24.3 Nursing Assessment

Collecting Subjective Data

Subjective data are information that comes from the patient, the “subject.” This is information that cannot be measured empirically and is often based on the perception of the patient. This information includes past and present medical history, family history, cardiac risk factors, symptoms, and current medications including vitamins, herbal remedies, and over-the-counter (OTC) medications. New or worsening symptoms should be documented and reported to the provider. Symptoms can include chest pain, shortness of breath (dyspnea), irregular pulse rate, dizziness, fatigue, peripheral edema, poor peripheral circulation, decreased pulses in the lower extremities, fluttering in the chest, and pain in the upper back, neck, or abdomen. Additional symptoms, such as heartburn, indigestion, nausea, or vomiting may be benign; however, they can also be indicative of a myocardial infarction. Therefore, it is imperative that the nurse ask appropriate inquiry-based questions to clarify subjective information provided by the patient (Centers for Disease Control and Prevention, n.d.).

When conducting the interview and assessment, clarifying questions should first address any immediate need for intervention (e.g., severe chest pain, shortness of breath) that may be indicative of a serious problem (e.g., myocardial infarction). When the situation is determined not to be urgent, the nurse should continue asking clarifying questions to further assess the patient’s condition (Table 24.5).

When assessing pain, the nurse may want to use the multidimensional PQRSTU Pain Assessment Model.

• Provocation/Palliation: What brings on the pain? What relieves the pain?
• Quality/Quantity (characteristics and duration): Please describe the pain. How often has it been occurring?
• Region/Radiation: Where is the pain? Does it radiate anywhere?
• Severity: How would you rate the pain on a scale of zero to ten, where zero is no pain and ten is the worst possible pain you could ever imagine?
• Timing: When did the pain start? How long does the pain last?
• Understanding: What do you think is causing the pain?

Obtaining Health History

The goal of obtaining a health history is to gain insight into the overall health status of the patient. Relevant information related to chronic illness can be revealed through patient interviews as well as discovery of prior illnesses that the patient has not been treated for resulting in lingering effects. In general, the health history will include the patient’s medical history, allergies, surgeries, medications, and social history, and the patient’s family history.

When gathering a comprehensive medical history as it pertains to cardiovascular health, there are several key points for the nurse to consider. This includes an in-depth exploration of existing medical conditions, ongoing treatments, and any lingering effects from previous illnesses. Recognizing chronic or pervasive symptoms will help the nurse identify areas that require further evaluation.

For example, current symptoms such as shortness of breath, palpitations, chest pain, and edema may point to a cardiovascular origin. The nurse should ask if the patient has a history of any cardiac conditions, including short-term infections or illnesses (e.g., endocarditis, rheumatic fever, heart attacks) and long-term or chronic conditions (e.g., heart failure, high blood pressure, valvular disease). The nurse should also ask if the patient has a family history of heart disease—for example, a sibling or parent who had a heart attack or sudden cardiac death. It’s important to find out, if possible, the age at which family members experienced these events.

The nurse also needs to assess cardiovascular disease risk factors that may be present in the patient’s lifestyle, such as their diet, smoking status, substance use, alcohol use, sleep habits, stress levels, and physical activity. In taking a social history, the nurse should also consider whether the patient’s job or leisure activities (such as travel) could be risk factors for heart disease.

Asking a patient about their current medication use is also important, not just to ascertain whether they are being treated for a cardiovascular condition (and are complying with treatment) but also to determine whether they are taking any medications that could have cardiovascular contraindications or side effects. For example, popular OTC supplements that contain stimulating substances such as caffeine or ginseng may cause palpitations. Certain prescription drugs (e.g., erythromycin) can cause QT prolongation.

In taking a detailed medication history, particularly in older patients or those with multiple chronic conditions, the nurse should be aware of an increasing number of medications that patients may be taking and the potential for drug-to-drug interactions. This relates not just to prescriptions, but to OTC drugs, herbs, supplements, and vitamins as well.

