sgul.ac.uk/cso/video.php?skil
l=cvs

• Now using this knowledge go and assess

your patients in practice
 Questions

• I will be happy to answer any questions

you may have through the discussion
board
 References
• Albarran J & Tagney J (2007) Chest pain. Advanced assessment and
management skills. Blackwell publishing. Oxford

• Cox C (2004) Physical assessment for nurses. Blackwell publishing.

Oxford

• International Liaison Committee on Resuscitation (2005) part 4

Advanced Life Support 2005 International Consensus on
Cardiovascular Resuscitation and Emergency Cardiovascular Care
Science and Treatment recommendations. Resuscitation 67, 213-247

• Jones I (2006) Cardiac Care: An introductory text. Whurr Publishers.

London.