Thorax

The anterior thorax and posterior thorax are inspected for skeletal deformities that may displace the heart and cause cardiac compromise. The skin on the chest wall and abdomen is inspected for scars, bruises, wounds, and bulges associated with pacemaker or defibrillator implants. Respiratory rate, pattern, and effort are also observed and recorded.

Abdomen

The abdomen is assessed for signs of distention or ascites, which may be associated with right-sided heart failure. Abdominal adiposity is a known risk factor for CAD.

Nail Beds and Cyanosis

The nail beds are inspected for signs of discoloration or cyanosis.⁴ Clubbing in the nail bed is a sign associated with long-standing central cyanotic heart disease or pulmonary disease with hypoxemia.^4,5 “Clubbing” of the nail refers to a nail that has lost the normal angle between the finger and the nail root; the nail becomes wide and convex. The terminal phalanx of the finger also becomes bulbous and swollen.⁶ Clubbing is rare and is a sign of severe central cyanosis (Fig. 13-1). Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output (CO). Clubbing never occurs as a result of peripheral cyanosis.

Lower Extremities

Legs are inspected for signs of peripheral arterial or venous vascular disease. The visible signs of peripheral arterial vascular disease include pale, shiny legs with sparse hair growth. Recent guidelines indicate that many individuals, especially women, can have peripheral atherosclerosis without obvious signs or symptoms.⁷ Venous disease causes edema of the limb, with deep red rubor, brown discoloration, and, frequently, leg ulceration. A comparison of typical assessment findings in arterial and venous diseases is presented in Table 13-2.

Posture

Body posture can indicate the amount of effort it takes to breathe. For example, sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning forward may be the least painful position for the patient with pericarditis.

Weight

The weight in proportion to height is assessed to determine whether the patient is obese or cachectic.⁸

Mentation

The patient is observed for signs of confusion or lethargy that may indicate hypotension, low CO, or hypoxemia.

Jugular Veins

The jugular veins of the neck are inspected for a noninvasive estimate of intravascular volume and pressure. The internal jugular veins are observed for jugular vein distention (JVD) (Fig. 13-2; Box 13-2). JVD is caused by an elevation in central venous pressure (CVP). This occurs with fluid volume overload, right ventricular dysfunction, pericardial effusion, or any condition that elevates right atrial pressure.^9,10 The right internal jugular vein can be palpated for measurement of CVP in centimeters of water (Fig. 13-3; Box 13-3). Bedside ultrasound is also used to evaluate JVD and estimate CVP.¹¹

Abdominojugular Reflux

The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. This noninvasive test is used in conjunction with measurement of JVD. The procedure for assessing abdominojugular reflux is described in Box 13-4. A positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP equivalent) of 4 cm or more sustained for at least 15 seconds.¹²

Thoracic Reference Points

The thoracic cage is divided with imaginary vertical lines (sternal, midclavicular, axillary, vertebral, and scapular), and the intercostal spaces are divided by imaginary horizontal lines to serve as reference points in locating or describing cardiac findings (Fig. 13-4). The ribs are numbered from 1 (the first rib below the clavicle) to 12. The intercostal space below each rib is given the same number as the rib that lies above it. The second rib is the easiest to locate because it is attached to the sternum at the angle of Louis. This angle (also called the sternal angle) is the bony ridge on the sternum that lies approximately 2 inches below the sternal notch (see Fig. 13-4A). After the second rib has been located, it can be used as a reference point to count off the other ribs and intercostal spaces.

Apical Impulse

The anterior thorax is inspected for the apical impulse, sometimes referred to as the point of maximal impulse (PMI). The apical impulse occurs as the left ventricle contracts during systole and rotates forward, causing the left ventricular apex of the heart to hit the chest wall. The apical impulse is a quick, localized, outward movement normally located just lateral to the left midclavicular line at the fifth intercostal space in the adult patient (Fig. 13-5). The apical impulse is the only normal pulsation visualized on the chest wall. In the patient without cardiac disease, PMI may not be noticeable (see Fig. 13-5).