Allergies are of utmost importance for all patients because of the potential for life-threatening consequences. Clear communication is key when asking about medication allergies, ensuring a thorough understanding of the patient’s reactions. Questions regarding allergies should cover more than just medications. The nurse should also inquire about allergies, sensitivities, or reactions to other substances (e.g., latex, medical/bandage tape, antiseptic solutions) as well as any herbs and vitamins.

Certain aspects of the medical history may be tailored to specific situations. Age and gender often guide healthcare professionals in determining when to inquire about additional details. For infants, parents should be asked about complications during pregnancy and delivery, and prematurity. Immunization status is crucial for pediatric patients, and it remains relevant for older adults with an increasing array of vaccination options making it an integral part of medical history assessments.

Inspection

Visual observation of areas of the body to assess for symmetry, color, movement, swelling, and obvious alterations in body function is called inspection (Table 24.7). For example, using the acronym CWMS (color-warmth-movement-sensation) helps the nurse efficiently and thoroughly inspect the extremities noting edema, numbness, and capillary refill. Alterations and bilateral inconsistencies in CWMS may indicate underlying conditions or injury. The face, lips, and ears are inspected for cyanosis or pallor, which may be caused by reduced blood flow, abnormal oxygenation levels, or a decreased number of red blood cells.

Palpation

Using the fingers or hand to assess size, consistency, texture, location, and tenderness of an organ, body part, or body area is called palpation. It is a method used to evaluate peripheral pulses, capillary refill, and lymph nodes and to look for the presence of edema. When palpating these areas, also pay attention to the temperature and moisture of the skin.

Edema

Edema occurs when visible swelling of the extremities is seen, which is caused by a buildup of fluid within the tissues. If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema (Figure 24.20).

Figure 24.20 Assess lower extremities for pitting edema by pressing into the skin and observing for indentations. (credit: modification of work “Oedema, finger marks” by John Campbell/Flickr, Public Domain)

The nurse should note the depth of the indention and how long it takes for the skin to rebound back to its original position. The depth of the indentation and time required to rebound to the original position are graded on a scale from 1 to 4 (Table 24.8). Additionally, it is helpful to note that edema may be difficult to observe in a patient with a higher weight. It is also important to monitor for any sudden increase in weight, which is considered a probable sign of fluid volume overload.

Grade	Description	Depth of Indentation	Time to Return to Normal
+1	Trace: Trace pitting No visible change in the shape of the extremity	0–2 mm	Rapidly (< 2 seconds)
+2	Mild: Mild pitting Swelling with no visible change in the shape of the extremity	3–4 mm	Up to 15 seconds
+3	Moderate: Deep pitting Swelling is more intense in the area	5–6 mm	More than 1 minute
+4	Severe: Very deep pitting Very swollen, distorted extremity	7 mm or more	More than 2 minutes

Table 24.8 Rating Edema

Peripheral Pulses

During the palpation phase of a nursing assessment, the nurse should compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. Bilateral comparison for all pulses (except the carotid) is important for determining subtle variations in pulse strength. Carotid pulses should be palpated on one side at a time to avoid decreasing perfusion of the brain. The posterior tibial artery is located on the medial aspect of the foot just behind the medial malleolus (Figure 24.21). It can be palpated by placing your fingertips on the area just behind and slightly below the medial malleolus.

Figure 24.21 Posterior tibial pulses are assessed by palpating just behind and slightly below the medial malleolus (ankle bone). (credit: “Assessing Tibial Pedal Pulses” by Chippewa Valley Technical College; CC BY 4.0)

The dorsalis pedis artery is located just lateral to the extensor tendon of the big toe on the top of the foot and can be identified by asking the patient to flex the toe while you provide resistance to this movement (Figure 24.22). Gently place the tips of your second, third, and fourth fingers adjacent to the tendon, and try to feel the pulse.

