10 Focused Assessment – Cardiovascular System

Review medical history for past illnesses such as diabetes, hypertension, high cholesterol.

Review the family history of heart problems, hypertension, diabetes, and high cholesterol.

Assess the social history, including smoking, exercise habits, and alcohol consumption.

2. Inspect:

• Face, lips, and ears for cyanosis
• Chest for deformities, scars, visible pulsations
• Bilateral arms/hands, noting color, warmth, movement, sensation (CWMS), edema, color of nail beds, nail shape, and capillary refill
• Bilateral legs, noting CWMS, hair distribution, edema to lower legs and feet, color of nail beds, and capillary refill, numbness/tingling
• calf size/pain for signs of deep venous thrombosis (DVT)

Alterations and bilateral inconsistencies in CWMS may indicate underlying conditions or injury.

While checking for capillary refill, inspect the nail base angle. The normal angle of the nail base is 160 degrees. Assessing for Clubbing Fingers  However, if the angle of nails become greater than 160 degrees, they are called clubbing fingers. Clubbing fingers are related to chronic hypoxemia.

Sudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of DVT, as is increased warmth, redness, tenderness, and swelling in the calf.

Note: DVT requires emergency referral because of the risk of developing a pulmonary embolism.

Have the patent breathe normally. Use the diaphragm side of the stethoscope to hear the five landmark areas:

• Aortic, Pulmonic, Erb’s point, Tricuspid, Mitral
• Auscultate apical pulse for one minute. Note the rate and rhythm.
• Heart Sounds (text and video)

Pulmonic Area – 2nd left ICS

ERB’s Point – 3^rd left ICS

Tricuspid Area – 4th left ICS (for children 4th or 5th left ICS)

Mitral Area (Apical) – 5th left ICS medial to the MCL

Auscultate for rate, rhythm, and pitch (the quality of the sound).

Auscultate apical pulse at the fifth intercostal space and midclavicular line.

Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.

• Use the ball of the hand (at the base of the fingers) to palpate the heart. Use the fingertips to palpate the point of maximal impulse (PMI), the location of apical pulse.
• The finger pads are more sensitive in detecting pulsations. Use the finger pads of the index and middle fingers and apply gentle pressure on the pulsation sites until the pulses can be felt.

Locations of Pulsation Sites:

• • Radial Pulse: On the lateral side of the writst, just below the thumb.
  • Brachial Pulse: On the medial side of the upper arm, in the bend of the elbow at the antecubital fossa.
  • Popliteal Pulse: Behind the knee in the popliteal fossa. This pulse is difficult to locate.
  • Posterior Tibial Pulse: Behind and below the medial malleolus, the bony prominence on the inndr side of the ankle.
  • Dorsalis Pedis Pulse: On the top of the foot, near the center, between the extension tendons of the big and second toes.
• Use the back of the hand to assess skin temperature while evaluating skin integrity. Check skin turgor by using the thumb and index fingers to pinch an area of the skin and release it; it should return to place instantly.
• Assess capillary refill by gently pressing finger pads or nails until they blanch. Release the pressure and observe how many seconds it takes for the color to return to normal. Assess on both fingers and toes bilaterally. Normal capillary refill time is less than 2-3 seconds.
• Assessing Edema  by pressing down on the skin and then releasing the pressure; the skin should normally return to place right away.

• The ball of the hand is the most sensitive at detecting thrills. Inspect and palpate for:
  • Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure.
  • Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.
  • Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow.

• If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded).

Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse

Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.

• A capillary refill time greater than 3 seconds indicates poor perfusion.
  

  

• When the indentation of the thumb or any fingers remain in the skin, it is pitting edema.  Documenting Pitting Edema