Arterial Pulses

Seven pairs of bilateral arterial pulses are palpated. The examination incorporates bilateral assessment of the carotid, brachial, radial, ulnar, popliteal, dorsalis pedis, and posterior tibial arteries. The pulses are palpated separately and compared bilaterally to check for consistency.¹³ Pulse volume is graded on a scale of 0 to 3+ (Box 13-5). The abdominal aortic pulse can also be palpated.

Carotid Pulses

The carotid arteries are assessed at the medial midneck region. If blood flow through the carotid arteries is compromised by atherosclerotic plaque, firm palpation could cause total occlusion. The touch is, therefore, light, and the carotid arteries are palpated gently and only one at a time.

Brachial, Ulnar, and Radial Pulses

The brachial pulse is assessed by gently palpating the inner aspect of the slightly bent elbow with the fingers. The radial pulse is palpated in the medial area of the wrist (thumb side). The ulnar artery is palpated at the opposite side of the wrist (little finger side). The radial and ulnar arterial pulses must be assessed before an arterial line is inserted; this test, known as the Allen test, is described in Box 13-6.

Femoral Pulses

The femoral arteries are palpated by pressing deeply into the groin beneath the inguinal ligament, approximately midway between the anterior superior iliac spine and the symphysis pubis.

Popliteal Pulses

The popliteal pulse is lightly palpated using the fingertips. The patient’s leg is very slightly bent, and the clinician’s two hands gently cup the patient’s knee with the thumbs on top of the kneecap and the fingertips behind the knee.

Dorsalis Pedis and Posterior Tibial Pulses

The pulses of the lower leg and foot are assessed to determine blood flow to the limb and to assess adequacy of CO to the extremities. The dorsalis pedis pulse is located on the upper aspect of the foot. The posterior tibial pulse is located behind the medial malleolus (inner ankle bone) of the lower leg.

Descending Aorta Pulse

When the patient is in the supine position, the abdominal aortic pulsation is located in the epigastric area and can be felt as a forward movement when firm fingertip pressure is applied above the umbilicus. If prominent or diffuse, the pulsation may indicate an abdominal aneurysm.

A diminished or absent pulse may indicate low CO, arterial stenosis, or occlusion proximal to the site of the examination. An abnormally strong or bounding pulse suggests the presence of an aneurysm or an occlusion distal to the examination site. If a distal pulse cannot be palpated by using light finger pressure, a Doppler ultrasound stethoscope may enhance diagnostic accuracy. It is important to mark the location of the audible signal with an indelible ink marker pen for future evaluation of pulse quality.

Capillary Refill

Capillary refill assessment is a maneuver that uses the patient’s nail beds to evaluate arterial circulation to the extremity and overall perfusion. The nail bed is compressed to produce blanching, after which release of the pressure should result in the return of blood flow and baseline nail color in less than 2 seconds.¹⁴ The severity of arterial insufficiency is directly proportional to the amount of time required to re-establish blood flow and color.

Edema

Edema is fluid accumulation in the extravascular spaces of the body. The dependent tissues within the legs and sacrum are particularly susceptible. Edema may be dependent, unilateral or bilateral, and pitting or nonpitting. The amount of edema is quantified by measuring the circumference of the limb or by pressing the skin of the feet, ankles, and shins against underlying bone. Edema is a symptom associated with several diseases, and further diagnostic evaluation is required to determine the cause. Although no universal scale for pitting edema exists, typical scales use a 0-to-4+ system (Table 13-3).

Noninvasive Blood Pressure Monitoring. 