Figure 24.22 Dorsalis pedis pulses are assessed by palpating the top of the foot at the first intermetatarsal space located on the side of the tendon that moves the large toe. If possible, have the patient extend their big toe upward to help locate this space. (credit: “Assessing Dorsalis Pedis” by Chippewa Valley Technical College; CC BY 4.0)

The quality of the pulse is graded on a scale of 0 to 4. Absent (0), weak (+1), normal (+2), strong (+3), full and bounding (+4). If unable to palpate a pulse, additional assessment is needed. First, determine if this is a new or chronic finding. Second, if available, use a Doppler ultrasound to determine the presence or absence of the pulse. An absent pulse could be a sign of an emergent condition requiring immediate follow-up and provider notification.

Percussion

The term percussion involves tapping the chest wall with the fingers to assess sound that may indicate an abnormality or dysfunction. This method of examination involves hyperextending the fingers of one hand with the middle distal finger placed firmly on the chest wall. Holding the opposite hand close to the hand on the patient, the middle finger of the second hand is retracted and the distal finger is firmly struck.

Resonant sounds can be heard when percussing the precordial area of the chest, which indicates normal tissue beneath the fingers used. When percussing over the lungs, the resonant sounds will be a semihollow, medium-pitched sound. Denser tissue, such as the heart will yield a flat or dull sound. Percussion is most often used to determine masses and blockages so it has a limited use in nursing. Auscultation will yield more accurate results and is much easier to conduct.

Auscultating Heart Sounds

The process of using a stethoscope to listen for normal and abnormal sounds (e.g., components of the heartbeat, murmurs, valvular sounds, bruits) is known as auscultation. When assessing the heart, auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic APE To Man, referring to the Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral areas (Figure 24.23). The aortic area is the second intercostal space to the right of the sternum. The pulmonic area is the second intercostal space to the left of the sternum. Erb’s point is directly below the pulmonic area and located at the third intercostal space to the left of the sternum. The tricuspid (or parasternal) area is at the fourth intercostal space to the left of the sternum. The mitral area (also called the apical or left ventricular area) is the fifth intercostal space at the midclavicular line.

Figure 24.23 Using the correct landmarks of auscultation for heart sounds is critical to ensuring accurate results. (credit: “Cardiac Auscultation Areas” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds, which make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1). Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and tricuspid area (fourth intercostal space). When assessing the mitral area for female patients, it is often helpful to ask them to lift up their breast tissue so the stethoscope can be placed directly on the chest wall.

Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a sixty-second period. For an adult, the heart rate should be between sixty and one hundred with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.

The first heart sound (“lub”) is designated as S1, which identifies the onset of systole, when the atrioventricular (AV) (mitral and tricuspid) valves close and the ventricles contract and eject the blood out of the heart. The second heart sound (“dub”) is designated as S2, which identifies the end of systole and the onset of diastole when the semilunar (pulmonic and aortic) valves close, the AV valves open, and the ventricles fill with blood. S1 corresponds to the palpable pulse. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds. Nurses should listen to a normal S1/S2 sound and then compare them to abnormal sounds. It may be helpful to use earbuds or a headphone.

Extra heart sounds include clicks, murmurs, S3 and S4 sounds, and pleural friction rubs. These extra sounds can be difficult for a novice to distinguish, so if any new or different sounds are noticed, consult an advanced practitioner or notify the provider. A midsystolic click, associated with mitral valve prolapse, may be heard with the diaphragm at the apex or left lower sternal border.

A click may be followed by a murmur. A murmur is a blowing or whooshing sound that signifies turbulent blood flow often caused by a valvular defect. New murmurs not previously recorded should be immediately communicated to the healthcare provider. In the aortic area, listen for possible murmurs of aortic stenosis and aortic regurgitation with the diaphragm of the stethoscope. In the pulmonic area, listen for potential murmurs of pulmonic stenosis and pulmonary and aortic regurgitation. In the tricuspid area, at the fourth and fifth intercostal spaces along the left sternal border, listen for the potential murmurs of tricuspid regurgitation, tricuspid stenosis, or a ventricular septal defect.

