Cardiovascular Clinical Assessment

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Cardiovascular Clinical Assessment

Mary E. Lough

Physical assessment of the patient with cardiovascular disease is a skill that must not be overlooked in the middle of all the technology of the critical care setting.1 Data collected from a thorough, thoughtful history taking and examination contribute to both the nursing and the medical decisions about therapeutic interventions.

History

Patient history is important because it provides data that contribute to diagnosis of cardiovascular disease and treatment plan. For a patient in acute distress, the history taking is shortened to just a few questions about the patient’s chief complaint, precipitating events, and current medications (Box 13-1). For a patient who is not in obvious distress, the history focuses on the following four areas:

Box 13-1   Data Collection

Cardiovascular History

Medical History

Adult

• Diseases and abnormalities

• Surgical history

• Allergies, especially to emergency medications (lidocaine, morphine), radiographic contrast agents, or iodine (shellfish)

• Recent dental work or infection

One of the unique challenges in cardiovascular assessment is identifying when “chest pain” is of cardiac origin and when it is not. The following safety information should always be considered:

• If any evidence of CAD or risk of heart disease exists, assume that the chest pain is caused by myocardial ischemia until proven otherwise.

• Questions to elicit the nature of the chest pain cover five basic areas: 1) quality, 2) location, 3) duration of pain, 4) factors that provoke the pain, and 5) factors that relieve the pain. Questions that may help elicit this information are listed in Table 13-1.

TABLE 13-1

CLARIFYING CHEST PAIN SYMPTOMS BY ASKING SPECIFIC QUESTIONS

DETERMINE TYPICAL QUESTION
Location, radiation Where is it?
  Does it move or stay in one place?
Quality What is it like?
Quantity How severe is it? How frequent?
  How long does it last?
Chronology When did it begin?
  How has it progressed?
  What are you doing when it occurs?
  What do you do to get rid of it?
Associated findings Do you feel any other symptoms at the same time?
Treatment sought and effect Have you seen a physician in the past for this same problem?
  What was the treatment?
Personal What do you think this is from?
Perception Why do you think it happened now?

• Little correlation may exist between the severity of chest discomfort and the gravity of its cause. This is a result of the subjective nature of pain and the unique presentation of ischemic disease in women, older patients, and individuals with diabetes.

• Subjective descriptors vary greatly among individuals. Not all patients use the word “pain”; some may describe their problem as “pressure,” heaviness,” discomfort,” or “indigestion.”

• A correlation is not always present between the location of chest discomfort and its source because of referred pain. For example, in patients with gastroesophageal reflux disease (GERD), esophageal spasm can cause visceral substernal chest pain that radiates to the left arm and jaw and may be described by patients as “heartburn.”2

• Other nonpainful symptoms that may signal cardiac dysfunction are dyspnea, palpitations, cough, fatigue, edema, ischemic leg pain, nocturia, syncope, and cyanosis.

In a meta-analysis of the evaluation of stable, intermittent chest pain, a patient’s description of chest pain was found to be the most important predictor of underlying coronary disease.3 In the evaluation of acute chest pain, the 12-lead electrocardiogram (ECG) was the most useful bedside predictor for a diagnosis of ST-elevation myocardial infarction (STEMI).3

Physical Examination

A comprehensive physical assessment is fundamental to arriving at an accurate diagnosis. The nurse who has developed the skills of inspection, palpation, and auscultation can be confident when assessing patients with cardiovascular disease. Percussion, however, is not employed when assessing the cardiovascular system.

Inspection

Face

The face is observed for the color of the skin (i.e., cyanotic, pale, or jaundiced) and for an apprehensive or painful expression. The patient’s skin, lips, tongue, and mucous membranes are inspected for pallor or cyanosis. Central cyanosis is a bluish discoloration of the tongue and sublingual area. Multiracial studies indicate that the tongue is the most sensitive site for observation of central cyanosis, which must be recognized and treated as a medical emergency. Pulse oximetry, arterial blood gas analysis, and treatment with 100% oxygen must be instituted immediately.

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.

TABLE 13-2

INSPECTION AND PALPATION OF EXTREMITIES: COMPARISON OF ARTERIAL AND VENOUS DISEASE

CHARACTERISTIC ARTERIAL DISEASE VENOUS DISEASE
Hair loss Present Absent
Skin texture Thin, shiny, dry Flaking, stasis, dermatitis, mottled
Ulceration Located at pressure points; painful, pale, dry with little drainage; well-demarcated with eschar or dried; surrounded by fibrous tissue; granulation tissue scant and pale Usually at the ankle; painless, pink, moist with large amount of drainage; irregular, dry, and scaly; surrounded by dermatitis; granulation tissue healthy
Skin color Elevational pallor, dependent rubor Brown patches, rubor, mottled cyanotic color when dependent
Nails Thick, brittle Normal
Varicose veins Absent Present
Temperature Cool Warm
Capillary refill Greater than 3 seconds Less than 3 seconds
Edema None or mild, usually unilateral Usually present foot to calf, unilateral or bilateral
Pulses Weak or absent (0 to 1+) Normal, strong, and symmetric

Modified from Krenzer ME. Peripheral vascular assessment: finding your way through arteries and veins. AACN Clin Issues. 1995;6(4):631.

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.

Palpation

Palpation is a technique that uses the sense of touch in the tips of the fingers and the palm of the hand.

Brachial, Ulnar, and Radial Pulses

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