The most common peripheral locations for blood pressure monitoring are the bilateral brachial arteries. The pressure is measured in both arms to rule out subclavian arterial stenosis. Normally, the difference in pressure between the arms is less than 10 mm Hg. A finding of more than 15 mm Hg difference between the bilateral arm pressures suggests arterial obstruction on the side with the lower pressure.¹⁶ Asymmetry is documented so that all subsequent measurements can be made on the arm with the higher pressure.

Correct positioning of the extremity being measured is essential. Blood pressure can be measured in any position as long as the arm or the leg is at the level of the heart. Falsely elevated readings are obtained if the arm is at a level lower than the heart, and falsely low pressures are obtained when the arm is at a level higher than the heart.

Orthostatic Hypotension. 

When a healthy person stands, 10% to 15% of the blood volume is pooled in the legs; this reduces venous return to the right side of the heart, which decreases CO and lowers arterial blood pressure.¹⁷ Transient orthostatic intolerance is part of daily life for many people, but acute orthostatic hypotension is a cause for concern.¹⁸ The fall in blood pressure activates baroreceptors; the subsequent reflex increases in sympathetic outflow and parasympathetic inhibition lead to peripheral vasoconstriction, with increased heart rate and contractility.¹⁷ Postural (orthostatic) hypotension occurs when the SBP or BP drops by 10 to 20 mm Hg, or the diastolic BP drops by 5 mm Hg, after a change from the supine posture to the upright posture. This is usually accompanied by dizziness, lightheadedness, or syncope. If a patient experiences these symptoms, it is important to complete a full set of postural vital signs before increasing the patient’s activity level (Box 13-7). Orthostatic hypotension can have many causes.¹⁸ The three most common causes of orthostatic vital sign changes (i.e., drop in blood pressure and rise in heart rate) observed in critical care are as follows:

Box 13-7   Measurement of Postural (Orthostatic) Vital Signs

Guidelines

1. Record blood pressure (BP) and heart rate (HR) in each position.

2. Do not remove the cuff between measurements.

3. Record all associated signs and symptoms.

4. Clearly document patient position.

Technique

1. Keep the patient as flat as possible for 10 minutes before the initial assessment.

2. Patient supine: Obtain initial BP and HR measurements.

3. Patient sitting with legs hanging: Measure immediately and after 2 minutes.

4. Patient standing: Measure immediately and after 2 minutes. If BP and HR are stable but orthostasis is suspected, BP and HR can be repeated every 2 minutes. Note that this is rarely practical for the critically ill patient.

Results

Normal Changes

HR increases by 5 to 20 beats/min (transiently).

Systolic BP drops by 10 mm Hg.

Diastolic BP drops by 5 mm Hg.

Positive Orthostasis

Drop in systolic BP by more than 20 mm Hg.

Drop in diastolic BP by more than 10 mm Hg within 3 minutes.

Blood Pressure Cuff Size. 

Correct size and placement of the inflatable bladder (inside the nondistensible cuff) are crucial to obtaining an accurate blood pressure measurement. The bladder should be long enough to encircle at least 80% of the width of the upper arm (or leg) in adults.¹⁹ Cuffs that are too small can give falsely high readings, and cuffs that are too large can give falsely low readings. Box 13-8 lists the key points to observe when obtaining blood pressure readings.

Korotkoff Sounds. 

Obtaining systemic blood pressure readings involves auscultation of Korotkoff sounds, the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood pressure cuff. The pressure in the cuff is inflated above the normal systolic pressure. As the pressure in the cuff is reduced, Korotkoff sounds change in quality and intensity. These sounds are divided into five stages. The SBP is the highest point at which initial tapping occurs. DBP is equated with the complete disappearance of Korotkoff sounds. Often, a muffling of diastolic sounds occurs before these sounds completely disappear. This has caused debate about which diastolic value to record. Because complete disappearance of Korotkoff sounds corresponds more closely to intra-arterial catheter measurement, it is the value that should be recorded.

Auscultatory Gap. 