If present, S3 and S4 sounds are often heard best by asking the patient to lie on their left side and listening over the apex of the heart with the bell of the stethoscope. An S3 sound, a ventricular gallop, occurs after the S2 and sounds like “lub-dub-dah,” or a sound similar to a horse galloping. An S3 can occur when a patient is experiencing fluid overload, such as during an acute exacerbation of heart failure. It can also be a normal finding in pregnancy due to increased blood flow through the ventricles.

The S4 sound, an atrial gallop, occurs immediately before the S1 and sounds like “ta-lub-dub.” An S4 sound during diastole may be created by the movement of blood out of the atria flowing against a stiff ventricular wall caused by hypertension, pulmonary hypertension, ventricular outflow obstruction, or ischemic heart disease.

A pericardial friction rub is a grating, to-and-fro sound or creaky-scratchy noise generated as the parietal and visceral membranes rub together, which is caused by inflammation of the pericardium. It is best heard with the diaphragm of the stethoscope at the apex or left lower sternal border as the patient sits up, leans forward, and holds their breath.

The carotid artery may be auscultated for bruit, a swishing sound caused by turbulence in the blood vessel. Bruits may be heard because of atherosclerotic changes.

Assessing Heart Rate and Rhythm

Pulses can be found at many points on the body and all could theoretically be used to assess heart rate. When palpating pulses, use moderate pressure, because too much pressure can impair blood flow and occlude the vessel. In some facilities, scales are used to document the quality of the pulse, such as absent (0), weak (+1), normal (+2), strong (+3), and full and bounding (+4).

If a pulse is regular, a thirty-second count multiplied by two is generally acceptable. If a pulse is irregular, the nurse should count for a full sixty seconds. A common pulse for assessment is the radial pulse (Figure 24.24).

Figure 24.24 Use the pads of your first two fingers to gently palpate the radial pulse at the inner lateral wrist. (credit: “Untitled” by Thompson Rivers University; CC BY 4.0)

The apical pulse is another common pulse and should be auscultated for rate and regularity (Figure 24.25). For accuracy, an apical heart rate should be taken for a full minute especially when giving medications that are dependent on the heart rate.

Figure 24.25 Apical pulses are assessed using a stethoscope placed over the fourth to fifth intercostal space of the midclavicular line on the left side on adults. (credit: “Untitled” by Thompson Rivers University; CC BY 4.0)

It is suggested that beginner nurses concentrate on rate and regularity. With practice, and depending on work location, skill level with specific heart sounds may improve, at which point the nurse will document in greater detail.

A carotid pulse may be taken when the radial pulse is not present or is difficult to palpate (Figure 24.26). It is important that the nurse NOT palpate both bilateral carotid arteries at the same time, to avoid decreasing perfusion of the brain.

Figure 24.26 When palpating the carotid pulse, use the pads of your first three fingers to gently palpate on either side of the trachea. (credit: “Assessing carotid pulse” by Thompson Rivers University; CC BY 4.0)

Diagnostic Testing

Cardiovascular diagnostic and screening tests offer comprehensive insights into the heart’s electrical activity, heartbeat rhythm, and efficiency of blood pumping through the heart’s chambers and valves into the coronary arteries and to the heart muscle. Other tests help providers identify the presence of tumors or other abnormalities in the structure of the cardiovascular system.

There are numerous types of diagnostic tests for cardiovascular disease including blood laboratory tests; electrocardiograms; echocardiograms; stress tests; electrophysiology studies; cardiac catheterization; and magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography (CT), and positron emission tomography (PET) scans. New tests are continually being developed and tested to ensure the safest avenues to obtain the most accurate results. It is important to recognize patient needs and abilities to perform some diagnostic tests as well as identify allergies or adverse events that may be associated with using a contrast medium.

