A comprehensive nursing cardiovascular assessment can indicate the need for further hemodynamic evaluation. The table below lists some key components and rationale for a cardiovascular nursing assessment.
Assessment |
Rationale |
| Observe the patient for cognitive or physical deficits during introductions/consent/history. | Hemodynamic instability may present as: shortness of breath, pulmonary congestion, decreased urine output, hypotension, abnormal heart rate, altered consciousness (restlessness, loss of consciousness, confusion), chest pain, etc. |
| Record vital signs: Assess pulse for rhythm, strength and rate. Assess blood pressure. | Blood pressure is determined by cardiac output, peripheral vascular resistance, circulating blood volume, blood viscosity, and vessel elasticity. |
Precordium: Inspect the anterior chest for heaves and an increase in visible pulsatility. Palpate the PMI (point of maximum impulse) for a normal 2+ pulse. |
Chest heaves may indicate ventricular hypertrophy due to an increased workload. A PMI that is displaced down and to the left indicates ventricular hypertrophy which may be due to volume overload. An increase in force and duration of the pulse may indicate an increase in pressure without volume overload. |
| Percuss the chest to determine the size of the heart. | Increase in heart size may indicate increased ventricular volume or wall thickness. |
| Auscultate the aortic, pulmonic, second pulmonic (Erb's point), mitral, and tricuspid areas of the precordium. | Listen for normal S1S2 and for abnormal sounds such as S3 or S4, murmurs, clicks, or rubs which could indicate heart pathology. |
Peripheral Vascular: Inspect the skin for temperature, color, moisture and turgor. Nailbed capillary refill which is normally less than 3 seconds. Palpate pulses the peripheral pulses for strength, regularity, bilateral symmetry and differences between upper and lower extremities (strength - 0, 1+,2+, 3+, 4+). |
Changes in skin indicate a change in tissue perfusion and cardiac output. Coolness, dependent edema, mottling, clubbing, cyanosis, indicate insufficient tissue perfusion. Abnormal strength, rate or regularity may indicate decreased cardiac output and tissue perfusion. Peripheral signs may be first indicators. |
| Inspect the neck for jugular venous distention (JVD). | Indicates CVP. Full distention as the patient sits at a 45 degree angle indicates an increase in CVP. |
| Auscultate and palpate the carotid arteries to assess arterial blood flow. | A decrease in pulse amplitude indicates a decrease in stroke volume. |
| Assess for hepatojugular reflux. | A positive hepatojugular reflux indicates heart failure. Visit Hepatojugular reflux (Semiopedia: Pathophysiology of semiotics) by Dr.Harinath, DMA, Chennai on Youtube https://www.youtube.com/watch?v=-v6Y2yfj0lQ |
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Peripheral tissue perfusion can be assessed by checking nailbed capillary refill. Normal refill should occur in less than 4 seconds.
References
Creed, F., & Hargreaves, J. (n.d.). Oxford Handbook of Critical Care Nursing. Oxford Medicine Online. Retrieved January 8, 2022, from https://oxfordmedicine.com/view/10.1093/med/9780198701071.001.0001/med-9780198701071
Zimmerman B, Williams D. (n.d.) Peripheral Pulse. [Updated 2021 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. From: https://www.ncbi.nlm.nih.gov/books/NBK542175/© RnCeus.com