In older patients with systolic hypertension, the presence of an auscultatory gap is not uncommon.¹⁹ It is important to inflate the cuff to greater than the patient’s normal systolic pressure to avoid this gap and underestimation of SBP. Use of an initial palpation estimate of the SBP taken before auscultation with a stethoscope is one recommended method to accurately determine the upper SBP.

Automated Blood Pressure Devices. 

Electronic automated devices are frequently used for measuring blood pressure and have replaced the mercury sphygmomanometer in many places. The mercury used in the sphygmomanometer is a nondegradable environmental pollutant that is difficult to dispose of safely. For this reason, mercury sphygmomanometers have been phased out of use in most hospitals.

In readings from automated devices, the systolic number is accurate, but the diastolic value is often calculated from the SBP and the mean arterial pressure (MAP), and therefore, it may not be accurate. Devices placed on the arm or the leg are considered accurate (as long as the cuff size is correct) for systolic measurement and trending of blood pressure. Considerable controversy exists with regard to automated devices being applied to the wrist or the finger, so this method should not be used to monitor blood pressure in any critically ill patient or one with cardiac disease.

Automatic blood pressure cuff placement should be rotated frequently to avoid excessive irritation to the extremity, especially when the automatic cuff is set to cycle more frequently than every 15 minutes.

Pulse Pressure. 

Pulse pressure describes the difference between systolic and diastolic values. The normal pulse pressure is 40 mm Hg (i.e., the difference between an SBP of 120 mm Hg and a DBP of 80 mm Hg). In the critically ill patient, a low blood pressure is frequently associated with a narrow pulse pressure. For example, a patient with a blood pressure of 90/72 mm Hg has a pulse pressure of 18 mm Hg. The narrowed pulse pressure is a temporary compensatory mechanism caused by arterial vasoconstriction resulting from volume depletion or heart failure. The narrow pulse pressure ensures that the MAP (78 mm Hg, in this example) remains in a therapeutic range to provide adequate organ perfusion.

In contrast, a hypotensive septic patient who exhibits vasodilation will have a wide pulse pressure and inadequate organ perfusion. If the blood pressure is 90/36 mm Hg, the pulse pressure is 54 mm Hg, and the MAP will be an inadequate 54 mm Hg. In both these examples, the SBP is the same (90 mm Hg); the difference in pulse pressure is a function of intravascular volume and vascular tone.

Pulsus Paradoxus. 

In normal physiology, the strength of the pulse fluctuates throughout the respiratory cycle. When the “pulse” is measured using the SBP, the pressure is observed to decrease slightly during inspiration and to rise slightly during respiratory exhalation. The normal difference is 2 to 4 mm Hg. In some clinical conditions such as cardiac tamponade, the blood pressure decline is abnormally large during inspiration. In general, an inspiratory decline of SBP greater than 10 mm Hg is considered diagnostic of pulsus paradoxus.20–22 The traditional technique for measuring pulsus paradoxus using a sphygmomanometer and a blood pressure cuff and pulse oximetry is described in Box 13-9. If the patient is hypotensive, pulsus paradoxus is more accurately assessed in the critical care unit by monitoring a pulse oximetry waveform or an indwelling arterial catheter waveform.^20–22

Pulsus Alternans. 

Pulsus alternans describes a regular pattern of pulse amplitude changes that alternate between stronger and weaker beats. This finding is suggestive of end-stage left ventricular heart failure.

Vascular Bruits. 

The carotid and femoral arteries are auscultated for bruits. A bruit, a high-pitched “sh-sh” sound, is an extracardiac vascular sound that vacillates in volume with systole and diastole. An abnormal bruit is produced as blood flows through a partially occluded vessel. Auscultation of a bruit can expedite the diagnosis of suspected arterial obstruction.

Normal Heart Sounds

Auscultation of the heart is the most challenging part of the cardiac physical examination, and, in an era of increasing technologic demands, it is daunting to new clinicians. To summarize the advice given by most experts, the examiner must do the following:23–25