Basic blood panels with complete blood counts and prothrombin platelet times are tested to evaluate blood components for blood clotting, anemia, diabetes, and other contributing factors to CVD. The D-dimer test measures fragments of protein that a body releases when a blood clot dissolves. It can help diagnose and monitor blood-clotting conditions such as DVT. Electrolytes can be used to screen for imbalances in potassium, sodium, or calcium, which may affect cardiac function and conduction. Increased cardiac enzymes (e.g., troponin, creatine kinase-MB [CK-MB]) can indicate ischemia, myocardial damage, or infarction. The antinuclear antibody profile is used to help diagnose autoimmune disorders, which may indicate an increased risk for CVD. Another important blood test is the B-type natriuretic peptides (BNP), which measures the levels of BNP protein in the bloodstream. High levels of BNP can be a sign of heart failure. Additional blood tests include testing for cholesterol and triglyceride levels to monitor for hyperlipidemia, which may suggest a risk of atherosclerosis or coronary artery disease.

Healthcare providers may use arterial blood gas (ABG) measurements, a more specific evaluation of oxygen and carbon dioxide levels, particularly in emergency situations involving deteriorating respiratory status. An ABG involves drawing blood from the radial artery, and provides insights into oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen (PaO₂) in arterial blood measures the pressure of oxygen dissolved in the blood, offering a more accurate assessment than SpO₂ because it is not influenced by hemoglobin levels. The normal PaO₂ level for a healthy adult ranges from 80 to 100 mm Hg. Additionally, ABGs provide information about the partial pressure of carbon dioxide (PaCO₂) in arterial blood and how well carbon dioxide can move out of the body; this assesses ventilation efficiency at the alveolar level. The normal PaCO₂ level is 35 to 45 mm Hg. The results of an ABG test also include pH levels (7.35–7.45), bicarbonate levels (22–26 mEq/L), and the calculated arterial oxygen saturation level (SaO₂). Nurses need to become versed with the normal values for common blood test values (Table 24.9).

Testing for heart rhythm and stability are electronic evaluations that assess for arrhythmias such as ventricular fibrillation, myocardial infarction, ischemia, and valvular dysfunction. An echocardiogram provides detailed images of the heart’s structure and function, identifying abnormalities in chambers, valves, or wall motion. An ECG can determine current electrical activity and can identify issues such as arrhythmias (e.g., ventricular tachycardia, atrial fibrillation, sinus-node arrhythmia, heart blockage), ischemia, and other cardiac dysfunction. Prior myocardial infarction and ischemia will also show up on ECG tracings through altered QRS complexes and inverted P waves.

Other diagnostic tests identify various types of heart dysfunction including partial or complete blockage, congenital heart disease, peripheral vascular disease, and risk factors for stroke. Such tests include the following:

• Stress test: The patient is placed on a treadmill to evaluate heart function during physical stress, uncovering abnormalities that may not be apparent at rest. A chemical stress test, or the use of medication to simulate the patient’s heart response to exercise, may be used to replace a treadmill stress test if the patient is unable to perform a regular stress test.
• Tilt table test: The patient is connected to an ECG and blood pressure monitor and is strapped to a table that tilts the patient from a lying to standing position. This test is used to determine if the patient is likely to have sudden drops in blood pressure (orthostatic hypotension) while standing, or slow pulse rates with position changes. This test might be performed if the patient is experiencing frequent fainting spells.
• Electrophysiology study: For this test, insulated electric catheters are placed through the femoral vein and threaded into the heart. It is used to test the heart’s electrical system. It helps healthcare providers identify causes of abnormal heart rhythms.
• Cardiac catheterization (coronary angiogram): During this test, a small catheter is guided through the femoral artery, or sometimes the wrist or arm, into the patient’s heart. Dye is injected through the catheter, and fluoroscopy (continuous x-rays) are taken as the dye travels through the heart arteries and heart chambers. This comprehensive test shows narrowing in the arteries, heart chamber size, heart pump efficiency, and the efficiency of valves opening and closing. It also measures the pressures within the heart chambers, arteries, and veins. This invasive procedure visualizes coronary arteries and identifies blockages or abnormalities.
• Cardiac MRI: This procedure uses a combination of large magnets, radiofrequencies, and a computer to make detailed images of organs and structures in the body. An MRI of the heart may be ordered to assess the heart valves and major vessels. It can also detect coronary artery disease and resultant damage caused. Tumors and congenital heart conditions can also be evaluated.
• Cardiac MRA: This is a special type of MRI procedure used to evaluate blood vessels in the heart. Contrast dye is used to help highlight blood flow.
• Cardiac CT scan: This imaging procedure uses X-rays and a computer to create a 3-dimensional images of the heart. Sometimes dye is injected into a vein so that the heart arteries can be seen as they uptake the dye. Sometimes medicine is administered to lower the patient’s heart rate so it captures a better image. A CT scan can also be used to find out how much calcium is in the heart arteries. Calcium is a marker for coronary artery disease.

Abnormalities in Cardiovascular Findings

Recognizing abnormal findings in cardiovascular health is critical for healthcare professionals in order to provide timely and effective care. Cardiovascular abnormalities can manifest through various signs and symptoms that could have catastrophic and life-altering results. Therefore, it is of utmost importance to conduct a comprehensive assessment to identify underlying issues. One key aspect is understanding the patient’s symptoms (complaints) related to potential cardiovascular problems (e.g., shortness of breath, chest pain, palpitations, dizziness, sweating, numbness, weakness). Clinical signs (e.g., edema, cyanosis, abnormal pulsations) can provide visual cues that may indicate cardiovascular issues.

In nursing practice, continuous monitoring and prompt recognition of deviations from baseline cardiovascular parameters are essential. Timely identification of abnormal findings empowers healthcare professionals to initiate appropriate interventions, collaborate with interdisciplinary teams, and guide patients toward optimal cardiovascular health outcomes. Using an algorithm for stroke assessment helps the nurse act quickly to minimize tissue injury:

Within sixty minutes of symptom onset:

• Transport to ER

Within five minutes of arrival at ER:

• Vital signs
• ECG

Within ten to twenty-five minutes of arrival at ER:

• Neurological assessment
• CT scan
• Laboratory tests
• Doppler ultrasonography (if necessary)

Within forty-five minutes of arrival at the ER:

• Administration of thrombolysis (clot buster), if eligible

Within three hours of stroke onset:

• Decision/administration of thrombolysis
• Admission to a specialized stroke unit

Continuous:

• Administration of nonglucose fluids to maintain hydration

As needed:

• Care for individual patient needs (e.g., insulin, aspirin, blood thinners, blood pressure medications, antibiotics)

Follow-up:

• Close monitoring and ongoing care for recovery

Education and awareness among healthcare providers plays a pivotal role in recognizing abnormal cardiovascular findings and delivering patient-centered care (Figure 24.27).

Figure 24.27 Identifying early signs of an ischemic attack or stroke can alert the nurse to respond quickly to help mitigate potential life-altering effects. (credit: “Stroke response times.jpg” by Webber/Wikimedia Commons; Public Domain)

Abnormalities in Peripheral Vascular Findings

Abnormal findings on peripheral examination may include edema, cellulitis, cool or warm skin, changes in the color of skin, reduced peripheral pulses, and ulcerations. Identifying these changes and how they correlate to the function of the peripheral vascular system is instrumental in creating an accurate nursing diagnosis and care plan. Venous stasis dermatitis, vasculitis, peripheral artery disease (PAD), and mixed venous and arterial insufficiency are common peripheral vascular system disorders (Table 24.10).